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Chow SH, Chan CK. Evaluation of the utilization of extracorporeal toxin removal in lithium poisoning patients in Hong Kong. HONG KONG J EMERG ME 2021. [DOI: 10.1177/10249079211049945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Extracorporeal toxin removal is used for enhanced elimination in severe lithium poisoning. The Extracorporeal TReatments In Poisoning workgroup provides recommendations on the use of extracorporeal toxin removal in poisoning. Objectives: Our aim was to identify the pattern for using extracorporeal toxin removal in managing lithium poisoning in Hong Kong and compare the outcomes in extracorporeal toxin removal-treated patients and non-extracorporeal toxin removal-treated patients if indicated for treatment as defined by The Extracorporeal TReatments In Poisoning criteria. Methods: Lithium poisoning presented between year 2009 and 2019 in Hong Kong Poison Information Centre (HKPIC) database was categorized into extracorporeal toxin removal-treated group and non-extracorporeal toxin removal-treated group. Comparative analyses were performed. Results: Among 112 lithium-poisoned patients, 21% were treated with extracorporeal toxin removal. Larger proportion of patients had fulfilled at least one Extracorporeal TReatments In Poisoning criteria for extracorporeal toxin removal in the extracorporeal toxin removal-treated group (87% vs 18%, p < 0.005). The extracorporeal toxin removal-treat group patients were more commonly presented with impaired consciousness, seizure and dysrhythmia ( p < 0.05). They also got higher admission (3.62 mmol/L vs 2.18 mmol/L, p < 0.05) and peak (4.15 mmol/L vs 2.28 mmol/L, p < 0.05) serum lithium concentrations, as well as a significantly higher serum creatinine concentration upon presentation (263.74 µmol/L vs 98.66 µmol/L, p < 0.05). Extracorporeal toxin removal-treat group patients more frequently had a severe poisoning outcome (91.3% vs 9%, p < 0.05) and developed complications (69.6% vs 13.5%, p < 0.05). Logistic regression identified seizure, peak serum lithium concentration, and serum creatinine concentration upon presentation as risk factors for severe poisoning outcome. In subgroup analysis on patients with at least one indication for extracorporeal toxin removal as defined by Extracorporeal TReatments In Poisoning criteria, the proportion of severe poisoning remained higher in the extracorporeal toxin removal-treated group (90% vs 43.7%, p < 0.05). Complication rate was not significantly different between the two groups. Conclusion: Clinically severe lithium poisoning patients were treated with extracorporeal toxin removal in Hong Kong. Extracorporeal TReatments In Poisoning criteria can serve as a reference in considering extracorporeal toxin removal treatment for lithium poisoning patients. Nevertheless, Extracorporeal TReatments In Poisoning criteria recommend more extracorporeal toxin removal treatment than it was actually done. Lithium poisoning patients with positive Extracorporeal TReatments In Poisoning criteria have been managed without extracorporeal toxin removal. No statistically significant adverse outcome was observed in these cases.
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Affiliation(s)
- Shuk Hang Chow
- Accident and Emergency Department, United Christian Hospital, Hong Kong
| | - Chi Keung Chan
- Hong Kong Poison Information Centre, United Christian Hospital, Hong Kong
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Vodovar D, Beaune S, Langrand J, Vicaut E, Labat L, Mégarbane B. Assessment of Extracorporeal Treatments in Poisoning criteria for the decision of extracorporeal toxin removal in lithium poisoning. Br J Clin Pharmacol 2019; 86:560-568. [PMID: 31378954 DOI: 10.1111/bcp.14087] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 07/15/2019] [Accepted: 07/28/2019] [Indexed: 12/20/2022] Open
Abstract
AIMS To assess recommendations provided by the EXtracorporeal TReatments In Poisoning (EXTRIP) workgroup on extracorporeal toxin removal (ECTR) in lithium poisoning. METHODS Retrospective assessment in a 128 lithium-poisoned patient cohort previously used to identify ECTR initiation criteria that could improve outcome (Paris criteria). ECTR requirement using EXTRIP criteria was compared to the actual practice or if Paris criteria were used. The potential impact on outcome if these different criteria were used was investigated. RESULTS Using the recommended (Rec-EXTRIP) or recommended + suggested (All-EXTRIP) EXTRIP criteria, ECTR would have been indicated in more patients than was actually done (P < .001), or if Paris criteria were used (P < .01). The non-actually ECTR-treated patients fulfilling Rec-EXTRIP or All-EXTRIP criteria had shorter intensive care unit stay (P < .05) and no significant increase in fatalities and neurological impairment on discharge in comparison to the actually ECTR-treated patients. ECTR requirements using EXTRIP vs Paris criteria were not concordant (P < .001). In the non-actually ECTR-treated patients, 31/106 and 55/106 patients fulfilled Rec-EXTRIP or All-EXTRIP but not Paris criteria, respectively. Those patients had longer stay (P < .01) but no worse neurological impairment on discharge than the patients not fulfilling any of these criteria (50/106 and 26/106, respectively). In the non-actually ECTR-treated patients, 7/106 fulfilled Paris but not Rec-EXTRIP criteria. Those patients had longer stay (P < .05) and worse neurological impairment on discharge (P < .01) than the 50/106 patients not fulfilling any of these criteria. CONCLUSION In this cohort of lithium poisonings, EXTRIP criteria may lead to more ECTR than actually performed or if the Paris criteria were used, with no demonstrated improvement in outcome.
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Affiliation(s)
- Dominique Vodovar
- Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, Paris-Diderot University, Paris, France.,Paris Poison Center, Federation of Toxicology APHP, Fernand-Widal Hospital, Paris, France.,Inserm UMRS 1144, Paris-Descartes University, Paris, France
| | - Sébastien Beaune
- Inserm UMRS 1144, Paris-Descartes University, Paris, France.,Department of Emergency Medicine, Ambroise Paré Hospital, Paris, France
| | - Jérôme Langrand
- Paris Poison Center, Federation of Toxicology APHP, Fernand-Widal Hospital, Paris, France.,Inserm UMRS 1144, Paris-Descartes University, Paris, France
| | - Eric Vicaut
- Department of Clinical Research and Biostatistics, Fernand-Widal Hospital, Paris, France
| | - Laurence Labat
- Laboratory of Toxicology, Federation of Toxicology APHP, Lariboisière Hospital, Paris-Descartes University, Paris, France
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, Paris-Diderot University, Paris, France.,Inserm UMRS 1144, Paris-Descartes University, Paris, France
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Ott M, Stegmayr B, Salander Renberg E, Werneke U. Lithium intoxication: Incidence, clinical course and renal function - a population-based retrospective cohort study. J Psychopharmacol 2016; 30:1008-19. [PMID: 27307388 PMCID: PMC5036078 DOI: 10.1177/0269881116652577] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
When prescribing lithium, the risk of toxicity remains a concern. In this study, we examined a cohort of patients exposed to lithium between 1997 and 2013. The aims of this study were to determine the frequency of lithium intoxication and to evaluate the clinical course and changes in renal function. Of 1340 patients, 96 had experienced at least one episode of lithium levels ⩾1.5 mmol/L, yielding an incidence of 0.01 per patient-year. Seventy-seven patients available for review had experienced 91 episodes, of whom 34% required intensive care and 13% were treated with haemodialysis. There were no fatalities. Acute kidney injury occurred, but renal function at baseline was not different to renal function after the episode. Renal impairment was often associated with co-morbidities and other factors. Both intermittent and continuous-venovenous haemodialysis were used, but the clearance of continuous-venovenous haemodialysis can be too low in cases where large amounts of lithium have been ingested. Saline and forced diuresis have been used and are safe. Lithium intoxication seems rare and can be safely managed in most cases. Physicians should not withhold lithium for fear of intoxication in patients who benefit from it. Yet, physicians should have a low threshold to screen for toxicity.
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Affiliation(s)
- Michael Ott
- Department of Public Health and Clinical Medicine - Medicine, University Hospital, Umeå, Sweden
| | - Bernd Stegmayr
- Department of Public Health and Clinical Medicine – Medicine, University Hospital, Umeå, Sweden
| | | | - Ursula Werneke
- Sunderby Research Unit – Psychiatry, Department of Clinical Sciences, Umeå University, Umeå, Sweden
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Baird-Gunning J, Lea-Henry T, Hoegberg LCG, Gosselin S, Roberts DM. Lithium Poisoning. J Intensive Care Med 2016; 32:249-263. [DOI: 10.1177/0885066616651582] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Lithium is a commonly prescribed treatment for bipolar affective disorder. However, treatment is complicated by lithium’s narrow therapeutic index and the influence of kidney function, both of which increase the risk of toxicity. Therefore, careful attention to dosing, monitoring, and titration is required. The cause of lithium poisoning influences treatment and 3 patterns are described: acute, acute-on-chronic, and chronic. Chronic poisoning is the most common etiology, is usually unintentional, and results from lithium intake exceeding elimination. This is most commonly due to impaired kidney function caused by volume depletion from lithium-induced nephrogenic diabetes insipidus or intercurrent illnesses and is also drug-induced. Lithium poisoning can affect multiple organs; however, the primary site of toxicity is the central nervous system and clinical manifestations vary from asymptomatic supratherapeutic drug concentrations to clinical toxicity such as confusion, ataxia, or seizures. Lithium poisoning has a low mortality rate; however, chronic lithium poisoning can require a prolonged hospital length of stay from impaired mobility and cognition and associated nosocomial complications. Persistent neurological deficits, in particular cerebellar, are described and the incidence and risk factors for its development are poorly understood, but it appears to be uncommon in uncomplicated acute poisoning. Lithium is readily dialyzable, and rationale support extracorporeal treatments to reduce the risk or the duration of toxicity in high-risk exposures. There is disagreement in the literature regarding factors that define patients most likely to benefit from treatments that enhance lithium elimination, including specific plasma lithium concentration thresholds. In the case of extracorporeal treatments, there are observational data in its favor, without evidence from randomized controlled trials (none have been performed), which may lead to conservative practices and potentially unnecessary interventions in some circumstances. More data are required to define the risk–benefit of extracorporeal treatments and their use (modality, duration) in the management of lithium poisoning.
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Affiliation(s)
- Jonathan Baird-Gunning
- Department of General Medicine, The Canberra Hospital, Garran, Australian Capital Territory, Australia
- Medical School, Australian National University, Acton, Australian Capital Territory, Australia
| | - Tom Lea-Henry
- Department of Renal Medicine, The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, Australia
| | - Lotte C. G. Hoegberg
- Department of Anesthesiology, Danish Poisons Information Centre, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Sophie Gosselin
- Department of Medicine and Emergency Medicine, McGill University & Health Centre, Montréal, Québec, Canada
- Centre Antipoison du Québec, Québec, Canada
- Province of Alberta Drug Information Service, Calgary, Alberta, Canada
| | - Darren M. Roberts
- Medical School, Australian National University, Acton, Australian Capital Territory, Australia
- Department of Renal Medicine, The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, Australia
- Drug Health Clinical Services, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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Vodovar D, El Balkhi S, Curis E, Deye N, Mégarbane B. Lithium poisoning in the intensive care unit: predictive factors of severity and indications for extracorporeal toxin removal to improve outcome. Clin Toxicol (Phila) 2016; 54:615-23. [DOI: 10.1080/15563650.2016.1185110] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
BACKGROUND Lithium salts, particularly lithium carbonate, are frequently used to treat bipolar disorder and mania. Lithium poisoning, which can occur as a result of reduced renal elimination, prescribing error, drug-drug interactions, or deliberate overdosage, produces neurologic injury that can be permanent. Hemodialysis is often recommended to treat lithium poisoning. Although hemodialysis clearly enhances the elimination of lithium, it is unclear whether this translates into improved patient outcomes. Evidence from observational studies, generally of low methodological quality, shows similar outcomes in patients managed with or without the use of hemodialysis. OBJECTIVES To determine whether hemodialysis, applied in addition to standard therapy, reduces the likelihood, severity, or duration of neurological sequelae following lithium poisoning. SEARCH METHODS We ran the search on 15 May 2015. We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE (OvidSP), Embase Classic+Embase (OvidSP), CINAHL Plus, clinical trials registers and four other databases. We screened the reference lists of relevant studies, textbook chapters, and review articles, and performed a Google search to identify grey literature. SELECTION CRITERIA In the context of this review, hemodialysis was defined as any extracorporeal technique to filter and extract toxicants from the serum, including all forms of hemodialysis, hemofiltration, and continuous renal replacement techniques, but not peritoneal dialysis. We included any clinical trials in which patients were randomly allocated to receive, or not receive, hemodialysis in addition to standard care for lithium poisoning. DATA COLLECTION AND ANALYSIS Two authors reviewed the abstracts of all identified articles. If either author identified an article as potentially meeting the inclusion criteria, both authors reviewed the full text of the article. MAIN RESULTS No randomized controlled trials of hemodialysis therapy for lithium poisoning were identified. AUTHORS' CONCLUSIONS Although the use of hemodialysis to enhance the elimination of lithium in patients with lithium poisoning appears logical, there is no evidence from randomized controlled trials to support nor refute the use of hemodialysis in the management of patients with lithium poisoning.
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Affiliation(s)
- Eric J Lavonas
- Denver Health and Hospital AuthorityRocky Mountain Poison and Drug Center777 Bannock StreetMC 0108DenverColoradoUSA80204
| | - Jennie Buchanan
- Denver Health and Hospital AuthorityRocky Mountain Poison and Drug Center777 Bannock StreetMC 0108DenverColoradoUSA80204
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XXXV International Congress of the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) 26–29 May 2015, St Julian's, Malta. Clin Toxicol (Phila) 2015. [DOI: 10.3109/15563650.2015.1024953] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Decker BS, Goldfarb DS, Dargan PI, Friesen M, Gosselin S, Hoffman RS, Lavergne V, Nolin TD, Ghannoum M. Extracorporeal Treatment for Lithium Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup. Clin J Am Soc Nephrol 2015; 10:875-87. [PMID: 25583292 DOI: 10.2215/cjn.10021014] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The Extracorporeal Treatments in Poisoning Workgroup was created to provide evidence-based recommendations on the use of extracorporeal treatments in poisoning. Here, the EXTRIP workgroup presents its recommendations for lithium poisoning. After a systematic literature search, clinical and toxicokinetic data were extracted and summarized following a predetermined format. The entire workgroup voted through a two-round modified Delphi method to reach a consensus on voting statements. A RAND/UCLA Appropriateness Method was used to quantify disagreement, and anonymous votes were compiled and discussed in person. A second vote was conducted to determine the final workgroup recommendations. In total, 166 articles met inclusion criteria, which were mostly case reports, yielding a very low quality of evidence for all recommendations. A total of 418 patients were reviewed, 228 of which allowed extraction of patient-level data. The workgroup concluded that lithium is dialyzable (Level of evidence=A) and made the following recommendations: Extracorporeal treatment is recommended in severe lithium poisoning (1D). Extracorporeal treatment is recommended if kidney function is impaired and the [Li(+)] is >4.0 mEq/L, or in the presence of a decreased level of consciousness, seizures, or life-threatening dysrhythmias irrespective of the [Li(+)] (1D). Extracorporeal treatment is suggested if the [Li(+)] is >5.0 mEq/L, significant confusion is present, or the expected time to reduce the [Li(+)] to <1.0 mEq/L is >36 hours (2D). Extracorporeal treatment should be continued until clinical improvement is apparent or [Li(+)] is <1.0 mEq/L (1D). Extracorporeal treatments should be continued for a minimum of 6 hours if the [Li(+)] is not readily measurable (1D). Hemodialysis is the preferred extracorporeal treatment (1D), but continuous RRT is an acceptable alternative (1D). The workgroup supported the use of extracorporeal treatment in severe lithium poisoning. Clinical decisions on when to use extracorporeal treatment should take into account the [Li(+)], kidney function, pattern of lithium toxicity, patient's clinical status, and availability of extracorporeal treatments.
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Affiliation(s)
- Brian S Decker
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - David S Goldfarb
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Paul I Dargan
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Marjorie Friesen
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Sophie Gosselin
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Robert S Hoffman
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Valéry Lavergne
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Thomas D Nolin
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Marc Ghannoum
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material.
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