1
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Leibovitch ER, Fujiwara AS, Chun IKH, Villanueva NC, Yamamoto LG. Ibuprofen dosing measurement accuracy using infants' versus children's ibuprofen: a randomized crossover comparison. Pediatr Res 2023; 94:1145-1150. [PMID: 36941340 DOI: 10.1038/s41390-023-02573-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 03/05/2023] [Accepted: 03/07/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Ibuprofen liquid comes in two pediatric concentrations: 200 mg/5 mL for infants and 100 mg/5 mL for children. This study aimed to investigate the misdosing of ibuprofen liquid products by comparing administration accuracy with differing pediatric concentrations and dosages. METHODS Subject selection included 116 volunteers. Participants were provided with the children's ibuprofen package including the dosing cup, the infants' ibuprofen package including the infant dosing dropper, and a 5 mL syringe. Each subject drew up a specified dose of infants' ibuprofen and children's ibuprofen and deposited each sample into a graduated cylinder. The dose (70 or 100 mg) and order of concentration usage (infants' first or children's first) were randomized. RESULTS A total of 116 subjects, with a mean age of 32 ± 14 years, participated in the study. Mean absolute dosing errors for all trials, including those who made no errors, were significantly higher for infants' ibuprofen compared to children's ibuprofen: 39 vs. 27 mg (p = 0.036). A total of 31% of all ibuprofen dosage experiments (71 of 232 trials) had greater than 50% error of the assigned dose. CONCLUSION Dosage errors using infants' ibuprofen were significantly higher than the children's ibuprofen. This suggests that removing the infant form from consumer availability may help reduce dosing errors when administering ibuprofen to pediatric patients. IMPACT Pediatric misdosing is a significant problem with over-the-counter medications, such as ibuprofen. A previous study found that 51% of patients under the age of 10 were inaccurately dosed with antipyretic medication, including ibuprofen, with an increased incidence in infants. We found significantly more dosing errors with the infant concentration (200 mg/5 mL) as opposed to the children's concentration (100 mg/5 mL), 39 vs. 27 mg, respectively (p = 0.036). We believe that this research is beneficial to pediatric patient caregivers, clinicians, and policymakers to identify the problem of inaccurate ibuprofen dosing and to propose a way to mitigate this by having one concentration easily accessible.
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Affiliation(s)
- Emily R Leibovitch
- Department of Pediatrics, University of Hawai'i John A. Burns School of Medicine, Honolulu, HI, USA.
| | - Alyssa S Fujiwara
- Department of Pediatrics, University of Hawai'i John A. Burns School of Medicine, Honolulu, HI, USA
| | - Ian K H Chun
- Department of Pediatrics, University of Hawai'i John A. Burns School of Medicine, Honolulu, HI, USA
| | - Nathaniel C Villanueva
- Department of Pediatrics, University of Hawai'i John A. Burns School of Medicine, Honolulu, HI, USA
| | - Loren G Yamamoto
- Department of Pediatrics, University of Hawai'i John A. Burns School of Medicine, Honolulu, HI, USA
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2
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Pollack BE, Barbaro RP, Selewski DT, Carlton EF. Lactic acidosis and multisystem organ failure following ibuprofen overdose requiring haemodialysis. Drug Ther Bull 2023:dtb.2022.244281.rep. [PMID: 36649974 DOI: 10.1136/dtb.2022.244281.rep] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Blythe E Pollack
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Ryan P Barbaro
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.,Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | | | - Erin F Carlton
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.,Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
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3
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Koshel CK, Alexander PMA, Rycus P, Alibrahim O. Extracorporeal Membrane Oxygenation for Pediatric Toxin Exposures: Review of the Extracorporeal Life Support Organization Registry. ASAIO J 2022; 68:844-849. [PMID: 34380950 DOI: 10.1097/mat.0000000000001550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Evidence for the use of extracorporeal membrane oxygenation (ECMO) in children with refractory respiratory failure or shock following ingestion or toxin exposure, has been confined to single-center experiences, individual case reports, and extrapolated from adult cohorts; no pediatric multicenter cohorts exist. The objective of this retrospective review of the Extracorporeal Life Support Organization registry is to describe pediatric ECMO use following ingestion or toxin exposure, and define factors associated with mortality. Twenty-eight children between the ages of 30 days and 18 years met inclusion criteria between January 1, 2008 and December 31, 2017. The primary outcome measure was mortality before hospital discharge, which occurred in 32% of patients. Factors associated with in-hospital mortality included pre-ECMO use of inhaled nitric oxide (44.4% vs. 5.3%, p = 0.026), lower pre-ECMO arterial blood gas pH (6.97 [6.80-7.17] vs. 7.20 [7.15-7.32], p = 0.034), and higher pre-ECMO PaCO2 (79 [57-85] vs. 49 [38-63], p = 0.014). Receipt of inotropic support during ECMO was more common in nonsurvivors (66.7% vs. 21.1%, p = 0.035). Extracorporeal membrane oxygenation should be considered in the most severe pediatric toxin exposures as a bridge to recovery, providing time for both toxin elimination and end-organ recovery.
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Affiliation(s)
- Christine K Koshel
- From the Division of Pediatric Critical Care, Nemours Children's Hospital, Orlando, Florida
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Peter Rycus
- Extracorporeal Life Support Organization (ELSO), University of Michigan, Ann Arbor, Michigan
| | - Omar Alibrahim
- Division of Pediatric Critical Care Medicine, John R. Oishei Children's Hospital, Buffalo, New York
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
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Man AM, Piffer A, Simonetti GD, Scoglio M, Faré PB, Lava SAG, Bianchetti MG, Milani GP. Ibuprofen-Associated Hypokalemia and Metabolic Acidosis: Systematic Literature Review. Ann Pharmacother 2022; 56:10600280221075362. [PMID: 35135381 DOI: 10.1177/10600280221075362] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Ibuprofen is a widely used nonsteroidal anti-inflammatory drug, which has been occasionally associated with hypokalemia and metabolic acidosis. The objective of this report is to analyze the literature on this issue and to address the underlying pathophysiology. DATA SOURCES Excerpta Medica, the National Library of Medicine, and Web of Science were searched from inception to July 16, 2021. STUDY SELECTION AND DATA EXTRACTION Papers reporting individually documented humans on ibuprofen with hypokalemia, acidosis, or both were retained. Data were extracted using a checklist. DATA SYNTHESIS For the final analysis, we evaluated 41 reports describing 50 cases (26 males and 24 females; 36 adults and 14 children) with often profound hypokalemia, acidosis, or both after ingestion of ibuprofen. Twenty-six cases were acute and 24 long term. Hypokalemia and acidosis occurred not only after ingestion of very high doses but also after ingestion of moderately high or even normal doses of ibuprofen. Laboratory values consistent with an excessive urinary potassium excretion or an altered urinary acidification were often disclosed in most cases. Discontinuation of ibuprofen resulted in a resolution of hypokalemia and acidosis within days in 47 cases. The course was lethal in 3 cases. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE This review highlights potentially fatal side effects of ibuprofen and can help doctors who are confronted with such a situation. CONCLUSIONS These data highlight the potential of ibuprofen to occasionally induce hypokalemia and acidosis of renal origin. Discontinuation of ibuprofen results in a resolution within days.
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Affiliation(s)
- Anca M Man
- Pediatric Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Arianna Piffer
- Pediatric Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Giacomo D Simonetti
- Pediatric Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Università della Svizzera Italiana, Lugano, Switzerland
| | - Martin Scoglio
- Family Medicine Institute, Università della Svizzera Italiana, Lugano, Switzerland
| | - Pietro B Faré
- Department of Internal Medicine, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Sebastiano A G Lava
- Pediatric Cardiology Unit, Department of Pediatrics, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Mario G Bianchetti
- Università della Svizzera Italiana, Lugano, Switzerland
- Family Medicine Institute, Università della Svizzera Italiana, Lugano, Switzerland
| | - Gregorio P Milani
- Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
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5
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Pollack BE, Barbaro RP, Selewski DT, Carlton EF. Lactic acidosis and multisystem organ failure following ibuprofen overdose requiring haemodialysis. BMJ Case Rep 2022; 15:e244281. [PMID: 35131772 PMCID: PMC8823053 DOI: 10.1136/bcr-2021-244281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2022] [Indexed: 11/04/2022] Open
Abstract
A 17-year-old man was admitted to the paediatric intensive care unit 2 hours following an intentional ingestion of unknown substances. In the first 23 hours of hospitalisation, lactate levels remained elevated at 2-4 mmol/L, during the 24th hour, he developed lactic acidosis with lactate levels increasing from 4 to 16 mmol/L. His neurological status declined, requiring orotracheal intubation. Central and arterial access were obtained, and vasoactive infusions were initiated for haemodynamic support. Due to increasing lactate levels (maximum level >24 mmol/L) and haemodynamic instability, a dialysis line was inserted, and continuous renal replacement therapy (CRRT) was initiated. The lactic acidosis resolved over 10 hours. Serum ibuprofen level subsequently resulted at 841 µg/mL (reference range 10-50). Few reported cases discuss the sequela of large quantity ibuprofen ingestion leading to severe lactic acidosis and multiorgan system failure. Early intervention with CRRT may reverse acidosis, stabilise haemodynamics and halt secondary organ failure.
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Affiliation(s)
- Blythe E Pollack
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Ryan P Barbaro
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
- Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | | | - Erin F Carlton
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
- Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
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6
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Yehya A, Albals D, Issa R, Fawadleh A. Retrospective assessment of acute poisoning incidents by pharmaceutical agents in Jordan: Data from Pharmacy One™ Poison Call Center, 2014 to 2018-Part II. Pharmacol Res Perspect 2020; 8:e00583. [PMID: 32302066 PMCID: PMC7164419 DOI: 10.1002/prp2.583] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/03/2020] [Accepted: 03/05/2020] [Indexed: 11/28/2022] Open
Abstract
Poison control centers provide surveillance data that can be used to estimate the magnitude of poisoning cases and the level of public awareness and to evaluate control measures. The aim of this study is to describe the drug-related poisoning queries received by the Pharmacy One™ Poisoning Call Center (P1 PCC) in Jordan. This is a retrospective descriptive study of the acute drug-related poisoning incidents in the Jordanian population recorded by the P1 PCC during the 2014-2018 period. The inquiries received were recorded on a predesigned form. The demographic data, including the age and the sex of the patient, the route of and reason for exposure and the drug therapeutic groups, in addition to medical outcomes, were extracted utilizing computerized Oracle and Excel spreadsheets. During the period of evaluation, 900 drug-related poisoning incidents were reported to the P1 PCC. The majority of calls (48.5%) were received via 911, followed by the public (48.56%) and healthcare professionals (27.1%). More than half of the poisoning incidents were recorded among males (52.5%). Adults were the most affected group (40.5%), followed by children (34.0%). Unintentional exposure was the most common cause of poisoning (58.6%), followed by suicide attempts (25.3%). Nonsteroidal anti-inflammatory drugs and paracetamol caused the majority of the reported cases. Poisoning incidents were mainly classified as mild to moderate (56.1%), while only 16.6% were severe. The P1 PCC has demonstrated an important and vital role in improving patient safety and providing education on rational drug use. Reflections on these data can be used to increase public awareness in promoting the rational use of medications among Jordanian citizens.
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Affiliation(s)
- Alaa Yehya
- Department of Pharmacy PracticeFaculty of PharmacyYarmouk UniversityIrbidJordan
| | - Dima Albals
- Department of Pharmaceutical sciencesFaculty of PharmacyYarmouk UniversityIrbidJordan
| | - Reem Issa
- Department of Pharmaceutical sciencesFaculty of PharmacyYarmouk UniversityIrbidJordan
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7
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Ibuprofen plasma concentration profile in deliberate ibuprofen overdose with circulatory depression treated with therapeutic plasma exchange: a case report. BMC Pharmacol Toxicol 2017; 18:81. [PMID: 29233194 PMCID: PMC5728060 DOI: 10.1186/s40360-017-0187-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 12/05/2017] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Inquiries relating to ibuprofen overdose have more than tripled in the last ten years in our poison control center. Although the vast majority of cases have a benign clinical course, there are few severe or even fatal cases present with refractory circulatory failure. CASE PRESENTATION We describe a case of a 48 year-old male with suicidal mono-ingestion of approximately 72 g ibuprofen. Despite an initial rapid spontaneous drop in the total ibuprofen plasma concentration (IPC) from 550 to 275 mcg/mL within the first 5 h after admission, the patient developed a circulatory failure, refractory to aggressive fluid resuscitation and high doses of vasopressors. Due to ibuprofen's favorable pharmacokinetics (>95% bound to albumin, low volume of distribution) and in the absence of specific therapeutic alternatives thereby avoiding escalating vasopressor doses, therapeutic plasma exchange (TPE) for extracorporeal elimination of ibuprofen was considered as a therapeutic rescue option. An improvement of hemodynamics with a significant reduction of vasopressors was observed with TPE-initiation. However, neither the observed IPC-profile nor a pharmacokinetic (PK) simulation provided evidence for a quantitative effective elimination of ibuprofen by TPE. Based on PK-modeling we calculated an overall ibuprofen half-life of 17.2 h for the entire observation period over 5 days. CONCLUSIONS To our knowledge this is the first report of a severe ibuprofen-mono intoxication treated with TPE and providing serial IPCs over a period of five days, indicating an estimated fivefold overall-elimination half-life of 17.2 h. Despite TPE clinically improved persistent hemodynamic instability, this procedure was neither consistent with the observed IPC-profile nor correlated with a meaningful quantitative elimination of ibuprofen.
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8
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Hughes A, Johnson NJ, Mazor SS. Extracorporeal Life Support: Indications and Use in Severely Poisoned Patients. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2017. [DOI: 10.1016/j.cpem.2017.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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9
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Sheridan DC, Hendrickson RG, Lin AL, Fu R, Horowitz BZ. Adolescent Suicidal Ingestion: National Trends Over a Decade. J Adolesc Health 2017; 60:191-195. [PMID: 27889404 DOI: 10.1016/j.jadohealth.2016.09.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 09/02/2016] [Accepted: 09/02/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Suicide attempts by adolescents most commonly involve the overdose of medications. To date, there has been little information on the over-the-counter or prescription medicines that adolescents ingest for self-harm. Identification of medications chosen in suicide attempts may help guide anticipatory guidance to parents by primary care providers and Poison Centers in prevention programs. METHODS This was a retrospective observational study using the American Association of Poison Control Center's National Poison Data System. Data were collected on patients aged 13-19 years old at the time of their substance ingestion, between the years 2004 and 2013 and that were coded as reason for ingestion of "intentional-suspected suicide." RESULTS During the 10-year study period, there were 390,560 poison center calls for intentional-suspected suicide in the United States between 2004 and 2013, accounting for 80.3% of all "intentional" ingestion calls in the adolescent population. Over the entire age range, the most common substance ingested included acetaminophen (10.9%), ibuprofen (9%), selective serotonin reuptake inhibitors (7.7%), atypical antipsychotic (6%), and antihistamines (5%). The most common medications coded as resulting in major clinical effects or death were antidepressants and atypical antipsychotics. CONCLUSIONS Adolescent ingestion choices for suicide attempts have remained relatively consistent over the past 10 years. However, there was a recent decrease in selective serotonin reuptake inhibitor ingestions. The most common medications used in an overdose attempt were ibuprofen and acetaminophen. Further preventative efforts are needed in this at-risk population from multiple providers at various levels.
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Affiliation(s)
- David C Sheridan
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon.
| | - Robert G Hendrickson
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon; Oregon Poison Center, Portland, Oregon
| | - Amber L Lin
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon; School of Public Health, Oregon Health & Science University, Portland, Oregon
| | - Rongwei Fu
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon; School of Public Health, Oregon Health & Science University, Portland, Oregon
| | - B Zane Horowitz
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon; Oregon Poison Center, Portland, Oregon
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10
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Arens A, Smollin C. Case Files of the University of California, San Francisco Medical Toxicology Fellowship: Seizures and a Persistent Anion Gap Metabolic Acidosis. J Med Toxicol 2016; 12:309-14. [PMID: 27079645 PMCID: PMC4996787 DOI: 10.1007/s13181-016-0547-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 03/25/2016] [Accepted: 03/30/2016] [Indexed: 10/22/2022] Open
Affiliation(s)
- Ann Arens
- Department of Emergency Medicine, University of California, 1001 Potrero Ave, San Francisco, CA 94110 USA
- California Poison Control Systems, 1001 Potrero Ave, SFGH 5, San Francisco, CA 94110 USA
- Veteran’s Affairs Hospital, 4150 Clement St, San Francisco, CA 94121 USA
| | - Craig Smollin
- Department of Emergency Medicine, University of California, 1001 Potrero Ave, San Francisco, CA 94110 USA
- California Poison Control Systems, 1001 Potrero Ave, SFGH 5, San Francisco, CA 94110 USA
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11
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Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are one of the most widely used classes of medications in children. Despite a reported positive safety profile, NSAIDs have been associated with toxicities in both overdose and routine use. Most children with NSAID overdoses are asymptomatic and should be managed conservatively, whereas a small number may present with severe symptoms. We review NSAID exposures in children and strategies for their clinical evaluation and management.
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12
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Al-Abri SA, Anderson IB, Pedram F, Colby JM, Olson KR. Massive naproxen overdose with serial serum levels. J Med Toxicol 2015; 11:102-5. [PMID: 24756481 DOI: 10.1007/s13181-014-0396-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
CONTEXT Massive naproxen overdose is not commonly reported. Severe metabolic acidosis and seizure have been described, but the use of renal replacement therapy has not been studied in the context of overdose. CASE DETAILS A 28-year-old man ingested 70 g of naproxen along with an unknown amount of alcohol in a suicidal attempt. On examination in the emergency department 90 min later, he was drowsy but had normal vital signs apart from sinus tachycardia. Serum naproxen level 90 min after ingestion was 1,580 mg/L (therapeutic range 25-75 mg/L). He developed metabolic acidosis requiring renal replacement therapy using sustained low efficiency dialysis (SLED) and continuous venovenous hemofiltration (CVVH) and had recurrent seizure activity requiring intubation within 4 h from ingestion. He recovered after 48 h. DISCUSSION Massive naproxen overdose can present with serious toxicity including seizures, altered mental status, and metabolic acidosis. CONCLUSION Hemodialysis and renal replacement therapy may correct the acid base disturbance and provide support in cases of renal impairment in context of naproxen overdose, but further studies are needed to determine the extraction of naproxen.
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Affiliation(s)
- Suad A Al-Abri
- California Poison Control System, San Francisco Division, University of California, UCSF Box 1369, San Francisco, CA, 94143-1369, USA,
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13
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Akingbola OA, Singh D, Kleinman JA, Frieberg EM. Functional adrenal insufficiency complicating an overdose of naproxen and ibuprofen. Clin Pediatr (Phila) 2015; 54:76-8. [PMID: 24895376 DOI: 10.1177/0009922814537112] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - Dinesh Singh
- Tulane University School of Medicine, New Orleans, LA, USA
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14
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Barrueto F, Gattu R, Mazer-Amirshahi M. Updates in the general approach to the pediatric poisoned patient. Pediatr Clin North Am 2013; 60:1203-20. [PMID: 24093904 DOI: 10.1016/j.pcl.2013.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Poison prevention remains essential to prevent the most vulnerable population from becoming exposed to potentially lethal toxins. The evaluation of a child presumed to have been exposed to a toxic substance should include a precise history of the exposure, a physical examination, and knowledge of current ingestions and recreational practices. New treatments and research guiding therapy continue to evolve. Poison centers and medical toxicologists can be consulted to assist with the diagnosis of medicinal/drug overdoses, for advice about the pitfalls inherent in stabilizing children who have been exposed to toxic compounds, and for treatment recommendations based on the latest research.
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Affiliation(s)
- Fermin Barrueto
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Emergency Medicine, Upper Chesapeake Health Systems, Bel Air, MD, USA.
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15
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Hypotension aux AINS : un effet indésirable méconnu, à connaître ! Rev Med Interne 2013. [DOI: 10.1016/j.revmed.2013.03.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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16
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de Lange DW, Sikma MA, Meulenbelt J. Extracorporeal membrane oxygenation in the treatment of poisoned patients. Clin Toxicol (Phila) 2013; 51:385-93. [DOI: 10.3109/15563650.2013.800876] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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17
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Hunter LJ, Wood DM, Dargan PI. The patterns of toxicity and management of acute nonsteroidal anti-inflammatory drug (NSAID) overdose. Open Access Emerg Med 2011; 3:39-48. [PMID: 27147851 PMCID: PMC4753966 DOI: 10.2147/oaem.s22795] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Indexed: 11/25/2022] Open
Abstract
The nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used for their analgesic, anti-inflammatory and antipyretic actions. They are commonly taken in overdose in many areas of the world. The majority of patients with acute NSAID overdose will remain asymptomatic or develop minor self-limiting gastrointestinal symptoms. However, serious clinical sequelae have been reported in patients with acute NSAID overdose and these include convulsions, metabolic acidosis, coma and acute renal failure. There appear to be some differences between the NSAIDs in terms of the relative risk of these complications; in particular mefenamic acid is most commonly associated with convulsions. The management of these serious clinical features is largely supportive and there are no specific antidotes for acute NSAID toxicity.
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Affiliation(s)
- Laura J Hunter
- Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - David M Wood
- Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
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18
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Abstract
Opioid-induced pulmonary edema has been previously reported, but its mechanism remains unclear. The use of extracorporeal membrane oxygenation as rescue therapy for methadone-induced pulmonary edema has not been reported in the literature. We describe 2 cases of methadone ingestion complicated by pulmonary edema, acute respiratory distress syndrome, and circulatory failure successfully managed with venoarterial extracorporeal membrane oxygenation.
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19
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Refractory hypotension from massive bupropion overdose successfully treated with extracorporeal membrane oxygenation. Pediatr Emerg Care 2011; 27:43-5. [PMID: 21206256 DOI: 10.1097/pec.0b013e3182045f76] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
An 11-month-old male infant presented with history of bupropion ingestion (750 mg/kg). He developed seizures, respiratory failure, and severe hypotension with metabolic acidosis refractory to inotropic support. The patient received mechanical ventilation, intralipids, phenytoin, inotropic support (dopamine, norepinephrine, and epinephrine), and extracorporeal membrane oxygenation (ECMO). Inotropes were weaned upon initiation of ECMO and discontinued 66 hours after ingestion. Total ECMO duration was 71 hours. The patient was extubated on hospital day 8 and has not had any neurological sequelae upon 12-month follow-up examinations. We report for the first time successful use of ECMO after ingestion of a potentially fatal dose of bupropion.
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Abstract
Ibuprofen was the first over-the-counter nonsteroidal anti-inflammatory drug available in the United States. Despite being a common agent of ingestion, significant toxicity in overdose is rare. We report a case of a massive ibuprofen ingestion who developed polyuria, acidosis, and coma but survived, despite having a serum ibuprofen concentration greater than previous fatal cases. A 19-year-old man ingested 90 g (1,200 mg/kg) ibuprofen. He was initially awake and alert, but his level of consciousness deteriorated over several hours. Seven hours following the ingestion, he was intubated and mechanically ventilated secondary to loss of airway reflexes. He developed a lactic acidosis and polyuria, which lasted for nearly 24 h. His serum creatinine peaked at 1.12 mg/dL. An ibuprofen level drawn 7 h postingestion was 739.2 mg/L (therapeutic 5-49 mg/L). We describe a case of a massive ibuprofen overdose characterized by metabolic acidosis, coma, and a state of high urine output who survived with aggressive supportive care. This case is unique in several ways. First, ibuprofen levels this high have only rarely been described. Second, polyuria is very poorly described following ibuprofen ingestions.
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Affiliation(s)
- Michael Levine
- Department of Medical Toxicology, Banner Good Samaritan Medical Center, Phoenix, AZ, USA.
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21
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Bushra R, Aslam N. An overview of clinical pharmacology of Ibuprofen. Oman Med J 2010; 25:155-1661. [PMID: 22043330 PMCID: PMC3191627 DOI: 10.5001/omj.2010.49] [Citation(s) in RCA: 184] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2010] [Accepted: 04/24/2010] [Indexed: 11/03/2022] Open
Abstract
Ibuprofen was the first member of Propionic acid derivatives introduced in 1969. It is a popular domestic and over the counter analgesic and antipyretic for adults and children. Ibuprofen has been rated as the safest conventional NSAID by spontaneous adverse drug reaction reporting systems in the UK. This article summarizes the main pharmacological effects, therapeutical applications and adverse drug reactions, drug-drug interactions and food drug interactions of ibuprofen that have been reported especially during the last 10 years.
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Affiliation(s)
- Rabia Bushra
- From Ziauddin College of Pharmacy, Ziauddin University, Kaarchi, Sindh, Pakistan
| | - Nousheen Aslam
- From Ziauddin College of Pharmacy, Ziauddin University, Kaarchi, Sindh, Pakistan
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Boyle JS, Bechtel LK, Holstege CP. Management of the critically poisoned patient. Scand J Trauma Resusc Emerg Med 2009; 17:29. [PMID: 19563673 PMCID: PMC2720377 DOI: 10.1186/1757-7241-17-29] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2009] [Accepted: 06/29/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinicians are often challenged to manage critically ill poison patients. The clinical effects encountered in poisoned patients are dependent on numerous variables, such as the dose, the length of exposure time, and the pre-existing health of the patient. The goal of this article is to introduce the basic concepts for evaluation of poisoned patients and review the appropriate management of such patients based on the currently available literature. METHODS An unsystematic review of the medical literature was performed and articles pertaining to human poisoning were obtained. The literature selected was based on the preference and clinical expertise of authors. DISCUSSION If a poisoning is recognized early and appropriate testing and supportive care is initiated rapidly, the majority of patient outcomes will be good. Judicious use of antidotes should be practiced and clinicians should clearly understand the indications and contraindications of antidotes prior to administration.
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Affiliation(s)
- Jennifer S Boyle
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA.
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23
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Abstract
Emergency physicians are regularly called on to care for critically poisoned patients. This article reviews the general approach and management of the critically poisoned patient. Specific clinical characteristics are identified that may clue the clinician into a specific toxin class as a diagnosis. Appropriate testing in the poisoned patient is reviewed. Complications of poisoning that may bring a rapid demise of the critically ill poisoned patient are highlighted and the management of those complications is discussed.
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