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Abstract
Folate and its derivatives have long been used as an adjunctive treatment in methanol poisoning. Methanol is ultimately metabolized to formate, the toxic compound. The accumulation of formate can lead to acidemia, retinal damage, visual impairment, and death. Formate is converted to carbon dioxide and water in a folate-dependent manner, and folate is often given in cases of methanol poisoning. In this paper, the evidence for folate as an adjunctive therapy in methanol poisoning is reviewed.
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Affiliation(s)
- Jillian Theobald
- Department of Emergency Medicine, Division of Medical Toxicology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Christopher Lim
- Department of Emergency Medicine, Kaiser Permanente San Jose Medical Center, San Jose, California, USA
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52
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Hassanian-Moghaddam H, Zamani N, Roberts DM, Brent J, McMartin K, Aaron C, Eddleston M, Dargan PI, Olson K, Nelson L, Bhalla A, Hantson P, Jacobsen D, Megarbane B, Balali-Mood M, Buckley NA, Zakharov S, Paasma R, Jarwani B, Mirafzal A, Salek T, Hovda KE. Consensus statements on the approach to patients in a methanol poisoning outbreak. Clin Toxicol (Phila) 2019; 57:1129-1136. [PMID: 31328583 DOI: 10.1080/15563650.2019.1636992] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background: Methanol poisoning is an important cause of mortality and morbidity worldwide. Although it often occurs as smaller sporadic events, epidemic outbreaks are not uncommon due to the illicit manufacture and sale of alcoholic beverages.Objective: We aimed to define methanol poisoning outbreak (MPO), outline an approach to triaging an MPO, and define criteria for prioritizing antidotes, extracorporeal elimination treatments (i.e., dialysis), and indications for transferring patients in the context of an MPO.Methods: We convened a group of experts from across the world to explore geographical, socio-cultural and clinical considerations in the management of an MPO. The experts answered specific open-ended questions based on themes aligned to the goals of this project. This project used a modified Delphi process. The discussion continued until there was condensation of themes.Results: We defined MPO as a sudden increase in the number of cases of methanol poisoning during a short period of time above what is normally expected in the population in that specific geographic area. Prompt initiation of an antidote is necessary in MPOs. Scarce hemodialysis resources require triage to identify patients most likely to benefit from this treatment. The sickest patients should not be transferred unless the time for transfer is very short. Transporting extracorporeal treatment equipment and antidotes may be more efficient.Conclusion: We have developed consensus statements on the response to a methanol poisoning outbreak. These can be used in any country and will be most effective when they are discussed by health authorities and clinicians prior to an outbreak.
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Affiliation(s)
- Hossein Hassanian-Moghaddam
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Clinical Toxicology, Loghman-Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nasim Zamani
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Clinical Toxicology, Loghman-Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Darren M Roberts
- Department of Clinical Pharmacology and Toxicology, and Department of Renal Medicine, St Vincent's Hospital, University of NSW, Sydney, NSW, Australia.,NSW Poisons Information Centre, Sydney Children's Hospital, Westmead, Sydney, NSW, Australia
| | - Jeffrey Brent
- School of Medicine, University of Colorado, Aurora, CO, USA
| | - Kenneth McMartin
- Department of Pharmacology, Toxicology and Neuroscience, Louisiana State University Health Sciences Center - Shreveport, Shreveport, LA, USA
| | - Cynthia Aaron
- Michigan Regional Poison Control Center at Children's Hospital of Michigan, Detroit, MI, USA.,Emergency Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - Michael Eddleston
- Department of Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Paul I Dargan
- Department of Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Kent Olson
- California Poison Control System, San Francisco Division, University of California, San Francisco, San Francisco, CA, USA
| | - Lewis Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Ashish Bhalla
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Philippe Hantson
- Université catholique de Louvain, Cliniques universitaires Saint Luc, Bruxelles-Department of Intensive Care, Brussels, Belgium.,Université catholique de Louvain, Cliniques universitaires Saint Luc, Bruxelles-Louvain Centre for Toxicology and Applied Pharmacology, Brussels, Belgium
| | - Dag Jacobsen
- Department of Acute Medicine, Oslo University Hospital, University of Oslo, Oslo, Norway
| | - Bruno Megarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM UMRS 1144, Paris-Diderot University, Paris, France
| | - Mahdi Balali-Mood
- Medical Toxicology Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Sergey Zakharov
- Department of Occupational Medicine, 1st Faculty of Medicine, Charles University and General University Hospital, Toxicological Information Centre, Prague 2, Czech Republic
| | - Raido Paasma
- Department of Anesthesiology and ICU, Pärnu County Hospital, Pärnu, Estonia
| | | | - Amirhossein Mirafzal
- Department of Emergency Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Tomas Salek
- Department of Clinical biochemistry and pharmacology, Tomas Bata Hospital, ZLÍN, Czech Republic
| | - Knut Erik Hovda
- The Norwegian CBRNE Centre of Medicine, Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
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53
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The Diagnosis and Management of Toxic Alcohol Poisoning in the Emergency Department: A Review Article. ADVANCED JOURNAL OF EMERGENCY MEDICINE 2019; 3:e28. [PMID: 31410405 PMCID: PMC6683589 DOI: 10.22114/ajem.v0i0.153] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Context: This review discusses the range of clinical presentations seen with poisonings by the major toxic alcohols--methanol, ethylene glycol, and isopropyl alcohol. It outlines a straightforward diagnostic strategy and discusses in detail the current treatment recommendations. Evidence acquisition: The authors conducted a literature search of primary and secondary sources related to the topic. For treatment recommendations, search restrictions included articles published between 2008 and 2019. For background information, search restrictions included articles written from 1990 – present. Results: This review discusses in detail how the diagnosis can be made via clinical signs, symptoms, and laboratory values as well as the most recent treatment recommendations. This paper will also discuss the limitations of the emergency department workup and how the absence of particular laboratory findings does not necessarily rule out the diagnosis. Conclusion: Poisoning with methanol, ethylene glycol, and isopropanol present diagnostic and therapeutic challenges to emergency physicians. Toxic alcohol poisonings lead to an elevated osmolar gap and, with the exception of Isopropanol, a metabolic acidosis. In order for the timely initiation of life-saving treatment, emergency physicians need a solid understanding of the pathophysiology, clinical presentation, laboratory workup, and treatment.
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54
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Jha VK, Padmaprakash KV. Extracorporeal Treatment in the Management of Acute Poisoning: What an Intensivist Should Know? Indian J Crit Care Med 2019; 22:862-869. [PMID: 30662226 PMCID: PMC6311976 DOI: 10.4103/ijccm.ijccm_425_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Extracorporeal treatment (ECTR) represents a treatment modality promoting removal of endogenous or exogenous poisons and supporting or temporarily replacing a vital organ. This article aims to provide a brief overview of the technical aspects and the potential indications and limitations of the different ECTRs, highlighting the important characteristics of poison amenable to ECTR and the most appropriate prescriptions used in the setting of acute poisoning. The various principles that govern poison elimination by ECTR (diffusion, convection, adsorption, and centrifugation) and how components of the ECTR can be adjusted to maximize clearance have also being discussed.
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Affiliation(s)
- Vijoy Kumar Jha
- Department of Nephrology, Command Hospital Air Force Bangalore, Bengaluru, Karnataka, India
| | - K V Padmaprakash
- Department of Medicine, INHS Kalyani, Visakhapatnam, Andhra Pradesh, India
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55
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Wang C, Samaha D, Hiremath S, Sikora L, Sood MM, Kanji S, Clark EG. Outcomes after toxic alcohol poisoning: a systematic review protocol. Syst Rev 2018; 7:250. [PMID: 30593287 PMCID: PMC6309090 DOI: 10.1186/s13643-018-0926-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 12/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Toxic alcohols have been implicated in accidental ingestions and intentional exposures. Recognition of toxic alcohol poisoning is challenging. The main treatment modalities include antidotes with alcohol dehydrogenase inhibitors and dialysis. Current guidelines exist for both methanol and ethylene glycol intoxication. However, treatment consensus related to other toxic alcohols is limited. Furthermore, uncertainties regarding thresholds for when to initiate antidotes and dialysis persist. As a consequence, variations exist in the interventions utilized for management of all toxic alcohol poisonings. To our knowledge, no prior systematic review of clinical outcomes of toxic alcohols exists. The objective of this study is to summarize existing evidence on short- and long-term outcomes of patients following toxic alcohol poisonings, including methanol, ethylene glycol, isopropanol, propylene glycol, and diethylene glycol. METHODS A literature search in PubMed, MEDLINE, and EMBASE will be performed based on pre-determined criteria. There will be no restrictions on publication dates or languages. The search will be supplemented by manual scan of bibliographies of eligible studies and gray literature assessment. Observational studies and clinical trials will be included in this review. Once eligible studies have been selected based on pre-specified criteria, two investigators will extract relevant data independently and perform quality assessment per validated tools. A pooled analysis of mortality and short- and long-term secondary outcomes will be performed. Pre-specified subgroup analyses will be performed according to the type of toxic alcohol intoxication, mode of renal replacement therapy, and medical interventions received. A meta-analysis will be performed if three or more studies with similar populations, type of toxic alcohol poisoning, and outcome measures, as well as adequate quality, are identified. This review will be reported according to the recommendations of the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) Statement. DISCUSSION This systematic review aims to synthesize current evidence in the short- and long-term outcomes of post-toxic alcohol poisoning. The results will enhance the understanding of patient morbidity and mortality after toxic alcohol poisoning, help inform uniform concrete management guideline development, identify gaps in the current state of knowledge, and provide evidence to help implement post-treatment follow-up. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018101955.
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Affiliation(s)
- Carol Wang
- Department of Medicine, University of Ottawa, 162 Parkdale Avenue, Ottawa, Ontario K1Y 1J8 Canada
- The Ottawa Hospital – Riverside Campus, 1967 Riverside Drive, Ottawa, Ontario K1H 7W9 Canada
| | - Daniel Samaha
- The Ottawa Hospital – Riverside Campus, 1967 Riverside Drive, Ottawa, Ontario K1H 7W9 Canada
- Division of Nephrology, Department of Medicine, University of Ottawa, 1967 Riverside Drive, Ottawa, K1H 7W9 Ontario Canada
| | - Swapnil Hiremath
- The Ottawa Hospital – Riverside Campus, 1967 Riverside Drive, Ottawa, Ontario K1H 7W9 Canada
- Division of Nephrology, Department of Medicine, University of Ottawa, 1967 Riverside Drive, Ottawa, K1H 7W9 Ontario Canada
- The Ottawa Hospital Research Institute, University of Ottawa, 501 Smyth Road, Ottawa, Ontario K1H 8L6 Canada
| | - Lindsey Sikora
- Health Sciences Library, University of Ottawa, 451 Smyth Road, Ottawa, K1H 8M5 Ontario Canada
| | - Manish M. Sood
- The Ottawa Hospital – Riverside Campus, 1967 Riverside Drive, Ottawa, Ontario K1H 7W9 Canada
- Division of Nephrology, Department of Medicine, University of Ottawa, 1967 Riverside Drive, Ottawa, K1H 7W9 Ontario Canada
- The Ottawa Hospital Research Institute, University of Ottawa, 501 Smyth Road, Ottawa, Ontario K1H 8L6 Canada
| | - Salmaan Kanji
- The Ottawa Hospital Research Institute, University of Ottawa, 501 Smyth Road, Ottawa, Ontario K1H 8L6 Canada
| | - Edward G. Clark
- The Ottawa Hospital – Riverside Campus, 1967 Riverside Drive, Ottawa, Ontario K1H 7W9 Canada
- Division of Nephrology, Department of Medicine, University of Ottawa, 1967 Riverside Drive, Ottawa, K1H 7W9 Ontario Canada
- The Ottawa Hospital Research Institute, University of Ottawa, 501 Smyth Road, Ottawa, Ontario K1H 8L6 Canada
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56
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Zakharov S, Hlusicka J, Nurieva O, Kotikova K, Lischkova L, Kacer P, Kacerova T, Urban P, Vaneckova M, Seidl Z, Diblik P, Kuthan P, Heissigerova J, Lesovsky J, Rulisek J, Vojtova L, Hubacek JA, Navratil T. Neuroinflammation markers and methyl alcohol induced toxic brain damage. Toxicol Lett 2018; 298:60-69. [DOI: 10.1016/j.toxlet.2018.05.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 04/22/2018] [Accepted: 05/03/2018] [Indexed: 12/29/2022]
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57
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Campion GH, Wang JJ, Hoffman RS, Cormier M, Lavergne V, Mowry JB, Roberts DM, Ghannoum M, Su MK, Gosselin S. Extracorporeal treatments in poisonings from four non-traditionally dialysed toxins (acetaminophen, digoxin, opioids and tricyclic antidepressants): A combined single-centre and national study. Basic Clin Pharmacol Toxicol 2018; 124:341-347. [PMID: 30248244 DOI: 10.1111/bcpt.13135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 09/12/2018] [Indexed: 01/16/2023]
Abstract
The use of extracorporeal treatments (ECTRs) for poisonings with four non-traditionally dialysed toxins (NTDTs) is increasing in the United States. This study evaluated whether ECTRs are prescribed for toxin removal or the treatment of other medical illnesses or complications. We performed a 2-Phase retrospective analysis evaluating the main indication for ECTRs in patients with poisoning from a NTDT (defined for this study as acetaminophen, opioids, tricyclic antidepressants (TCAs) or digoxin) and ECTR. The first phase assessed all cases from a single site (New York City Poison Control Center) between the years 2000 and 2016, and the second phase surveyed all United States Poison Control Centers (PCCs). In Phase 1, demographics, toxin ingested and main indication for ECTR were extracted. In Phase 2, a query to the National Poison Data System using the a pragmatic subset of inclusion criteria from Phase 1 restricted to single toxin ingestions over a narrower time frame (2014-2016) provided the cases for study. A structured online questionnaire was sent to all United States PCCs to request their database review regarding the indication for ECTR for their cases. In Phase 1, 92 cases met inclusion criteria. In Phase 2, 519 cases were screened and 425 met inclusion criteria. In Phase 1 91/92 (98.9%) and Phase 2 411/425 (96.7%), of extracorporeal treatments were used to treat underlying medical conditions or poisoning-related complications rather than accelerate toxin removal. The increasing number of ECTRs reported in patients who ingested one of the four NTDTs thus appears to be for medical indications rather than attempts at toxin removal, a distinction that is important.
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Affiliation(s)
| | | | - Robert S Hoffman
- NYU School of Medicine, New York, New York.,New York City Poison Control Center, New York, New York.,Montreal Medical Toxicology Initiative, Montréal, Quebec, Canada
| | - Monique Cormier
- Montreal Medical Toxicology Initiative, Montréal, Quebec, Canada
| | | | | | - Darren M Roberts
- New South Wales Poisons Information Centre, Sydney Children's Hospital Network, Randwick, New South Wales, Australia
| | | | - Mark K Su
- NYU School of Medicine, New York, New York.,New York City Poison Control Center, New York, New York
| | - Sophie Gosselin
- McGill University, Montréal, Quebec, Canada.,Montreal Medical Toxicology Initiative, Montréal, Quebec, Canada.,McGill University Health Center, Montréal, Quebec, Canada
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58
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Ghannoum M, Hoffman RS, Gosselin S, Nolin TD, Lavergne V, Roberts DM. Use of extracorporeal treatments in the management of poisonings. Kidney Int 2018; 94:682-688. [DOI: 10.1016/j.kint.2018.03.026] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 03/16/2018] [Accepted: 03/22/2018] [Indexed: 11/30/2022]
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59
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Holt NR, Nickson CP. Severe methanol poisoning with neurological sequelae: implications for diagnosis and management. Intern Med J 2018; 48:335-339. [PMID: 29512320 DOI: 10.1111/imj.13725] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 10/22/2017] [Accepted: 10/22/2017] [Indexed: 11/29/2022]
Abstract
A 22-year-old woman presented with methanol toxicity manifesting as headache, reduced conscious state and visual change after consuming home-made grappa. She progressed to a coma with fixed mydriasis and severe acidaemia (pH 6.55). She was treated with empirical antidote administration (intravenous ethanol) and enhanced elimination through haemodialysis. She survived despite her delayed presentation but developed significant neurological sequelae, including visual impairment. We provide an overview of key elements of diagnosis and recent updates in treatment recommendations.
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Affiliation(s)
- Nicolette R Holt
- Department of General Internal Medicine, Alfred Hospital, Melbourne, Victoria, Australia
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60
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Burratti L, Casalboni M, De Matteis F, Pizzoferrato R, Prosposito P. Polystyrene Opals Responsive to Methanol Vapors. MATERIALS (BASEL, SWITZERLAND) 2018; 11:E1547. [PMID: 30154304 PMCID: PMC6165557 DOI: 10.3390/ma11091547] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 08/24/2018] [Accepted: 08/24/2018] [Indexed: 12/13/2022]
Abstract
Photonic crystals (PCs) show reflectance spectra depending on the geometrical structure of the crystal, the refractive index (neff), and the light incident angle, according to the Bragg-Snell law. Three-dimensional photonic crystals (3D-PCs) composed of polymeric sub-micrometer spheres, are arranged in an ordered face cubic centered (fcc) lattice and are good candidates for vapor sensing by exploiting changes of the reflectance spectra. We synthesized high quality polystyrene (PS) 3D-PCs, commonly called opals, with a filling factor f near to the ideal value of 0.74 and tested their optical response in the presence of different concentrations of methanol (MeOH) vapor. When methanol was present in the voids of the photonic crystals, the reflectance spectra experienced energy shifts. The concentration of methyl alcohol vapor can be inferred, due to a linear dependence of the reflectance band maximum wavelength as a function of the vapor concentration. We tested the reversibility of the process and the time stability of the system. A limit of detection (LOD) equal to 5% (v/v₀), where v was the volume of methanol and v₀ was the total volume of the solution (methanol and water), was estimated. A model related to capillary condensation for intermediate and high methanol concentrations was discussed. Moreover, a swelling process of the PS spheres was invoked to fully understand the unexpected energy shift found for very high methanol content.
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Affiliation(s)
- Luca Burratti
- Industrial Engineering Department, University of Rome "Tor Vergata", Via del Politecnico 1, 00133 Rome, Italy.
| | - Mauro Casalboni
- Industrial Engineering Department, University of Rome "Tor Vergata", Via del Politecnico 1, 00133 Rome, Italy.
- Centre of Regenerative Medicine, Centre of Regenerative Medicine of University of Rome "Tor Vergata", Via Montpellier 1, 00133 Rome, Italy.
- National Interuniversity Consortium of Materials Science and Technology (INSTM), University of Rome "Tor Vergata", 00133 Rome, Italy.
| | - Fabio De Matteis
- Industrial Engineering Department, University of Rome "Tor Vergata", Via del Politecnico 1, 00133 Rome, Italy.
- Centre of Regenerative Medicine, Centre of Regenerative Medicine of University of Rome "Tor Vergata", Via Montpellier 1, 00133 Rome, Italy.
- National Interuniversity Consortium of Materials Science and Technology (INSTM), University of Rome "Tor Vergata", 00133 Rome, Italy.
| | - Roberto Pizzoferrato
- Industrial Engineering Department, University of Rome "Tor Vergata", Via del Politecnico 1, 00133 Rome, Italy.
| | - Paolo Prosposito
- Industrial Engineering Department, University of Rome "Tor Vergata", Via del Politecnico 1, 00133 Rome, Italy.
- Centre of Regenerative Medicine, Centre of Regenerative Medicine of University of Rome "Tor Vergata", Via Montpellier 1, 00133 Rome, Italy.
- National Interuniversity Consortium of Materials Science and Technology (INSTM), University of Rome "Tor Vergata", 00133 Rome, Italy.
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Roberts DM, Sevastos J, Carland JE, Stocker SL, Lea-Henry TN. Clinical Pharmacokinetics in Kidney Disease: Application to Rational Design of Dosing Regimens. Clin J Am Soc Nephrol 2018; 13:1254-1263. [PMID: 30042221 PMCID: PMC6086693 DOI: 10.2215/cjn.05150418] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A change in pharmacokinetics can alter drug exposure and predispose the patient to either over- or underdosing, potentially resulting in adverse drug reactions or therapeutic failure. Kidney disease is characterized by multiple physiologic effects, which induce clinically significant changes in pharmacokinetics. These vary between individuals and may be quantitated in certain instances. An understanding of pharmacokinetic concepts is, therefore, important for a rational approach to the design of drug dosing regimens for the delivery of personalized medical care. Whether kidney disease is acute or chronic, drug clearance decreases and the volume of distribution may remain unchanged or increase. AKI is defined by dynamic changes in kidney function, which complicates attempts to accurately quantify drug clearance. In contrast, changes in drug clearance progress more slowly with CKD. In general, kidney replacement therapies increase drug clearance, but the extent to which this occurs depends on the modality used and its duration, the drug's properties, and the timing of drug administration. However, the changes in drug handling associated with kidney disease are not isolated to reduced kidney clearance and an appreciation of the scale of potential derangements is important. In most instances, the first dose administered in patients with kidney disease is the same as in patients with normal kidney function. However, in some cases, a higher (loading) initial dose is given to rapidly achieve therapeutic concentrations, followed by a lower maintenance dose, as is well described when prescribing anti-infectives to patients with sepsis and AKI. This review provides an overview of how pharmacokinetic principles can be applied to patients with kidney disease to personalize dosage regimens. Patients with kidney disease are a vulnerable population and the increasing prevalence of kidney disease means that these considerations are important for all prescribers.
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Affiliation(s)
- Darren M. Roberts
- Departments of Clinical Pharmacology and Toxicology, and
- Department of Renal Medicine, The Canberra Hospital, Woden, Australian Capital Territory, Australia
- Medical School, Australian National University, Acton, Australian Capital Territory, Australia
| | - Jacob Sevastos
- Nephrology and Renal Transplantation, St. Vincent’s Hospital, Darlinghurst, New South Wales, Australia
- Department of Medicine, St. Vincent’s Clinical School, University of New South Wales, Sydney, Australia; and
| | - Jane E. Carland
- Departments of Clinical Pharmacology and Toxicology, and
- Department of Medicine, St. Vincent’s Clinical School, University of New South Wales, Sydney, Australia; and
| | - Sophie L. Stocker
- Departments of Clinical Pharmacology and Toxicology, and
- Department of Medicine, St. Vincent’s Clinical School, University of New South Wales, Sydney, Australia; and
| | - Tom N. Lea-Henry
- Department of Renal Medicine, The Canberra Hospital, Woden, Australian Capital Territory, Australia
- Nephrology and Transplantation Unit, John Hunter Hospital, Newcastle, New South Wales, Australia
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Yoshizawa T, Kamijo Y, Fujita Y, Suzuki Y, Hanazawa T, Usui K, Kishino T. Mild manifestation of methanol poisoning half a day after massive ingestion of a fuel alcohol product containing 70% ethanol and 30% methanol: a case report. Acute Med Surg 2018; 5:289-291. [PMID: 29988682 PMCID: PMC6028797 DOI: 10.1002/ams2.339] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 02/26/2018] [Indexed: 12/04/2022] Open
Abstract
Case Is fomepizole necessary after massive ingestion of a mixture of methanol and ethanol? We report the case of a 37‐year‐old man who was transported to our Poison Center 12 h after ingesting 500 mL of fuel alcohol containing 70% methanol and 30% ethanol in a suicide attempt. On admission, he presented only with somnolence and mild metabolic acidosis. We hypothesized that most of the ethanol had been metabolized. Outcome As the estimated serum concentration of methanol was lethal (242.6 mg/dL), fomepizole was given i.v. and hemodialysis was carried out twice, resulting in complete recovery. Later, the serum concentrations of both methanol and ethanol on admission were found to be 224.1 and 0.51 mg/dL, respectively. Conclusion Therapeutic intervention was delayed by half a day after ingestion of a product containing methanol and ethanol in the present case. If the patient had arrived earlier, he may have only been treated with hemodialysis, but not fomepizole.
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Affiliation(s)
- Tomohiro Yoshizawa
- Department of Pharmacy Saitama Medical University Hospital Iruma-gun Saitama Japan.,Emergency Medical Center & Poison Center Saitama Medical University Hospital Iruma-gun Saitama Japan
| | - Yoshito Kamijo
- Emergency Medical Center & Poison Center Saitama Medical University Hospital Iruma-gun Saitama Japan
| | - Yuji Fujita
- Department of Emergency, Disaster and General Medicine Iwate Medical University School of Medicine Morioka city Iwate Japan
| | - Yoshiki Suzuki
- Department of Pharmacy Saitama Medical University Hospital Iruma-gun Saitama Japan.,Emergency Medical Center & Poison Center Saitama Medical University Hospital Iruma-gun Saitama Japan
| | - Tomoki Hanazawa
- Emergency Medical Center & Poison Center Saitama Medical University Hospital Iruma-gun Saitama Japan
| | - Kiyotaka Usui
- Department of Forensic Medicine Tohoku University Graduate School of Medicine Aoba-ku Sendai Japan
| | - Tohru Kishino
- Department of Pharmacy Saitama Medical University Hospital Iruma-gun Saitama Japan
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63
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Affiliation(s)
- Jeffrey A Kraut
- From Medical and Research Services and Division of Nephrology, Veterans Health Administration Greater Los Angeles (VHAGLA) Healthcare System, and Membrane Biology Laboratory, David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (J.A.K.); and the Division of Emergency Medicine, Washington University School of Medicine, St. Louis (M.E.M.)
| | - Michael E Mullins
- From Medical and Research Services and Division of Nephrology, Veterans Health Administration Greater Los Angeles (VHAGLA) Healthcare System, and Membrane Biology Laboratory, David Geffen School of Medicine, University of California, Los Angeles - both in Los Angeles (J.A.K.); and the Division of Emergency Medicine, Washington University School of Medicine, St. Louis (M.E.M.)
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64
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Palevsky PM. Acute renal replacement therapy during hospitalization: Is training adequate? Semin Dial 2018; 31:135-139. [PMID: 29333659 DOI: 10.1111/sdi.12669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Acute renal replacement therapy is one of the most common interventions provided by nephrologists, however, data on the quality of training provided to nephrology fellows is limited. Extensive curricula for acute renal replacement therapy and the management of poisonings and intoxications have been published, but personal experience suggests that there are significant opportunities to improve training. Particular areas to be considered include the use of novel technologies for assessment of volume status, greater emphasis on the dosing of medications during acute renal replacement therapy, greater training in assessing and tailoring treatment to the goals of care of the individual patient, incorporation of continuous quality improvement tools into the management of acute renal replacement therapy programs and development of robust simulation training to augment training.
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Affiliation(s)
- Paul M Palevsky
- Renal Section, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,University of Pittsburgh, Pittsburgh, PA, USA
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Zakharov S, Rulisek J, Nurieva O, Kotikova K, Navratil T, Komarc M, Pelclova D, Hovda KE. Intermittent versus continuous renal replacement therapy in acute methanol poisoning: comparison of clinical effectiveness in mass poisoning outbreaks. Ann Intensive Care 2017; 7:77. [PMID: 28730555 PMCID: PMC5519513 DOI: 10.1186/s13613-017-0300-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 07/10/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Intermittent hemodialysis (IHD) is the modality of choice in the extracorporeal treatment (ECTR) of acute methanol poisoning. However, the comparative clinical effectiveness of intermittent versus continuous modalities (CRRT) is unknown. During an outbreak of mass methanol poisoning, we therefore studied the effect of IHD versus CRRT on mortality and the prevalence of visual/central nervous system (CNS) sequelae in survivors. METHODS The study was designed as prospective observational cohort study. Patients hospitalized with a diagnosis of acute methanol poisoning were identified for the study. Exploratory factor analysis and multivariate logistic regression were applied to determine the effect of ECTR modality on the outcome. RESULTS Data were obtained from 41 patients treated with IHD and 40 patients with CRRT. The follow-up time in survivors was two years. Both groups of patients were comparable by age, time to presentation, laboratory data, clinical features, and other treatment applied. The CRRT group was more acidemic (arterial blood pH 6.96 ± 0.08 vs. 7.17 ± 0.07; p < 0.001) and more severely poisoned (25/40 vs. 9/41 patients with Glasgow Coma Scale (GCS) ≤ 8; p < 0.001). The median intensive care unit length of stay (4 (range 1-16) days vs. 4 (1-22) days; p = 0.703) and the number of patients with complications during the treatment (11/41 vs. 13/40 patients; p = 0.576) did not differ between the groups. The mortality was higher in the CRRT group (15/40 vs. 5/41; p = 0.008). The number of survivors without sequelae of poisoning was higher in the IHD group (23/41 vs. 10/40; p = 0.004). There was a significant association of ECTR modality with both mortality and the number of survivors with visual and CNS sequelae of poisoning, but this association was not present after adjustment for arterial blood pH and GCS on admission (all p > 0.05). CONCLUSIONS In spite of the faster correction of the acidosis and the quicker removal of the toxic metabolite in intermittent dialysis, we did not find significant differences in the treatment outcomes between the two groups after adjusting for the degree of acidemia and the severity of poisoning on admission. These findings support the strategy of "use what you have" in situations with large outbreaks and limited dialysis capacity.
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Affiliation(s)
- Sergey Zakharov
- Department of Occupational Medicine, Toxicological Information Center, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic.
| | - Jan Rulisek
- Department of Anesthesia and Intensive Care, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Olga Nurieva
- Department of Occupational Medicine, Toxicological Information Center, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Katerina Kotikova
- Department of Occupational Medicine, Toxicological Information Center, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Tomas Navratil
- Department of Occupational Medicine, Toxicological Information Center, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic.,Department of Biomimetic Electrochemistry, J. Heyrovský Institute of Physical Chemistry of CAS, v.v.i, Prague, Czech Republic
| | - Martin Komarc
- Institute of Biophysics and Informatics, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Daniela Pelclova
- Department of Occupational Medicine, Toxicological Information Center, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Knut Erik Hovda
- The Norwegian CBRNE Centre of Medicine, Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
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Hernández-Tejedor A, Peñuelas O, Sirgo Rodríguez G, Llompart-Pou J, Palencia Herrejón E, Estella A, Fuset Cabanes M, Alcalá-Llorente M, Ramírez Galleymore P, Obón Azuara B, Lorente Balanza J, Vaquerizo Alonso C, Ballesteros Sanz M, García García M, Caballero López J, Socias Mir A, Serrano Lázaro A, Pérez Villares J, Herrera-Gutiérrez M. Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.medine.2017.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Cost-effectiveness of hospital treatment and outcomes of acute methanol poisoning during the Czech Republic mass poisoning outbreak. J Crit Care 2017; 39:190-198. [DOI: 10.1016/j.jcrc.2017.03.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 02/25/2017] [Accepted: 03/03/2017] [Indexed: 12/21/2022]
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Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients. Med Intensiva 2017; 41:285-305. [PMID: 28476212 DOI: 10.1016/j.medin.2017.03.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 02/25/2017] [Accepted: 03/11/2017] [Indexed: 12/14/2022]
Abstract
The standardization of the Intensive Care Medicine may improve the management of the adult critically ill patient. However, these strategies have not been widely applied in the Intensive Care Units (ICUs). The aim is to elaborate the recommendations for the standardization of the treatment of critical patients. A panel of experts from the thirteen working groups (WG) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2002 to 2016 was extracted. The clinical evidence was discussed and summarised by the experts in the course of a consensus finding of every WG and finally approved by the WGs after an extensive internal review process that was carried out between December 2015 and December 2016. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and are intended as a guide for the intensivists in the management of critical patients.
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69
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Sureda-Vives M, Morell-Garcia D, Rubio-Alaejos A, Valiña L, Robles J, Bauça JM. Stability of serum, plasma and urine osmolality in different storage conditions: Relevance of temperature and centrifugation. Clin Biochem 2017; 50:772-776. [PMID: 28372954 DOI: 10.1016/j.clinbiochem.2017.03.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 03/18/2017] [Accepted: 03/22/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Osmolality reflects the concentration of all dissolved particles in a body fluid, and its measurement is routinely performed in clinical laboratories for the differential diagnosis of disorders related with the hydrolytic balance regulation, the renal function and in small-molecule poisonings. The aim of the study was to assess the stability of serum, plasma and urine osmolality through time and under different common storage conditions, including delayed centrifugation. METHODS Blood and urine samples were collected, and classified into different groups according to several preanalytical variables: serum or plasma lithium-heparin tubes; spun or unspun; stored at room temperature (RT), at 4°C or frozen at -21°C. Aliquots from each group were assayed over time, for up to 14days. Statistical differences were based on three different international performance criteria. RESULTS Whole blood stability was higher in the presence of anticoagulant. Serum osmolality was stable for 2days at RT and 8days at 4°C, while plasma was less stable when refrigerated. Urine stability was 5days at RT, 4days at 4°C and >14days when frozen. DISCUSSION Osmolality may be of great interest for the management of several conditions, such as in case of a delay in the clinical suspicion, or in case of problems in sample collection or processing. The ability to obtain reliable results for samples kept up to 14days also offers the possibility to retrospectively assess baseline values for patients which may require it.
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Affiliation(s)
| | - Daniel Morell-Garcia
- Department of Laboratory Medicine, Hospital Universitari Son Espases, Palma, Balearic Islands, Spain; Institut d'Investigació Sanitària de Palma (IdISPa), Palma, Balearic Islands, Spain
| | - Ana Rubio-Alaejos
- Department of Laboratory Medicine, Hospital Universitari Son Espases, Palma, Balearic Islands, Spain
| | - Laura Valiña
- Department of Laboratory Medicine, Hospital Universitari Son Espases, Palma, Balearic Islands, Spain
| | - Juan Robles
- Department of Laboratory Medicine, Hospital Universitari Son Espases, Palma, Balearic Islands, Spain
| | - Josep Miquel Bauça
- Department of Laboratory Medicine, Hospital Universitari Son Espases, Palma, Balearic Islands, Spain; Institut d'Investigació Sanitària de Palma (IdISPa), Palma, Balearic Islands, Spain.
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70
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Bouchard J, Lavergne V, Roberts DM, Cormier M, Morissette G, Ghannoum M. Availability and cost of extracorporeal treatments for poisonings and other emergency indications: a worldwide survey. Nephrol Dial Transplant 2017; 32:699-706. [DOI: 10.1093/ndt/gfw456] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 12/12/2016] [Indexed: 01/04/2023] Open
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Can duration of hemodialysis be estimated based on the on-arrival laboratory tests and clinical manifestations in methanol-poisoned patients? Int Urol Nephrol 2017; 49:1057-1062. [DOI: 10.1007/s11255-017-1521-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 01/19/2017] [Indexed: 11/25/2022]
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Collister D, Duff G, Palatnick W, Komenda P, Tangri N, Hingwala J. A Methanol Intoxication Outbreak From Recreational Ingestion of Fracking Fluid. Am J Kidney Dis 2017; 69:696-700. [PMID: 28111025 DOI: 10.1053/j.ajkd.2016.10.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 10/13/2016] [Indexed: 12/21/2022]
Abstract
Single-patient methanol intoxications are a common clinical presentation, but outbreaks are rare and usually occur in settings in which there is limited access to ethanol and methanol is consumed as a substitute. In this case report, we describe an outbreak of methanol intoxications that was challenging from a public health perspective and discuss strategies for managing such an outbreak.
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Affiliation(s)
- David Collister
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Canada; Health Sciences Center, Chronic Disease Innovation Centre, Winnipeg, Canada; Seven Oaks General Hospital, Chronic Disease Innovation Centre, Winnipeg, Canada.
| | - Graham Duff
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Canada
| | - Wesley Palatnick
- Health Sciences Center, Chronic Disease Innovation Centre, Winnipeg, Canada; Department of Emergency Medicine, University of Manitoba, Winnipeg, Canada
| | - Paul Komenda
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Canada; Seven Oaks General Hospital, Chronic Disease Innovation Centre, Winnipeg, Canada
| | - Navdeep Tangri
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Canada; Seven Oaks General Hospital, Chronic Disease Innovation Centre, Winnipeg, Canada
| | - Jay Hingwala
- Section of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Canada; Health Sciences Center, Chronic Disease Innovation Centre, Winnipeg, Canada
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Zakharov S, Pelclova D, Navratil T, Belacek J, Latta J, Pisar M, Rulisek J, Leps J, Zidek P, Kucera C, Bocek R, Mazur M, Belik Z, Chalupa J, Talafa V, Kodras K, Nalos D, Sedlak C, Senkyrik M, Smid J, Salek T, Roberts DM, Hovda KE. Efficiency of acidemia correction on intermittent versus continuous hemodialysis in acute methanol poisoning. Clin Toxicol (Phila) 2016; 55:123-132. [DOI: 10.1080/15563650.2016.1250901] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Sergey Zakharov
- Department of Occupational Medicine, First Faculty of Medicine, Toxicological Information Centre, Charles University and General University Hospital, Prague, Czech Republic
| | - Daniela Pelclova
- Department of Occupational Medicine, First Faculty of Medicine, Toxicological Information Centre, Charles University and General University Hospital, Prague, Czech Republic
| | - Tomas Navratil
- Department of Occupational Medicine, First Faculty of Medicine, Toxicological Information Centre, Charles University and General University Hospital, Prague, Czech Republic
- First Faculty of Medicine, Institute of Medical Biochemistry and Laboratory Diagnostics, Charles University and General University Hospital, Prague, Czech Republic
- J. Heyrovský Institute of Physical Chemistry of the AS CR, v.v.i, Prague, Czech Republic
| | - Jaromir Belacek
- First Faculty of Medicine, Institute of Biophysics and Informatics, Charles University and General University Hospital, Prague, Czech Republic
| | - Jiri Latta
- Department of Internal Medicine, Tomas Bata Regional Hospital, Zlin, Czech Republic
| | - Michal Pisar
- Department of Internal Medicine, Tomas Bata Regional Hospital, Zlin, Czech Republic
| | - Jan Rulisek
- Department of Anesthesiology, Resuscitation, and Intensive Medicine, General University Hospital, Prague, Czech Republic
| | - Jiri Leps
- Department of Anesthesiology and Resuscitation, Znojmo City Hospital, Znojmo, Czech Republic
| | - Pavel Zidek
- Department of Anesthesiology and Resuscitation, Benešov City Hospital, Benešov, Czech Republic
| | - Cyril Kucera
- Department of Anesthesiology and Resuscitation, Ostrava City Hospital, Ostrava, Czech Republic
| | - Robert Bocek
- Department of Anesthesiology and Intensive Medicine, Havířov Hospital, Havířov, Czech Republic
| | - Miroslav Mazur
- Department of Anesthesiology and Intensive Medicine, Havířov Hospital, Havířov, Czech Republic
| | - Zdenek Belik
- Department of Anesthesiology and Intensive Medicine, Karvina-Raj Hospital, Orlova, Czech Republic
| | - Josef Chalupa
- Department of Anesthesiology and Resuscitation, Frydek-Mistek City Hospital, Frydek-Mistek, Czech Republic
| | - Viktor Talafa
- Department of Internal Medicine, Frydek-Mistek City Hospital, Frydek-Mistek, Czech Republic
| | - Kamil Kodras
- Department of Anesthesiology and Resuscitation, Kladno City Hospital, Kladno, Czech Republic
| | - Daniel Nalos
- Department of Anesthesiology and Resuscitation, Masaryk Hospital, Ústínad Labem, Czech Republic
| | - Ctirad Sedlak
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Olomouc, Olomouc, Czech Republic
| | - Michal Senkyrik
- Department of Internal Medicine, Faculty Hospital Brno, Brno, Czech Republic
| | - Jan Smid
- Department of Internal Medicine, Ostrava City Hospital, Ostrava, Czech Republic
| | - Tomas Salek
- Department of Clinical Biochemistry, Tomas Bata Regional Hospital, Zlin, Czech Republic
| | | | - Knut Erik Hovda
- Department of Acute Medicine, The Norwegian CBRNe Centre of Medicine, Oslo University Hospital, Oslo, Norway
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74
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Bhatia M. Understanding toxicology: mechanisms and applications. Cell Biol Toxicol 2016; 33:1-4. [DOI: 10.1007/s10565-016-9363-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 09/27/2016] [Indexed: 12/11/2022]
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75
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Kraut JA, Madias NE. Lactic Acidosis: Current Treatments and Future Directions. Am J Kidney Dis 2016; 68:473-82. [DOI: 10.1053/j.ajkd.2016.04.020] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 04/01/2016] [Indexed: 11/11/2022]
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76
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Lavergne V, Hoffman RS, Mowry JB, Cormier M, Gosselin S, Roberts DM, Ghannoum M. Why are we Still Dialyzing Overdoses to Tricyclic Antidepressants? A subanalysis of the NPDS database. Semin Dial 2016; 29:403-9. [DOI: 10.1111/sdi.12520] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Valery Lavergne
- Department of Medical Biology; Sacré-Coeur Hospital; University of Montreal; Montreal Canada
| | - Robert S. Hoffman
- Division of Medical Toxicology; Ronald O. Perelman Department of Emergency Medicine; New York University School of Medicine; New York
| | - James B. Mowry
- Indiana Poison Center; Indiana University Health; Indianapolis
| | - Monique Cormier
- Department of Nephrology; Verdun Hospital; University of Montreal; Montreal Canada
| | - Sophie Gosselin
- Department of Medicine & Emergency Medicine; McGill University Health Centre; McGill University, Centre anti-poison du Quebec; Montreal Canada
- Province of Alberta Drug Information Service; Calgary Alberta
| | - Darren M. Roberts
- Medical School; Australian National University and Renal Medicine; The Canberra Hospital; Canberra Australia
| | - Marc Ghannoum
- Department of Nephrology; Verdun Hospital; University of Montreal; Montreal Canada
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Gero D, Gié O, Hübner M, Demartines N, Hahnloser D. Postoperative ileus: in search of an international consensus on definition, diagnosis, and treatment. Langenbecks Arch Surg 2016; 402:149-158. [PMID: 27488952 DOI: 10.1007/s00423-016-1485-1] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Accepted: 07/17/2016] [Indexed: 12/18/2022]
Abstract
PURPOSE Postoperative ileus (POI) is a frequent complication after abdominal surgery; nonetheless, it remains poorly defined. Our aim was to achieve an international consensus among leading colorectal surgeons on definition, prevention, and treatment of POI. METHODS Thirty-five experts from five continents participated in a three-round Delphi process. Round 1 contained open-ended questions on POI and postoperative nausea and vomiting (PONV). Round 2 included closed-ended questions. Round 3 measured agreement on a 5-point Likert scale. Consensus was defined when items were rated as agree or strongly agree by at least 70 % of the experts. RESULTS Experts reached following consensus: POI is a temporary inhibition (86 %) of gastrointestinal motility after surgical intervention due to non-mechanical causes (89 %) and prevents sufficient oral intake (96 %). Abdominal distension/tenderness are the most relevant clinical signs (71 %). Nasogastric tube placement is not mandatory (78 %) but can be removed without previous clamping (81 %)/gastrointestinal contrast study (100 %). Preventive measures are recommended to decrease the risk of POI (96 %): narcotic sparing analgesia (89 %) and fluid optimization (74 %). Treatment of POI should include stimulation of ambulation (96 %) and stop of opioids (74 %). Total parenteral nutrition is recommended from the 7th day without sufficient oral intake (81 %). There was no consensus on the ranking of POI's symptoms, on the imaging modality of choice for the diagnosis of POI, neither on the difference between POI and PONV. CONCLUSIONS This Delphi study achieved consensus on the definition, relevant clinical signs, prevention, treatment, and supportive care of POI. Areas of non-consensus were identified (necessity and modality of radiologic imaging to establish the diagnosis, difference between POI and PONV), giving opportunity for further research.
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Affiliation(s)
- Daniel Gero
- Department of Visceral Surgery, University Hospital CHUV, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Olivier Gié
- Department of Visceral Surgery, University Hospital CHUV, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, University Hospital CHUV, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, University Hospital CHUV, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Dieter Hahnloser
- Department of Visceral Surgery, University Hospital CHUV, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland.
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Kraut JA. Approach to the Treatment of Methanol Intoxication. Am J Kidney Dis 2016; 68:161-7. [DOI: 10.1053/j.ajkd.2016.02.058] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 02/04/2016] [Indexed: 11/11/2022]
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79
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Nazir S, Melnick S, Ansari S, Kanneh HT. Mind the gap: a case of severe methanol intoxication. BMJ Case Rep 2016; 2016:bcr-2015-214272. [PMID: 26917798 DOI: 10.1136/bcr-2015-214272] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a case of a 37-year-old woman with non-insulin-dependent diabetes on sitagliptin, an alcohol abuser who was brought unresponsive to the emergency department of our hospital. On arrival, the patient was intubated and mechanically ventilated due to a low Glasgow Coma score of 3/15. Initial laboratory testing identified profound high anion gap metabolic acidosis. Owing to the dubious circumstances and the depth of acidosis, methanol and ethylene glycol intoxication was suspected. Further evaluation revealed a significantly increased serum osmolal gap. Pending volatile compound screen, fomepizole was started and urgent haemodialysis undertaken. Subsequent brain MRI identified changes in putamen of bilateral basal ganglia, suggestive of methanol intoxication. The patient was later found to have an initial methanol level of 237 mg/dL. She was successfully extubated on day 2 of hospitalisation, with residual cognitive and visual deficits.
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Affiliation(s)
- Salik Nazir
- Department of Internal Medicine, Reading Hospital and Medical Center, Reading, Pennsylvania, USA
| | - Stephen Melnick
- Department of Internal Medicine, Reading Hospital and Medical Center, Reading, Pennsylvania, USA
| | - Shabana Ansari
- Department of Internal Medicine, Reading Hospital and Medical Center, Reading, Pennsylvania, USA
| | - Haitham T Kanneh
- Department of Pulmonary and Critical Care, Reading Hospital and Medical Center, Reading, Pennsylvania, USA
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Zakharov S, Pelclova D, Urban P, Navratil T, Nurieva O, Kotikova K, Diblik P, Kurcova I, Belacek J, Komarc M, Eddleston M, Hovda KE. Use of Out-of-Hospital Ethanol Administration to Improve Outcome in Mass Methanol Outbreaks. Ann Emerg Med 2016; 68:52-61. [PMID: 26875060 DOI: 10.1016/j.annemergmed.2016.01.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Revised: 12/29/2015] [Accepted: 01/05/2016] [Indexed: 12/21/2022]
Abstract
STUDY OBJECTIVE Methanol poisoning outbreaks are a global public health issue, with delayed treatment causing poor outcomes. Out-of-hospital ethanol administration may improve outcome, but the difficulty of conducting research in outbreaks has meant that its effects have never been assessed. We study the effect of out-of-hospital ethanol in patients treated during a methanol outbreak in the Czech Republic between 2012 and 2014. METHODS This was an observational case-series study of 100 hospitalized patients with confirmed methanol poisoning. Out-of-hospital ethanol as a "first aid antidote" was administered by paramedic or medical staff before the confirmation of diagnosis to 30 patients; 70 patients did not receive out-of-hospital ethanol from the staff (12 patients self-administered ethanol shortly before presentation). RESULTS The state of consciousness at first contact with paramedic or medical staff, delay to admission, and serum methanol concentration were similar among groups. The median serum ethanol level on admission in the patients with out-of-hospital administration by paramedic or medical staff was 84.3 mg/dL (interquartile range 32.7 to 129.5 mg/dL). No patients with positive serum ethanol level on admission died compared with 21 with negative serum ethanol level (0% versus 36.2%). Patients receiving out-of-hospital ethanol survived without visual and central nervous system sequelae more often than those not receiving it (90.5% versus 19.0%). A positive association was present between out-of-hospital ethanol administration by paramedic or medical staff, serum ethanol concentration on admission, and both total survival and survival without sequelae of poisoning. CONCLUSION We found a positive association between out-of-hospital ethanol administration and improved clinical outcome. During mass methanol outbreaks, conscious adults with suspected poisoning should be considered for administration of out-of-hospital ethanol to reduce morbidity and mortality.
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Affiliation(s)
- Sergey Zakharov
- Toxicological Information Center, Department of Occupational Medicine, First Faculty of Medicine, Charles University, and General University Hospital, Prague, Czech Republic.
| | - Daniela Pelclova
- Toxicological Information Center, Department of Occupational Medicine, First Faculty of Medicine, Charles University, and General University Hospital, Prague, Czech Republic
| | - Pavel Urban
- Toxicological Information Center, Department of Occupational Medicine, First Faculty of Medicine, Charles University, and General University Hospital, Prague, Czech Republic
| | - Tomas Navratil
- Toxicological Information Center, Department of Occupational Medicine, First Faculty of Medicine, Charles University, and General University Hospital, Prague, Czech Republic; Department of Biomimetic Electrochemistry, J. Heyrovsky Institute of Physical Chemistry of the AS CR, Prague, Czech Republic
| | - Olga Nurieva
- Toxicological Information Center, Department of Occupational Medicine, First Faculty of Medicine, Charles University, and General University Hospital, Prague, Czech Republic
| | - Katerina Kotikova
- Toxicological Information Center, Department of Occupational Medicine, First Faculty of Medicine, Charles University, and General University Hospital, Prague, Czech Republic
| | - Pavel Diblik
- Department of Ophthalmology, General University Hospital, Prague, Czech Republic
| | - Ivana Kurcova
- Department of Toxicology and Forensic Medicine, First Faculty of Medicine, Charles University, and General University Hospital, Prague, Czech Republic
| | - Jaromir Belacek
- Institute of Biophysics and Informatics, First Faculty of Medicine, Charles University, and General University Hospital, Prague, Czech Republic
| | - Martin Komarc
- Institute of Biophysics and Informatics, First Faculty of Medicine, Charles University, and General University Hospital, Prague, Czech Republic
| | - Michael Eddleston
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Knut Erik Hovda
- Norwegian CBRNe Center of Medicine, Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
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Zakharov S, Kotikova K, Vaneckova M, Seidl Z, Nurieva O, Navratil T, Caganova B, Pelclova D. Acute Methanol Poisoning: Prevalence and Predisposing Factors of Haemorrhagic and Non-Haemorrhagic Brain Lesions. Basic Clin Pharmacol Toxicol 2016; 119:228-38. [DOI: 10.1111/bcpt.12559] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 01/14/2016] [Indexed: 01/06/2023]
Affiliation(s)
- Sergey Zakharov
- First Faculty of Medicine; Department of Occupational Medicine; Toxicological Information Center; Charles University in Prague and General University Hospital; Prague Czech Republic
| | - Katerina Kotikova
- First Faculty of Medicine; Department of Occupational Medicine; Toxicological Information Center; Charles University in Prague and General University Hospital; Prague Czech Republic
| | - Manuela Vaneckova
- First Faculty of Medicine; Department of Radiology; Charles University in Prague and General University Hospital; Prague Czech Republic
| | - Zdenek Seidl
- First Faculty of Medicine; Department of Radiology; Charles University in Prague and General University Hospital; Prague Czech Republic
| | - Olga Nurieva
- First Faculty of Medicine; Department of Occupational Medicine; Toxicological Information Center; Charles University in Prague and General University Hospital; Prague Czech Republic
| | - Tomas Navratil
- First Faculty of Medicine; Department of Occupational Medicine; Toxicological Information Center; Charles University in Prague and General University Hospital; Prague Czech Republic
- Department of Biomimetic Electrochemistry; J. Heyrovsky Institute of Physical Chemistry of AS CR; Prague Czech Republic
| | - Blazena Caganova
- National Toxicological Information Center; University Hospital Bratislava; Bratislava Slovakia
| | - Daniela Pelclova
- First Faculty of Medicine; Department of Occupational Medicine; Toxicological Information Center; Charles University in Prague and General University Hospital; Prague Czech Republic
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Mowry JB, Burdmann EA, Anseeuw K, Ayoub P, Ghannoum M, Hoffman RS, Lavergne V, Nolin TD, Gosselin S. Extracorporeal treatment for digoxin poisoning: systematic review and recommendations from the EXTRIP Workgroup. Clin Toxicol (Phila) 2016; 54:103-14. [DOI: 10.3109/15563650.2015.1118488] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- James B. Mowry
- Indiana Poison Center, Indiana University Health, Indianapolis, IN, USA
| | - Emmanuel A. Burdmann
- Division of Nephrology, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Kurt Anseeuw
- Department of Emergency Medicine, ZNA, Campus Stuivenberg, Antwerpen, Belgium
| | - Paul Ayoub
- Department of Nephrology, Verdun Hospital, University of Montreal, Verdun, Canada
| | - Marc Ghannoum
- Department of Nephrology, Verdun Hospital, University of Montreal, Verdun, Canada
| | - Robert S. Hoffman
- Ronald O. Perelman Department of Emergency Medicine, Division of Medical Toxicology, New York University School of Medicine, New York, NY, USA
| | - Valery Lavergne
- Department of Medical Biology, Sacré-Coeur Hospital, University of Montreal, Montreal, Canada
| | - Thomas D. Nolin
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Sophie Gosselin
- Department of Medicine and Emergency Medicine, McGill University Health Centre, McGill University, Montreal, Canada
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McMartin K, Jacobsen D, Hovda KE. Antidotes for poisoning by alcohols that form toxic metabolites. Br J Clin Pharmacol 2016; 81:505-15. [PMID: 26551875 DOI: 10.1111/bcp.12824] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 11/02/2015] [Accepted: 11/03/2015] [Indexed: 12/20/2022] Open
Abstract
The alcohols, methanol, ethylene glycol and diethylene glycol, have many features in common, the most important of which is the fact that the compounds themselves are relatively non-toxic but are metabolized, initially by alcohol dehydrogenase, to various toxic intermediates. These compounds are readily available worldwide in commercial products as well as in homemade alcoholic beverages, both of which lead to most of the poisoning cases, from either unintentional or intentional ingestion. Although relatively infrequent in overall occurrence, poisonings by metabolically-toxic alcohols do unfortunately occur in outbreaks and can result in severe morbidity and mortality. These poisonings have traditionally been treated with ethanol since it competes for the active site of alcohol dehydrogenase and decreases the formation of toxic metabolites. Although ethanol can be effective in these poisonings, there are substantial practical problems with its use and so fomepizole, a potent competitive inhibitor of alcohol dehydrogenase, was developed for a hopefully better treatment for metabolically-toxic alcohol poisonings. Fomepizole has few side effects and is easy to use in practice and it may obviate the need for haemodialysis in some, but not all, patients. Hence, fomepizole has largely replaced ethanol as the toxic alcohol antidote in many countries. Nevertheless, ethanol remains an important alternative because access to fomepizole can be limited, the cost may appear excessive, or the physician may prefer ethanol due to experience.
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Affiliation(s)
- Kenneth McMartin
- Department of Pharmacology, Toxicology & Neuroscience, Louisiana State University Health Sciences Center - Shreveport, 1501 Kings Highway, Shreveport, Louisiana, 71130-3932, USA
| | - Dag Jacobsen
- Department of Acute Medicine, Division of Medicine, Oslo University Hospital, NO-0424, Oslo, Norway
| | - Knut Erik Hovda
- The Norwegian CBRNe Centre of Medicine, Department of Acute Medicine, Division of Medicine, Oslo University Hospital, NO-0424, Oslo, Norway
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84
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Anseeuw K, Mowry JB, Burdmann EA, Ghannoum M, Hoffman RS, Gosselin S, Lavergne V, Nolin TD. Extracorporeal Treatment in Phenytoin Poisoning: Systematic Review and Recommendations from the EXTRIP (Extracorporeal Treatments in Poisoning) Workgroup. Am J Kidney Dis 2015; 67:187-97. [PMID: 26578149 DOI: 10.1053/j.ajkd.2015.08.031] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 08/28/2015] [Indexed: 01/12/2023]
Abstract
The Extracorporeal Treatments in Poisoning (EXTRIP) Workgroup conducted a systematic literature review using a standardized process to develop evidence-based recommendations on the use of extracorporeal treatment (ECTR) in patients with phenytoin poisoning. The authors reviewed all articles, extracted data, summarized findings, and proposed structured voting statements following a predetermined format. A 2-round modified Delphi method was used to reach a consensus on voting statements, and the RAND/UCLA Appropriateness Method was used to quantify disagreement. 51 articles met the inclusion criteria. Only case reports, case series, and pharmacokinetic studies were identified, yielding a very low quality of evidence. Clinical data from 31 patients and toxicokinetic grading from 46 patients were abstracted. The workgroup concluded that phenytoin is moderately dialyzable (level of evidence = C) despite its high protein binding and made the following recommendations. ECTR would be reasonable in select cases of severe phenytoin poisoning (neutral recommendation, 3D). ECTR is suggested if prolonged coma is present or expected (graded 2D) and it would be reasonable if prolonged incapacitating ataxia is present or expected (graded 3D). If ECTR is used, it should be discontinued when clinical improvement is apparent (graded 1D). The preferred ECTR modality in phenytoin poisoning is intermittent hemodialysis (graded 1D), but hemoperfusion is an acceptable alternative if hemodialysis is not available (graded 1D). In summary, phenytoin appears to be amenable to extracorporeal removal. However, because of the low incidence of irreversible tissue injury or death related to phenytoin poisoning and the relatively limited effect of ECTR on phenytoin removal, the workgroup proposed the use of ECTR only in very select patients with severe phenytoin poisoning.
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Affiliation(s)
- Kurt Anseeuw
- Campus Stuivenberg, Emergency Medicine, Antwerpen, Belgium
| | - James B Mowry
- Indiana University Health, Indiana Poison Center, Indianapolis, IN
| | - Emmanuel A Burdmann
- LIM 12, Division of Nephrology, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Marc Ghannoum
- Department of Nephrology, Verdun Hospital, University of Montreal, Verdun, QC, Canada
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, NY
| | - Sophie Gosselin
- Department of Emergency Medicine, Medical Toxicology Division, McGill University Health Centre & Department of Medicine, McGill University, Montreal, QC, Canada
| | - Valery Lavergne
- Department of Medical Biology, Sacre-Coeur Hospital, University of Montreal, Montreal, QC, Canada
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, PA; Renal Electrolyte Division, Department of Medicine, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, PA.
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85
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Ghannoum M, Lavergne V, Gosselin S, Mowry JB, Hoegberg LCG, Yarema M, Thompson M, Murphy N, Thompson J, Purssell R, Hoffman RS. Practice Trends in the Use of Extracorporeal Treatments for Poisoning in Four Countries. Semin Dial 2015; 29:71-80. [DOI: 10.1111/sdi.12448] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Marc Ghannoum
- Department of Nephrology; Verdun Hospital; University of Montreal; Montreal QC Canada
| | - Valery Lavergne
- Department of Medical Biology; Sacré-Coeur Hospital; University of Montreal; Montreal QC Canada
| | - Sophie Gosselin
- Department of Emergency Medicine; McGill University Health Centre; Centre Anti-Poison du Quebec; McGill University; Montreal QC Canada
| | - James B. Mowry
- Indiana Poison Center; Indiana University Health; Indianapolis Indiana
| | - Lotte C. G. Hoegberg
- Department of Anesthesiology; The Danish Poisons Information Center; Copenhagen University Hospital Bispebjerg; Copenhagen Denmark
| | - Mark Yarema
- Poison and Drug Information Service; Alberta Health Services; Calgary Alberta Canada
- Department of Emergency Medicine; University of Calgary; Calgary Alberta Canada
| | - Margaret Thompson
- Ontario & Manitoba Poison Centres and Divisions; Clinical Pharmacology and Emergency Medicine; University of Toronto; Toronto Ontario Canada
| | - Nancy Murphy
- Department of Emergency Medicine; Dalhousie University and IWK Regional Poison Centre; Halifax Nova Scotia Canada
| | - John Thompson
- National Poisons Information Service; Cardiff and Vale University Health Board; Cardiff United Kingdom
| | - Roy Purssell
- British Columbia Drug and Poison Information Centre; Department of Emergency Medicine; University of British Columbia; Vancouver British Columbia Canada
| | - Robert S. Hoffman
- Division of Medical Toxicology; Ronald O. Perelman Department of Emergency Medicine; New York University School of Medicine; New York City New York
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Zakharov S, Nurieva O, Kotikova K, Urban P, Navratil T, Pelclova D. Factors predicting optic nerve axonal degeneration after methanol-induced acute optic neuropathy: a 2-year prospective study in 54 patients. MONATSHEFTE FUR CHEMIE 2015. [DOI: 10.1007/s00706-015-1581-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Nurieva O, Kotikova K, Urban P, Pelclova D, Petrik V, Navratil T, Zakharov S. Prevalence, dynamics, and biochemical predictors of optic nerve remyelination after methanol-induced acute optic neuropathy: a 2-year prospective study in 54 patients. MONATSHEFTE FUR CHEMIE 2015. [DOI: 10.1007/s00706-015-1580-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Chiang PJ, Li TC, Chang CH, Chen LL, Lin JD, Su YC. SEED: the six excesses (Liu Yin) evaluation and diagnosis scale. Chin Med 2015; 10:30. [PMID: 26516343 PMCID: PMC4624590 DOI: 10.1186/s13020-015-0059-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Accepted: 09/14/2015] [Indexed: 11/27/2022] Open
Abstract
Background Infections such as common colds, influenza, acute upper respiratory infections, bacterial gastroenteritis, and urinary tract infections are usually diagnosed according to patients’ signs and symptoms. This study aims to develop a scale for the diagnosis of infectious diseases based on the six excesses (Liu Yin) etiological theory of Chinese medicine (CM) by the Delphi method. Methods A total of 200 CM-guided diagnostic items measuring signs and symptoms for infectious diseases were compiled from CM literature archives from the Han to Ming dynasties, CM textbooks in both China and Taiwan, and journal articles from the China Knowledge Resource Integrated Database. The items were based on infections and the six excesses (Liu Yin) etiological theory, i.e., Feng Xie (wind excess), Han Xie (coldness excess), Shu Xie (summer heat excess), Shi Xie (dampness excess), Zao Xie (dryness excess), and Huo Xie (fire excess). The items were further classified into the six excess syndromes and reviewed via a Delphi process to reach consensus among CM experts. Results In total, 178 items with a mean or median rating of 7 or above on a scale of 1–9 from a panel of 32 experts were retained. The numbers of diagnostic items in the categories of Feng (wind), Han (coldness), Shu (summer heat), Shi (dampness), Zao (dryness), and Huo (fire) syndromes were 15, 22, 25, 37, 17, and 62, respectively. Conclusions A CM-based six excesses (Liu Yin) evaluation and diagnosis (SEED) scale was developed for the evaluation and diagnosis of infectious diseases based only on signs and symptoms.
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Affiliation(s)
- Pei-Jung Chiang
- Graduate Institute of Chinese Medicine, School of Chinese Medicine, China Medical University, Taichung, Taiwan ; Department of Traditional Chinese Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Tsai-Chung Li
- Graduate Institute of Biostatistics, China Medical University, Taichung, Taiwan
| | - Chih-Hung Chang
- Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Li-Li Chen
- School of Nursing, China Medical University, Taichung, Taiwan ; Department of Nursing, China Medical University Hospital, Taichung, Taiwan
| | - Jun-Dai Lin
- Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan
| | - Yi-Chang Su
- Graduate Institute of Chinese Medicine, School of Chinese Medicine, China Medical University, Taichung, Taiwan
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Extracorporeal Treatment for Metformin Poisoning: Systematic Review and Recommendations From the Extracorporeal Treatments in Poisoning Workgroup. Crit Care Med 2015; 43:1716-30. [PMID: 25860205 DOI: 10.1097/ccm.0000000000001002] [Citation(s) in RCA: 128] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Metformin toxicity, a challenging clinical entity, is associated with a mortality of 30%. The role of extracorporeal treatments such as hemodialysis is poorly defined at present. Here, the Extracorporeal Treatments In Poisoning workgroup, comprising international experts representing diverse professions, presents its systematic review and clinical recommendations for extracorporeal treatment in metformin poisoning. METHODS A systematic literature search was performed, data extracted, findings summarized, and structured voting statements developed. A two-round modified Delphi method was used to achieve consensus on voting statements and RAND/UCLA Appropriateness Method to quantify disagreement. Anonymized votes and opinions were compiled and discussed. A second vote determined the final recommendations. RESULTS One hundred seventy-five articles were identified, including 63 deaths: one observational study, 160 case reports or series, 11 studies of descriptive cohorts, and three pharmacokinetic studies in end-stage renal disease, yielding a very low quality of evidence for all recommendations. The workgroup concluded that metformin is moderately dialyzable (level of evidence C) and made the following recommendations: extracorporeal treatment is recommended in severe metformin poisoning (1D). Indications for extracorporeal treatment include lactate concentration greater than 20 mmol/L (1D), pH less than or equal to 7.0 (1D), shock (1D), failure of standard supportive measures (1D), and decreased level of consciousness (2D). Extracorporeal treatment should be continued until the lactate concentration is less than 3 mmol/L (1D) and pH greater than 7.35 (1D), at which time close monitoring is warranted to determine the need for additional courses of extracorporeal treatment. Intermittent hemodialysis is preferred initially (1D), but continuous renal replacement therapies may be considered if hemodialysis is unavailable (2D). Repeat extracorporeal treatment sessions may use hemodialysis (1D) or continuous renal replacement therapy (1D). CONCLUSION Metformin poisoning with lactic acidosis appears to be amenable to extracorporeal treatments. Despite clinical evidence comprised mostly of case reports and suboptimal toxicokinetic data, the workgroup recommended extracorporeal removal in the case of severe metformin poisoning.
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90
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Prediction and validation of hemodialysis duration in acute methanol poisoning. Kidney Int 2015; 88:1170-7. [PMID: 26244924 PMCID: PMC4653586 DOI: 10.1038/ki.2015.232] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 05/29/2015] [Accepted: 06/04/2015] [Indexed: 11/17/2022]
Abstract
The duration of hemodialysis (HD) in methanol poisoning (MP) is dependent on the methanol concentration, the operational parameters used during HD, and the presence and severity of metabolic acidosis. However, methanol assays are not easily available, potentially leading to undue extension or premature termination of treatment. Here we provide a prediction model for the duration of high-efficiency HD in MP. In a retrospective cohort study, we identified 71 episodes of MP in 55 individuals who were treated with alcohol dehydrogenase inhibition and HD. Four patients had residual visual abnormality at discharge and only one patient died. In 46 unique episodes of MP with high-efficiency HD the mean methanol elimination half-life (T1/2) during HD was 108 min in women, significantly different from the 129 min in men. In a training set of 28 patients with MP, using the 90th percentile of gender-specific elimination T1/2 (147 min in men and 141 min in women) and a target methanol concentration of 4 mmol/l allowed all cases to reach a safe methanol of under 6 mmol/l. The prediction model was confirmed in a validation set of 18 patients with MP. High-efficiency HD time in hours can be estimated using 3.390 × (Ln (MCi/4)) for women and 3.534 × (Ln (MCi/4)) for men, where MCi is the initial methanol concentration in mmol/l, provided that metabolic acidosis is corrected.
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91
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Patel N, Bayliss GP. Developments in extracorporeal therapy for the poisoned patient. Adv Drug Deliv Rev 2015; 90:3-11. [PMID: 26050528 DOI: 10.1016/j.addr.2015.05.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 05/25/2015] [Accepted: 05/30/2015] [Indexed: 12/18/2022]
Abstract
The modern use of extracorporeal therapies to treat poisoning and drug overdoses dates back to the early 20th century and has evolved along with their use as treatment for acute kidney injury or as maintenance therapy in advanced kidney disease. As our understanding of drug pharmacokinetics and membrane materials has increased, the technologies of extracorporeal therapy and their applications have become more sophisticated. Despite that, there is little robust evidence to guide clinicians on the optimal use of extracorporeal therapy in treating poisoning beyond case reports and series. New efforts are underway to remedy that: the Extracorporeal Treatments in Poisoning Workgroup (EXTRIP) is an international effort on the part of nephrologists, pharmacists and toxicologists to review the available data and formulate evidence-based guidelines on how to use extracorporeal techniques to treat poisoning and improve patient outcomes. Meanwhile, new techniques and membranes are under development. This review will summarize those key scientific and technologic developments, the efforts to optimize their use and new directions in research.
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92
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Ghannoum M, Laliberté M, Nolin TD, MacTier R, Lavergne V, Hoffman RS, Gosselin S. Extracorporeal treatment for valproic acid poisoning: systematic review and recommendations from the EXTRIP workgroup. Clin Toxicol (Phila) 2015; 53:454-65. [PMID: 25950372 DOI: 10.3109/15563650.2015.1035441] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The EXtracorporeal TReatments In Poisoning (EXTRIP) workgroup presents its systematic review and clinical recommendations on the use of extracorporeal treatment (ECTR) in valproic acid (VPA) poisoning. METHODS The lead authors reviewed all of the articles from a systematic literature search, extracted the data, summarized the key findings, and proposed structured voting statements following a predetermined format. A two-round modified Delphi method was chosen to reach a consensus on voting statements and the RAND/UCLA Appropriateness Method was used to quantify disagreement. Anonymous votes were compiled, returned, and discussed in person. A second vote was conducted to determine the final workgroup recommendations. RESULTS The latest literature search conducted in November 2014 retrieved a total of 79 articles for final qualitative analysis, including one observational study, one uncontrolled cohort study with aggregate analysis, 70 case reports and case series, and 7 pharmacokinetic studies, yielding a very low quality of evidence for all recommendations. Clinical data were reported for 82 overdose patients while pharmaco/toxicokinetic grading was performed in 55 patients. The workgroup concluded that VPA is moderately dialyzable (level of evidence = B) and made the following recommendations: ECTR is recommended in severe VPA poisoning (1D); recommendations for ECTR include a VPA concentration > 1300 mg/L (9000 μmol/L)(1D), the presence of cerebral edema (1D) or shock (1D); suggestions for ECTR include a VPA concentration > 900 mg/L (6250 μmol/L)(2D), coma or respiratory depression requiring mechanical ventilation (2D), acute hyperammonemia (2D), or pH ≤ 7.10 (2D). Cessation of ECTR is indicated when clinical improvement is apparent (1D) or the serum VPA concentration is between 50 and 100 mg/L (350-700 μmol/L)(2D). Intermittent hemodialysis is the preferred ECTR in VPA poisoning (1D). If hemodialysis is not available, then intermittent hemoperfusion (1D) or continuous renal replacement therapy (2D) is an acceptable alternative. CONCLUSIONS VPA is moderately dialyzable in the setting of overdose. ECTR is indicated for VPA poisoning if at least one of the above criteria is present. Intermittent hemodialysis is the preferred ECTR modality in VPA poisoning.
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Affiliation(s)
- Marc Ghannoum
- Department of Nephrology, Verdun Hospital, University of Montreal , Verdun, QC , Canada
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93
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Prioritizing the Intoxicated Patients for Extracorporeal Treatments in Methanol Poisoning. Crit Care Med 2015; 43:e210-1. [DOI: 10.1097/ccm.0000000000000907] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Affiliation(s)
- Darren M Roberts
- Burns, Trauma and Critical Care Research Centre, School of Medicine, University of Queensland, Brisbane, QLD, Australia, and Drug Health Clinical Services, Royal Prince Alfred Hospital, Sydney, NSW, Australia Division of Medical Toxicology, Department of Emergency Medicine, New York University School of Medicine, New York, NY Department of Emergency Medicine, Medical Toxicology Service, McGill University Health Centre, McGill University, Montréal, QC, Canada Réanimation Médicale et Toxicologique, Hôpital Lariboisière, INSERM U1144, Université Paris-Diderot, Paris, France Emergency Medicine Department/Clinical Toxicology Unit, Hospital Universitari Son Espases, Palma de Mallorca, Spain Department of Medicine, University of Montreal, Verdun Hospital, Montreal, QC, Canada
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Juurlink DN, Gosselin S, Kielstein JT, Ghannoum M, Lavergne V, Nolin TD, Hoffman RS. Extracorporeal Treatment for Salicylate Poisoning: Systematic Review and Recommendations From the EXTRIP Workgroup. Ann Emerg Med 2015; 66:165-81. [PMID: 25986310 DOI: 10.1016/j.annemergmed.2015.03.031] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Revised: 03/09/2015] [Accepted: 03/25/2015] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVE Salicylate poisoning is a challenging clinical entity associated with substantial morbidity and mortality. The indications for extracorporeal treatments such as hemodialysis are poorly defined. We present a systematic review of the literature along with evidence- and consensus-based recommendations on the use of extracorporeal treatment in salicylate poisoning. METHODS The Extracorporeal Treatments in Poisoning (EXTRIP) Workgroup is a multidisciplinary group with international representation whose aim is to provide evidence-based recommendations on the use of extracorporeal treatments in poisoning. We conducted a systematic literature review followed by data extraction and summarized findings, following a predetermined format. The entire work group voted by a 2-round modified Delphi method to reach consensus on voting statements, using a RAND/UCLA Appropriateness Method to quantify disagreement. Anonymous votes were compiled, returned, and discussed in person. A second vote determined the final recommendations. RESULTS Eighty-four articles met inclusion criteria, including 1 controlled clinical trial, 3 animal studies, and 80 case reports or case series, yielding an overall very low quality of evidence for all recommendations. Clinical data on 143 patients (130 sets of which could be analyzed for patient-level entry data), including 14 fatalities, were reviewed. Toxicokinetic data on 87 patients were also included. After the second round of voting, the workgroup concluded that salicylates are dialyzable by hemodialysis and hemoperfusion (level of evidence=B) and recommended extracorporeal treatment in patients with severe salicylate poisoning (1D), including any patient with altered mental status (1D), with acute respiratory distress syndrome requiring supplemental oxygen (1D), and for those in whom standard therapy is deemed to be failing (1D) regardless of the salicylate concentration. High salicylate concentrations warrant extracorporeal treatment regardless of signs and symptoms (>7.2 mmol/L [100 mg/dL] [1D]; and >6.5 mmol/L [90 mg/dL] [2D]), with lower thresholds applied for patients with impaired kidney function (>6.5 mmol/L [90 mg/dL] [1D]; >5.8 mmol/L [80 mg/dL] [2D]). Extracorporeal treatment is also suggested for patients with severe acidemia (pH ≤7.20 in the absence of other indications) (2D). Intermittent hemodialysis is the preferred modality (1D), although hemoperfusion (1D) and continuous renal replacement therapies (3D) are acceptable alternatives if hemodialysis is unavailable, as is exchange transfusion in neonates (1D). CONCLUSION Salicylates are readily removed by extracorporeal treatment, with intermittent hemodialysis being the preferred modality. The signs and symptoms of salicylate toxicity listed warrant extracorporeal treatment, as do high concentrations regardless of clinical status.
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Affiliation(s)
- David N Juurlink
- Departments of Medicine, Pediatrics and the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Sophie Gosselin
- Department of Emergency Medicine, Medical Toxicology Service, McGill University Health Centre, McGill University, Montréal, Quebec, Canada
| | - Jan T Kielstein
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Marc Ghannoum
- Department of Nephrology, Verdun Hospital, University of Montréal, Verdun, Quebec, Canada
| | - Valéry Lavergne
- Department of Medical Biology, Sacré-Coeur Hospital, University of Montréal, Montréal, Quebec, Canada
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics and the Department of Medicine Renal Electrolyte Division, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, PA
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, NY.
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Liu Z, Sun M, Zhao H, Zhao M. Acute self-induced poisoning with sodium ferrocyanide and methanol treated with plasmapheresis and continuous renal replacement therapy successfully: a case report. Medicine (Baltimore) 2015; 94:e890. [PMID: 26020397 PMCID: PMC4616416 DOI: 10.1097/md.0000000000000890] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Self-induced poisoning with chemicals is one of the most commonly used suicide methods. Suicide attempts using massive pure sodium ferrocyanide and methanol are rare. This article discusses the management of acute intentional self-poisoning using sodium ferrocyanide and methanol. We present a case of acute self-induced poisoning using sodium ferrocyanide and methanol admitted to our hospital 2 hours after ingestion. He was deeply unconscious and unresponsive to painful stimuli. The laboratory findings showed acute kidney injury and severe metabolic acidosis. We took effective measures including endotracheal intubation and mechanical ventilation to ensure the vital signs were stable. Subsequently, we treated the patient using gastric lavage, bicarbonate, ethanol, plasmapheresis (plasma exchange), and continuous renal replacement therapy (CRRT) successfully. He gradually recovered from poisoning and was discharged without abnormalities on the 6th day. Follow-up for 3 months revealed no sequelae. Blood purification including plasmapheresis and CRRT is an effective method to scavenge toxicants from the body for acute self-poisoning with sodium ferrocyanide and methanol. Treatment strategies in the management of poisoning, multiple factors including the removal efficiency of toxin, the protection of vital organs, and the maintenance of homeostasis must be considered.
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Affiliation(s)
- Zhenning Liu
- From the Department of Emergency Medicine, Shengjing Hospital of China Medical University (ZL, HZ, MZ); and Pharmacy College, China Medical University, Shenyang, China (MS)
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Ghannoum M, Wiegand TJ, Liu KD, Calello DP, Godin M, Lavergne V, Gosselin S, Nolin TD, Hoffman RS. Extracorporeal treatment for theophylline poisoning: systematic review and recommendations from the EXTRIP workgroup. Clin Toxicol (Phila) 2015; 53:215-29. [PMID: 25715736 DOI: 10.3109/15563650.2015.1014907] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The Extracorporeal Treatments in Poisoning workgroup was created to provide evidence-based recommendations on the use of extracorporeal treatments (ECTRs) in poisoning. Here, the workgroup presents its systematic review and recommendations for theophylline. METHODS After a systematic review of the literature, a subgroup reviewed articles, extracted data, summarized findings, and proposed structured voting statements following a pre-determined format. A two-round modified Delphi method was chosen to reach a consensus on voting statements and the RAND/UCLA Appropriateness Method was used to quantify disagreement. Anonymous votes were compiled, returned, and discussed. A second vote determined the final recommendations. RESULTS 141 articles were included: 6 in vitro studies, 4 animal studies, 101 case reports/case series, 7 descriptive cohorts, 4 observational studies, and 19 pharmacokinetic studies, yielding a low-to-very-low quality of evidence for all recommendations. Data on 143 patients were reviewed, including 10 deaths. The workgroup concluded that theophylline is dialyzable (level of evidence = A) and made the following recommendations: ECTR is recommended in severe theophylline poisoning (1C). Specific recommendations for ECTR include a theophylline concentration [theophylline] > 100 mg/L (555 μmol/L) in acute exposure (1C), the presence of seizures (1D), life-threatening dysrhythmias (1D) or shock (1D), a rising [theophylline] despite optimal therapy (1D), and clinical deterioration despite optimal care (1D). In chronic poisoning, ECTR is suggested if [theophylline] > 60 mg/L (333 μmol/L) (2D) or if the [theophylline] > 50 mg/L (278 μmol/L) and the patient is either less than 6 months of age or older than 60 years of age (2D). ECTR is also suggested if gastrointestinal decontamination cannot be administered (2D). ECTR should be continued until clinical improvement is apparent or the [theophylline] is < 15 mg/L (83 μmol/L) (1D). Following the cessation of ECTR, patients should be closely monitored. Intermittent hemodialysis is the preferred method of ECTR (1C). If intermittent hemodialysis is unavailable, hemoperfusion (1C) or continuous renal replacement therapies may be considered (3D). Exchange transfusion is an adequate alternative to hemodialysis in neonates (2D). Multi-dose activated charcoal should be continued during ECTR (1D). CONCLUSION Theophylline poisoning is amenable to ECTRs. The workgroup recommended extracorporeal removal in the case of severe theophylline poisoning.
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Affiliation(s)
- Marc Ghannoum
- Department of Nephrology, Verdun Hospital, University of Montreal , Verdun , Canada
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Nurieva O, Kotikova K. Severe Methanol Poisoning with Supralethal Serum Formate Concentration: A Case Report. Med Princ Pract 2015; 24:581-3. [PMID: 26380973 PMCID: PMC5588285 DOI: 10.1159/000439350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 08/12/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To present a case of survival without visual and central nervous system sequelae at a formate concentration of twice the reported lethal level. CLINICAL PRESENTATION AND INTERVENTION This was a case of a 33-year-old man who ingested 1 liter of a toxic mixture of methanol and ethanol. Upon admission, he presented with anxiety, tachycardia and hypertension and had a serum formate level of 1,400 mg/l (normal range 0.9-2.1 mg/l), a methanol level of 806 mg/l (normal range 2-30 mg/l), an undetectable ethanol concentration and a normal lactate level. A 10% solution of ethanol and folinic acid was administered intravenously and two 8-hour sessions of intermittent hemodialysis were performed. The patient was discharged on the fifth day without sequelae of poisoning. The follow-up examinations 3 months and 2 years later revealed no damage to the basal ganglia. The patient had normal visual-evoked potential and findings on optical coherence tomography. The genetic analysis revealed a rare minor allele for the gene coding CYP2E1 enzyme of the microsomal ethanol oxidizing system. CONCLUSION The patient survived acute methanol poisoning without long-term sequelae despite a high serum level of formic acid upon admission.
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Affiliation(s)
- Olga Nurieva
- *Olga Nurieva, MD, Department of Occupational Medicine, Toxicological Information Center, First Faculty of Medicine, Charles University in Prague and General University Hospital, Na Bojisti 1, Z-120 00 Prague 2 (Czech Republic), E-Mail
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