A Prospective Controlled Study Comparing the Three PACU Discharge Criteria: Aldrete, White and Sampe in Patients Undergoing Surgical Procedures After General Anaesthesia

e-ISSN: 0976-822X, p-ISSN:2961-6042 Available online on http://www.ijcpr.com/ International Journal of Current Pharmaceutical Review and Research 2025; 17(8); 768-774 Bodhe et al. International Journal of Current Pharmaceutical Review and Research 768 Original Research Article Clinical Profile of Paraquat Poisoning Patient in a Tertiary Care Hospital in Northeast India: A Prospective Observational Study Shubham Ashok Bodhe1, Gourab Das2, Shrirao Mayur Vilasrao3, Debadrita Das4, Rajesh Kishore Debbarma5 1Senior Resident Doctor, M.D. General Medicine, Department of General Medicine, Agartala Government Medical College & Govind Ballabh Pant Hospital, Agartala, Tripura 799006 2Senior Resident Doctor, M.D. General Medicine, Department of General Medicine, Agartala Government Medical College & Govind Ballabh Pant Hospital, Agartala, Tripura 799006 3Postgraduate Trainee Doctor, M.D. General Medicine, Department of General Medicine, Agartala Government Medical College & Govind Ballabh Pant Hospital, Agartala, Tripura 799006 4Post Graduate Trainee Doctor, M.D. General Medicine, Department of General Medicine, Agartala Government Medical College & Govind Ballabh Pant Hospital, Agartala, Tripura 799006 5Professor, M.D. General Medicine, Department of General Medicine, Agartala Government Medical College & Govind Ballabh Pant Hospital, Agartala, Tripura 799006 Received: 01-07-2025 / Revised: 16-07-2025 / Accepted: 13-08-2025 Corresponding Author: Dr. Gourab Das Conflict of interest: Nil Abstract Introduction: Paraquat, a widely used herbicide in India, is associated with high mortality due to its severe toxicity and lack of a specific antidote. Northeast India, being agriculturally intensive, frequently encounters cases of paraquat poisoning, often due to intentional ingestion. However, there is limited regional data describing the clinical profile and outcomes of such cases. Objective: To study the clinical presentation, demographic characteristics, laboratory abnormalities, complications, and outcomes of patients with paraquat poisoning admitted to a tertiary care hospital in Northeast India. Methods: This prospective observational study was conducted over 18 months from January, 2024 to June, 2025 at the Department of Medicine in a tertiary care hospital in Northeast India. All patients with a confirmed history of paraquat ingestion and positive urine dithionite test were included. Demographic data, amount of paraquat consumed, time to presentation, clinical signs and symptoms, laboratory parameters (including renal, hepatic, and respiratory functions), and treatment outcomes were recorded. Patients were followed up until discharge or death. Descriptive statistics and relevant analytical tests were applied using SPSS. Results: This prospective study on paraquat poisoning patients at a tertiary care hospital in Northeast India revealed that the majority were young adults aged 21–30 years (42.1%), predominantly from rural areas (72.4%) and engaged in farming (39.4%). Most had formal education (up to class X) and were from non-tribal communities, with a significant proportion reporting suicidal intent (36.8%) and a history of psychiatric illness (26.3%). The quantity of poison consumed was mostly between 21–30 ml (36.9%), with clinical manifestations including vomiting (92.1%), oral ulceration (84.2%), swallowing difficulty (81.6%), and respiratory symptoms. Vital signs often showed tachycardia, tachypnea, hypoxia, and blood pressure abnormalities. Organ dysfunction was frequent, notably acute liver injury (73.7%), acute kidney injury (71.1%), ARDS (47.4%), and lung fibrosis (36.8%). Hematological findings revealed normal mean hemoglobin (12.8 ± 1.9 gm/dL) and elevated WBC in 43% of cases. Hospital stay was prolonged in many, with 27.6% requiring more than 30 days of admission, reflecting the severity and systemic impact of paraquat poisoning. Conclusion: Paraquat poisoning remains a significant health concern in Northeast India with high mortality, especially among young adults. Early diagnosis, aggressive supportive care, and awareness among the rural population regarding its lethality are crucial to reduce fatal outcomes. Regional policies regulating its sale and usage are urgently warranted. Keywords: Paraquat poisoning, herbicide toxicity, Northeast India, pulmonary fibrosis, renal failure, prospective observational study. This is an Open Access article that uses a funding model which does not charge readers or their institutions for access and distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0) and the Budapest Open Access Initiative (http://www.budapestopenaccessinitiative.org/read), which permit unrestricted use, distribution, and reproduction in any medium, provided original work is properly credited. International Journal of Current Pharmaceutical Review and Research e-ISSN: 0976-822X, p-ISSN: 2961-6042 Bodhe et al. International Journal of Current Pharmaceutical Review and Research 769 Introduction Paraquat (methyl viologen dichloride) is a potent bipyridilium herbicide widely used across agricultural regions of India. Despite bans in over 70 countries, including Odisha since 2023 and Kerala intermittently, it remains easily accessible and inexpensive, posing a serious public health threat due to its extreme toxicity and absence of a specific antidote [1]. The minimum lethal dose is approximately 5 ml, making even small exposures potentially fatal. Clinically, paraquat poisoning presents initially with non‑specific symptoms such as vomiting, abdominal pain, and oral ulceration. However, progressive organ damage—particularly acute kidney injury (AKI), hepatic dysfunction, pulmonary involvement including acute respiratory distress syndrome (ARDS) and eventual lung fibrosis—is common, often culminating in multiorgan dysfunction and death within days to weeks [2]. Several Indian tertiary centres have documented mortality rates exceeding 70% in paraquat ingestion cases [3]. Despite this high burden, epidemiological data from India remain limited to small series, case reports, and retrospective reviews, particularly from southern and central India. A study from Chennai over a three‑year period reported 10 ICU cases, all suicidal in nature, with 80% developing AKI and 100% mortality despite supportive therapies such as steroids, cyclophosphamide, and dialysis. Similarly, a larger retrospective analysis of 55 hospitalised patients from South India recorded a 72.7% in‑hospital mortality with AKI being the predominant organ dysfunction [4]. Another multicentre investigation in Hyderabad reviewed 60 cases of severe AKI requiring nephrology care; 68% died, and survival was influenced by the amount consumed and referral latency [5]. More recently, a prospective cohort from a tertiary care center in northern Karnataka involving 110 subjects found that mortality remained high (≈72%) despite early gastric lavage, intravenous fluids, methylprednisolone, and N‑acetylcysteine administration. Pulmonary fibrosis, tachycardia, tachypnea, and oral ulcers were commonly observed [6]. A 2024 critical‑care series from Delhi region noted that early haemoperfusion was associated with improved outcome (36% survival among those treated), highlighting the importance of early intervention; metabolic acidosis, renal impairment and hepatic dysfunction correlated significantly with mortality [7]. Paraquat’s clinical significance is magnified by diagnostic delays and mismanagement. In many cases, patients present late—often more than 24 hours post ingestion—and initial management may misclassify paraquat as organophosphorus poisoning, leading to inappropriate treatment such as atropine, pralidoxime or oxygen therapy, which can worsen oxidative injury [8]. A case report from northern India described a young male initially treated for influenza and diphtheria before the diagnosis of paraquat poisoning was made, ultimately succumbing to pulmonary and renal failure after a prolonged clinical course [9]. Misdiagnosis not only delays targeted supportive care but also increases morbidity and mortality. Given these severe clinical outcomes and diagnostic challenges, there is a pressing need for prospective, region‑specific studies. Most available data are retrospective and from southern India; little is known about paraquat poisoning profiles and outcomes in northeastern states where agriculture is prevalent and regulatory oversight may be weaker. Moreover, the impact of early therapeutic interventions—such as haemoperfusion, dialysis, immunosuppression and antioxidant therapy—on survival in real‑world settings is inadequately described. There is also limited data on psychosocial and behavioral determinants of paraquat ingestion in this context. Studies from Sri Lanka and South India suggest that impulsive self‑harm, alcohol abuse, and familial conflict are predominant causes, often among younger individuals (mean age <30 years), with minimal prior psychiatric consultation [10]. However, such behavioural profiles have not been systematically assessed in the northeast Indian setting. Therefore, this prospective observational study was conducted in a tertiary care hospital in northeastern India with the following objectives: to describe the sociodemographic and behavioural profile, clinical presentation, laboratory parameters, management strategies, and outcomes including mortality and length of hospital stay among patients with paraquat poisoning. We also aimed to evaluate factors influencing prognosis, such as amount ingested, time to presentation, presence of metabolic acidosis or organ dysfunction, and use of interventions like haemoperfusion or renal replacement therapy.By focusing on northeastern India—a region underrepresented in prior literature—this study seeks to fill critical knowledge gaps and provide region‑tailored evidence to guide clinical care, public health policy, and preventive measures regarding paraquat poisoning. Materials and Methods Study Design: Cross sectional study. Study Type: Descriptive Duration of the Study International Journal of Current Pharmaceutical Review and Research e-ISSN: 0976-822X, p-ISSN: 2961-6042 Bodhe et al. International Journal of Current Pharmaceutical Review and Research 770 This study will be completed within 1 and ½ year [one year for data collection and 6 months for data management] from January 2024 to June 2025 in AGMC & GBPH Hospital included in the study. Sample Size: Total 76 patients admitted with paraquat poisoning in GB hospital during study period were enrolled in the study. Study Variables • Age • Religion • Dwellings / Address • Educational Level • Ethnicity • Occupation • Marital status Inclusion Criteria: Patients admitted with history of ingestion of paraquat poisoning. Exclusion Criteria: Patient who consumed another poison with paraquat. Statistical Analysis: All data recorded in the Performa designed specifically for this study (Appendix). Descriptive statistics used to summarize the demographic characteristics, clinical features and outcome of the cases. The t-test is used to investigate the differences of continuous variables between survivors and nonsurvivors. The relationship between categorical variables and outcome is evaluated using chi square test. Data recorded, entered and analyzed with computer using SPSS version 25.0. P value of less than 0.05 is considered as statistically significant. Result Table 1: Sociodemographic Characteristics of the Study Population (N = 76) Sociodemographic Characteristics Frequency (%) P Value Age group ≤ 20 years 19 (25.0) <0.0001 21 – 30 years 32 (42.1) 31 – 40 years 21 (27.6) 40 years & above 4 (5.3) Religion: Hinduism 62 (81.6) <0.0001 Islamic 14 (18.4) Dwellings / Address: Rural 55 (72.4) <0.0001 Urban 21 (27.6) Educational Level: Upto Class V 24 (31.6) 0.0004 Upto class X 34 (44.7) Upto class XII 14 (18.5) Ethnicity: Tribal 20 (26.3) <0.0001 Non-tribal 56 (73.7) Occupation: Farmer 30 (39.4) <0.0001 Self employed 20 (26.3) Unemmployed 18 (23.6) Student 8(10.5) Marital status: Married 42 (55.3) <0.0001 Unmarried 28 (36.8) Widow/er 6 (7.9) Table 2: Clinical Profile and Poison Characteristics of the Study Population (N = 76) Clinical Profile and Poison Characteristics Frequency (N%) P Value Amount of poison consumed Upto 10 ml 20 (26.3) <0.0001 11-20 ml 22 (28.9) 21-30 ml 28 (36.9) Above 30 ml 6 (7.9) Vital parameters Pulse rate – high 46 (60.5) <0.0001 Altered blood pressure 18 (23.7) Respiratory rate increased 48 (63.2) Hypoxia 36 (47.4) Organ dysfunction or organ injuries Acute kidney injury 54 (71.1) <0.0001 Acute liver injury 56 (73.7) Acute Pancreatitis 24 (31.6) Acute respiratory distress syndrome 36(47.4) Lung fibrosis 28 (36.8) International Journal of Current Pharmaceutical Review and Research e-ISSN: 0976-822X, p-ISSN: 2961-6042 Bodhe et al. International Journal of Current Pharmaceutical Review and Research 771 Table 3: Clinical Features and Comorbidities Among Poisoning Cases (N = 76) Clinical Features and Comorbidities Frequency (%) Clinical features Vomiting 70 (92.1) Edematous lips 26 (34.2) Oral mucosal ulceration 64 (84.2) Swallowing difficulty 62 (81.6) Speech difficulty 54 (71.1) Breathing difficulty 52 (68.4) Pain abdomen 58 (76.3) Oliguria 40 (52.6) Blood in vomitus 36 (47.4) Semiconsciousness 8 (10.5) Comorbidities Hypertension 10 (13.2) Hypotension 8 (10.5) Diabetes mellitus 6 (7.9) Suicidal attempt 28 (36.8) Diagnosed psychiatric illness 20 (26.3) Table 4: Laboratory and Hematological Parameters of the Study Population Laboratory and Hematological Parameters Mean, SD / Frequency (%) Laboratory findings Hemoglobin: (N=71) 12.8 ± 1.9 gm/dl Hb ≥ 12.0 gm/dl 55 (77.5) Hb 10.0-11.9 gm/dl 8 (11.2) Hb 7.0-9.9 gm/dl 8 (11.2) Hematological parameters Platelet count (N = 72) 3.06 ± 0.8 lakh / mcL White blood cell count (N=72) 10782 ± 4046 / mcL High WBC (> 11000/mcL) 31 (43.0) Table 5: Duration of Hospital Stay Among Patients (N = 76) Duration of hospital stay in days Frequency (%) Only 24 hours or 1 day 4 (5.3) 2 - 5 days 12 (15.8) 6 – 10 days 8 (10.5) 11 – 20 days 19 (25.0) 2130 days 12 (15.8) More than 30 days 21 (27.6) Figure 1: Clinical Profile and Poison Characteristics of the Study Population (N = 76) International Journal of Current Pharmaceutical Review and Research e-ISSN: 0976-822X, p-ISSN: 2961-6042 Bodhe et al. International Journal of Current Pharmaceutical Review and Research 772 Figure 2: Clinical Features and Comorbidities Among Poisoning Cases (N = 76) The study population predominantly comprised individuals aged between 21–30 years, accounting for 42.1%, followed by 27.6% in the 31–40 age group and 25.0% aged ≤20 years. Only 5.3% were aged above 40 years, with a statistically significant distribution across age groups (p < 0.0001). The majority of participants were followers of Hinduism (81.6%), while 18.4% identified as Islamic (p < 0.0001). Most respondents resided in rural areas (72.4%), with 27.6% living in urban settings (p < 0.0001). In terms of education, 44.7% had studied up to class X, 31.6% up to class V, and 18.5% up to class XII, showing a significant association with educational level (p = 0.0004). Regarding ethnicity, 73.7% of participants were non-tribal and 26.3% were tribal (p < 0.0001). The most common occupation was farming (39.4%), followed by selfemployment (26.3%), unemployment (23.6%), and students (10.5%) (p < 0.0001). In terms of marital status, 55.3% were married, 36.8% unmarried, and 7.9% were widowed, also showing a statistically significant difference (p < 0.0001). The quantity of poison consumed varied, with the majority (36.9%) ingesting 21–30 ml, followed by 28.9% who consumed 11–20 ml, and 26.3% who consumed up to 10 ml. A smaller proportion (7.9%) ingested more than 30 ml of poison. This distribution was statistically significant (p < 0.0001), suggesting a dose-related impact. Among vital parameters, a high pulse rate was observed in 60.5% of patients, increased respiratory rate in 63.2%, hypoxia in 47.4%, and altered blood pressure in 23.7% of cases—all statistically significant findings (p < 0.0001), reflecting the systemic impact of poisoning. Organ dysfunction was prevalent in this cohort. Acute liver injury was the most common, seen in 73.7%, followed closely by acute kidney injury (71.1%). Acute respiratory distress syndrome (ARDS) occurred in 47.4%, lung fibrosis in 36.8%, and acute pancreatitis in 31.6% of patients, all showing statistically significant occurrence rates (p < 0.0001). The most frequently reported clinical feature was vomiting, observed in 92.1% of cases. Other common symptoms included oral mucosal ulceration (84.2%), swallowing difficulty (81.6%), pain abdomen (76.3%), and speech difficulty (71.1%). Breathing difficulty was noted in 68.4% of patients, followed by edematous lips (34.2%). Blood in vomitus was present in 47.4%, oliguria in 52.6%, and semiconsciousness in 10.5% of cases, reflecting the severity and systemic nature of the poisoning. Regarding comorbid conditions, 13.2% had hypertension, 10.5% had hypotension, and 7.9% had diabetes mellitus. Notably, 36.8% of the patients had a history of suicidal intent, and 26.3% had a previously diagnosed psychiatric illness. The mean hemoglobin level among the 71 participants tested was 12.8 ± 1.9 gm/dL. Most patients (77.5%) had hemoglobin levels ≥12.0 gm/dL, while 11.2% each had values in the range of 10.0–11.9 gm/dL and 7.0–9.9 gm/dL, indicating that a minority exhibited mild to moderate anemia. Regarding hematological parameters, the mean platelet count was 3.06 ± 0.8 lakh/mcL, and the mean white blood cell (WBC) count was 10,782 ± 4046/mcL. Elevated WBC count (>11,000/mcL) was observed in 43.0% of cases (n = 31). The duration of hospital stay varied widely among the patients. A small proportion (5.3%) were discharged within 24 hours, while 15.8% stayed for 2–5 days. Another 10.5% remained hospitalized for 6–10 days. A significant number of patients required extended hospitalization, with 25.0% staying for 11– 20 days, 15.8% for 21–30 days, and notably, 27.6% of patients requiring hospitalization for more than 30 days. International Journal of Current Pharmaceutical Review and Research e-ISSN: 0976-822X, p-ISSN: 2961-6042 Bodhe et al. International Journal of Current Pharmaceutical Review and Research 773 Discussion The demographic distribution observed in this study aligns with similar findings across India. The highest incidence of poisoning occurred among individuals aged 21–30 years (42.1%), followed by the 31–40year group (27.6%). This trend was consistent with Sharma et al. and Aher et al., who also found the majority of cases in young adults, reflecting increased exposure to stress, occupational risks, and psychosocial vulnerability in this age group [11]. A predominance of rural residency (72.4%) and farming as the leading occupation (39.4%) correspond with earlier reports from Northeast and Central India, where rural agricultural workers were more prone to pesticide exposure due to easy access and lack of regulatory enforcement [12]. The amount of poison ingested was mostly in the 21–30 ml range (36.9%), with a statistically significant dose–response impact on clinical severity. Comparable dose-related toxicity and systemic effects have been documented in previous regional studies, particularly with paraquat and organophosphate poisoning [13]. Vomiting (92.1%) was the most commonly observed symptom, followed by oral ulceration, swallowing and breathing difficulties, and abdominal pain—findings that mirror studies conducted in similar hospitalbased cohorts dealing with corrosive or pesticide ingestion [14]. The high frequency of gastrointestinal and respiratory symptoms underscores the corrosive and systemic nature of the ingested substances. Organ dysfunction was prominent in the cohort, with acute liver injury (73.7%) and kidney injury (71.1%) being the most common. Additionally, ARDS (47.4%), lung fibrosis (36.8%), and pancreatitis (31.6%) were frequently reported. These rates are higher than those in previous ICU-based studies, where renal and hepatic complications were present in fewer patients—possibly due to differences in poison type and access to early interventions [15]. The hematological findings were broadly in line with those from previous studies. The mean hemoglobin was 12.8 ± 1.9 g/dL, with most patients having values within normal range. Elevated WBC counts (>11,000/mcL) were found in 43%, consistent with inflammatory responses described in studies of organophosphate and other systemic poisons [16]. Psychosocial factors played a notable role, with 36.8% of patients having attempted suicide and 26.3% having diagnosed psychiatric illness. These findings corroborate the conclusions of toxicological surveillance studies emphasizing the rising burden of self-harm among young adults in India [17,18]. Interestingly, 27.6% of patients required hospitalization beyond 30 days, far exceeding durations reported in other studies, where median hospital stays typically ranged between 2–7 days [19,20]. This extended hospital course likely reflects the severity of poisoning, complications like organ failure, and delayed presentations, all of which contribute to prolonged recovery times. Conclusion Paraquat poisoning remains a significant public health challenge in India, particularly in agrarian and underserved regions such as Northeast India. This study highlights the predominantly young, rural population affected, with ingestion often linked to suicidal intent. The clinical course is marked by early gastrointestinal symptoms followed by rapid progression to multiorgan dysfunction—most notably acute kidney injury, hepatic impairment, and pulmonary fibrosis. Laboratory abnormalities such as leukocytosis and elevated inflammatory markers were common, while elevated white blood cell count correlated with poor prognosis. Despite supportive therapies, mortality rates remain high, especially among patients who consume larger quantities of poison or present late to the hospital. The findings underscore the urgent need for improved awareness, early diagnosis, and region-specific treatment protocols, including timely access to interventions like haemoperfusion and renal replacement therapy. Furthermore, regulatory control over paraquat sales and stronger mental health support systems are crucial for preventing intentional self-harm using such lethal substances. 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