A randomized controlled trial of fresh frozen plasma for treating venom-induced consumption coagulopathy in cases of Australian snakebite (ASP-18)

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Abstract

Background

Venom-induced consumption coagulopathy (VICC) is a major effect of snake envenoming.

Objectives

To investigate whether fresh frozen plasma (FFP) given after antivenom resulted in more rapid correction of coagulation.

Patients/Methods

This was a multicenter open-label randomized controlled trial in patients with VICC of FFP vs. no FFP within 4 h of antivenom administration. Patients (> 2 years) recruited to the Australian snakebite project with VICC (International Normalized Ratio [INR] > 3) were eligible. Patients were randomized 2 : 1 to receive FFP or no FFP. The primary outcome was the proportion with an INR of < 2 at 6 h after antivenom administration. Secondary outcomes included time from antivenom administration to discharge, adverse effects, major hemorrhage, and death.

Results

Of 70 eligible patients, 65 consented to be randomized: 41 to FFP, and 24 to no FFP. Six hours after antivenom administration, more patients randomized to FFP had an INR of < 2 (30/41 [73%] vs. 6/24 [25%]; absolute difference, 48%; 95% confidence interval 23–73%; P = 0.0002). The median time from antivenom administration to discharge was similar (34 h, range 14–230 h vs. 39 h, range 14–321 h; P = 0.44). Seven patients developed systemic hypersensitivity reactions after antivenom administration – two mild and one severe (FFP arm), and three mild and one severe (no FFP). One serious adverse event (intracranial hemorrhage and death) occurred in an FFP patient with pre-existing hypertension, who was hypertensive on admission, and developed a headache 6 h after FFP administration. Post hoc analysis showed that the median time from bite to FFP administration was significantly shorter for non-responders to FFP than for responders (4.7 h, interquartile range [IQR] 4.2–6.7 h vs. 7.3 h, IQR 6.1–8 h; P = 0.002).

Conclusions

FFP administration after antivenom administration results in more rapid restoration of clotting function in most patients, but no decrease in discharge time. Early FFP administration (< 6–8 h) post-bite is less likely to be effective.

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