Consultation with a physician-expert is recommended in cases where initial control of the envenomation syndrome has not been achieved following two doses of antivenom. Recurrent or delayed-onset of venom effects As described above, the

management of recurrent or delayed-onset hematologic venom effects is controversial. Most patients tolerate hematologic venom effects Inhibitors,research,lifescience,medical well, but several serious cases and one fatality have been described [27]. Compared to the initial treatment response, the response to repeat antivenom dosing is often attenuated and may be transient [26,28,50,52]. While guidelines exist, there is no settled clinical decision rule for which patients require retreatment, and estimates of which patients are at highest risk are largely derived from experience with other diseases Inhibitors,research,lifescience,medical [57]. Although the risk to the patient of additional antivenom dosing appears to be minimal, cost-benefit considerations are significant, particularly when re-hospitalization is required. For these reasons, the panel recommends direct consultation with a physician-expert to assist in management of these patients. Allergic reactions to antivenom Signs of immediate hypersensitivity to antivenom are observed in 5 – 6% of patients treated with ovine Fab antivenom [37,44]. Although most of these reactions are relatively minor and do not Inhibitors,research,lifescience,medical preclude antivenom therapy, some are severe. As described

above, the initial management of a hypersensitivity reaction is straightforward: halt the antivenom infusion and administer antihistamines, corticosteroids, and fluids as needed until signs of hypersensitivity have resolved. Epinephrine may be required for severe reactions. At this point, the decision to resume or discontinue antivenom therapy involves Inhibitors,research,lifescience,medical a complex balancing of risk and benefit that the panel could not reduce to an algorithm. Because few clinicians have the opportunity to gain experience with this uncommon clinical scenario, consultation with an expert clinician is recommended. Hematologic venom effects when transfusion is considered

old Thrombin-like enzymes in Inhibitors,research,lifescience,medical crotaline venom incompletely cleave fibrinogen, leading to the formation of an unstable fibrin clot that is not cross-linked [23,58]. The mechanism that underlies venom-induced thrombocytopenia is less well-understood; venom-induced injury to platelet cell membranes and endothelial activation Obeticholic Acid mouse caused by microvascular damage have been proposed [24,58,59]. Transfusion alone can produce transient improvement in coagulation parameters and platelet counts, but rarely has a sustained effect unless adequate doses of antivenom have also been administered. Aggressive antivenom administration should always precede fresh frozen plasma, cryoprecipitate, or platelet transfusion if antivenom is available. Transfusion is indicated for cases in which medically significant bleeding is occurring.