1
|
Lewis AS, Boomhower SR, Marsh CM, Jack MM. Considerations for deriving a safe intake of propylene glycol. Food Chem Toxicol 2024; 186:114460. [PMID: 38325632 DOI: 10.1016/j.fct.2024.114460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/05/2024] [Accepted: 01/14/2024] [Indexed: 02/09/2024]
Abstract
The use of propylene glycol (PG) in food and other applications is widespread, and some estimates of dietary exposure to PG approach or exceed the Acceptable Daily Intake (ADI) of 25 mg/kg bw-day. The current ADI for PG applies a cumulative uncertainty factor of 100, which includes factors of 10 for both interspecies and intraspecies differences. Available toxicology studies and human data, however, indicate a plausible mode of action (MoA) that would support a chemical-specific adjustment factor (CSAF) of 1 for interspecies toxicodynamic differences, reducing the total uncertainty factor from 100 to 40. The MoA involves an increase in serum PG concentrations after metabolic saturation, leading to serum hyperosmolarity, which can ultimately cause hemolytic changes and red blood cell damage. Therefore, the species similarities in toxicodynamic response for this critical effect could support increasing the ADI from 25 to 62.5 mg/kg bw-day, applicable to both children and adults.
Collapse
Affiliation(s)
| | - Steven R Boomhower
- Gradient, Boston, MA, 02108, USA; Harvard Division of Continuing Education, Harvard University, Cambridge, MA, 02138, USA
| | | | - Maia M Jack
- American Beverage Association, Washington, DC, 20004, USA
| |
Collapse
|
2
|
|
3
|
Bulathsinghala M, Keefer K, Van de Louw A. Trimethoprim/Sulfamethoxazole-Induced Severe Lactic Acidosis: A Case Report and Review of the Literature. Medicine (Baltimore) 2016; 95:e3478. [PMID: 27124045 PMCID: PMC4998708 DOI: 10.1097/md.0000000000003478] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Propylene glycol (PG) is used as a solvent in numerous medications, including trimethoprim/sulfamethoxazole (TMP/SMX) and lorazepam, and is metabolized in the liver to lactic acid. Cases of lactic acidosis related to PG toxicity have been described and always involved large doses of benzodiazepines and PG. We present the first case of severe lactic acidosis after a 3-day course of TMP/SMX alone, involving allegedly safe amounts of PG.A 31-year-old female with neurofibromatosis and pilocytic astrocytoma, receiving temozolomide and steroids, was admitted to the intensive care unit for pneumonia and acute respiratory failure requiring intubation. Her initial hemodynamic and acid-base statuses were normal. She was treated with intravenous TMP/SMX for possible Pneumocystis jirovecii pneumonia and was successfully extubated on day 2. On day 3, she developed tachypnea and arterial blood gas analysis revealed a severe metabolic acidosis (pH 7.2, PCO2 19 mm Hg, bicarbonates 8 mEq/L) with anion gap of 25 mEq/L and lactate of 12.1 mmol/L. TMP/SMX was discontinued and the lactate decreased to 2.9 mmol/L within 24 hours while her plasma bicarbonates normalized, without additional intervention. The patient never developed hypotension or severe hypoxia, and her renal and liver functions were normal. No other cause for lactic acidosis was identified and it resolved after TMP/SMX cessation alone, suggesting PG toxicity.Although PG-related lactic acidosis is well recognized after large doses of lorazepam, clinicians should bear in mind that TMP/SMX contains PG as well and should suspect PG toxicity in patients developing unexplained metabolic acidosis while receiving TMP/SMX.
Collapse
Affiliation(s)
- Marie Bulathsinghala
- From the Division of Pulmonary and Critical Care Medicine (MB, AVDL) and Department of Pharmacy, Penn State University College of Medicine and Milton S Hershey Medical Center (KK), Hershey, PA
| | | | | |
Collapse
|
4
|
Acute kidney injury with medazepam-hyoscine buthylbromide. Wien Klin Wochenschr 2014; 126:291-3. [DOI: 10.1007/s00508-014-0523-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2013] [Accepted: 02/05/2014] [Indexed: 10/25/2022]
|
5
|
Abstract
The toxicological profiles of monopropylene glycol (MPG), dipropylene glycol (DPG), tripropylene glycol (TPG) and polypropylene glycols (PPG; including tetra-rich oligomers) are collectively reviewed, and assessed considering regulatory toxicology endpoints. The review confirms a rich data set for these compounds, covering all of the major toxicological endpoints of interest. The metabolism of these compounds share common pathways, and a consistent profile of toxicity is observed. The common metabolism provides scientific justification for adopting a read-across approach to describing expected hazard potential from data gaps that may exist for specific oligomers. None of the glycols reviewed presented evidence of carcinogenic, mutagenic or reproductive/developmental toxicity potential to humans. The pathologies reported in some animal studies either occurred at doses that exceeded experimental guidelines, or involved mechanisms that are likely irrelevant to human physiology and therefore are not pertinent to the exposures experienced by consumers or workers. At very high chronic doses, MPG causes a transient, slight decrease in hemoglobin in dogs and at somewhat lower doses causes Heinz bodies to form in cats in the absence of any clinical signs of anemia. Some evidence for rare, idiosyncratic skin reactions exists for MPG. However, the larger data set indicates that these compounds have low sensitization potential in animal studies, and therefore are unlikely to represent human allergens. The existing safety evaluations of the FDA, USEPA, NTP and ATSDR for these compounds are consistent and point to the conclusion that the propylene glycols present a very low risk to human health.
Collapse
|
6
|
Claus MA, Jandrey KE, Poppenga RH. Propylene glycol intoxication in a dog. J Vet Emerg Crit Care (San Antonio) 2011; 21:679-83. [DOI: 10.1111/j.1476-4431.2011.00688.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Melissa A. Claus
- Veterinary Medical Teaching Hospital; University of California Davis; Davis; CA; 95616
| | - Karl E. Jandrey
- The Department of Surgical and Radiological Sciences; University of California Davis; Davis; CA; 95616
| | - Robert H. Poppenga
- Department of Molecular Biosciences; California Animal Health and Food Safety Laboratory; University of California Davis; Davis; CA; 95616
| |
Collapse
|
7
|
Sampathkumar K, Yesudas S. Hair dye poisoning and the developing world. J Emerg Trauma Shock 2011; 2:129-31. [PMID: 19561974 PMCID: PMC2700586 DOI: 10.4103/0974-2700.50749] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2008] [Accepted: 09/16/2008] [Indexed: 12/05/2022] Open
Abstract
Hair dye poisoning has been emerging as one of the important causes of intentional self harm in the developing world. Hair dyes contain paraphenylene-diamine and a host of other chemicals that can cause rhabdomyolysis, laryngeal edema, severe metabolic acidosis and acute renal failure. Intervention at the right time has been shown to improve the outcome. In this article, we review the various manifestations, clinical features and treatment modalities for hair dye poisoning.
Collapse
Affiliation(s)
- Krishnaswamy Sampathkumar
- Department of Nephrology, Meenakshi Mission Hospital and Research Centre, Lake Area, Melur Road, Madurai, Tamil Nadu - 625 107, India
| | | |
Collapse
|
8
|
Abstract
Metabolic acidosis may occasionally develop in the course of treatment with drugs used in everyday clinical practice, as well as with the exposure to certain chemicals. Drug-induced metabolic acidosis, although usually mild, may well be life-threatening, as in cases of lactic acidosis complicating antiretroviral therapy or treatment with biguanides. Therefore, a detailed medical history, with special attention to the recent use of culprit medications, is essential in patients with acid-base derangements. Effective clinical management can be handled through awareness of the adverse effect of certain pharmaceutical compounds on the acid-base status. In this review, we evaluate relevant literature with regard to metabolic acidosis associated with specific drug treatment, and discuss the clinical setting and underlying pathophysiological mechanisms. These mechanisms involve renal inability to excrete the dietary H+ load (including types I and IV renal tubular acidoses), metabolic acidosis owing to increased H+ load (including lactic acidosis, ketoacidosis, ingestion of various substances, administration of hyperalimentation solutions and massive rhabdomyolysis) and metabolic acidosis due to HCO3- loss (including gastrointestinal loss and type II renal tubular acidosis). Determinations of arterial blood gases, the serum anion gap and, in some circumstances, the serum osmolar gap are helpful in delineating the pathogenesis of the acid-base disorder. In all cases of drug-related metabolic acidosis, discontinuation of the culprit medications and avoidance of readministration is advised.
Collapse
Affiliation(s)
- George Liamis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | | | | |
Collapse
|
9
|
Abstract
Double gap metabolic acidosis occurs in the setting of unmeasured active osmoles in the serum (osmolal gap) and anion gap (AG) metabolic acidosis. We describe a 67-year-old woman with acute respiratory failure on mechanical ventilator from pneumonia and anuric acute on chronic renal failure (urea nitrogen 21.4 mmol/L, creatinine 530.4 μmol/L) requiring haemodialysis (HD). On hospital day 5, she was found to have progressive metabolic acidosis (serum pH 7.16, PCO2 4.38 kPa, HCO3− 12.1 mmol/L and AG 21 mmol/L). There was no evidence of hypoxaemia, hypoperfusion or haemodynamic instability. Normal serum ketone and l-lactate but high serum osmolal gap (89.4 mmol/kg) was detected. A search for toxic alcohols revealed a high serum propylene glycol (PG 32.9 mmol/L), a stabilizing solvent for intravenous formulations of lorazepam, which was being used as sedation for mechanical ventilation. Unexpectedly, serum l- and d-lactate as metabolites of PG were not elevated. Although extended HD for eight hours completely removed serum PG and the osmolal gap, the predialysis high AG metabolic acidosis persisted, potentially related to hypercatabolism and anuric renal failure. PG should be in the differential diagnosis of the disorders with high osmolar gap and may not always be associated with l- or d-lactic acidosis.
Collapse
Affiliation(s)
- Ming-Tso Yan
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tom Chau
- Department of Medicine, Providence St Vincent Medical Center, Portland, OR, USA
| | - Chih-Jen Cheng
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shih-Hua Lin
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| |
Collapse
|
10
|
|
11
|
Arend LJ, Nadasdy T. Emerging therapy-related kidney disease. Arch Pathol Lab Med 2009; 133:268-78. [PMID: 19195969 DOI: 10.5858/133.2.268] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2008] [Indexed: 11/06/2022]
Abstract
CONTEXT Many new therapies have emerged within the last 5 to 10 years to treat a variety of conditions. Several of these have direct or indirect renal toxicities that may go undiagnosed without careful attention of the pathologist to a patient's clinical history, particularly the addition of new medications or treatments. OBJECTIVE To discuss patterns of renal injury resulting from medications or therapeutic regimens that have been introduced within the last 10 years. Recognition of these patterns may allow the pathologist to alert the attending clinician to a possible drug-induced renal injury and prevent further deterioration of renal function and possible chronic kidney disease. DATA SOURCES A review of recent literature and unpublished observations of case-derived material. CONCLUSIONS A number of newer therapies have emerged as agents of renal toxicity, producing a variety of pathologic changes in the kidney. The outcome can be acute or chronic glomerular, tubular, interstitial, and/or vascular injury. Some drugs will result in irreversible changes and end-stage renal disease, whereas many of the alterations can be reversed with removal of the offending agent, avoiding potential long-term kidney injury.
Collapse
Affiliation(s)
- Lois J Arend
- Department of Pathology and Laboratory Medicine, University of Cincinnati Academic Health Center, Cincinnati, Ohio, USA
| | | |
Collapse
|
12
|
Nelsen JL, Haas CE, Habtemariam B, Kaufman DC, Partridge A, Welle S, Forrest A. A prospective evaluation of propylene glycol clearance and accumulation during continuous-infusion lorazepam in critically ill patients. J Intensive Care Med 2008; 23:184-94. [PMID: 18543419 DOI: 10.1177/0885066608315808] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Propylene glycol is a commonly used diluent in several pharmaceutical preparations, including the sedative lorazepam. Fifty critically ill patients receiving continuous-infusion lorazepam for a minimum of 36 hours were prospectively evaluated to determine the extent of propylene glycol accumulation over time, characterize propylene glycol clearance in the presence of critical illness, and develop a pharmacokinetic model that would predict clearance based on patient-specific clinical, laboratory, and demographic factors. In this cohort, the median lorazepam infusion rate was 2.1 mg/h (0.5-18). Propylene glycol concentration correlated poorly with osmolality, osmol gap, and lactate. In all, 8 patients (16%) had significant propylene glycol accumulation (>25mg/dL). When propylene glycol concentrations were >25 mg/dL, the median lorazepam infusion rate before sample collection was higher, 6.4 (1.9-11.3) versus 2.0 (0.5-7.4) mg/h (P =.0003). A linear first-order model with interoccasion variability on clearance adjusted for total body weight and Acute Physiology and Chronic Health Evaluation II score predicted propylene glycol concentration.
Collapse
Affiliation(s)
- Jamie L Nelsen
- Department of Emergency Medicine, State University of New York, Upstate Medical University, Syracuse, NY 13210, USA.
| | | | | | | | | | | | | |
Collapse
|
13
|
Yahwak JA, Riker RR, Fraser GL, Subak-Sharpe S. Determination of a Lorazepam Dose Threshold for Using the Osmol Gap to Monitor for Propylene Glycol Toxicity. Pharmacotherapy 2008; 28:984-91. [DOI: 10.1592/phco.28.8.984] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
14
|
Abstract
The correct identification of the cause, and ideally the individual acid, responsible for metabolic acidosis in the critically ill ensures rational management. In Part 2 of this review, we examine the elevated (corrected) anion gap acidoses (lactic, ketones, uraemic and toxin ingestion) and contrast them with nonelevated conditions (bicarbonate wasting, renal tubular acidoses and iatrogenic hyperchloraemia) using readily available base excess and anion gap techniques. The potentially erroneous interpretation of elevated lactate signifying cell ischaemia is highlighted. We provide diagnostic and therapeutic guidance when faced with a high anion gap acidosis, for example pyroglutamate, in the common clinical scenario 'I can't identify the acid--but I know it's there'. The evidence that metabolic acidosis affects outcomes and thus warrants correction is considered and we provide management guidance including extracorporeal removal and fomepizole therapy.
Collapse
Affiliation(s)
- C G Morris
- Intensive Care Medicine and Anaesthesia, Derby Hospitals Foundation Trust, Derby Royal Infirmary, London Road, Derby DE1 2QY, UK.
| | | |
Collapse
|
15
|
Buggins TR, Dickinson PA, Taylor G. The effects of pharmaceutical excipients on drug disposition. Adv Drug Deliv Rev 2007; 59:1482-503. [PMID: 18198495 DOI: 10.1016/j.addr.2007.08.017] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Many new chemical entities are poorly soluble, requiring the use of co-solvents or excipients to produce suitable intravenous formulations for early pre-clinical development studies. There is some evidence in the literature that these formulation components can have significant physiological and physicochemical effects which may alter the distribution and elimination of co-administered drugs. Such effects have the potential to influence the results of pre-clinical pharmacokinetic studies, giving a false impression of a compound's intrinsic pharmacokinetics and frustrating attempts to predict the drug's ultimate clinical pharmacokinetics. This review describes the reported effects of commonly used co-solvents and excipients on drug pharmacokinetics and on physiological systems which are likely to influence drug disposition. Such information will be useful in study design and evaluating data from pharmacokinetic experiments, so that the potential influence of formulation components can be minimised.
Collapse
|
16
|
Zar T, Yusufzai I, Sullivan A, Graeber C. Acute kidney injury, hyperosmolality and metabolic acidosis associated with lorazepam. ACTA ACUST UNITED AC 2007; 3:515-20. [PMID: 17717564 DOI: 10.1038/ncpneph0573] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2007] [Accepted: 06/29/2007] [Indexed: 11/09/2022]
Abstract
BACKGROUND A 54-year-old male with a history of multiple admissions for alcohol intoxication was admitted to hospital with right flank pain. He received a high-dose lorazepam infusion for alcohol withdrawal during hospitalization and developed severe hyperosmolality, high anion gap metabolic acidosis, and acute kidney injury on his eighth day of hospitalization. INVESTIGATIONS Serum chemistries, arterial blood gas analysis, and measurement of serum propylene glycol, ethylene glycol and methanol levels. DIAGNOSIS Propylene glycol toxicity. MANAGEMENT Discontinuation of lorazepam infusion, administration of fomepizole, hemodialysis for five consecutive days, hemodynamic support, and follow-up of serum osmolality as a measure of propylene glycol decay.
Collapse
Affiliation(s)
- Tausif Zar
- Division of Nephrology, Department of Medicine, University of Connecticut School of Medicine, Farmington, CT, USA.
| | | | | | | |
Collapse
|
17
|
Abstract
Propylene glycol is a commonly used solvent for oral, intravenous, and topical pharmaceutical preparations. Although it is considered safe, large intravenous doses given over a short period of time can be toxic. Underlying renal insufficiency and hepatic dysfunction raise risk for toxicity. Toxic effects include hyperosmolality, increased anion gap metabolic acidosis (due to lactic acidosis), acute kidney injury, and sepsis-like syndrome. Treatment of toxicity includes hemodialysis to effectively remove propylene glycol. Prevention is best achieved by limiting the dose of propylene glycol infused.
Collapse
Affiliation(s)
- Tausif Zar
- Sections of Nephrology, Department of Medicine, University of Connecticut, Farmington, Connecticut 06030, USA.
| | | | | |
Collapse
|
18
|
Sampathkumar K, Sooraj YS, Ajeshkumar RP, Mahaldar AR, Muthiah R. Rhabdomyolysis due to hair dye poisoning: An emerging threat. Indian J Crit Care Med 2007. [DOI: 10.4103/0972-5229.37717] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
19
|
Barnes BJ, Gerst C, Smith JR, Terrell AR, Mullins ME. Osmol Gap as a Surrogate Marker for Serum Propylene Glycol Concentrations in Patients Receiving Lorazepam for Sedation. Pharmacotherapy 2006; 26:23-33. [PMID: 16422667 DOI: 10.1592/phco.2006.26.1.23] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVES To correlate serum propylene glycol concentration with osmol gap, serum lactate concentration, and amount of propylene glycol administered to mechanically ventilated patients receiving continuous infusions of lorazepam (80% propylene glycol by weight), and to characterize the prevalence of hyperosmolality and range of serum propylene glycol concentrations in this patient population. DESIGN Prospective, controlled, observational study. SETTING Adult surgical and cardiothoracic intensive care units (ICUs) of a 1200-bed, urban, tertiary care, teaching hospital. PATIENTS Sixty-four consecutively enrolled intensive care patients requiring mechanical ventilation and pharmacologic sedation. INTERVENTION Thirteen patients received continuous infusions of high-dose lorazepam (> or = 6 mg/hr) for a minimum of 36 hours, and 26 received continuous infusions of low-dose lorazepam (2-5.99 mg/hr) for 36 hours. Twenty-five control patients received sedatives that did not contain propylene glycol. MEASUREMENTS AND MAIN RESULTS Serum propylene glycol and lactate concentrations, osmolality, and basic metabolic profiles were obtained 72-108 hours after ICU admission. Clinical data, drug administration, and severity of illness scores were recorded. Osmol gap and the amount of propylene glycol administered before serum sampling predicted propylene glycol concentrations (r(2)=0.692, p<0.05). Osmol gap alone also predicted serum propylene glycol concentrations (r(2)=0.532, p<0.05). Serum lactate concentrations did not correlate with serum propylene glycol concentrations. Unlike the low-dose and control patients, eight (62%) of 13 high-dose patients had osmol gaps above 10. All 13 high-dose patients had serum propylene glycol concentrations previously associated with toxicity. CONCLUSION Osmol gap can be used as a surrogate marker for serum propylene glycol concentration. In critically ill patients receiving lorazepam for sedation, an osmol gap above 10 was associated with concentrations previously reported to cause toxicity.
Collapse
Affiliation(s)
- Brian J Barnes
- Department of Pharmacy, Barnes-Jewish Hospital, Washington University, School of Medicine, St. Louis, Missouri, USA.
| | | | | | | | | |
Collapse
|
20
|
Neale BW, Mesler EL, Young M, Rebuck JA, Weise WJ. Propylene Glycol–Induced Lactic Acidosis in a Patient with Normal Renal Function: A Proposed Mechanism and Monitoring Recommendations. Ann Pharmacother 2005; 39:1732-6. [PMID: 16159998 DOI: 10.1345/aph.1g083] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE:To report a case of severe propylene glycol–induced lactic acidosis not attributable to renal dysfunction that was secondary to administration of high-dose intravenous lorazepam.CASE SUMMARY:A 24-year-old female with community-acquired pneumonia presented with severe acute respiratory distress syndrome. To maintain adequate sedation and ventilation and reduce airway pressure, several relaxation strategies were used including high-dose intravenous lorazepam, fentanyl, and cisatracurium. After 18 days of high-dose continuous infusion of lorazepam (maximum dose 50 mg/h), the patient developed severe lactic acidosis secondary to propylene glycol toxicity, the main diluent of lorazepam. The acidosis temporarily resolved with bicarbonate administration and discontinuation of lorazepam. Her renal function remained stable for a time (serum creatinine 0.5 mg/dL, blood urea nitrogen 10 mg/dL, urine output 100–200 mL/h). However, after several more days, the patient's condition deteriorated, and she ultimately died.DISCUSSION:Previous cases of propylene glycol toxicity secondary to high-dose lorazepam infusion have occurred in patients with compromised renal function. Our patient's renal function remained stable throughout the hospital course, which caused us to look further for an explanation for the propylene glycol–induced lactic acidosis. Based on the Naranjo probability scale, propylene glycol was determined to be the probable cause of lactic acidosis. Since this case occurred, our intensive care unit has instituted recommendations for the prevention of lorazepam-associated propylene glycol toxicity.CONCLUSIONS:Our case highlights the development of propylene glycol–induced lactic acidosis secondary to high-dose lorazepam infusion not associated with renal dysfunction.
Collapse
Affiliation(s)
- Bruce W Neale
- Department of Pharmacy, Fletcher Allen Health Care, Burlington, VT 05401-1473, USA
| | | | | | | | | |
Collapse
|
21
|
Riker RR, Fraser GL. Adverse Events Associated with Sedatives, Analgesics, and Other Drugs That Provide Patient Comfort in the Intensive Care Unit. Pharmacotherapy 2005; 25:8S-18S. [PMID: 15899744 DOI: 10.1592/phco.2005.25.5_part_2.8s] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Since the 2002 publication of multidisciplinary clinical practice guidelines for intensive care unit (ICU) sedation and analgesia, additional information regarding adverse drug events has been reported. Our understanding of the risks associated with these sedative and analgesic agents promises to improve outcomes by helping clinicians identify and respond to therapeutic misadventures sooner. This review focuses on many issues, including the potentially fatal consequences associated with the propofol infusion syndrome, the evolving understanding of propylene glycol intoxication associated with parenteral lorazepam, new data involving high-dose and long-term dexmedetomidine therapy, haloperidol- and methadone-related prolongation of QTc intervals on the electrocardiogram, adverse events associated with atypical antipsychotics, and the potential for nonsteroidal antiinflammatory drugs to interfere with bone healing.
Collapse
Affiliation(s)
- Richard R Riker
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Maine Medical Center, Portland, Maine 04102, USA
| | | |
Collapse
|
22
|
Arroliga AC, Shehab N, McCarthy K, Gonzales JP. Relationship of continuous infusion lorazepam to serum propylene glycol concentration in critically ill adults*. Crit Care Med 2004; 32:1709-14. [PMID: 15286548 DOI: 10.1097/01.ccm.0000134831.40466.39] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The primary objective was to evaluate the relationship between high-dose lorazepam and serum propylene glycol concentrations. Secondary objectives were a) to document the occurrence of propylene glycol accumulation associated with continuous high-dose lorazepam infusion; b) to assess the relationship between lorazepam dose, serum propylene glycol concentrations, and propylene glycol accumulation; and c) to assess the relationship between the osmol gap and serum propylene glycol concentrations. DESIGN Prospective, observational study. SETTING Tertiary care, medical intensive care unit. PATIENTS Nine critically ill adults receiving high-dose lorazepam (> or =10 mg/hr) infusion. INTERVENTIONS Cumulative lorazepam dose (mg/kg) and the rate of infusion (mg.kg(-1).hr(-1)) were monitored from initiation of lorazepam infusion until 24 hrs after discontinuation of the high-dose lorazepam infusion. Serum osmolarity was collected at 48 hrs into the high-dose lorazepam infusion and daily thereafter. Serum propylene glycol concentrations were drawn at 48 hrs into the high-dose lorazepam infusion, and the presence of propylene glycol accumulation, as evidenced by a high anion gap (> or =15 mmol/L) metabolic acidosis with elevated osmol gap (> or =10 mOsm/L), was assessed at that time. MEASUREMENTS AND MAIN RESULTS The mean cumulative high-dose lorazepam received and mean high-dose lorazepam infusion rate were 8.1 mg/kg (range, 5.1-11.7) and 0.16 mg.kg(-1).hr (-1)(range, 0.11-0.22), respectively. A significant correlation between high-dose lorazepam infusion rate and serum propylene glycol concentrations was observed (r =.557, p =.021). Osmol gap was the strongest predictor of serum propylene glycol concentrations (r =.804, p =.001). Propylene glycol accumulation was observed in six of nine patients at 48 hrs. No significant correlation between duration of lorazepam infusion and serum propylene glycol concentrations was observed (p =.637). CONCLUSION Propylene glycol accumulation, as reflected by a hyperosmolar anion gap metabolic acidosis, was observed in critically ill adults receiving continuous high-dose lorazepam infusion for > or =48 hrs. Study findings suggest that in critically ill adults with normal renal function, serum propylene glycol concentrations may be predicted by the high-dose lorazepam infusion rate and osmol gap.
Collapse
Affiliation(s)
- Alejandro C Arroliga
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | | | | | | |
Collapse
|
23
|
|