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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 2  |  Issue : 4  |  Page : 156-159

Prefer to avoid sedatives in patients with acute hepatotoxicity due to rodenticide ingestion: Knowledge, attitude, and practice survey of doctors from Tamil Nadu


1 Department of Hepatology, Christian Medical College, Vellore, Tamil Nadu, India
2 Centre for Biostatistics and Evidence-Based Medicine, Vellore, Tamil Nadu, India
3 Department of Gastroenterology, Apollo Hospitals; The Secretary, The Tamil Nadu Chapter of Indian Society of Gastroenterology, Chennai, Tamil Nadu, India

Date of Submission21-Sep-2022
Date of Acceptance23-Sep-2022
Date of Web Publication13-Oct-2022

Correspondence Address:
Ashish Goel
Department of Hepatology, Christian Medical College, Vellore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ghep.ghep_25_22

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  Abstract 


Background and Aim: While sedative drugs are not hepatotoxic, the use of sedative drugs in patients with acute liver dysfunction may lead to unrecognized sedative overdose, or trigger or aggravate encephalopathy. This study hopes to draw more attention to the need to correctly interpret and use the expert guidelines in this regard. The aim of this study was to assess the knowledge, attitude, and practice of doctors regarding sedative use in patients with acute liver dysfunction secondary to rodenticide poisoning in Tamil Nadu. Subjects and Methods: This was a cross-sectional online survey carried out between December 2021 and May 2022 among doctors in Tamil Nadu involved in the care of patients with rodenticide poisoning regarding sedative use in patients with rodenticidal hepatotoxicity. Results: Responses were obtained from 168 doctors (including 86 gastroenterologists): ([152, 90.5%] from doctors in the government sector and [16, 9.5%] from private sector). Most (96, 57.1%) respondents had managed >10 patients of rodenticide poisoning in a year. Most doctors opined that the patients they cared for did not have access to urgent liver transplantation. One hundred and fifty-one (89.9%) doctors opined that sedative use could depress sensorium further and lead to unfavorable outcomes in these patients. About 79 (47%) patients would avoid using a sedative, if possible, in patients with acute liver dysfunction. They felt the indications for sedative use were to avoid fluctuations in raised intracranial pressure (134, 79.8%) and to facilitate invasive procedures (129, 76.8%) such as endotracheal intubation. When sedative was needed, 10 doctors (6%) favored the use of a reduced dose of sedative. Conclusions: In a resource-constrained setting, where emergency liver transplantation is not easily accessible, doctors prefer to avoid sedatives in patients with rodenticidal hepatotoxicity. Increased awareness of the need to avoid sedatives or restrict the use of sedatives may improve survival in these patients.

Keywords: Chemical and drug-induced liver injury, hypnotics and sedatives, liver transplantation, rodenticides


How to cite this article:
Thomas Z, Janeela A, Kirubakaran R, Dhus U, Zachariah U, Eapen C E, Goel A. Prefer to avoid sedatives in patients with acute hepatotoxicity due to rodenticide ingestion: Knowledge, attitude, and practice survey of doctors from Tamil Nadu. Gastroenterol Hepatol Endosc Pract 2022;2:156-9

How to cite this URL:
Thomas Z, Janeela A, Kirubakaran R, Dhus U, Zachariah U, Eapen C E, Goel A. Prefer to avoid sedatives in patients with acute hepatotoxicity due to rodenticide ingestion: Knowledge, attitude, and practice survey of doctors from Tamil Nadu. Gastroenterol Hepatol Endosc Pract [serial online] 2022 [cited 2022 Nov 27];2:156-9. Available from: http://www.ghepjournal.com/text.asp?2022/2/4/156/358477




  Introduction Top


The most common cause of acute hepatotoxicity in Tamil Nadu is the ingestion of yellow phosphorus poison.[1] While urgent liver transplantation is the definitive treatment for acute liver failure, this is not feasible in resource-constrained settings. In a prospective study conducted by the Tamil Nadu chapter of the Indian Society of Gastroenterology (TN-ISG) from January to June 2019, of 451 patients with rodenticidal hepatoxicity across Tamil Nadu, 35% of patients died or were discharged to a moribund state but only one patient underwent urgent liver transplantation.[1] There is a pressing need to maximize survival with nonliver transplant treatment options.

The use of sedatives in acute liver failure patients is often directed toward preventing surges in intracranial pressure, as a chemical restraint in an agitated patient, and during endotracheal intubation.[2] However, most sedative drugs are metabolized in the liver, and thus, their half-lives are prolonged in patients with acute liver dysfunction, leading to the sustained effect of the sedative drug, which could cause further worsening of the sensorium, respiratory depression, and trigger or worsen encephalopathy. In fact, the benzodiazepine antagonist, flumazenil, has been studied to treat hepatic encephalopathy in patients with cirrhosis.[3]

Thus, sedative use in patients with acute liver dysfunction may lead to a profound worsening of the clinical situation making liver transplant inevitable. In this background, our study aims to assess the knowledge, attitude, and practice (KAP) regarding sedative use in patients with rodenticidal hepatotoxicity among doctors caring for these patients in Tamil Nadu.


  Subjects and Methods Top


The study was carried out using a novel questionnaire which focused on the KAP of doctors on the use of sedatives in rodenticide-induced acute liver dysfunction. The questionnaire contained information on which sector they were working, their experience in managing patients with rodenticide poisoning, whether their facility offered urgent liver transplantation and their opinion on the use of sedatives, details on preferred sedatives, their doses, and the common indications for sedative use in patients with rodenticide induced acute liver dysfunction.

Following expert validation of content and a short pilot study, the questionnaire was disseminated anonymously through Google Forms to doctors involved in the management of rodenticide poisoning in various hospitals in Tamil Nadu. TN-ISG members were invited to participate in this study through a common WhatsApp group. In addition, doctors from government hospitals who underwent specialized training in managing rodenticide ingestion by a protocol developed by the Tamil Nadu Accident and Emergency Care Initiative – National Health Mission were also invited to participate.[4] Access to relevant international and national guidelines was made available to all study participants.[5],[6],[7]

An arbitrary sample size of 200 study participants was taken. Following data collection, the anonymized data were cleaned, exported to IBM SPSS statistics for windows, version 26.0, Arnmonk, NY, USA and analyzed.

This study was approved by the Institutional Review Board and Ethics Committee (IRB Minute no. 14331).


  Results Top


Details of hospitals where the doctors are working and access to urgent liver transplantation for acute live failure patients

Out of a total of 168 respondents, 152 (90.5%) and 16 (9.5%) were from the government and private sectors, respectively. Eighty-six respondents were gastroenterologists or hepatologists (consultants: 62, trainess: 24). Only nine respondents (5.4%) stated that their institutes offered urgent liver transplantation [Table 1].
Table 1: Responses to knowledge, attitude, and practice survey of doctors managing rodenticide hepatotoxicity patients in Tamil Nadu about the use of sedative drugs: Details of the hospital and treatment with urgent liver transplantation

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Over the past 1 year, 62 (36.5%) doctors surveyed had managed >20 patients of rodenticide poison ingestion, whereas 96 (57.1%) physicians had managed >10 patients of rodenticidal poisoning and ≥1 such patient who developed acute liver injury/failure. Fifty (49.5%) doctors who cared for acute liver failure patients did not refer them to a higher center for further management [Table 1].

Opinion of doctors about the use of sedative drugs in patients with rodenticidal hepatotoxicity

About 57.1% of participants felt that the existing guidelines were not clear on the role of sedation among patients with acute liver dysfunction [Table 2].
Table 2: Responses to knowledge, attitude, and practice survey of doctors managing rodenticide hepatotoxicity patients in Tamil Nadu about the use of sedative drugs: Opinion about the use of sedative drugs in these patients

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Regarding the use of sedation among these patients, 47% of doctors would avoid sedatives, whereas 53% felt it could be used if required. Sedation was deemed necessary for interhospital transfer by 52.4% of doctors to prevent fluctuations in intracranial pressure, whereas 47.6% preferred to avoid sedatives in view of the risk of depressing sensorium. About 86.3% of doctors advocated sedation for endotracheal intubation.

Midazolam was the most commonly preferred sedative (55, 32.7%), followed by propofol (40, 23.8%) in patients with acute liver dysfunction.

Ten doctors (5.95%) recommended the use of a lower dose of the sedative drug if necessary [Table 2].


  Discussion Top


The majority (93.5%) of doctors surveyed were aware that most sedative drugs are metabolized in the liver and 89.9% were concerned about the risk of depressing the sensorium and worsening the outcome of administering sedatives in patients with rodenticide-induced acute hepatotoxicity. In a setting of lack of access to urgent liver transplantation, doctors prefer to avoid sedation/restrict the use of sedative drugs in patients with rodenticidal hepatotoxicity. Most doctors agree on the use of sedative drugs during endotracheal intubation. At the same time, there is a strong consensus on the threats posed by sedative use.

The Indian National Association for Study of the Liver (INASL), the American Association for Study of Liver Disease (AASLD), and the European Association for the Study of the Liver (EASL) advocate avoiding sedative drugs, if possible, in acute liver failure patients.[5],[6],[7]

In patients who need sedation, the sedative drug is to be administered in a critical care setting (patients should not be given sedative drugs in the ward) and is given only for evolving hepatic encephalopathy, before intubation and during interhospital patient transfer as per the EASL guidelines.[7] AASLD recommends the use of short-acting benzodiazepines for seizures and unmanageable agitation in patients with acute liver failure.[6] INASL suggests the use of sedation in acute liver failure patients only in a tertiary care setting where urgent liver transplantation is a feasible option, to manage agitation, for hepatic encephalopathy grades 3 and 4 and for intubation.[5]

The recent TN-ISG guidelines on managing rodenticide poisoning recommend avoiding sedatives among patients with hepatotoxicity who do not have encephalopathy.[8]

As access to urgent liver transplantation is not feasible for most patients with acute liver dysfunction in resource-constrained settings, one of the key factors for survival is to avoid mechanical ventilation, if possible. Hence, it is important to try avoiding sedative drugs in these patients. If the patient is on mechanical ventilation, the attempt must be made to wean off mechanical ventilation, at the earliest. In this situation, the smallest dose of sedative maybe used for the minimum duration with serial assessment for improvement in sensorium.


  Conclusions Top


In this KAP survey of doctors in Tamil Nadu caring for patients who ingest rodenticide poison, the majority of doctors were concerned about the risk of depressing the sensorium and worsening outcomes of administering sedative drugs to patients who develop acute hepatotoxicity. In a setting of lack of access to urgent liver transplantation, most doctors prefer to avoid sedative drugs or restrict the use of sedative drugs in patients with rodenticidal hepatotoxicity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Govindarajan R, Ramamoorthy G, Shanmugam RM, Bavanandam S, Murugesan M, Shanmugam C, et al. Rodenticide ingestion is an important cause of acute hepatotoxicity in Tamil Nadu, southern India. Indian J Gastroenterol 2021;40:373-9.  Back to cited text no. 1
    
2.
Vadivukkarasi TJ, Kandasamy S, Abhilash KP, Zachariah U, Goel A, Eapen CE. Safe sedation practices in acute liver failure in resource-constrained settings: A viewpoint. Gastroenterol Hepatol Endosc Pract 2021;1:17.  Back to cited text no. 2
  [Full text]  
3.
Goh ET, Andersen ML, Morgan MY, Gluud LL. Flumazenil versus placebo or no intervention for people with cirrhosis and hepatic encephalopathy. Cochrane Database Syst Rev 2017;8:CD002798.  Back to cited text no. 3
    
4.
CMC Organises Workshop on Managing Rat Poison Ingestion. The Hindu; 30th July 2022.  Back to cited text no. 4
    
5.
Anand AC, Nandi B, Acharya SK, Arora A, Babu S, Batra Y, et al. Indian National Association for the study of liver consensus statement on acute liver failure (Part-2): Management of acute liver failure. J Clin Exp Hepatol 2020;10:477-517.  Back to cited text no. 5
    
6.
Lee WM, Stravitz RT, Larson AM. Introduction to the Revised American Association for the study of liver diseases position paper on acute liver failure 2011. Hepatology 2012;55:965-7.  Back to cited text no. 6
    
7.
European Association for the Study of the Liver Electronic address: [email protected], Clinical practice guidelines panel, Wendon, J, Panel members, Cordoba J, Dhawan A, et al. EASL Clinical Practical Guidelines on the management of acute (fulminant) liver failure. J Hepatol 2017;66:1047-81.  Back to cited text no. 7
    
8.
Eapen CE, Balasubramanian V, Ramamoorthy G, Jayanthi V, Sathiyasekaran M, Murugan N, et al. Management of rodenticide poisoning: Tamil Nadu Chapter of Indian Society of Gastroenterology Guidelines. Gastroenterol Hepatol Endosc Pract 2022;2:1-6.  Back to cited text no. 8
  [Full text]  



 
 
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