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Shingina A, Mukhtar N, Wakim-Fleming J, Alqahtani S, Wong RJ, Limketkai BN, Larson AM, Grant L. Acute Liver Failure Guidelines. Am J Gastroenterol 2023; 118:1128-1153. [PMID: 37377263 DOI: 10.14309/ajg.0000000000002340] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 04/04/2023] [Indexed: 06/29/2023]
Abstract
Acute liver failure (ALF) is a rare, acute, potentially reversible condition resulting in severe liver impairment and rapid clinical deterioration in patients without preexisting liver disease. Due to the rarity of this condition, published studies are limited by the use of retrospective or prospective cohorts and lack of randomized controlled trials. Current guidelines represent the suggested approach to the identification, treatment, and management of ALF and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence was reviewed using the Grading of Recommendations, Assessment, Development and Evaluation process to develop recommendations. When no robust evidence was available, expert opinions were summarized using Key Concepts. Considering the variety of clinical presentations of ALF, individualization of care should be applied in specific clinical scenarios.
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Affiliation(s)
- Alexandra Shingina
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nizar Mukhtar
- Department of Gastroenterology, Kaiser Permanente, San Francisco, California, USA
| | - Jamilé Wakim-Fleming
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland Ohio, USA
| | - Saleh Alqahtani
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
- Liver Transplantation Unit, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California, Gastroenterology Section, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA
| | | | - Anne M Larson
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, Washington, USA
| | - Lafaine Grant
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
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Activated Carbon Fiber Cloth/Biomimetic Apatite: A Dual Drug Delivery System. Int J Mol Sci 2021; 22:ijms222212247. [PMID: 34830128 PMCID: PMC8624510 DOI: 10.3390/ijms222212247] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/02/2021] [Accepted: 11/08/2021] [Indexed: 02/07/2023] Open
Abstract
A biomaterial that is both bioactive and capable of controlled drug release is highly attractive for bone regeneration. In previous works, we demonstrated the possibility of combining activated carbon fiber cloth (ACC) and biomimetic apatite (such as calcium-deficient hydroxyapatite (CDA)) to develop an efficient material for bone regeneration. The aim to use the adsorption properties of an activated carbon/biomimetic apatite composite to synthetize a biomaterial to be used as a controlled drug release system after implantation. The adsorption and desorption of tetracycline and aspirin were first investigated in the ACC and CDA components and then on ACC/CDA composite. The results showed that drug adsorption and release are dependent on the adsorbent material and the drug polarity/hydrophilicity, leading to two distinct modes of drug adsorption and release. Consequently, a double adsorption approach was successfully performed, leading to a multifunctional and innovative ACC-aspirin/CDA-tetracycline implantable biomaterial. In a second step, in vitro tests emphasized a better affinity of the drug (tetracycline or aspirin)-loaded ACC/CDA materials towards human primary osteoblast viability and proliferation. Then, in vivo experiments on a large cortical bone defect in rats was carried out to test biocompatibility and bone regeneration ability. Data clearly highlighted a significant acceleration of bone reconstruction in the presence of the ACC/CDA patch. The ability of the aspirin-loaded ACC/CDA material to release the drug in situ for improving bone healing was also underlined, as a proof of concept. This work highlights the possibility of bone patches with controlled (multi)drug release features being used for bone tissue repair.
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Hoegberg LCG, Shepherd G, Wood DM, Johnson J, Hoffman RS, Caravati EM, Chan WL, Smith SW, Olson KR, Gosselin S. Systematic review on the use of activated charcoal for gastrointestinal decontamination following acute oral overdose. Clin Toxicol (Phila) 2021; 59:1196-1227. [PMID: 34424785 DOI: 10.1080/15563650.2021.1961144] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The use of activated charcoal in poisoning remains both a pillar of modern toxicology and a source of debate. Following the publication of the joint position statements on the use of single-dose and multiple-dose activated charcoal by the American Academy of Clinical Toxicology and the European Association of Poison Centres and Clinical Toxicologists, the routine use of activated charcoal declined. Over subsequent years, many new pharmaceuticals became available in modified or alternative-release formulations and additional data on gastric emptying time in poisoning was published, challenging previous assumptions about absorption kinetics. The American Academy of Clinical Toxicology, the European Association of Poison Centres and Clinical Toxicologists and the Asia Pacific Association of Medical Toxicology founded the Clinical Toxicology Recommendations Collaborative to create a framework for evidence-based recommendations for the management of poisoned patients. The activated charcoal workgroup of the Clinical Toxicology Recommendations Collaborative was tasked with reviewing systematically the evidence pertaining to the use of activated charcoal in poisoning in order to update the previous recommendations. OBJECTIVES The main objective was: Does oral activated charcoal given to adults or children prevent toxicity or improve clinical outcome and survival of poisoned patients compared to those who do not receive charcoal? Secondary objectives were to evaluate pharmacokinetic outcomes, the role of cathartics, and adverse events to charcoal administration. This systematic review summarizes the available evidence on the efficacy of activated charcoal. METHODS A medical librarian created a systematic search strategy for Medline (Ovid), subsequently translated for Embase (via Ovid), CINAHL (via EBSCO), BIOSIS Previews (via Ovid), Web of Science, Scopus, and the Cochrane Library/DARE. All databases were searched from inception to December 31, 2019. There were no language limitations. One author screened all citations identified in the search based on predefined inclusion/exclusion criteria. Excluded citations were confirmed by an additional author and remaining articles were obtained in full text and evaluated by at least two authors for inclusion. All authors cross-referenced full-text articles to identify articles missed in the searches. Data from included articles were extracted by the authors on a standardized spreadsheet and two authors used the GRADE methodology to independently assess the quality and risk of bias of each included study. RESULTS From 22,950 titles originally identified, the final data set consisted of 296 human studies, 118 animal studies, and 145 in vitro studies. Also included were 71 human and two animal studies that reported adverse events. The quality was judged to have a Low or Very Low GRADE in 469 (83%) of the studies. Ninety studies were judged to be of Moderate or High GRADE. The higher GRADE studies reported on the following drugs: paracetamol (acetaminophen), phenobarbital, carbamazepine, cardiac glycosides (digoxin and oleander), ethanol, iron, salicylates, theophylline, tricyclic antidepressants, and valproate. Data on newer pharmaceuticals not reviewed in the previous American Academy of Clinical Toxicology/European Association of Poison Centres and Clinical Toxicologists statements such as quetiapine, olanzapine, citalopram, and Factor Xa inhibitors were included. No studies on the optimal dosing for either single-dose or multiple-dose activated charcoal were found. In the reviewed clinical data, the time of administration of the first dose of charcoal was beyond one hour in 97% (n = 1006 individuals), beyond two hours in 36% (n = 491 individuals), and beyond 12 h in 4% (n = 43 individuals) whereas the timing of the first dose in controlled studies was within one hour of ingestion in 48% (n = 2359 individuals) and beyond two hours in 36% (n = 484) of individuals. CONCLUSIONS This systematic review found heterogenous data. The higher GRADE data was focused on a few select poisonings, while studies that addressed patients with unknown and or mixed ingestions were hampered by low rates of clinically meaningful toxicity or death. Despite these limitations, they reported a benefit of activated charcoal beyond one hour in many clinical scenarios.
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Affiliation(s)
- Lotte C G Hoegberg
- Department of Anesthesiology, The Danish Poisons Information Centre, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Greene Shepherd
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Jami Johnson
- Oklahoma Center for Poison and Drug Information, University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - E Martin Caravati
- Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Wui Ling Chan
- Department of Emergency Medicine, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Silas W Smith
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Kent R Olson
- California Poison Control System, San Francisco Division, University of California, San Francisco, California
| | - Sophie Gosselin
- Emergency Department CISSS Montérégie Centre, Greenfield Park, Canada.,Centre antipoison du Québec, Québec, Canada.,Department of Emergency Medicine, McGill Faculty of Medicine, Montreal, Canada
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Sümer E, Senturk GE, Demirel ÖU, Yesilada E. Comparative biochemical and histopathological evaluations proved that receptacle is the most effective part of Cynara scolymus against liver and kidney damages. JOURNAL OF ETHNOPHARMACOLOGY 2020; 249:112458. [PMID: 31809787 DOI: 10.1016/j.jep.2019.112458] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 11/21/2019] [Accepted: 12/02/2019] [Indexed: 06/10/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE The liver and kidney are among the most important organs in the body, where metabolic and elimination functions take place. During this process, liver and kidneys may suffer damage due to ingestion or formation of toxic metabolites leading to organ loss and even death. Artichoke (Cynara scolymus L.) leaf has long been recognized as a popular herbal remedy in traditional medicines with beneficial effects on liver. AIM OF THE STUDY In phytotherapy leaves are the part used to support the liver functions and for treatment of damage induced by various toxins, while fleshy receptacle is cooked as meal to support liver homeostasis. However, effects of other plant parts on liver such as stems, bracts have not much attracted the attention of scientific community so far. In this study we investigated comparatively the hepatoprotective and nephroprotective effects of different plant parts of artichoke, i.e. receptacles, outer bracts, inner bracts, and stems with that of leaves upon paracetamol-induction in rats. MATERIALS AND METHODS Aqueous ethanol (80%) extracts obtained from the different parts of artichoke were administered for five consecutive days after paracetamol induction to rats. At the end of experimental period blood samples from the experimental animals were taken for biochemical tests, while livers and kidneys were removed for further histopathological evaluation. RESULTS The histopathological examinations of liver and kidney tissues revealed that the receptacle and stem extracts of the artichoke were the most effective parts by improving the experimentally induced pathology in both liver and kidney. Biochemical tests also supported the histopathological data; receptacle, stem and bract extracts reduced serum alanine transaminase (ALT) and aspartate transaminase (AST) levels, but not alkaline phosphatase (ALP), creatinine and blood urea nitrogen (BUN) levels. CONCLUSIONS Histopathological and biochemical studies have shown that receptacle and stem extracts of artichoke were found to exert higher protective activity on liver and kidney damage induced by paracetamol comparing to its bract and leaf extracts, the latest is officially recognized as herbal remedy.
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Affiliation(s)
- Engin Sümer
- Yeditepe University, Graduate School of Health Sciences, Department of Phytotherapy, Ataşehir, İstanbul, Turkey.
| | - Gözde Erkanli Senturk
- Istanbul University, Cerrahpasa Medical Faculty, Department of Histology and Embryology, Cerrahpaşa, İstanbul, Turkey.
| | - Özlem Unay Demirel
- Bahçeşehir University, School of Medicine, Department of Biochemistry, Kadıköy, İstanbul, Turkey.
| | - Erdem Yesilada
- Yeditepe University, Faculty of Pharmacy, Department of Pharmacognosy and Phytotherapy, Ataşehir, 34755, İstanbul, Turkey.
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Hepatic Failure. PRINCIPLES OF ADULT SURGICAL CRITICAL CARE 2016. [PMCID: PMC7123541 DOI: 10.1007/978-3-319-33341-0_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The progression of liver disease can cause several physiologic derangements that may precipitate hepatic failure and require admission to an intensive care unit. The underlying pathology may be acute, acute-on chronic, or chronic in nature. Liver failure may manifest with a variety of clinical signs and symptoms that need prompt attention. The compromised synthetic and metabolic activity of the failing liver affects all organ systems, from neurologic to integumentary. Supportive care and specific therapies should be instituted in order to improve outcome and minimize time of recovery. In this chapter we will discuss the definition, clinical manifestations, workup, and management of acute and chronic liver failure and the general principles of treatment of these patients. Management of liver failure secondary to certain common etiologies will also be presented. Finally, liver transplantation and alternative therapies will also be discussed.
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Waring WS. Criteria for acetylcysteine treatment and clinical outcomes after paracetamol poisoning. Expert Rev Clin Pharmacol 2014; 5:311-8. [DOI: 10.1586/ecp.12.15] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Tu X, Ma Y, Cao Y, Huang J, Zhang M, Zhang Z. PEGylated carbon nanoparticles for efficient in vitro photothermal cancer therapy. J Mater Chem B 2014; 2:2184-2192. [DOI: 10.1039/c3tb21750g] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PEGylated carbon nanoparticles possess strong heat-producing ability and exhibit great potential in photothermal cancer therapy.
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Affiliation(s)
- Xiaolong Tu
- Suzhou Key Laboratory of Nanobiomedicine
- Division of Nanobiomedicine
- Collaborative Innovation Center of Suzhou Nano Science and Technology
- Suzhou Institute of Nano-Tech and Nano-Bionics
- Chinese Academy of Sciences
| | - Yufei Ma
- Suzhou Key Laboratory of Nanobiomedicine
- Division of Nanobiomedicine
- Collaborative Innovation Center of Suzhou Nano Science and Technology
- Suzhou Institute of Nano-Tech and Nano-Bionics
- Chinese Academy of Sciences
| | - Yuhua Cao
- Suzhou Key Laboratory of Nanobiomedicine
- Division of Nanobiomedicine
- Collaborative Innovation Center of Suzhou Nano Science and Technology
- Suzhou Institute of Nano-Tech and Nano-Bionics
- Chinese Academy of Sciences
| | - Jie Huang
- Suzhou Key Laboratory of Nanobiomedicine
- Division of Nanobiomedicine
- Collaborative Innovation Center of Suzhou Nano Science and Technology
- Suzhou Institute of Nano-Tech and Nano-Bionics
- Chinese Academy of Sciences
| | - Mengxin Zhang
- Suzhou Key Laboratory of Nanobiomedicine
- Division of Nanobiomedicine
- Collaborative Innovation Center of Suzhou Nano Science and Technology
- Suzhou Institute of Nano-Tech and Nano-Bionics
- Chinese Academy of Sciences
| | - Zhijun Zhang
- Suzhou Key Laboratory of Nanobiomedicine
- Division of Nanobiomedicine
- Collaborative Innovation Center of Suzhou Nano Science and Technology
- Suzhou Institute of Nano-Tech and Nano-Bionics
- Chinese Academy of Sciences
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Chu M, Peng J, Zhao J, Liang S, Shao Y, Wu Q. Laser light triggered-activated carbon nanosystem for cancer therapy. Biomaterials 2013; 34:1820-32. [DOI: 10.1016/j.biomaterials.2012.11.027] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 11/20/2012] [Indexed: 10/27/2022]
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Abstract
PURPOSE OF REVIEW Gastrointestinal decontamination in overdose patients remains a controversial problem in emergency medicine. There has been a significant decrease in the use of single-dose activated charcoal (SDAC) in recent years based on little new evidence and possibly because the overall mortality in overdose patients is low. RECENT FINDINGS Human volunteer studies suggest SDAC is effective and this effect occurs for up to 4 h after ingestion, but the magnitude of the reduction in area under the curve (AUC) decreases over time. Two randomized controlled trials including one recent large study did not find SDAC to be beneficial. Pharmacokinetic and pharmacodynamic studies of specific drugs in overdose suggest that for most drugs SDAC decreases drug exposure, but this does not translate to clinical benefit in all cases. The administration of SDAC is a low-risk intervention. SUMMARY Although SDAC is unlikely to be beneficial in many overdose patients, for some subgroups with severe poisoning, the benefits will outweigh the low risk of administration. The use of SDAC should be based on the potential toxicity of the drug ingested and the potential benefit of SDAC balanced against the willingness of the patient to take SDAC and the low risk of administration.
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Tuuri RE, Wright JL, He J, McCarter RJ, Ryan LM. Does prearrival communication from a poison center to an emergency department decrease time to activated charcoal for pediatric poisoning? Pediatr Emerg Care 2011; 27:1045-51. [PMID: 22068066 DOI: 10.1097/pec.0b013e318235ea02] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE A poison center plays an important role in directing appropriate care, which is critical in reducing morbidity due to poisoning. Activated charcoal (AC) is one intervention for some poisonings. This study examined whether children with a poisoning who were preannounced by a poison center received AC earlier than patients without a referral. METHODS A retrospective review of AC administration in children aged 0 to 18 years in a pediatric emergency department (ED) from 2000 to 2006 was performed. Abstracted covariates were poison center referral status, age, sex, acuity, disposition, transportation mode, triage time, and time of AC administration. Analysis of variance controlling for covariates tested the equality of mean time intervals between the groups with and without a poison center referral. RESULTS Three hundred fifty-one cases met the inclusion criteria. One hundred thirty-five (39%) were male. Eighty cases (23%) had a poison center referral. Time from triage to charcoal administration for patients with a poison center referral was a mean of 59 (SD, 34) minutes. Time for the group without a referral was a mean of 71 (SD, 43) minutes (P = 0.0036). CONCLUSIONS Advanced communication from a poison center was associated with earlier administration of AC in the ED for this population. Nevertheless, the duration to charcoal administration was frequently suboptimal. Triage and prehospital practices should be reexamined to improve timeliness of AC when indicated and consider exclusion of administration if beyond an appropriate time frame. Advanced notification should be the paradigm for all poison centers, and early response protocols for poison center referrals should be used by EDs.
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Affiliation(s)
- Rachel E Tuuri
- Division of Pediatric Emergency Medicine, Medical University of South Carolina, Charleston, SC, USA.
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Albertson TE, Owen KP, Sutter ME, Chan AL. Gastrointestinal decontamination in the acutely poisoned patient. Int J Emerg Med 2011; 4:65. [PMID: 21992527 PMCID: PMC3207879 DOI: 10.1186/1865-1380-4-65] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 10/12/2011] [Indexed: 12/15/2022] Open
Abstract
Objective To define the role of gastrointestinal (GI) decontamination of the poisoned patient. Data Sources A computer-based PubMed/MEDLINE search of the literature on GI decontamination in the poisoned patient with cross referencing of sources. Study Selection and Data Extraction Clinical, animal and in vitro studies were reviewed for clinical relevance to GI decontamination of the poisoned patient. Data Synthesis The literature suggests that previously, widely used, aggressive approaches including the use of ipecac syrup, gastric lavage, and cathartics are now rarely recommended. Whole bowel irrigation is still often recommended for slow-release drugs, metals, and patients who "pack" or "stuff" foreign bodies filled with drugs of abuse, but with little quality data to support it. Activated charcoal (AC), single or multiple doses, was also a previous mainstay of GI decontamination, but the utility of AC is now recognized to be limited and more time dependent than previously practiced. These recommendations have resulted in several treatment guidelines that are mostly based on retrospective analysis, animal studies or small case series, and rarely based on randomized clinical trials. Conclusions The current literature supports limited use of GI decontamination of the poisoned patient.
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Affiliation(s)
- Timothy E Albertson
- Department of Internal Medicine, School of Medicine, University of California, Davis, Sacramento, California, USA.
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Affiliation(s)
- Kent R Olson
- California Poison Control System, San Francisco Division, University of California, San Francisco, San Francisco, CA 94143-1369, USA.
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Tuuri RE, Ryan LM, He J, McCarter RJ, Wright JL. Does Emergency Medical Services Transport for Pediatric Ingestion Decrease Time to Activated Charcoal? PREHOSP EMERG CARE 2009; 13:295-303. [DOI: 10.1080/10903120902935272] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Toxicologic conditions are encountered in critically ill patients due to intentional or unintentional misuse of or exposure to therapeutic or illicit drugs. Additionally, toxicities related to medical interventions may develop in hospitalized patients. This review focuses on recent developments in the field of critical care toxicology. Early interventions to decrease absorption or enhance elimination of toxins have limited value. Specific interventions to manage toxicities due to analgesics, sedative-hypnotics, antidepressants, antipsychotics, cardiovascular agents, alcohols, carbon monoxide, and cholinergic agents are reviewed. Hospital-acquired toxicities due to methemoglobinemia, propylene glycol, and propofol should be recognized and treated. The clinician is continually required to incorporate clinical judgment along with available scientific data and clinical evidence to determine the best therapy for toxicologic conditions.
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