Evaluation of the Role of N Acetyl Cysteine and Vitamin D in Improving Outcomes After Corrosive Ingestion

The current study is a controlled randomized, single-blinded clinical trial, conducted on acutely poisoned patients with confirmed history of corrosive ingestion who were admitted to the Poison Control Center, Ain Shams University Hospitals (PCC-ASUH) The required sample size is 80 patients, 20 patients in each group according to the recommendation of statistics committee (Community Medicine, Environmental, and Occupational Medicine Department - Faculty of Medicine, Ain shams University)

Eighty patients were randomly assigned into four groups (1 control and 3 intervention groups 20 patients each)

Group 1 (Control group):

• Patients allocated in this group received the standard treatment protocol only according to PCC-ASUH guideline This included patient stabilization, maintaining patent airways, oxygen administration and ventilatory support when necessary.

In patients presenting with oral symptoms such as lip edema, excessive drooling (sialorrhea), or oral ulcers, the child was kept NPO to prevent further irritation. Topical treatments including antibiotics, anti-inflammatory agents, and antifungals were applied to manage local infection and inflammation.

Intravenous fluids were started to maintain hydration, with the volume calculated based on the Holliday-Segar method as follows: 100 mL/kg for the first 10 kg of body weight, 50 mL/kg for the next 10 kg, and 20 mL/kg for any weight above 20 kg. Fluid selection depended on the clinical condition where isotonic fluids such as 0.9% saline were often used initially, followed by hypotonic solutions containing dextrose and electrolytes for maintenance to prevent complications like hyponatremia or fluid overload Corticosteroids, especially dexamethasone, were administered when there was severe lip edema or suspected airway swelling to reduce inflammation and to prevent airway compromise. The typical dose used was 0.6 mg/kg, up to a maximum of 10 mg. However, steroids were avoided in children presenting with hematemesis or melena, due to the risk of worsening gastrointestinal bleeding.

In cases with GIT symptoms, supportive care was provided. If vomiting was present, ondansetron was administered at a dose of 4 mg every 8 hours until symptoms were controlled, and then on demand. To treat esophagitis and abdominal discomfort, proton pump inhibitors (PPIs) such as omeprazole were used to reduce acid secretion and promote healing of the mucosa. Omeprazole was given at 0.4-0.8 mg/kg, either every 12 or 24 hours, depending on symptom severity.

For children with signs of upper GI bleeding such as hematemesis or melena, urgent resuscitation was initiated. This included blood transfusion in cases of hemoglobin drop, fresh frozen plasma, IV PPI infusion, and hemostatic agents like tranexamic acid (Kapron), etamsylate (Dicynone), and vitamin K (Konakion). Diagnostic imaging such as chest X-ray, erect and supine abdominal X-rays, and abdominal ultrasound were performed to assess complications like perforation or effusion.

In children with respiratory symptoms, especially those with stridor or laryngeal edema, adrenaline was administered to reduce airway swelling. If chemical pneumonitis was suspected, inhaled bronchodilators (e.g., salbutamol every 4-6 hours), mucolytics like N-acetyl cysteine (NAC) or hypertonic saline every 6 hours, and antibiotics (based on culture and sensitivity) were given. Additionally, IV paracetamol at 10-15 mg/kg every 6 hours was used for fever, pain, and inflammation.

For patients who developed dysphagia and could not tolerate oral or enteral feeding for more than 3-5 days, total parenteral nutrition (TPN) was initiated to prevent malnutrition and support tissue healing. TPN was carefully tailored to the child's age, weight, and clinical status. Fluid needs were typically 100-150 mL/kg/day. Glucose, the main energy source, was started at 6-8 mg/kg/min in neonates (up to 12-14 mg/kg/min as tolerated) and 5-10 mg/kg/min in older children. Amino acids, essential for growth and repair, were given at 2-3 g/kg/day in neonates and 1-2 g/kg/day in older children. Lipids were started early at 1-2 g/kg/day, increasing to 3 g/kg/day if needed, particularly in neonates.

Electrolyte supplementation was guided by lab values: sodium (2-5 mEq/kg/day), potassium (1-3 mEq/kg/day), calcium (50-100 mg/kg/day of elemental calcium), magnesium (0.25-0.5 mEq/kg/day), and phosphate (1-2 mmol/kg/day). Micronutrients were also essential - daily multivitamins were given (e.g.,1 mL/day for infants, 2-5 mL/day for older children), along with trace elements such as zinc (100-400 mcg/kg/day), copper (20 mcg/kg/day), manganese (1 mcg/kg/day), selenium (2 mcg/kg/day), and chromium (0.14-0.2 mcg/kg /day).

Group 2 (NAC group):

• Patients in this group received the standard treatment protocol according to PCC-ASUH guidelines in addition to NAC with loading dose of 150 mg/kg diluted in 200 ml dextrose 5% or saline over 1 hour, followed by a maintenance dose of 50 mg/kg diluted in 500 ml of dextrose 5% or saline over 4 hours then followed by 100 ml/kg diluted in 1000 ml of dextrose 5% or saline over 16 hours

Preparation and administration of NAC were adjusted according to the age of the patient. In those>12 years old, total volume (NAC and IV fluid) for the bolus, 4-hour infusion, and 16 hours infusion was 200 ml, 500 ml, and 1 liter, respectively. In children <12 years but over 20 kg, volumes were 100 ml, 250 ml, and 500 ml, respectively. In those under 20 kg, volumes were 3 ml/kg, 7 ml/kg, and 14 ml/kg, respectively

Group 3 (Vitamin D group):

Patients in this group received the standard treatment protocol according to PCC-ASUH guidelines in addition to vitamin D in a single intramuscular high-dose (300,000 IU) which was given to all patients regardless patient's age

Group 4 (NAC + Vitamin D group):

Patients in this group received the standard treatment protocol according to PCC-ASUH guidelines in addition to both vitamin D and NAC, in the same doses as groups (2 and 3)

Study tools:

Data collection:

A sheet will be constructed for every patient including the following collected data:

(a) History taking:

• Socio-demographic data:
• These include data regarding age, sex, and residence. (b) Intoxication data:
• Type of corrosive substance (acid or alkali).
• Manner of poisoning, whether suicidal, accidental, or criminal.
• Time elapsed between corrosive ingestion and arrival to PCC-ASUH (Delay time).
• Past medical history. (b) Clinical examination
• General examination:
• Vital data including blood pressure, pulse, respiratory rate, and temperature.
• Systemic examination:
• Chest and abdominal examination
• Symptoms (e.g., lip edema, tongue ulcers, vomiting, dysphagia, salivation, and others). (C) Investigations:

1. Laboratory investigations:

Both arterial and venous blood samples will be obtained, under complete aseptic condition, for performing the following investigations on admission, 24 hours, and 48 hours after receiving the treatment.

• Arterial blood gas analysis.
• Random blood glucose.
• Serum electrolytes (sodium and potassium).
• Liver enzymes (ALT and AST).
• Renal function tests (Serum urea and creatinine).
• Complete blood count. The neutrophil to lymphocyte ratio and the platelet to lymphocyte ratio will be calculated by dividing the absolute count of neutrophils and platelets, respectively, over the absolute count of lymphocytes (Siddique et al., 2021).
• C-reactive protein (CRP).

II) Radiological investigations:

• Plain chest and abdominal radiograph will be carried out at the time of admission.
• Barium swallow and meal will be done 21 days after acute corrosive ingestion.