Cyanide toxicity following nitroprusside induced hypotension

Cyanogenic glycoside amygdalin influences functions of human osteoblasts in vitro

Amygdalin has been promoted as an alternative cancer cure. However, it is still unclear how this cyanogenic glycoside affects non-cancer cells including bone cells. This study first investigated the impact of amygdalin on viability, morphology and expression of important genes in human osteoblasts in vitro. Primary human osteoblast cultures were exposed to amygdalin at concentrations 0; 0.1; 1 and 10 mg/mL in growth medium for 72 h. Cell viability, osteoblasts morphology and expression of 10 genes associated with osteoblast-specific pathways, oxidative stress and cell death were determined. Osteoblasts viability was significantly decreased (-27.26%) and their size was reduced (-23.20%) at the highest concentration of amygdalin (10 mg/mL). This concentration of amygdalin down-regulated the expression of COL1A1 and ALPL genes, whereas the expression of BGLAP, TNFSF11 and WNT5A genes was increased. The osteoblast cultivation with 0.1 mg/mL amygdalin caused down-regulation of COL1A1 gene. No changes in expression were determined for RUNX2, BAX, CASP1, SOD1 and GPX1 genes among all tested concentrations of amygdalin. In conclusion, amygdalin in a high concentration negatively affected mineralization of extracellular matrix, increased bone resorption and decreased osteoblast viability. These changes were accompanied by modified expression profiles of responsible genes.

Past, present and future of cyanide antagonism research: From the early remedies to the current therapies

This paper reviews milestones in antidotal therapies for cyanide (CN) spanning early remedies, current antidotal systems and research towards next generation therapies. CN has been a part of plant defense mechanisms for millions of years. It became industrially important in the nineteenth century with the advent of CN assisted gold mining and the use of CN as a pest control agent. The biochemical basis of CN poisoning was actively studied and key mechanisms were understood as early as 1929. These fundamental studies led to a variety of antidotes, including indirect CN binders that generate methemoglobin, direct CN binders such as hydroxocobalamin, and sulfur donors that convert CN to the less toxic thiocyanate. Research on blood gases at the end of the twentieth century shed new light on the role of nitric oxide (NO) in the body. The discovery of NO’s ability to compete with CN for enzymatic binding sites provided a previously missed explanation for the rapid efficacy of NO generating antidotes such as the nitrites. Presently used CN therapies include: methemoglobin/NO generators (e.g., sodium nitrite, amyl nitrite, and dimethyl aminophenol), sulfur donors (e.g., sodium thiosulfate and glutathione), and direct binding agents [(e.g., hydroxocobalamin and dicobalt salt of ethylenediaminetetraacetic acid (dicobalt edetate)]. A strong effort is being made to explore novel antidotal systems and to formulate them for rapid administration at the point of intoxication in mass casualty scenarios. New antidotes, formulations, and delivery systems are enhancing bioavailability and efficacy and hold promise for a new generation of improved CN countermeasures.

Dosing-time dependent effects of sodium nitroprusside on cerebral, renal, and hepatic catalase activity in mice

To investigate the time dependence of sodium nitroprusside- (NPS-) induced oxidative effects, the authors study the variation of the antioxidant enzyme CAT activity in various tissues after the administration of a single 2.5 mg/kg dose of SNP or sodium chloride (NaCl 0.9%). For each of the two dosing times (1 and 13 hours after light onset, HALO, which correspond to the beginning of diurnal rest span and of nocturnal activity span of mice, resp.), brain, kidney, and liver tissues were excised from animals at 0, 1, 3, 6, 9, 12, 24, and 36 h following the drug administration and CAT activity was assayed. The results suggest that SNP-induced stimulation of CAT activity is greater in all three tissues when the drug is administered at 1 HALO than at 13 HALO. Two-way ANOVA revealed that CAT activity significantly (P < 0.004) varied as a function of the sampling time but not of the treatment in all three tissues. Moreover, a statistically significant (P < 0.004) interaction between the organ sampling-time and the SNP treatment was revealed in kidney regardless of the dosing time, whereas a highly significant (P < 0.0002) interaction was validated in liver only in animals injected at 13 HALO.

Cyanide poisoning in the post-transplantation patient-a cautionary tale

There have been few reported cases of cyanide toxicity following treatment with sodium nitroprusside. We report on the case of a paediatric patient who had received sodium nitroprusside for intractable hypertension in the post-operative period, resulting in cyanide toxicity. Treatment with sodium thiosulphate, sodium nitrate and haemodialysis resulted in the elimination of cyanide from the circulation. The patient made a full recovery with no neurological sequelae.

Effect of combined exposure to carbon monoxide and cyanides in selected forensic cases

Carbon monoxide is a toxic gas with potentially lethal action, which forms as a result of incomplete combustion in conditions where there is a lack of oxygen and which, therefore, is present in varying percentages in environments where fire develops. In addition to carbon monoxide, other factors such as cyanide may contribute or might actually be the primary cause of a subject's demise. In cases of exposure to both substances, the role of cyanide as a toxic/lethal agent in death by asphyxiation is still not clear: some authors attribute a primary action to such a gas in causing the demise, others consider carbon monoxide to be the only cause of the lethal event. For this reason it is in the interest of forensic medicine to study all lethal cases of exposure to toxic substances originating from fires of various types of materials, in order to determine information regarding kinetic action and the possible strengthening of the effect of the two substances. Two case studies are presented here, in which the results of the toxicological examinations are quite different, and the contributions of CO and HCN in a fire asphyxiation are considered.

Cyanide toxicity from sodium nitroprusside: risks and management

OBJECTIVE

To review the risks, manifestations, and treatment of cyanide toxicity from nitroprusside therapy.

DATA SOURCES

All English case reports identified in Index Medicus (MEDLINE) of cyanide intoxication related to nitroprusside from 1970 to the present were reviewed. In addition, literature regarding the incidence, risks, and treatment of cyanide toxicity from nitroprusside is presented.

CONCLUSIONS

Numerous cases of cyanide toxicity associated with nitroprusside have been reported. The overall incidence appears to be infrequent; however, certain patients may be at high risk. Risk factors may include hypoalbuminemia, cardiopulmonary bypass procedures, or the administration of moderate to high doses of nitroprusside. Treatment of cyanide toxicity requires the cessation of nitroprusside and, for severe toxicity, use of the cyanide antidote kit. Cyanide toxicity from nitroprusside may be prevented by concomitant administration of sodium thiosulfate infusions.

Lactic acidosis

An understanding of the pathophysiology of lactic acidosis is crucial in facilitating the optimal care of critically ill patients. The relevant biochemistry of lactic acidosis is reviewed, and the more controversial aspects relating to the genesis of the acidosis are highlighted. The current system of classification of lactic acidosis divides etiologies on the basis of the presence or absence of clinical signs of tissue hypoperfusion. Several types of lactic acidosis in which clinical evidence of tissue hypoperfusion is lacking demonstrate hemodynamic evidence of occult hypoperfusion. The diagnostic and therapeutic implications of this observation are discussed. Current diagnostic criteria for lactic acidosis include a pH less than 7.35 and blood lactate concentration greater than 5 to 6 mM/L. An important issue relates to the implications of lactate values that are greater than normal but below this diagnostic range. The use of the oxygen flux test may be valuable in the diagnosis of occult tissue hypoperfusion in patients with low-grade elevations in lactate levels. The current therapy for lactic acidosis involves addressing the primary cause and supportive management. The use of bicarbonate in the therapy for lactic acidosis is controversial due to potential adverse effects on cardiac function. The specifics of this controversy are outlined, and newer therapeutic alternatives are reviewed. The use of blood lactate concentration as a prognostic index may be more useful in patients with shock than without shock.

Drug and chemical-induced metabolic acidosis

Metabolic acidosis produced by drugs and/or chemicals can be conveniently divided into those with an increase in the anion gap (anion gap = Na- (Cl + HCO3)) and those with a normal anion gap. The increase in the anion gap is due to the accumulation of unmeasured organic anions, such as lactate or acetoacetate and beta-hydroxybutyrate, as occurs in ketoacidosis and lactic acidosis, or the accumulation of toxic anions such as formate or glycolate, as occurs with the ingestion of methanol or ethylene glycol. Increased concentrations of lactic acid may also be present in the toxic forms of metabolic acidosis. The most common drugs and chemicals that induce the anion gap type of acidosis are biguanides, alcohols, polyhydric sugars, salicylates, cyanide and carbon monoxide. In normal anion gap acidosis the reduction in bicarbonate is balanced by a reciprocal increase in the chloride concentration so that the sum of the two remains unchanged. Normal anion gap acidosis is caused by carbonic anhydrase inhibitors, hydrochloride salts of amino acids, toluene, amphotericin, spironolactone and non-steroidal anti-inflammatory drugs. The mechanism by which these substances produce metabolic acidosis and the therapy are discussed.

Cyanide toxicity of sodium nitroprusside in therapeutic use with and without sodium thiosulphate

Sodium nitroprusside (SNP) as a mono-infusion was administered to 51 patients for periods of a few hours. A further group of 19 patients received SNP for periods of several days as a combination solution of SNP mixed with sodium thiosulphate. The concentrations of cyanide and of thiocyanate in the blood of all patients were measured. In seven of the patients the level of thiosulphate was also measured. Infusion of SNP on its own at levels exceeding 2 microgram/kg/min led to the rising of cyanide levels in the blood being proportional to dosage. Infusion of SNP mixed with thiosulphate showed no such accumulation of cyanide in any patient, irrespective of dosage level and duration. The efficacy at lowering blood pressure was fully maintained in the mixed infusion. The elimination half-life for thiosulphate was 16.5 min. Pharmacokinetic calculation of the rise in cyanide level showed that mono-infusions of 5-10 micrograms SNP/kg/min could within 5-10 h cause a life-threatening cyanide level in the blood. By contrast, mixed infusion of SNP together with thiosulphate, for which light-opaque syringes and tubing must be used, is a procedure free of danger and should become the technique of choice when therapeutically administering SNP in order to lower blood pressure.

Combined antidotal and hemodialysis treatments for nitroprusside-induced cyanide toxicity

A case report is presented for a patient with nitroprusside-induced cyanide intoxication. The patient received approximately 1 g sodium nitroprusside through an intravenous infusion of the drug over 6 d. The toxicity was treated with antidotes, sodium nitrite and sodium thiosulfate, followed by hemodialysis. Hemodialysis significantly removed thiocyanate but not cyanide from the patient's extracorporeal circulation. The removal of thiocyanate by hemodialysis enhanced the liberation of cyanide from the cytochrome oxidase. Hemodialysis is a significant addition to the therapy of cyanide toxicity, particularly for intoxicated patient with reduced renal function

Blood carboxyhaemoglobin and cyanide levels in fire survivors

Blood carboxyhaemoglobin and cyanide concentrations were measured in 53 fire survivors, 36 of whom had clinical evidence of smoke inhalation. Carboxyhaemoglobin and cyanide levels were raised only in patients with smoke inhalation. Blood carboxyhaemoglobin measurement can be used to confirm the diagnosis of severe smoke inhalation in cases in which the clinical data are inconclusive, provided that the time of sampling after exposure is taken into account. A nomogram has been constructed for this purpose. There is no quick method of measuring blood cyanide levels, but the close relation between cyanide and carboxyhaemoglobin levels suggests that carboxyhaemoglobin concentrations, which can be rapidly and easily measured, could be used to identify those who might benefit from treatment with cyanide antidotes.

Cyanide poisoning

In recent years, the increasing use of laetrile has been added to the traditional sources of exposure to cyanide in industry, chemistry labs, and fumigation. The events in Jonestown in 1978 were a grim reminder of the lethality of cyanide. Nonetheless, advancement in new modes of treatment has been slow. The traditional method of treatment used in the United States is effective, but not without its own morbidity and mortality. Using two case reports as models, we review here the topic of cyanide poisoning including sources of exposure, pathophysiology, clinical manifestations of both acute and chronic exposure, and modes of treatment. Although there is currently no accepted alternate treatment in this country, review of the literature shows promise in other modalities being investigated in Europe, including hydroxocobalamin, cobalt salts, and particularly aminophenols.

[Blood and urinary cyanide concentrations during long-term sodium nitroprusside perfusion]

Five deeply comatose neurological patients were administered a continuous perfusion of sodium nitroprusside (SNP) at the rate of 3 microgram.kg-1.min-1. The levels of blood cyanide (CN-) were measured two hours after the start, then every 12 hours during, and 12 and 24 hours after the end of perfusion. The urinary output of CN- was also studied. The results show that total blood CN- stabilized after 36 hours to a mean value of 0.11 mg/l. When perfusion was stopped, CN- blood levels dropped but did not reach pre-perfusion values at the 24th hour. Urinary excretion of CN- which reached a maximum value of 0.050 mg/24 h represents a negligible amount and does not explain the fall of blood CN- and the occurrence of a concentration plateau. The results showing lower values obtained on non-anesthetized patients during the first hours of perfusion compared to those of a previous study done under neuroleptanaesthesia are discussed. These results suggest that prolonged perfusions at SNP at the rate of 0.177 mg.kg-1.h-1 do not produce toxic blood level of CN-.