Acute intoxications: differences in management between six Dutch hospitals; prospective testing of an admission algorithm

Transcription

1 Acute intoxications: differences in management between six Dutch hospitals; prospective testing of an admission algorithm Cornelis Kramers, internist, Clinical Pharmacologist Radboud University Medical Center, Nijmegen, the Netherlands Dept. Pharmacology-Toxicology. Dept. Clinical Pharmacy Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands

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3 It is 1 AM. There are no hospital beds available. There are no beds on the ICU either

4 Casus 1 Man 42 years old 70 kg. Healthy, no alcohol abuse. Took 6 grams paracetamol, I hour ago. Liver enzyms and creatinin normal. Gastric lavage, charcoal? Blood concentration measurement? NAC? Admission?

5 Literature <150 mg/kg is safe Unreliable history Suicide attempt Emotion Amnesia in the case of benzodiazepines Question If intake <150 mg/kg, blood concentration above treatment line of the Rumack Nomogram?

6 concentratie t.o.v. nomogram (%) mg/kg ingenomen

7 History: 8 gram Calculated: 20 gram Dangerous liar? Log C Time

8 History: 20 gram Calculated: 8 gram Harmless liar? Log C Time

9 History: 20 gram Log C Time

10 Admission policy acute intoxications No national admission policy: differences in admission:60% (1), 42% (2) 33% (3) Great Britain: Kapur et al: 3 city s, 6 hospitals, admission17%-80% (4) Large differences in Europe Population comparable with respect to gender, age, ingestion Admission policy Radboud Univeristy Nijmegen Medical Center 1997: 60% (2) 1999: 48% (2) 2007: 43% (2) 1) Meulendijks ) Ambrosius ) Vermes ) Kapur 2003

11 Aim and questions Admission policy in 6 Dutch hospitals Population characteristis Admission percentage per hospital? Wards of admission? Admission duration? Outcome?

12 Methoden DOA and suicide attempts analysed separately Retrospective study Canisius Wilhemina Ziekenhuis Nijmegen Radboud University Nijmegen Medical Center Rijnstate ziekenhuis Arnhem AMC Amsterdam Jeroen Bosch Ziekenhuis Den Bosch Isala Klinieken Zwolle 1 jan dec 2008 DBC coding (code 042)

13 Methods Variables: Age, gender, type of intoxication History of intake Admission: ward and duration Outcome Exclusion criteria <14 years Chronic intoxication Admission because of other reason Intoxication with gas or skin contact Referral to other hospital Analysis SPSS: Chi-square test, multivariate analysis Significant if <0.02

14 Hospital A: Amsterdam Medical Centre (AMC) Amsterdam. Hospital B: Radboud University Medical Centre (RUMC) Nijmegen. Hospital C: Jeroen Bosch ziekenhuis (JBZ) Den Bosch. Hospital D: Isala Klinieken Zwolle. Hospital E: Rijnstate Ziekenhuis Arnhem. Hospital F: Canisius Wilhemina Ziekenhuis Nijmegen.

15 Gender - suicide attempt Gender - drugs of abuse hospital F hospital E hospital D male sex female sex hospital F hospital E hospital D male sex female sex hospital C hospital C hospital B hospital B hospital A hospital A 0% 20% 40% 60% 80% percentage 0% 20% 40% 60% 80% percentage

16 percentage Intention of poisoning 80% 70% 60% 50% TS Drugs of abuse other/unknown 40% 30% 20% 10% 0% hospital A hospital B hospital C hospital D hospital E hospital F

17 percentage 100% Admission rate according to intention 90% 80% 70% 60% intoxication due to suicide attempt 50% 40% 30% intoxication due to drugs of abuse 20% 10% 0% AMC RUMC JBZ Isala Rijnstate CWZ

18 percentage Admission wards 80% 70% 60% 50% 40% 30% 20% 10% 0% intensive care medium care general medical ward discharge or psychiatry hospital A hospital B hospital C hospital D hospital E hospital F

19 Table II: Discharge and admission percentage (general medical ward, intensive care unit, medium care unit and psychiatry) for suicide attempts. * Analysis with Fischer s Exact Test Suicide attempt General medical ward (N) Medium care unit (N) Intensive care unit (N) Psychiatry (N) Discharge AMC 43.8% (7) 25.0% (4) 18.8% (3) 0.0% (0) 48.4% (15) RUMC 57.4% (27) 19.1% (9) 10.6% (5) 19.1% (9) 38.2% (29) JBZ 56.0% (47) 22.6% (19) 13.1% (11) 1.2% (1) 16.0% 16) Isala 73.2% (104) 0.7% (1) 7.7% (11) 17.6% (25) 17.0% (29) Rijnstate 29.2% (62) 46.7% (99) 16.0% (34) 5.7% (12) 13.1% (32) CWZ 12.9% (12) 60.2% (56) 12.9% (12) 5.4% (5) 17.7% (20) Total 34.3% (252) 4.2% (31) 10.3% (76) 7.1% (52) 19.2% (141) P value * 0.192* 0.000* 0.000

20 Tabel III: Discharge and admission percentage (general medical ward, intensive care unit, medium care unit and psychiatry) for intoxications because of drugs of abuse. * Analysis with Fischer s Exact Test Intoxication because of DOA N General medical ward (N) Medium care unit (N) Intensive care unit (N) Psychiatry (N) Discharge AMC % (8) 3.9% (3) 3.9% (3) 0.0 % (0) 81.5% (62) RUMC % (3) 1.7% (1) 1.7% (1) 0.0 % (0) 91.7% (55) JBZ % (13) 3.1% (1) 9.4% (3) 0.0 % (0) 46.9% (15) Isala % (25) 0.0 % (0) 8.5% (4) 4.3 % (2) 31.9% (15) Rijnstate % (10) 4.9% (3) 8.2% (5) 0.0 % (0) 70.5% (43) CWZ % (8) 42.9% (18) 2.4% (1) 0.0 % (0) 28.6% (12) Total % (76) 8.2% (26) 5.3% (17) 0.6% (2) 63.5% (202) P value 0.000* 0.000* 0.317* 0.608* 0.000

21 Multivariate analysis of factors influencing admission Hospital Odds ratio for admission (95% CI) Age 1.0 ( ) Sex 0.7 ( ) Hospital RUMC 1.4 ( ) Rijnstate 5.2 ( ) CWZ 6.6 ( ) JBZ 5.9 ( ) Isala 6.9 ( ) AMC Reference group Reason of poisoning Suicide attempt 2.5 ( ) Drugs of abuse Reference group Unknown/other reason of poisoning 0.9 ( ) Substance used Reported TCA use 2.2 ( ) Reported paracetamol use 1.2 ( ) Reported alcohol intoxication 0.6 ( )

22 Table VIII: decontamination treatment for suicide attempts *Analysis with Fischer s Exact Test Suicide attempt Gastric lavage Activated charcoal AMC 9.7% (3) 16.1% (5) RUMC 6.6% (5) 30.3% (23) JBZ 16.7% (5) 30.0% (30) Isala 9.9% (17) - Rijnstate 10.2% (25) 37.3% (91) CWZ 7.1% (8) 42.5% (48) Total 8.6% (63) 34.9% (197) P value 0.614* 0.037*

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24 Conclusion Hospital admission rates and admission wards vary considerably in Dutch hospitals. Variations cannot be explained by differences in sex, age or substances ingested. National guidelines on hospital admission may make the care for intoxicated patients more (cost)- efficient.

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31 Gastric lavage No, unless Within 1 (or 2 ) hours Large tube Hand warm Small volume Left side No evidence in clinical practice Good mechanistic evidence

32 Contra-indications Airway secured Not in case of carbon hydrates Not in case of caustic lesions

33 Activated charcoal Yes, unless As soon as possible With laxative Does not bind lithium/iron No evidence in clinical practice Good mechanistic evidence

34 Contra-indications Airway secured Not in case of caustic lesions

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38 Flumazenil or naloxone Beware of co-ingestion Flumazenil: TCA/benzo notorious Naloxone: Heroin-Cocaine notorious

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