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Buisman L, Riphagen IJ, Kwant M, Themmen MD, Bouma M, Bethlehem C. Case report: Salicylate intoxication can present with a normal anion gap metabolic acidosis depending on method used for measuring chloride. Br J Clin Pharmacol 2022; 88:4933-4936. [PMID: 35971785 DOI: 10.1111/bcp.15492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 08/04/2022] [Accepted: 08/08/2022] [Indexed: 11/28/2022] Open
Abstract
Severe salicylate intoxication usually presents with a high anion gap metabolic acidosis. We describe a patient with severe salicylate intoxication that presented with a surprisingly normal anion gap metabolic acidosis. Initial salicylate level was 594 mg/L (therapeutic range 50-300 mg/L). In this case, the anion gap was normal due to a falsely elevated chloride concentration measured using a direct ion-selective electrode (ISE) (ABL90-flex). Since earlier case reports have shown that salicylate ions can interfere with chloride measurement using different ISEs, available samples were re-analyzed using an indirect ISE (Roche Cobas 8000), in which salicylate levels up to 1000 mg/L were found to cause no significant interference. With this method, chloride concentration was found to be 115 instead of 122 mmol/L, leading to the expected elevated anion gap. We performed a spike experiment to investigate the impact of different salicylate levels and bicarbonate concentrations on the measured chloride concentration for both methods. This experiment showed that the difference between chloride concentrations was mainly explained by interference with bicarbonate. It is important for clinicians to be aware of this possible interference, since a high anion gap metabolic acidosis can be a clue to suspect salicylate poisoning and early recognition and appropriate treatment is important. The patient was successfully treated with hemodialysis and no rebound toxicity was observed.
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Affiliation(s)
- Laura Buisman
- Department of Intensive Care Medicine, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - Ineke J Riphagen
- Department of Clinical Chemistry, Certe, Leeuwarden, the Netherlands
| | - Marieke Kwant
- Department of Emergency Medicine, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - Margo D Themmen
- Department of Internal Medicine, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - Marjan Bouma
- Department of Clinical Pharmacy and Pharmacology, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - Carina Bethlehem
- Department of Intensive Care Medicine, Medical Centre Leeuwarden, Leeuwarden, the Netherlands.,Department of Clinical Pharmacy and Pharmacology, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
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2
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Teder K, Maddison L, Soeorg H, Meos A, Karjagin J. The Pharmacokinetic Profile and Bioavailability of Enteral N-Acetylcysteine in Intensive Care Unit. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57111218. [PMID: 34833436 PMCID: PMC8620940 DOI: 10.3390/medicina57111218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/01/2021] [Accepted: 11/05/2021] [Indexed: 12/24/2022]
Abstract
Background and Objectives: N-acetylcysteine (NAC) is a mucolytic agent used to prevent ventilator-associated pneumonia in intensive care units. This study aimed to evaluate the oral bioavailability of NAC in critically ill patients with pneumonia, isolated acute brain injury and abdominal sepsis. Materials and Methods: This quantitative and descriptive study compared NAC's pharmacokinetics after intravenous and enteral administration. 600 mg of NAC was administered in both ways, and the blood levels for NAC were measured. Results: 18 patients with pneumonia, 19 patients with brain injury and 17 patients with abdominal sepsis were included in the population pharmacokinetic modelling. A three-compartmental model without lag-time provided the best fit to the data. Oral bioavailability was estimated as 11.6% (95% confidence interval 6.3-16.9%), similar to bioavailability in healthy volunteers and patients with chronic pulmonary diseases. Conclusions: The bioavailability of enteral NAC of ICU patients with different diseases is similar to the published data on healthy volunteers.
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Affiliation(s)
- Kersti Teder
- Institute of Pharmacy, University of Tartu, Nooruse 1, 50411 Tartu, Estonia;
- Pharmacy Department, Tartu University Hospital, L. Puusepa 8, 50406 Tartu, Estonia
- Correspondence: ; Tel.: +372-566-849-33
| | - Liivi Maddison
- Institute of Clinical Medicine, University of Tartu, L. Puusepa 8, 50406 Tartu, Estonia; (L.M.); (J.K.)
- Clinic of Anaesthesiology and Intensive Care, Tartu University Hospital, L. Puusepa 8, 50406 Tartu, Estonia
| | - Hiie Soeorg
- Department of Microbiology, Institute of Biomedicine and Translational Medicine, University of Tartu, Ravila 19, 50411 Tartu, Estonia;
| | - Andres Meos
- Institute of Pharmacy, University of Tartu, Nooruse 1, 50411 Tartu, Estonia;
| | - Juri Karjagin
- Institute of Clinical Medicine, University of Tartu, L. Puusepa 8, 50406 Tartu, Estonia; (L.M.); (J.K.)
- Clinic of Anaesthesiology and Intensive Care, Tartu University Hospital, L. Puusepa 8, 50406 Tartu, Estonia
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3
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Shah KR, Beuhler MC. Single bag high dose intravenous N-acetylcysteine associated with decreased hepatotoxicity compared to triple bag intravenous N-acetylcysteine in high-risk acetaminophen ingestions. Clin Toxicol (Phila) 2021; 60:493-498. [PMID: 34549670 DOI: 10.1080/15563650.2021.1979231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION There is controversy that the triple bag intravenous (IV) N-acetylcysteine (NAC) regimen may be underdosing the sickest patients in its current, common usage. We hypothesize that a higher dose IV NAC regimen improves some outcomes. METHODS We conducted a poison center based retrospective observational study from January 1, 2016 to December 31, 2017 comparing a single bag higher dose IV NAC regimen (150 mg/kg over 1 h, 15 mg/kg/hour) to the triple bag IV NAC regimen (150 mg/kg over 1 h, 12.5 mg/kg/hour for 4 h, 6.25 mg/kg/hour). In a high-risk population of patients with acetaminophen ingestion (defined as multiplication product ≥ 10,000 mg/L IU/L, not acute ingestions receiving NAC within 8 h, and not hepatotoxic on first contact), we evaluated the rate of hepatotoxicity, peak transaminase, and rate of laboratory coagulopathy. RESULTS 89 patients met the inclusion criteria. 12 of the 23 patients (52%) who received triple bag NAC became hepatotoxic and 10 (43%) became coagulopathic, while only 19 of 66 patients (29%) who received single bag NAC became hepatotoxic and 15 (23%) became coagulopathic; p = .043 and .057, resp. Mean peak transaminase was 4481 IU/L vs 2143 IU/L in those receiving triple bag NAC vs single bag NAC, difference of means 2338 IU/L; p = .026. CONCLUSION In this exploratory study of a high-risk population of patients with acetaminophen ingestions, the single bag IV NAC regimen was associated with lower peak transaminase and fewer patients becoming hepatotoxic as compared to the triple bag IV NAC regimen.
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Affiliation(s)
- Kartik R Shah
- Division of Medical Toxicology, Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, NC, USA
| | - Michael C Beuhler
- North Carolina Poison Control, Atrium Health's Carolinas Medical Center, Charlotte, NC, USA
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4
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Abstract
Acetaminophen is a common medication taken in deliberate self-poisoning and unintentional overdose. It is the commonest cause of severe acute liver injury in Western countries. The optimal management of most acetaminophen poisonings is usually straightforward. Patients who present early should be offered activated charcoal and those at risk of acute liver injury should receive acetylcysteine. This approach ensures survival in most. The acetaminophen nomogram is used to assess the need for treatment in acute immediate-release overdoses with a known time of ingestion. However, scenarios that require different management pathways include modified-release, large/massive, and repeated supratherapeutic ingestions.
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Affiliation(s)
- Angela L Chiew
- Clinical Toxicology Unit, Prince of Wales Hospital, Barker Street, Randwick, New South Wales 2031, Australia.
| | - Nicholas A Buckley
- Pharmacology and Biomedical Informatics and Digital Health, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales 2050, Australia
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Massive Acetaminophen Overdose Treated Successfully with N-Acetylcysteine, Fomepizole, and Hemodialysis. Case Rep Crit Care 2021; 2021:6695967. [PMID: 34336301 PMCID: PMC8289598 DOI: 10.1155/2021/6695967] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 06/28/2021] [Indexed: 01/22/2023] Open
Abstract
Acetaminophen overdose is one of the most common causes of acute hepatic failure in the developed world. There is strong evidence for N-acetylcysteine (NAC) as a safe and effective antidote for acetaminophen toxicity. However, there is less clarity in the management of massive overdoses (acute, single ingestions > 500 mg/kg with 4-hour equivalent concentrations ~6000 μmol/L) which are often associated with metabolic acidosis and multiorgan dysfunction. In such ingestions, the role of adjuvant treatments such as fomepizole and extracorporeal removal is unclear. We present a case of a 20-year-old female presenting with an acute ingestion of over 120 grams (1764.7 mg/kg) and an acetaminophen concentration of 5880 μmol/L who developed refractory shock, decreased level of consciousness, and metabolic acidosis requiring mechanical ventilation and vasopressor support. She was treated with gastric decontamination with activated charcoal, IV NAC, fomepizole, and hemodialysis. The patient had complete clearance of acetaminophen by 32 hours after presentation and normalization of her acid base and hemodynamic status without any organ failure. This case highlights the potential benefit of a triple strategy of NAC, fomepizole, and early hemodialysis in massive acetaminophen overdose, potentially sparing complications of prolonged intubation and ICU hospitalization.
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Cuninghame S, Lotfy K, Cameron P. Massive acetaminophen overdose with metabolic acidosis refractory to N-acetylcysteine, fomepizole, and renal replacement therapy. Toxicol Rep 2021; 8:804-807. [PMID: 33868959 PMCID: PMC8044808 DOI: 10.1016/j.toxrep.2021.03.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 01/08/2023] Open
Abstract
Massive Acetaminophen (N-acetyl-p-aminophenol; APAP) overdose is a common presentation to emergency departments around the world. While N-acetylcysteine (NAC) remains the cornerstone of treatment for APAP overdose, extracorporeal treatment, in the form of renal replacement therapy with intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT) may provide benefit in cases associated with altered mental status and metabolic acidosis. One treatment with IHD is typically sufficient for resolution of acidosis and global improvement clinically. We describe a case of massive APAP overdose presenting with altered mental status and lactic acidosis, refractory to multiple treatments of IHD as well as CRRT and high-dose NAC along with fomepizole. Despite these interventions, fulminant liver failure progressed with cerebral edema, coagulopathy and death. This is the first description of a fatal acetaminophen ingestion refractory to both IHD and prolonged CRRT. This case highlights the need for further investigation in the management of massive APAP overdose, including optimal method and timing of renal replacement therapy.
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Affiliation(s)
- Sean Cuninghame
- Department of Medicine, Western University, London, ON, Canada
| | - Khaled Lotfy
- Department of Medicine, Western University, London, ON, Canada.,Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
| | - Paul Cameron
- Department of Medicine, Western University, London, ON, Canada.,Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
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Harding SA, Biary R, Hoffman RS, Su MK, Howland MA. A Pharmacokinetic Analysis of Hemodialysis for Metformin-Associated Lactic Acidosis. J Med Toxicol 2020; 17:70-74. [PMID: 32789583 DOI: 10.1007/s13181-020-00802-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 07/26/2020] [Accepted: 07/28/2020] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE Although hemodialysis is recommended for patients with severe metformin-associated lactic acidosis (MALA), the amount of metformin removed by hemodialysis is poorly documented. We analyzed endogenous clearance and hemodialysis clearance in a patient with MALA. METHODS A 62-year-old man with a history of type II diabetes mellitus presented after several days of vomiting and diarrhea and was found to have acute kidney injury (AKI) and severe acidemia. Initial serum metformin concentration was 315.34 μmol/L (40.73 μg/mL) (typical therapeutic concentrations 1-2 μg/mL). He underwent 6 h of hemodialysis. We collected hourly whole blood, serum, urine, and dialysate metformin concentrations. Blood, urine, and dialysate samples were analyzed, and clearances were determined using standard pharmacokinetic calculations. RESULTS The total amount of metformin removed by 6 h of hemodialysis was 888 mg, approximately equivalent to one therapeutic dose. Approximately 142 mg of metformin was cleared in the urine during this time. His acid-base status and creatinine improved over the following days. No further hemodialysis was required. CONCLUSION We report a case of MALA likely secondary to AKI and severe volume depletion. The patient improved with supportive care, sodium bicarbonate, and hemodialysis. Analysis of whole blood, serum, urine, and dialysate concentrations showed limited efficacy of hemodialysis in the removal of metformin from blood, contrary to previously published data. Despite evidence of acute kidney injury, a relatively large amount of metformin was eliminated in the urine while the patient was undergoing hemodialysis. These data suggest that clinical improvement is likely due to factors besides removal of metformin.
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Affiliation(s)
- Stephen A Harding
- Division of Medical Toxicology, Henry J.N. Taub Department of Emergency Medicine, Baylor College of Medicine, 1504 Ben Taub Loop, Houston, TX, 77030, USA.
| | - Rana Biary
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, NY, USA
- New York City Poison Control Center, New York, NY, USA
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, NY, USA
- New York City Poison Control Center, New York, NY, USA
| | - Mark K Su
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, NY, USA
- New York City Poison Control Center, New York, NY, USA
| | - Mary Ann Howland
- New York City Poison Control Center, New York, NY, USA
- St. John's University College of Pharmacy and Health Sciences, New York, NY, USA
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Awasthi P, Jindal A, Sharma Y, Williams V, Ravikumar N, Nallasamy K, Angurana SK. Continuous Venovenous Hemofiltration as a Rescue Therapy for Severe Acetaminophen Toxicity in a Toddler. J Pediatr Intensive Care 2020; 10:159-161. [PMID: 33884219 DOI: 10.1055/s-0040-1712158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/17/2020] [Indexed: 02/05/2023] Open
Abstract
Acetaminophen poisoning is one of the common accidental poisoning in children. Accidental administration of mismatched doses of drops for syrups can lead to life-threatening overdose. N-acetylcysteine (NAC) is the specific antidote; however, extracorporeal therapy such as continuous venovenous hemofiltration (CVVH) can be used as a rescue measure when there is no improvement despite adequate NAC therapy and can be lifesaving. We reported an 18-month-old male infant patient who presented with acetaminophen poisoning following accidental ingestion of acetaminophen drops in place of syrup and developed fulminant hepatic failure. Treatment with NAC did not lead to improvement and CVVH was used as a rescue therapy for 24 hours which led to dramatic clinical and biochemical improvement with intact neurological outcome.
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Affiliation(s)
- Puspraj Awasthi
- Division of Pediatric Critical Care, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Ankush Jindal
- Division of Pediatric Critical Care, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Yogish Sharma
- Division of Pediatric Critical Care, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Vijai Williams
- Division of Pediatric Critical Care, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Namita Ravikumar
- Division of Pediatric Critical Care, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Karthi Nallasamy
- Division of Pediatric Critical Care, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Suresh Kumar Angurana
- Division of Pediatric Critical Care, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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9
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Hendrickson RG. What is the most appropriate dose of N-acetylcysteine after massive acetaminophen overdose? Clin Toxicol (Phila) 2019; 57:686-691. [DOI: 10.1080/15563650.2019.1579914] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Robert G. Hendrickson
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA
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10
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Abstract
Pain is one of the most common symptoms among patients with end-stage renal disease (ESRD), and is often under recognized and not adequately managed in hemodialysis (HD) patients. Barriers to adequate pain management include poor awareness of the problem, insufficient medical education, fears of possible drug-related side effects, and common misconceptions about the inevitability of pain in elderly and HD patients. Caregivers working in HD should be aware of the possible consequences of inadequate pain assessment and management. Common pain syndromes in HD patients include musculoskeletal diseases and metabolic neuropathies, associated with typical intradialytic pain. Evaluating the etiology, nature, and intensity of pain is crucial for choosing the correct analgesic. A mechanism-based approach to pain management may result in a better outcome. Pharmacokinetic considerations on clearance alterations and possible toxicity in patients with ESRD should drive the right analgesic prescription. Comorbidities and polymedications may increase the risk of drug-drug interactions, therefore drug metabolism should be taken into account when selecting analgesic drugs. Automedication is common among HD patients but should be avoided to reduce the risk of hazardous drug administration. Further research is warranted to define the efficacy and safety of analgesic drugs and techniques in the context of patients with ESRD as generalizing information from studies conducted in the general population could be inappropriate and potentially dangerous. A multidisciplinary approach is recommended for the management of complex pain syndromes in frail patients, such as those suffering from ESRD.
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Affiliation(s)
- Flaminia Coluzzi
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Polo Pontino, Corso della Repubblica 79, 04100, Latina, Italy.
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11
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Kitzler TM, Gupta IR, Osterman B, Poulin C, Trakadis Y, Waters PJ, Buhas DC. Acute and Chronic Management in an Atypical Case of Ethylmalonic Encephalopathy. JIMD Rep 2018; 45:57-63. [PMID: 30349987 DOI: 10.1007/8904_2018_136] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 08/01/2018] [Accepted: 08/17/2018] [Indexed: 12/19/2022] Open
Abstract
Ethylmalonic encephalopathy (EE) is caused by mutations in the ETHE1 gene. ETHE1 is vital for the catabolism of hydrogen sulfide (H2S). Patients with pathogenic mutations in ETHE1 have markedly increased thiosulfate, which is a reliable index of H2S levels. Accumulation of H2S is thought to cause the characteristic metabolic derangement found in EE. Recently introduced treatment strategies in EE, such as combined use of metronidazole (MNZ) and N-acetylcysteine (NAC), are aimed at lowering chronic H2S load. Experience with treatment strategies directed against acute episodes of metabolic decompensation (e.g., hemodialysis) is limited. Here we present an unusually mild, molecularly confirmed, case of EE in a 19-year-old male on chronic treatment with MNZ and NAC. During an acute episode of metabolic decompensation, we employed continuous renal replacement therapy (CRRT) to regain metabolic control. On continuous treatment with NAC and MNZ during the months preceding the acute event, plasma thiosulfate levels ranged from 1.6 to 4 μg/mL (reference range up to 2 μg/mL) and had a mean value of 2.5 μg/mL. During the acute decompensation, thiosulfate levels were 6.7 μg/mL, with hyperlactatemia and perturbed organic acid, acylglycine, and acylcarnitine profiles. CRRT decreased thiosulfate within 24 h to 1.4 μg/mL. Following discontinuation of CRRT, mean thiosulfate levels were 3.2 μg/mL (range, 2.4-3.7 μg/mL) accompanied by clinical improvement with metabolic stabilization of blood gas, acylcarnitine, organic acid, and acylglycine profiles. In conclusion, CRRT may help to regain metabolic control in patients with EE who have an acute metabolic decompensation on chronic treatment with NAC and MNZ.
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Affiliation(s)
- Thomas M Kitzler
- Department of Medical Genetics, McGill University Health Centre, Montreal, QC, Canada.
| | - Indra R Gupta
- Department of Pediatrics, Division of Nephrology, McGill University Health Centre, Montreal, QC, Canada
| | - Bradley Osterman
- Department of Pediatric Neurology, Centre Hospitalier de l'Université Laval (CHUL), Quebec City, QC, Canada
| | - Chantal Poulin
- Department of Pediatrics, Division of Neurology, McGill University Health Centre, Montreal, QC, Canada
| | - Yannis Trakadis
- Department of Medical Genetics, McGill University Health Centre, Montreal, QC, Canada
| | - Paula J Waters
- Medical Genetics Service, Department of Pediatrics, University of Sherbrooke Hospital Centre (CHUS), Sherbrooke, QC, Canada
| | - Daniela C Buhas
- Department of Medical Genetics, McGill University Health Centre, Montreal, QC, Canada
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12
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Gonzalez HC, Jafri SM, Gordon SC. Management of Acute Hepatotoxicity Including Medical Agents and Liver Support Systems. Clin Liver Dis 2017; 21:163-180. [PMID: 27842770 DOI: 10.1016/j.cld.2016.08.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Drug-induced liver injury (DILI) can be predictable or idiosyncratic and has an estimated incidence of approximately 20 cases per 100,000 persons per year. DILI is a common cause of acute liver failure in the United States. No accurate tests for diagnosing DILI exist, and its diagnosis is based on exclusion of other conditions. Managing DILI includes discontinuing the suspected causative agent and in selected cases administering an antidote. Liver support systems are used for long-term support or as a bridge to transplantation and are effective for improving encephalopathy, hyperbilirubinemia, and other liver-related conditions, but whether they improve survival remains uncertain.
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Affiliation(s)
- Humberto C Gonzalez
- Department of Transplant Surgery/Center of Advanced Liver Disease, Methodist University Hospital, University of Tennessee Health Science Center, 1211 Union Avenue, Suite 340, Memphis, TN 38104, USA
| | - Syed-Mohammed Jafri
- Division of Gastroenterology and Hepatology, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA
| | - Stuart C Gordon
- Division of Gastroenterology and Hepatology, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA.
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Ghannoum M, Kazim S, Grunbaum AM, Villeneuve E, Gosselin S. Massive acetaminophen overdose: effect of hemodialysis on acetaminophen and acetylcysteine kinetics. Clin Toxicol (Phila) 2016; 54:519-22. [PMID: 27118496 DOI: 10.1080/15563650.2016.1175006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
CONTEXT Early onset acidosis from mitochondrial toxicity can be observed in massive acetaminophen poisoning prior to the development of hepatotoxicity. In this context, the efficacy of acetylcysteine to reverse mitochondrial toxicity remains unclear and hemodialysis may offer prompt correction of acidosis. Unfortunately, toxicokinetics of acetaminophen and acetylcysteine during extracorporeal treatments hemodialysis have seldom been described. CASE DETAILS An 18-year-old woman presented to the emergency department 60 minutes after ingestion of 100 g of acetaminophen, and unknown amounts of ibuprofen and ethanol. Initial assessment revealed an agitated patient. Her mental status worsened and she required intubation for airway protection. Investigations showed metabolic acidosis with lactate peaking at 8.6 mmol/L. Liver and coagulation profiles remained normal. Acetaminophen concentration peaked at 981 μg/ml (6496 μmol/L). Pending hemodialysis, the patient received 100 g of activated charcoal and an acetylcysteine infusion at 150 mg/kg over 1 hour, followed by 12.5 mg/kg/h for 4 hours. During hemodialysis, the infusion was maintained at 12.5 mg/kg/h to compensate for expected removal before it was decreased to 6.25 mg/kg for 20 hours after hemodialysis. The patient rapidly improved during hemodialysis and was discharged 48 hours post-admission. TOXICOKINETICS The acetaminophen elimination half-life was 5.2 hours prior to hemodialysis, 1.9-hours during hemodialysis and 3.6 hours post hemodialysis. The acetaminophen and acetylcysteine clearances by A-V gradient during hemodialysis were 160.4 ml/min and 190.3 ml/min, respectively. Hemodialysis removed a total of 20.6 g of acetaminophen and 17.9 g of acetylcysteine. CONCLUSION This study confirms the high dialyzability of both acetaminophen and acetylcysteine. Hemodialysis appears to be a beneficial therapeutic option in cases of massive acetaminophen ingestion with coma and lactic acidosis. Additionally, these results suggest that the infusion rate of acetylcysteine must be more than double during hemodialysis to compensate for its ongoing removal and provide similar plasma concentrations to the usual acetylcysteine regimen.
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Affiliation(s)
- Marc Ghannoum
- a Nephrology Department , Verdun Hospital , Montréal , Québec , Canada
| | - Sara Kazim
- b Department of Emergency Medicine, McGill University Health Centre , Montréal , Québec , Canada
| | - Ami M Grunbaum
- c Division of Medical Biochemistry, Department of Medicine , McGill University Health Centre , Montréal , Québec , Canada
| | - Eric Villeneuve
- d Department of Pharmacy, McGill University Health Centre , Montréal , Québec , Canada
| | - Sophie Gosselin
- b Department of Emergency Medicine, McGill University Health Centre , Montréal , Québec , Canada ;,e Centre Antipoison Du Québec , Montréal , Québec , Canada
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