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Indian J Crit Care Med. 2017 March; 21(3): 182.
PMCID: PMC5363112

Sophism in the Management of Acute Aluminum Phosphide Poisoning may Cause Patient Harm

Sir,

In December 2016, the Indian Journal of Critical Care Medicine published our review article on the current management of acute aluminum phosphide toxicity, as well as our new proposals for therapy.[1] One month later, in the first issue of 2017, Hassanian-Moghaddam and Zamani raised some concerns in the review.[2] We appreciate their interest in our article and would like to address the concerns.

  • In that review, we referred to a study, that reported conversion of oxyhemoglobin to methemoglobin after incubation of rat erythrocytes with phosphine.[1,3] However, their letter referred to another study that used a co-oximeter to confirm methemoglobinemia and claimed “this could be a dyshemoglobin falsely positive for methemoglobin” and cite two of their previous publications, which were not germane to the issue[2]
  • Interestingly, it seems that the authors seem to emphasize the outdated practice to washout phosphine using water soluble compounds. In fact, gastric ventilation, another approach proposed by the same authors, only assist in emitting phosphine gas produced by their conventional gastric decontamination methods.[2] As we explained in our review, using charcoal, or potassium permanganate, is not efficacious considering their chemical properties.[1,4,5] Another experiment by Sanaei-Zadeh and Marashi recently showed castor oil can effectively protect phosphine liberation from aluminum phosphide pellets[6]
  • We believe that all efforts should be focused on resuscitation of refractory hypotension. Hence, we accept that if the patient's systemic perfusion does not improve using our new proposals, administrating glucose/insulin/potassium could be helpful.

Lastly, we think acute aluminum phosphide poisoning is not an irremediable situation, but sophism in its management may cause patient harm. According to our previous experience, it seems that following the new proposals for therapy can improve survival. However, without a randomized controlled trial, everything is just a “claim.”

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

REFERENCES

1. Farahani MV, Soroosh D, Marashi SM. Thoughts on the current management of acute aluminum phosphide toxicity and proposals for therapy: An evidence-based review. Indian J Crit Care Med. 2016;20:724–30. [PMC free article] [PubMed]
2. Hassanian-Moghaddam H, Zamani N. Re: Thoughts on the current management of acute aluminum phosphide toxicity and proposals for therapy: An evidence-based review. Indian J Crit Care Med. 2017;21:61–2. [PMC free article] [PubMed]
3. Chin KL, Mai X, Meaklim J, Scollary GR, Leaver DD. The interaction of phosphine with haemoglobin and erythrocytes. Xenobiotica. 1992;22:599–607. [PubMed]
4. Nasri Nasrabadi Z, Marashi SM. Comments on “A systematic review of aluminium phosphide poisoning” Arh Hig Rada Toksikol. 2012;63:551. [PubMed]
5. Marashi SM, Majidi M, Raji Asadabadi H, Nasri-Nasrabadi Z. A common misconception in the management of aluminium phosphide poisoning. Arh Hig Rada Toksikol. 2013;64:475–6. [PubMed]
6. Sanaei-Zadeh H, Marashi SM. Gastric decontamination in aluminium phosphide poisoning: A case against the use of water-based solutions. Arh Hig Rada Toksikol. 2016;67:364–5. [PubMed]

Articles from Indian Journal of Critical Care Medicine : Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine are provided here courtesy of Wolters Kluwer -- Medknow Publications