To Study the Role of Forced Alkaline Diuresis in Prevention of Acute Kidney Injury in Patients with Hematotoxic Snake Bite

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Abstract (English)

Background: Snake bite is a common medical emergency and an occupational hazard, more so in tropical India, where farming is a major source of employment. Viper bites are more common than other poisonous snakebites in humans. INDIA is among the countries most dramatically affected by snake bite and accounts for almost half the total number of annual deaths across the world. According to WHO estimate- India had 1.2 million snake bite deaths from 2000-2019 and nearly half of the victims aged 30-69 and over a quarter being children under 15. The WHO has set the target of reducing these deaths to half the number by 2030 and India’s efforts to prevent and control these deaths will largely influence this global target. To avoid gross under reporting, few authors have even recommended Government of India to designate and enforce snake bite as “NOTIFIABLE DISEASE” within Integrated Disease. Surveillance Program. More than 2700 species of snakes exist in the world, of which only 450 have front fangs making them capable of injecting venom during bite. India harbors more than 250 species and subspecies, out of which around 50 are venomous. Hence the need for a useful tool to fight the most dreaded complication of snake bite is necessary. Methods: After obtaining approval and clearance from the institutional ethics committee, a study was conducted in the department of emergency medicine in KIMS over a period of 1.5yrs which included 25 patients above the age of 18 years. Each patient with a definitive history of snake bite was admitted, evaluated and considered for forced alkaline diuresis based on the relevant comorbidities. Patient was followed up throughout the stay and renal functions monitored. Patients who failed were taken up for hemodialysis and outcome of the procedure charted. Results: In the study, 20% were <30 years, 40% were 31 to 40 years, 28% were 41 to 50 years, 12% were >50 years. 36% were Female and 64% were Male. At baseline 24% and had metabolic acidosis and 76% had Normal ABG. In the study, HB was 12.97 ± 2.25, TLC was   11271.6 ± 4019.09, Platelets was 2.33 ± 0.99, Neutrophil was 81.94 ± 9.63, Lymphocyte was 18.05 ± 9.81, Monocyte was 4.68 ± 5.35, Basophil was 0.88 ± 2.13 and Eosinophil was 1.44 ± 2.74. In Fang Marks Distribution, 4% had in Left Ankle, 28% had in Left Foot, 4% had in Left Great Toe, 12% had in Left Hand, 4% had in Left Thumb, 4% had in Left Wrist, 8% had in Right Ankle, 8% had in Right Finger, 4% had in Right Foot, 12% had in Right Hand, 8% had in Right Leg and 4% had in Right Toe. Most common site of fang marks was Left Hand and Right Hand (12% respectively). In 2D echo, 8% had LVH and 92% were WNL. In Doppler, 60.0% had No DVT and for 40% doppler was not done. Cellulitis was present in 64%. Cycle 1 FAD was Done in 100.0%, 24.0% in cycle 2, 8.0% in cycle 3. Haemodialysis was done in 4% of subjects. Interpretation & Conclusion:  Forced alkaline diuresis proved to be a good intervention to save patients from developing or worsening AKI. It is a much-needed tool in our country which contributes significantly to snake bite related deaths. It also helps to decide on early intervention with hemodialysis, in case of failure to respond to FAD.