Poisoning of glutaraldehyde-containing products: clinical characteristics and outcomes.

OBJECTIVE: This study describes the clinical characteristics, outcomes, and factors at presentation associated with death of cases poisoned by glutaraldehyde (GA)-containing products. METHODS: We performed a 5-year retrospective cohort study (July 2013-June 2018) using data from the Ramathibodi Poison Center. RESULTS: There were 244 cases included in this study. Most were men with a median age of 37 years. The GA-containing products were mainly used as farm disinfectants (99.2%), with a median concentration of 15%. Most products (76.2%) contained co-formulants such as cationic detergents and formaldehyde.Most circumstances were accidental (56.9%). The others were suicide attempts by ingestion, except one patient who intentionally injected GA subcutaneously. The most common route of exposure was ingestion (95.0%). Local symptoms in areas of exposure were common. Ingestion resulted in more severe local effects than other routes, and corrosive effects occurred in 23 cases (9.4%). Systemic signs and symptoms occurred in 149 patients (61.1%). Systemic effects included abnormal vital signs, desaturation, altered mental status, hypo/hypernatremia, hypokalemia, low bicarbonate/metabolic acidosis, acute kidney injury (AKI), hepatitis, and rhabdomyolysis. Systemic effects mostly resulted from ingestion. Most patients had mild severity, received only supportive treatment, and fully recovered. The median length of hospital stay was 2 days. The one case of subcutaneous injection developed both local and systemic effects but survived. The mortality rate was 3.7%. Multivariate analysis indicated that either neurological symptoms or AKI at presentation were associated with death. CONCLUSIONS: In our study, patients were exposed to GA-containing products that were mainly used as farm disinfectants and were generally co-formulated with other substances. Poisoning with these products commonly resulted in mild local irritative symptoms. However, some cases developed corrosive symptoms, systemic effects, or even died. As neurological symptoms or AKI could prognosticate deaths; physicians should look for these factors in patients with GA exposure at presentation for close monitoring and aggressive treatment.

Web based listing of agents associated with new onset work-related asthma.

BACKGROUND: Work-related asthma is common and yet remains a challenge to diagnose. Access to a listing of agents associated with work-related asthma has been suggested as useful in assisting in the diagnosis. METHODS: The Association of Occupational and Environmental Clinics (AOEC) developed criteria that were used to review the peer-reviewed medical literature published in English. Based on this review, substances were designated either as a sensitizing agent or an irritant. The reviews were conducted by a board certified internist/pulmonologist/occupational medicine specialist from 2002 to 2007 and a board certified internist/occupational medicine physician from 2008- date. All reviews were then reviewed by the nine member AOEC board of directors. RESULTS: The original list of agents associated with new onset work-related asthma was derived from the tables of a text book on work-related asthma. After 13 years of review, there are 327 substances designated as asthma agents on the AOEC list; 173 (52.9%) coded as sensitizers, 35 (10.7%) as generally recognized as an asthma causing agent, four (1.2%) as irritants, two (0.6%) as both a sensitizer and an irritant and 113(34.6%) agents that still need to be reviewed. CONCLUSIONS: The AOEC has developed a readily available web based listing of agents associated with new onset work-related asthma in adults. The listing is based on peer-reviewed criteria. The listing is updated twice a year. Regular review of the peer-reviewed medical literature is conducted to determine whether new substances should be added to the list. Clinicians should find the list useful when considering the diagnosis of work-related asthma.

Adverse staff health outcomes associated with endoscope reprocessing.

There are occupational challenges associated with cleaning, disinfecting, storing, and transporting flexible endoscopes. Although the Occupational Safety and Health Administration (OSHA) has set standards to protect the safety of health workers in the United States, the standards are not specific to endoscope reprocessing, and the general standards that are in place are not fully implemented. Furthermore, adverse staff outcomes may not be fully preventable. To assess the evidence for adverse outcomes in staff associated with endoscope reprocessing, a literature review was performed in the PubMed database for articles on this topic published between Jan. 1, 2007 and March 7, 2012. Eight studies were identified, mainly European, which reported numerous adverse outcomes to healthcare personnel associated with endoscope reprocessing including respiratory ailments and physical discomfort. More scientifically rigorous studies are required to comprehensively describe adverse health outcomes in personnel engaged in reprocessing, particularly in the United States, and examine whether increased automation of the reprocessing process leads to decreased adverse health outcomes for staff.

Laryngeal edema and metabolic acidosis after Omnicide ingestion.

INTRODUCTION: Glutaraldehyde and quaternary ammonium compounds are widely used as disinfectants and sterilizing agents. Glutaraldehyde is irritating to the eyes and upper respiratory tract, and has been associated with occupational asthma. Acute oral ingestion of a concentrated solution has not been previously reported in humans. CASE REPORT: A 19-year-old woman presented after deliberate ingestion of a biocide containing glutaraldehyde and a quaternary ammonium compound. She developed respiratory distress and severe metabolic acidosis 10 hours after admission. Marked laryngeal edema was noted when she was being intubated. She eventually improved following supportive care and was discharged alive after 9 hospital days. DISCUSSION: There are no reports of acute ingestions of both glutaraldehyde and quaternary ammonium compounds. As both these substances are known to cause metabolic acidosis, localized edema, erosion and sensitization of both the respiratory and alimentary tract. The clinical effect may be additive or synergistic. CONCLUSIONS: Omnicide ingestion should be closely monitored for metabolic acidosis and laryngeal edema which may progress to upper airway obstruction requiring urgent airway stabilization.

Considering risks to healthcare workers from glutaraldehyde alternatives in high-level disinfection.

Due to concerns over glutaraldehyde's toxicity, two substitutes have recently been introduced; ortho-phthalaldehyde (OPA), and a mixture of hydrogen peroxide and peracetic acid. There is limited information about the health effects for employees from these products. This study assesses the current practices regarding the use of high-level disinfectants in British Columbian hospitals and predicts the relative toxicities of each product. Industry practices were compiled using a comprehensive survey of current practices and decision processes in all hospitals in British Columbia. Of 95 hospitals, 64 returned surveys; 80% of these used high-level disinfection. Among user hospitals, 49% used glutaraldehyde alone and 51% had introduced alternatives. Concern about staff health was the most common reason for substituting, but this was frequently not considered when choosing specific alternatives. Hospitals that involved occupational health, infection control or regional staff in high-level disinfectant decisions used glutaraldehyde alternatives less often. In most hospitals, it was difficult to find individuals who were knowledgeable about the use of disinfectants. Potential health effects associated with each type of high-level disinfectant were assessed by review of the published literature and available manufacturers' data along with qualitative structure-activity relationship analysis. Results indicated that although all products irritate the skin and respiratory tract, OPA is a potential dermal and respiratory sensitizer but hydrogen peroxide and peracetic acid do not cause allergic reactions. Despite little being known about the risks to employees from glutaraldehyde alternatives, their use is widespread. The potential risks of all high-level disinfectants are serious; thus regulators and users are faced with important risk management decisions before and after they have been introduced into the workplace.

A case report of occupational asthma due to gluteraldehyde exposure.

INTRODUCTION: We report the first case of occupational asthma due to gluteraldehyde exposure in Singapore and also describe the use of a specific inhalational challenge (SIC) test in confirming the diagnosis. CLINICAL PICTURE: A 32-year-old laboratory technician presented with adult-onset asthma 2 years after daily exposure to gluteraldehyde which was used to sterilise the mouthpieces used for lung function testing. SIC testing showed a 25% drop in FEV1 after exposure to gluteraldehyde but not after exposure to a control, thus confirming the diagnosis. TREATMENT: Alternative arrangements were made for sterilisation of the mouthpieces so that gluteraldehyde could be removed from the workplace. There was a marked improvement in her asthmatic control thereafter. CONCLUSIONS: This case illustrates the use of a SIC test in the diagnosis of occupational asthma. Gluteraldehyde is a known cause of occupational asthma and should be kept in mind when evaluating asthmatic patients in at-risk occupations. Effective ventilation and proper storage should be ensured to minimise exposure to gluteraldehyde where its use is necessary.

[Suspected glutaraldehyde poisoning: a case report]. / Sospetta intossicazione da glutaraldeide: case report.

AIMS: To report a case of anxiety, possibly due to glutaraldehyde poisoning in a female anaesthesiologist working in an operating room and exposed to 2% solution of glutaraldehyde, the only chemical used for disinfection of flexible endoscopic instruments. METHODS: A clinical evaluation was made and neurobehavioural functions were explored by sensitive neuropsychological testing: testing included a simple and complex reaction time and examination of the autonomic nervous system. The atmospheric concentration of glutaraldehyde was measured by means of a Brüel & Kjaer Multigas Monitor type 1302 analyzer. RESULTS: Adverse neurobehavioural effects, including headache, loss of attention, dizziness, anxiety, drowsiness on the job, alteration of homeostatic reflexes, were observed, and sensitive neuropsychological testing confirmed neurobehavioural impairment. No blood alterations related to exposure were found. Very high levels of glutaraldehyde were detected in the operating theatre. After ten days away from exposure to glutaraldehyde no symptoms and no behavioral effects on the central and autonomic nervous systems were detectable. CONCLUSIONS: Although conclusions cannot be drawn from a single case, exposure to a high level of glutaraldehyde, subjective symptoms, alteration of neurobehavioural performance, no consumption of CNS medication, no neurological or psychiatric disorders, no coffee consumption and alcohol intake, no exposure to other neurotoxic agents, complete recovery after removal from exposure to glutaraldehyde, are indicative of glutaraldehyde poisoning.

In-vivo glutaraldehyde fixation of the brain stem and spinal cord after inadvertent intrathecal injection.

A 64-year-old diabetic man underwent total maxillectomy with orbital exenteration because of recurrent carcinoma. In order to decrease pressure at the surgical site, 50 mL of cerebrospinal fluid were withdrawn. After the procedure was completed, 5% glutaraldehyde was inadvertently injected into the subarachnoid space instead of reinjection of the original cerebrospinal fluid. The patient suffered hypotension and coma culminating in death five days after the procedure. Postmortem examination revealed exquisite fixation of the outer cortical shell of the spinal cord and brain stem. The mishap occurred because an unlabeled vial was mistaken for the withdrawn cerebrospinal fluid. Graicunas' theory and formula on relationship complexities in organizations is exemplified by this occurrence. One may calculate the theoretical potential for 24,708 miscommunications during such a complex and lengthy surgical procedure. Proper operating room procedures must be developed and followed in order to prevent such tragedies.