The role of therapeutic plasma exchange in poisonings and intoxications

Extra-corporeal non-liver transplant therapies for acute liver failure: Focus on plasma exchange and continuous renal replacement therapy

The acute inflammatory milieu in patients with acute liver failure (ALF) results in 'toxic' blood in these patients. In vitro experiments have shown that the plasma obtained from ALF patients is toxic to rabbit hepatocytes and inhibits regeneration of rat hepatocytes. Treatments such as plasma exchange and continuous renal replacement therapy to cleanse the blood have improved survival in ALF patients. In the liver microcirculation, the exchange of fluid across fenestrae in liver sinusoidal endothelial cells (LSECs) is vital for proper functioning of hepatocytes. Clogging of the liver filter bed by inflammatory debris and cells ('traffic jam hypothesis') impeding blood flow in sinusoids may in turn reduce the exchange of fluid across LSEC fenestrae and cause dysfunction and necrosis of hepatocytes in ALF patients. In mouse model of paracetamol overdose, disturbances in microcirculation in the liver preceded the development of injury and necrosis of hepatocytes. This may represent a reversible pathophysiological mechanism in ALF which may be improved by the anti-inflammatory effect of plasma exchange. Wider access to urgent plasma exchange is a major advantage compared to urgent liver transplantation to treat ALF patients worldwide, especially so in resource constrained settings. Continuous hemo-filtration or dialysis is used to reduce ammonia levels and treat cerebral edema in ALF patients. In this review, we discuss the different modalities to cleanse the blood in ALF patients, with an emphasis on plasma exchange, from a hepatology perspective.

Use of extracorporeal therapies to treat life-threatening intoxications

Toxic ingestions are a significant cause of pediatric morbidity and mortality, with some requiring extracorporeal removal for therapy. Given the emergent and life-threatening nature of such scenarios, it is paramount that clinicians caring for intoxicated children be familiar with the subject. This review summarizes the following: (a) the properties of a substance which lend it amenable to removal; (b) the current extracorporeal treatment modalities available for such removal (of which hemodialysis is typically the ideal choice); (c) an introduction and framework to use a quick reference guide from the Extrip organization, which has a website available to guide clinicians' rapid decisions; and (d) new membranes/approaches that may optimize clearance of certain intoxications.

Indications and Outcomes of Patients Receiving Therapeutic Plasma Exchange under Critical Care Conditions: A Retrospective Eleven-Year Single-Center Study at a Tertiary Care Center

Background: Therapeutic plasma exchange (TPE) is frequently performed in critical care settings for heterogenous indications. However, specific intensive care unit (ICU) data regarding TPE indications, patient characteristics and technical details are sparse. Methods: We performed a retrospective, single-center study using data from January 2010 until August 2021 for patients treated with TPE in an ICU setting at the University Hospital Zurich. Data collected included patient characteristics and outcomes, ICU-specific parameters, as well as apheresis-specific technical parameters and complications. Results: We identified n = 105 patients receiving n = 408 TPEs for n = 24 indications during the study period. The most common was thrombotic microangiopathies (TMA) (38%), transplant-associated complications (16.3%) and vasculitis (14%). One-third of indications (35.2%) could not be classified according to ASFA. Anaphylaxis was the most common TPE-related complication (6.7%), while bleeding complications were rare (1%). The median duration of ICU stay was 8 ± 14 days. Ventilator support, renal replacement therapy or vasopressors were required in 59 (56.2%), 26 (24.8%), and 35 (33.3%) patients, respectively, and 6 (5.7%) patients required extracorporeal membrane oxygenation. The overall hospital survival rate was 88.6%. Conclusion: Our study provides valuable real-world data on heterogenous TPE indications for patients in the ICU setting, potentially supporting decision-making.

State of the Evidence: Drug Removal via Apheresis

Therapeutic apheresis refers to a diversity of procedures in which specific hematologic components (e.g., plasma, erythrocytes, leukocytes, etc.) with pathological associations are removed from circulation (with possible replacement) in order to treat a variety of disease processes. As pharmacologic agents also circulate with these components, their removal is sometimes incidental, or in the scenario of drug toxicity, a therapeutic goal. The corpus of published manuscripts on this subject has grown immensely over the past few decades; however, the breadth of diseases, methods, and drugs that co-exist in this space make it challenging to generate generalizable evidence regarding drug removal via apheresis. This review discusses factors worth considering when interpreting literature-reported data on drug removal by apheresis with examples from several notable studies and highlights topics in need of evidential improvement and growth as our palette of therapeutic agents continues to expand.

Dialysis and Extracorporeal Therapies for Enhanced Elimination of Toxic Ingestions and Poisoning

Poisoning and toxic ingestions cause significant morbidity and mortality worldwide. Extracorporeal therapies such as dialysis, haemoperfusion and plasma exchange are selectively applied to patients with severe intoxications unresponsive to standard interventions and can be lifesaving. Extracorporeal therapies are a complex but fundamental aspect of the practice of nephrology. Without high-quality evidence to guide implementation, an understanding of toxicokinetics and the physiochemical principles of the enhanced elimination techniques is especially important. This review provides a comphrensive, user-friendly outline of the application of extracorporeal therapy in the poisoned patient.

Successful management of severe carprofen toxicity with manual therapeutic plasma exchange in a dog

OBJECTIVE

To report the use of manual therapeutic plasma exchange (TPE) in a dog with severe carprofen toxicity.

SUMMARY

A 12-year-old neutered female Pembroke Welsh Corgi weighing 20 kg was evaluated after ingesting 223 mg/kg of carprofen. Emesis was attempted with apomorphine at the primary care veterinarian but was unsuccessful, and a dose of activated charcoal with sorbitol was administered. On presentation to the referral center, approximately 8 hours after ingestion, the dog's physical examination revealed mild abdominal discomfort but was otherwise unremarkable. Treatment consisted of a combination of supportive care including activated charcoal with sorbitol, cholestyramine, IV lipid emulsion, and manual TPE. Blood samples were collected prior to the initiation of manual TPE and at the completion of 12 exchange cycles. Carprofen levels were determined by high-pressure liquid chromatography. A 57% decrease in carprofen levels was achieved with the combination of activated charcoal, cholestyramine, IV lipid emulsion, and manual TPE. The dog did not develop organ dysfunction secondary to toxicity and was discharged 4 days after ingestion.

NEW OR UNIQUE INFORMATION PROVIDED

This report describes the successful decrease of plasma carprofen in a dog with the combination of decontamination techniques and manual TPE. While TPE has been previously reported as a successful therapeutic in dogs with nonsteroidal anti-inflammatory toxicity, including carprofen, equipment and expertise of this platform is not readily available. Manual TPE is technically simple and can be performed in any hospital with a large blood centrifuge.

Treatment of comatose patient from cyclobenzaprine overdose with therapeutic plasma exchange

We present a case of a 15-year-old female who was admitted in a comatose state with no spontaneous respiratory effort and absence of brainstem reflexes after cyclobenzaprine ingestion. Due to severe presentation and recent ingestion of high plasma protein binding medication with long half-life, therapeutic plasma exchange (TPE) was performed and resulted in full neurological recovery. This case explores the role of TPE as an effective treatment option for life-threatening cyclobenzaprine overdose. TPE is generally beneficial for drugs that have a low volume of distribution and high plasma protein binding. Cyclobenzaprine is known to have a relatively high volume of distribution. However, in the case of drug intoxication with relatively high-volume distribution, high protein binding, and long half-life, TPE could be effective if it is conducted promptly.

Massive bee envenomation treated by therapeutic plasma exchange

In the unfortunate event of massive envenomation and precipitation of multiorgan failure, therapeutic plasma exchange (TPE) can be considered as a modality for therapy. We present a patient case where TPE potentially allowed for removal of toxin with subsequent clinical improvement.

Extracorporeal Therapies in the Emergency Room and Intensive Care Unit

Extracorporeal treatments create opportunity for removing disease causing solutes within blood. Intoxications, renal failure, and immune-mediated diseases may be managed with these treatments, often providing new hope for patients with severe or refractory disease. Understanding solute pharmacokinetics and the limitations of each type of extracorporeal technique can allow for the selection of the optimal treatment modality.

Management of pharmaceutical and recreational drug poisoning

BACKGROUND

Poisoning is one of the leading causes of admission to the emergency department and intensive care unit. A large number of epidemiological changes have occurred over the last years such as the exponential growth of new synthetic psychoactive substances. Major progress has also been made in analytical screening and assays, enabling the clinicians to rapidly obtain a definite diagnosis.

METHODS

A committee composed of 30 experts from five scientific societies, the Société de Réanimation de Langue Française (SRLF), the Société Française de Médecine d'Urgence (SFMU), the Société de Toxicologie Clinique (STC), the Société Française de Toxicologie Analytique (SFTA) and the Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP) evaluated eight fields: (1) severity assessment and initial triage; (2) diagnostic approach and role of toxicological analyses; (3) supportive care; (4) decontamination; (5) elimination enhancement; (6) place of antidotes; (7) specificities related to recreational drug poisoning; and (8) characteristics of cardiotoxicant poisoning. Population, Intervention, Comparison, and Outcome (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Analysis of the literature and formulation of recommendations were then conducted according to the GRADE® methodology.

RESULTS

The SRLF-SFMU guideline panel provided 41 statements concerning the management of pharmaceutical and recreational drug poisoning. Ethanol and chemical poisoning were excluded from the scope of these recommendations. After two rounds of discussion and various amendments, a strong consensus was reached for all recommendations. Six of these recommendations had a high level of evidence (GRADE 1±) and six had a low level of evidence (GRADE 2±). Twenty-nine recommendations were in the form of expert opinion recommendations due to the low evidences in the literature.

CONCLUSIONS

The experts reached a substantial consensus for several strong recommendations for optimal management of pharmaceutical and recreational drug poisoning, mainly regarding the conditions and effectiveness of naloxone and N-acetylcystein as antidotes to treat opioid and acetaminophen poisoning, respectively.

The Role of Therapeutic Plasma Exchange in the Treatment of Childhood Intoxication: A Single-Center Experience

OBJECTIVES

Therapeutic plasma exchange is used to treat neurologic, hematological, renal, and autoimmune diseases with a known or suspected etiopathogenesis. However, there is incomplete understanding of the use of therapeutic plasma exchange in pediatric cases of intoxication. This study investigated 5 years of experience with therapeutic plasma exchange to treat intoxication cases.

DESIGN

A retrospective, case series, single-center study.

SETTING

PICU of Baskent University, Dr. Turgut Noyan Teaching, and Medical Research Center Hospital in Adana, Turkey.

PATIENTS

Fourteen patients diagnosed with intoxication who underwent therapeutic plasma exchange between January 2013 and January 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data pertaining to 14 patients, including their medical history (exposure to drugs/toxicants), demographics, initial presentation, and severity of clinical symptoms (requirement of mechanical ventilation, Glasgow Coma Scale score, and the pediatric severity of illness score [Pediatric Logistic Organ Dysfunction] were retrospectively reviewed. The most common indication for therapeutic plasma exchange was multiple drug intoxication, followed by amitriptyline, Amanita phalloides mushroom, carbamazepine, mercury, verapamil, and botulism. All patients underwent therapeutic plasma exchange and two patients underwent hemodialysis before therapeutic plasma exchange. There was no mortality or complications related to the therapeutic plasma exchange procedure. Clinical improvement was observed after therapeutic plasma exchange in 13 of the 14 patients; one patient with verapamil intoxication died.

CONCLUSIONS

Therapeutic plasma exchange appears to be safe and effective for treating pediatric cases of intoxication, including multidrug and amitriptyline intoxication, and is associated with significant recovery in the majority of severely affected patients. Treatment of intoxication with therapeutic plasma exchange should be guided primarily by the properties of the causative toxic substances/drugs, and consideration of patient age, the severity of clinical symptoms, Pediatric Logistic Organ Dysfunction score and response to initial supportive and antidotal treatment.

Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue

The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.

Successful treatment of a patient with severe thallium poisoning in a coma using Prussian blue and plasma exchange: A case report

RATIONALE

This is the first reported severe thallium poisoning patient successfully treated with Prussian blue (PB) and plasma exchange (PE).

PATIENT CONCERNS

A 42-year-old woman in a coma owing to severe thallium poisoning was admitted to our department after day 44 of poisoning. At admission, blood and urine thallium concentrations were 380.0 and 2580.0 ng/mL, respectively.

DIAGNOSIS

The patient was diagnosed with toxic encephalopathy induced by thallium poisoning; in addition, she was also diagnosed with bilateral pneumonia, respiratory failure, moderate anemia, hypoproteinemia, and electrolyte imbalance based on her chest X-ray, blood gas analysis, Hb level, albumin levels, and serum electrolyte results.

INTERVENTIONS

The patient was intubated and treated with PB (6600 mg/d, 15 days in total) combined with PE (once daily, 5 days in total) as well as other symptomatic supportive care measures.

OUTCOMES

After treatments, her blood and urinary thallium concentrations gradually decreased and on the 13th day after admission, the blood thallium concentration decreased to 0 ng/mL. The oxygenation index gradually improved, meantime, the patient gradually regained consciousness, and on the 50th day of admission, the patient's consciousness reverted to a clear-headed state. The patient recovered mostly after 37 months of follow-up.

LESSONS

Through this case, we learned that the gradual reduction in blood and urine thallium concentration and the patient's improved condition is correlated with PB and PE treatment. For patients with severe thallium poisoning, this treatment method might be effective; but the exact curative effect is unconfirmed, requiring further research to verify.

Use of therapeutic plasma exchange to treat nonsteroidal anti-inflammatory drug overdose in dogs

Background

Therapeutic plasma exchange (TPE) may be an effective technique for treatment of accidental nonsteroidal anti‐inflammatory drug (NSAID) overdose, but information regarding the use of this technique in veterinary medicine is currently limited.

Objectives

To evaluate the overall outcome for dogs with NSAID overdose treated with TPE and to determine if any presenting factors can predict or influence overall outcome. Secondary objectives included investigating TPE complications as well as the utility of other adjunctive treatments.

Animals

Eleven client‐owned dogs presented for NSAID overdose that received TPE. All patients also received additional supportive treatment including IV lipid infusion.

Methods

Retrospective review of medical records.

Results

Eleven cases were included in the study. Of these, the NSAID ingested was ibuprofen in 6 (54.5%), naproxen in 4 (36.4%), and deracoxib in 1 (9.1%). All dogs survived to discharge with 3 (27.3%) developing acute kidney injury during hospitalization. A larger initial dose of NSAID ingested was associated with a higher maximum serum creatinine concentration during hospitalization (P = .04) and larger change in serum creatinine concentration from baseline (P = .02). Six dogs (54.5%) developed complications associated with TPE. The use of other treatments did not affect the overall outcome.

Conclusions and Clinical Importance

We identified TPE as an effective treatment for NSAID overdose with good outcomes despite high doses of NSAID ingestion in dogs treated with a single TPE treatment. Complications were common but did not affect the final outcome. Therapeutic plasma exchange should be considered in patients presenting for high‐dose NSAID ingestion.

Treatment of carprofen overdose with therapeutic plasma exchange in a dog

OBJECTIVE

To report the use of therapeutic plasma exchange (TPE) in a dog with carprofen toxicosis.

SUMMARY

A 6-year-old female neutered Bichon Frise weighing 6.9 kg was examined after it had ingested 72 mg/kg carprofen. Mild dehydration without azotemia and with a urine specific gravity of 1.050 was noted at presentation. Treatment consisted of induction of emesis, symptomatic medical therapy, and TPE. The TPE achieved 1.5 plasma volume exchanges over 3 hours. Blood samples and effluent samples were collected every 30 minutes during TPE and additional blood samples were collected 11 and 35 hours after treatment. Carprofen concentrations in these samples were determined by high-pressure liquid chromatography. A 51% reduction in serum carprofen concentration was achieved following TPE.

NEW OR UNIQUE INFORMATION PROVIDED

This report describes the successful reduction of plasma carprofen concentration in a dog using TPE. Although recent studies suggest that this particular dog may not have received a toxic dose, a 51% reduction of plasma carprofen concentration was achieved over 180 minutes, and TPE may be beneficial for treatment of dogs that have ingested higher doses.

Therapeutic Plasma Exchange and Its Impact on Drug Levels: An ACLPS Critical Review

OBJECTIVES

To examine and summarize the current literature on the effects of therapeutic plasma exchange on medication levels.

METHODS

Literature review was performed via searches of the Cochrane Database and PubMed-MEDLINE (1996 to August 2016) looking for all case reports, case series, and human randomized controlled trials involving therapeutic plasma exchange (TPE)-associated drug removal.

RESULTS

Approximately 60 peer-reviewed articles were identified with the majority being case reports; no randomized controlled trials were identified. These reports and the authors' own experiences were used to derive practical guidance regarding the effect of TPE on circulating drug levels.

CONCLUSIONS

There were several limitations with existing studies, many of which relate to procedural and/or clinical properties of patients undergoing TPE. As such, additional studies are needed before definitive guidelines can be established. There is clear need for development of consensus and additional investigations in this domain.

Treatment of ibuprofen intoxication in a dog via therapeutic plasma exchange

OBJECTIVE

To describe the treatment of ibuprofen intoxication with therapeutic plasma exchange in a dog (TPE).

SUMMARY

A 13-year-old male neutered mixed breed dog presented after ingesting approximately 200 mg/kg of ibuprofen. Treatment consisted of supportive medical therapy with IV fluids, gastrointestinal protectants, antiemetics and prostaglandin analogs, and TPE. A cycle of TPE was performed over 180 minutes, achieving 1.5 plasma volume exchanges. During therapy, heparinized blood and effluent samples were collected. Ibuprofen concentrations were determined in the samples by high-pressure liquid chromatography. Post TPE, the dog was continued on supportive medical therapy and was discharged 96 hours after the overdose.

NEW OR UNIQUE INFORMATION

This report describes the use of TPE as an adjunct for ibuprofen intoxication. An 85% reduction in plasma ibuprofen concentration occurred and recovery from a potentially lethal ingestion of ibuprofen was achieved with TPE and supportive care. TPE should be considered when presented with acute ibuprofen intoxication due to the rapid and efficacious nature of therapy.

Treatment of meloxicam overdose in a dog via therapeutic plasma exchange

OBJECTIVE

To describe the treatment of a meloxicam overdose in a dog with therapeutic plasma exchange (TPE).

CASE SUMMARY

A 6-month-old female Bulldog, presented for routine laparoscopic ovariectomy. Postoperatively the dog received an accidental overdose of meloxicam (1 mg/kg IV [intravenously]). The patient was treated with supportive medical therapy and TPE over 210 minutes achieving 1.2 plasma volume exchanges. During therapy, heparinized blood and effluent samples were collected. Meloxicam concentrations were determined in the samples by high pressure liquid chromatography. Post TPE, the dog continued to receive supportive medical therapy and was discharged 48 hours after the overdose. The dog remained asymptomatic for meloxicam intoxication. Follow-up rechecks at 1 and 6 weeks were unremarkable with no further treatment required.

NEW OR UNIQUE INFORMATION

This report describes the successful use of TPE adjunctively following an acute meloxicam overdose. An 82% reduction of plasma meloxicam concentration was achieved over 210 minutes. Twenty-four hours after therapy, a 47% sustained reduction of plasma meloxicam was measured after redistribution of drug between body compartments.

Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue

The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.

Experience of Treatments of Amanita phalloides-Induced Fulminant Liver Failure with Molecular Adsorbent Recirculating System and Therapeutic Plasma Exchange

Ingestion of the mushroom containing Amanita phalloides can induce fulminant liver failure and death. There are no specific antidotes. Blood purifications, such as molecular adsorbent recirculating system (MARS) and therapeutic plasma exchange (TPE), are potential therapies. However, the extent to which these technologies avert the deleterious effects of amatoxins remains controversial; the optimal intensity, duration, and initiation criteria have not been determined yet. This study aimed to retrospectively observe the effects of MARS and TPE on nine patients with A. phalloides-induced fulminant liver failure. The survival rate for the nine patients was 66.7%. Both TPE and MARS might remove toxins and improve liver functions. However, a single session of TPE produced immediately greater improvements in alanine aminotransferase (-60% vs. -16.3%), aspartate aminotransferase (-47.6% vs. -15.4%), and total bilirubin (-37.3% vs. -17.1%) (compared with the values of pretreatment, all p < 0.05) than MARS compared with MARS. Early intervention may be more effective than delayed therapy. Additionally, the presence of severe liver failure and renal failure indicated worse outcome. Although these findings are promising, additional case-controlled, randomized studies are required to confirm our results.

Early plasma exchange for treating ricin toxicity in children after castor bean ingestion

Plasma exchange (PE) for the treatment of ricin toxicity has not been previously reported. Here we describe the use of PE to treat children who experienced ricin toxicity after ingesting castor beans. Seven children (median age: 8.1 years) who consumed castor beans (median: 5 beans) were treated with PE. All had bradycardia and sinus arrhythmia, and most had experienced episodes of vomiting and/or diarrhea. PE settings were blood flow, 50-80 mL/min; PE rate, 600-800 mL/h; volume of exchange, 1440-1950 mL. Median time from ingestion to PE was 73 h. All clinical symptoms disappeared and vital signs rapidly returned to normal after PE; no severe organ dysfunction occurred. All children were discharged and recovered uneventfully. Concentrations of all serum biochemical parameters significantly decreased immediately after PE. Some, but not all, of these parameters were also significantly decreased at 48 and 72 h after PE compared with before PE. Our findings suggest that PE can be an effective early intervention in the treatment of ricin toxicity due to castor bean ingestion.

Available extracorporeal treatments for poisoning: overview and limitations

Poisoning is a significant public health problem. In severe cases, extracorporeal treatments (ECTRs) may be required to prevent or reverse major toxicity. Available ECTRs include intermittent hemodialysis, sustained low-efficiency dialysis, intermittent hemofiltration and hemodiafiltration, continuous renal replacement therapy, hemoperfusion, therapeutic plasma exchange, exchange transfusion, peritoneal dialysis, albumin dialysis, cerebrospinal fluid exchange, and extracorporeal life support. The aim of this article was to provide an overview of the technical aspects, as well as the potential indications and limitations of the different ECTRs used for poisoned patients.