1
|
Dyrud M, Niu J, Kohler L. Elevated methemoglobin levels in patients treated with high-dose hydroxocobalamin. Lab Med 2024; 55:50-55. [PMID: 37226975 DOI: 10.1093/labmed/lmad037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
OBJECTIVE The aim of this study was to assess the impact of hydroxocobalamin (OHCbl) infusion on arterial blood gas and oximetry values in patients with vasoplegic syndrome. METHODS Blood samples collected from 95 patients receiving OHCbl infusion were assayed using the ABL90 FLEX Plus blood gas analyzer for the concentration of methemoglobin (MetHb), total hemoglobin (tHb), carboxyhemoglobin (COHb), arterial oxygen saturation (SaO2), arterial oxygen partial pressure (PaO2), and arterial carbon dioxide partial pressure (PaCO2). Interference of OHCbl on these variables was evaluated using the measured difference between the preinfusion and postinfusion samples. RESULTS Blood MetHb (%) measured after the infusion of OHCbl (5g) were significantly higher than the baseline levels, with a median of 4.8 (IQR, 3.0-6.5) versus 1.0 (IQR, 1.0-1.2) (P < .001). Blood COHb (%) increased from a median of 1.3 (IQR, 1.0-1.8) to 1.7 (IQR, 1.3-2.2) (P < .001) following the OHCbl infusion. No differences were seen in median levels of tHb, PaO2, PaCO2, and SaO2 between pre- and post-OHCbl treatment. CONCLUSION The presence of OHCbl in blood clearly interfered with the oximetry measurements of the hemoglobin component fractions by falsely increasing the levels of MetHb and COHb. Blood levels of MetHb and COHb cannot be reliably determined by the co-oximetry when OHCbl is known or suspected.
Collapse
Affiliation(s)
- Martinus Dyrud
- Memorial Cardiac & Vascular Institute, Memorial Healthcare System, Hollywood, FL, US
| | - Jianli Niu
- Memorial Cardiac & Vascular Institute, Memorial Healthcare System, Hollywood, FL, US
| | - Lisa Kohler
- Memorial Cardiac & Vascular Institute, Memorial Healthcare System, Hollywood, FL, US
| |
Collapse
|
2
|
OUP accepted manuscript. Clin Chem 2022; 68:504-508. [DOI: 10.1093/clinchem/hvac014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 12/13/2021] [Indexed: 11/13/2022]
|
3
|
Bezinover D, Mukhtar A, Wagener G, Wray C, Blasi A, Kronish K, Zerillo J, Tomescu D, Pustavoitau A, Gitman M, Singh A, Saner FH. Hemodynamic Instability During Liver Transplantation in Patients With End-stage Liver Disease: A Consensus Document from ILTS, LICAGE, and SATA. Transplantation 2021; 105:2184-2200. [PMID: 33534523 DOI: 10.1097/tp.0000000000003642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hemodynamic instability (HDI) during liver transplantation (LT) can be difficult to manage and increases postoperative morbidity and mortality. In addition to surgical causes of HDI, patient- and graft-related factors are also important. Nitric oxide-mediated vasodilatation is a common denominator associated with end-stage liver disease related to HDI. Despite intense investigation, optimal management strategies remain elusive. In this consensus article, experts from the International Liver Transplantation Society, the Liver Intensive Care Group of Europe, and the Society for the Advancement of Transplant Anesthesia performed a rigorous review of the most current literature regarding the epidemiology, causes, and management of HDI during LT. Special attention has been paid to unique LT-associated conditions including the causes and management of vasoplegic syndrome, cardiomyopathies, LT-related arrhythmias, right and left ventricular dysfunction, and the specifics of medical and fluid management in end-stage liver disease as well as problems specifically related to portal circulation. When possible, management recommendations are made.
Collapse
Affiliation(s)
- Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Pennsylvania State University, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA. Represents ILTS and LICAGE
| | - Ahmed Mukhtar
- Department of Anesthesia and Surgical Intensive Care, Cairo University, Almanyal, Cairo, Egypt. Represents LICAGE
| | - Gebhard Wagener
- Department of Anesthesiology, Columbia University Medical Center, New York, NY. Represents SATA and ILTS
| | - Christopher Wray
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Ronald Reagan Medical Center, Los Angeles, CA. Represents SATA
| | - Annabel Blasi
- Department of Anesthesia, IDIBAPS (Institut d´investigació biomèdica Agustí Pi i Sunyé) Hospital Clinic, Villaroel, Barcelona, Spain. Represents LICAGE and ILTS
| | - Kate Kronish
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA. Represents SATA
| | - Jeron Zerillo
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY. Represents SATA and ILTS
| | - Dana Tomescu
- Department of Anesthesiology and Intensive Care, Carol Davila University of Medicine and Pharmacy, Fundeni Clinical Institute, Bucharest, Romania. Represents LICAGE
| | - Aliaksei Pustavoitau
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Johns Hopkins School of Medicine, Baltimore, MD. Represents ILTS
| | - Marina Gitman
- Department of Anesthesiology, University of Illinois Hospital, Chicago, IL. Represents SATA and ILTS
| | - Anil Singh
- Department of Liver Transplant and GI Critical Care, Sir HN Reliance Foundation Hospital, Cirgaon, Mumbai, India. Represents ILTS
| | - Fuat H Saner
- Department of General, Visceral and Transplant Surgery, Essen University Medical Center, Essen, Germany. Represents LICAGE
| |
Collapse
|
4
|
Dang S, Tsui AK, Herndon R, Babiak C, Szkotak A, Füzéry AK, Raizman JE. Hydroxocobalamin interference in routine laboratory tests: Development of a protocol for identifying samples and reporting results from patients treated with Cyanokit TM. Clin Biochem 2021; 91:31-38. [PMID: 33444605 DOI: 10.1016/j.clinbiochem.2021.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 01/01/2021] [Accepted: 01/04/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Hydroxocobalamin (OHCob) is an antidote for cyanide poisoning in patients rescued from house fires and is known to cause interference with certain laboratory tests. Consensus is lacking on the extent of this interference and on how to handle these samples. The objectives of this study were to characterize OHCob interference across a wide range of laboratory tests and to develop protocols for identifying and reporting these samples. DESIGNS & METHODS Patient plasma samples (n = 5) were spiked with OHCob (1.5 mg/mL) and compared to controls without this drug. A series of analytes were measured using chemistry, urinalysis, coagulation, hematology, and blood gas instruments. Dose-response testing was performed on a subset of assays that showed interferences ≥10%. RESULTS Of the 77 analytes evaluated, 27 (35%) showed interference from OHCob, with chemistry and coagulation analytes showing the greatest effects. Of those affected, 22 analytes had a positive interference, whereas 5 analytes had negative interference. Dose-response studies showed dose-dependent increases and/or decreases consistent with initial spiking studies. Although red in colour, plasma samples with OHCob did not trigger hemolysis index flags, necessitating a special sample identification and reporting protocol. CONCLUSION OHCob had significant effects on several analytes across different instruments. These findings led to the development of special sample handling and reporting protocols to identify OHCob samples and ensure only accurate results are released. It is vital for emergency departments to document and notify their laboratories whenever blood samples from these patients are drawn.
Collapse
Affiliation(s)
- Steven Dang
- Medical Laboratory Science Program, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada; Alberta Precision Laboratories, North Sector, Edmonton, Alberta, Canada
| | - Albert K Tsui
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada; Alberta Precision Laboratories, North Sector, Edmonton, Alberta, Canada
| | - Richard Herndon
- Misericordia Community Hospital, Laboratory Services, Edmonton, Alberta, Canada
| | - Cheryl Babiak
- Misericordia Community Hospital, Respiratory Therapy Program, Edmonton, Alberta, Canada
| | - Artur Szkotak
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada; Alberta Precision Laboratories, North Sector, Edmonton, Alberta, Canada
| | - Anna K Füzéry
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada; Alberta Precision Laboratories, North Sector, Edmonton, Alberta, Canada
| | - Joshua E Raizman
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada; Alberta Precision Laboratories, North Sector, Edmonton, Alberta, Canada.
| |
Collapse
|
5
|
Affiliation(s)
- Fred M Henretig
- From the Division of Emergency Medicine and Poison Control Center, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia (F.M.H.); the Department of Homeland Security, Washington, DC (M.A.K.); and the Division of Medical Toxicology, Department of Emergency Medicine, University of Connecticut Health Center and Hartford Hospital, Hartford (C.A.M.)
| | - Mark A Kirk
- From the Division of Emergency Medicine and Poison Control Center, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia (F.M.H.); the Department of Homeland Security, Washington, DC (M.A.K.); and the Division of Medical Toxicology, Department of Emergency Medicine, University of Connecticut Health Center and Hartford Hospital, Hartford (C.A.M.)
| | - Charles A McKay
- From the Division of Emergency Medicine and Poison Control Center, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia (F.M.H.); the Department of Homeland Security, Washington, DC (M.A.K.); and the Division of Medical Toxicology, Department of Emergency Medicine, University of Connecticut Health Center and Hartford Hospital, Hartford (C.A.M.)
| |
Collapse
|
6
|
Hendrix RJ, Martins PN, Stoff JS, Ahearn A, Bozorgzadeh A, Movahedi B. Successful Renal Transplantation after Presumed Cyanide Toxicity Treated with Hydroxocobalamin and Review of the Literature. Case Rep Transplant 2018; 2018:3753479. [PMID: 30271651 PMCID: PMC6151203 DOI: 10.1155/2018/3753479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 07/10/2018] [Accepted: 07/17/2018] [Indexed: 11/18/2022] Open
Abstract
We report two cases of successful renal transplantation with allografts from donors who suffered anoxic brain injury as the primary cause of death from house fires. Each was treated prophylactically with hydroxocobalamin (Cyanokit) for suspected cyanide toxicity. During organ procurement, gross examination was notable for deep discoloration of the parenchymal tissues. Approximately 6 and 18 months after transplantation, both recipients have excellent renal graft function and remain independent from hemodialysis (HD). Hydroxocobalamin is the antidote for suspected acute cyanide toxicity. While largely tolerated by the recipient, there is concern over the potential functional implications of the associated side effects of dramatic tissue discoloration and development of oxalate crystals. Furthermore, difficulties performing hemodialysis in patients treated with hydroxocobalamin have been reported due to discoloration of the effluent fluid impacting the colorimetric sensor, causing false alarms and repetitive interruptions. As such, many transplant centers in the United States (US) continue to reject these organs. We seek to highlight two cases of successful transplantation following donor administration of hydroxocobalamin (Cyanokit) and present the first documented case of successful perioperative intermittent hemodialysis following transplantation of an allograft exposed to hydroxocobalamin. Furthermore, we emphasize the importance of optimal organ utilization and caution against unnecessary refusal.
Collapse
Affiliation(s)
- Ryan J. Hendrix
- University of Massachusetts Medical School, Department of Surgery, Division of Organ Transplantation, USA
| | - Paulo N. Martins
- University of Massachusetts Medical School, Department of Surgery, Division of Organ Transplantation, USA
| | - Jeffrey S. Stoff
- University of Massachusetts Medical School, Department of Medicine, Division of Nephrology, USA
| | - Aaron Ahearn
- University of Massachusetts Medical School, Department of Surgery, Division of Organ Transplantation, USA
| | - Adel Bozorgzadeh
- University of Massachusetts Medical School, Department of Surgery, Division of Organ Transplantation, USA
| | - Babak Movahedi
- University of Massachusetts Medical School, Department of Surgery, Division of Organ Transplantation, USA
| |
Collapse
|
7
|
Lim K, Heher E, Steele D, Fenves AZ, Tucker JK, Thadhani R, Christopher K, Tolkoff-Rubin N. Hemodialysis failure secondary to hydroxocobalamin exposure. Proc (Bayl Univ Med Cent) 2017; 30:167-168. [PMID: 28405068 DOI: 10.1080/08998280.2017.11929569] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Hydroxocobalamin is a recently approved antidote for the treatment of cyanide poisoning. The case presented involves a young patient administered empiric hydroxocobalamin due to suspected cyanide overdose. Due to the development of acute kidney injury and severe metabolic derangement, emergent hemodialysis was initiated. Unfortunately, hemodialysis was confounded by a recurrent "blood leak" alarm. This unforeseen effect was secondary to interference from hydroxocobalamin. Hydroxocobalamin causes orange/red discoloration of bodily fluids and permeates the dialysate. This leads to defraction of light in the effluent path of the blood leak detector from discolored dialysate, which can result in activation of the blood leak alarm and an inability to continue hemodialysis treatment. This case highlights several new and emerging critical concerns with this medication, including the potential consequence of delayed initiation of emergent renal replacement therapy with empiric administration, the need for increased awareness among clinicians of various disciplines, and the need for multidisciplinary communication.
Collapse
Affiliation(s)
- Kenneth Lim
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Heher, Steele, Fenves, Tucker, Thadhani, Tolkoff-Rubin); and the Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Tucker, Christopher)
| | - Eliot Heher
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Heher, Steele, Fenves, Tucker, Thadhani, Tolkoff-Rubin); and the Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Tucker, Christopher)
| | - David Steele
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Heher, Steele, Fenves, Tucker, Thadhani, Tolkoff-Rubin); and the Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Tucker, Christopher)
| | - Andrew Z Fenves
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Heher, Steele, Fenves, Tucker, Thadhani, Tolkoff-Rubin); and the Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Tucker, Christopher)
| | - John Kevin Tucker
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Heher, Steele, Fenves, Tucker, Thadhani, Tolkoff-Rubin); and the Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Tucker, Christopher)
| | - Ravi Thadhani
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Heher, Steele, Fenves, Tucker, Thadhani, Tolkoff-Rubin); and the Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Tucker, Christopher)
| | - Kenneth Christopher
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Heher, Steele, Fenves, Tucker, Thadhani, Tolkoff-Rubin); and the Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Tucker, Christopher)
| | - Nina Tolkoff-Rubin
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Heher, Steele, Fenves, Tucker, Thadhani, Tolkoff-Rubin); and the Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Lim, Tucker, Christopher)
| |
Collapse
|
8
|
Boettcher BT, Woehlck HJ, Reck SE, Hong JC, Zimmerman MA, Kim J, Zundel MT, Freed JK, Pagel PS. Treatment of Vasoplegic Syndrome With Intravenous Hydroxocobalamin During Liver Transplantation. J Cardiothorac Vasc Anesth 2017; 31:1381-1384. [DOI: 10.1053/j.jvca.2016.10.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Indexed: 11/11/2022]
|
9
|
Cheungpasitporn W, Hui J, Kashani KB, Wittwer ED, Albright RC, Dillon JJ. High-dose hydroxocobalamin for vasoplegic syndrome causing false blood leak alarm. Clin Kidney J 2017; 10:357-362. [PMID: 28616214 PMCID: PMC5466086 DOI: 10.1093/ckj/sfx004] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 01/17/2017] [Indexed: 12/20/2022] Open
Abstract
Blood leak alarms are important safety features in a hemodialysis machine to protect patients from loss of blood through a rupture in the dialyzer membrane (true alarms). A false blood leak alarm can be triggered by air bubbles or detector malfunction (such as deposits of grease or scale). Hydroxocobalamin is an injectable form of vitamin B12 approved by the US Food and Drug Administration for the treatment of confirmed or suspected cyanide toxicity. Due to observations of an increase in arterial pressure after high-dose hydroxocobalamin infusion for the treatment of acute cyanide poisoning, it has recently been reported as an off-label rescue treatment for post–cardiopulmonary bypass vasoplegic syndrome. We report an 83-year-old man who received hydroxocobalamin following cardiac surgery for treatment of vasoplegic syndrome. The patient developed severe acute kidney injury with volume overload. Hydroxocobalamin interference with the blood leak detector compromised his dialysis treatment. We describe the use of continuous renal replacement therapy to overcome the hydroxocobalamin-related interference with hemodialysis. As the utility of hydroxocobalamin potentially expands, physicians must be aware of its inadvertent effect on renal replacement therapy.
Collapse
Affiliation(s)
- Wisit Cheungpasitporn
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - John Hui
- Department of Anesthesiology, Division of Critical Care Medicine and Cardiothoracic Anesthesiology, Mayo Clinic, Rochester, MN, USA.,Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kianoush B Kashani
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.,Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Erica D Wittwer
- Department of Anesthesiology, Division of Critical Care Medicine and Cardiothoracic Anesthesiology, Mayo Clinic, Rochester, MN, USA.,Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Robert C Albright
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - John J Dillon
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
10
|
Fueyo L, Robles J, Aguilar I, Yáñez AM, Socias M, Parera M. Hemolysis index to detect degree of hydroxocobalamin interference with common laboratory tests. J Clin Lab Anal 2016; 31. [PMID: 27859624 DOI: 10.1002/jcla.22089] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 10/07/2016] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Cyanokit® (hydroxocobalamin OHCo) is the recommended treatment for cyanide poisoning. OHCo is a red chromophore and may cause interference with some biochemical measurements. In this study, we assessed the possible interference of Cyanokit on several cooximetric and plasma biochemistry tests and then determined the possible mathematical correction for some analytes. We studied the possibility of detecting and evaluating the degree of interference with the hemolysis index (HI) provided by our autoanalyzer because it is not possible to measure the OHCo concentration in conventional laboratories. METHODS Several pools of plasma samples spiked with increasing concentrations of OHCo were prepared. Each one was compared to the pool without interferent. Interference was considered when the bias was more than 10%. An interferograph was developed for those analytes with significant interference. The correlation between interference agent concentration and HI was calculated by Spearman correlation coefficient. We used multiple regression analysis to determine the mathematical correction for amylase, creatinine, and lactate. RESULTS We detected significant interference in the amylase, carboxyhemoglobin, creatinine, creatine kinase, bilirubin, lactate, and total protein measurement. The HI was positively correlated with OHCo concentration. Corresponding equations for estimating lactate and creatinine concentrations were obtained. CONCLUSIONS OHCo interferes with many laboratory assays in an unpredictable way making some results invalid and confounding clinical decision making. We can detect and evaluate the degree of interference with the HI. We can still estimate real creatinine and lactate levels using the regression equation obtained in this study.
Collapse
Affiliation(s)
- Laura Fueyo
- Servicio de Análisis Clínicos, Hospital Universitario Son Espases, Palma, Balearic Islands, Spain
| | - Juan Robles
- Servicio de Análisis Clínicos, Hospital Universitario Son Espases, Palma, Balearic Islands, Spain
| | - Irene Aguilar
- Servicio de Análisis Clínicos, Hospital Universitario Son Espases, Palma, Balearic Islands, Spain
| | - Aina M Yáñez
- Instituto de investigación sanitaria de Palma (IdISPa), Palma, Balearic Islands, Spain
| | - Magdalena Socias
- Servicio de Urgencias, Hospital Universitario Son Espases, Palma, Balearic Islands, Spain
| | - Magdalena Parera
- Servicio de Análisis Clínicos, Hospital Universitario Son Espases, Palma, Balearic Islands, Spain
| |
Collapse
|
11
|
Case Files from the University of California San Diego Health System Fellowship Coma and Severe Acidosis: Remember to Consider Acetaminophen. J Med Toxicol 2016; 11:368-76. [PMID: 26153488 DOI: 10.1007/s13181-015-0492-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
|
12
|
Ranjitkar P, Greene DN. Therapeutic concentrations of hydroxocobalamin interferes with several spectrophotometric assays on the Beckman Coulter DxC and AU680 chemistry analyzers. Clin Chim Acta 2015; 450:110-4. [DOI: 10.1016/j.cca.2015.07.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 07/17/2015] [Accepted: 07/25/2015] [Indexed: 10/23/2022]
|
13
|
Pace R, Bon Homme M, Hoffman RS, Lugassy D. Effects of hydroxocobalamin on carboxyhemoglobin measured under physiologic and pathologic conditions. Clin Toxicol (Phila) 2014; 52:647-50. [PMID: 25089720 DOI: 10.3109/15563650.2014.939659] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Pre-hospital administration of hydroxocobalamin (B12a) is used for empiric treatment of cyanide poisoning because cyanide poisoning is difficult to identify and requires immediate treatment. B12a interferes with the accuracy of several blood laboratory tests. This study aimed to explore how B12a affects carboxyhemoglobin (COHb) measurements in human blood at both physiologic and pathologic COHb levels. METHODS Several clinically relevant concentrations of B12a were added to human blood samples containing physiologic (∼ 3%) and pathologic (30% and 50%) COHb levels. We then measured the COHb levels of the samples using two different co-oximeters, the Radiometer ABL 700 and the Rapidpoint 500, and compared to their actual baseline COHb levels. RESULTS B12a had minimal effects on the COHb measured at both physiologic and pathologic levels when measured on the Radiometer. In contrast, the Rapidpoint B12a caused a dose-dependent decrease in the COHb measured, especially of pathologic COHb levels (∼ 30 and 50%). CONCLUSION The magnitude of B12a interference on measured COHb is dependent upon the specific co-oximeter used, the actual COHb level and the serum B12a concentration. These errors may potentially influence clinical decision making and thus affect patient outcomes. Our findings emphasize the importance of measuring COHb levels on blood samples collected prior to B12a administration.
Collapse
Affiliation(s)
- R Pace
- Department of Mental Health and Hygiene, New York City Poison Control Center , New York, NY , USA
| | | | | | | |
Collapse
|
14
|
Gehrie E, Booth G. An unusual cause of red plasma. Transfusion 2014; 54:11. [DOI: 10.1111/trf.12337] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 05/16/2013] [Accepted: 05/31/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Eric Gehrie
- Department of Pathology, Microbiology, and Immunology; Vanderbilt University Medical Center; Nashville Tennessee
| | - Garrett Booth
- Department of Pathology, Microbiology, and Immunology; Vanderbilt University Medical Center; Nashville Tennessee
| |
Collapse
|
15
|
Abstract
INTRODUCTION The newer cyanide antidote, hydroxocobalamin, due to its pigmentation, has been found to cause interferences in some laboratory assays. Co-oximetry may also be affected by hydroxocobalamin, leading to false elevations in hemoglobin concentration, methemoglobin, carboxyhemoglobin, and false decreases in oxyhemoglobin. The Masimo Radical-7 is a medical device that performs noninvasive oximetry and estimates hemoglobin (Hb) concentration and percent carboxyhemoglobin (COHb), methemoglobin (MetHb), and oxyhemoglobin saturation (O2Hb). STUDY OBJECTIVES The study sought to determine the effect of hydroxocobalamin on noninvasive measurement of hemoglobin indices using the Masimo Radical-7 monitor. METHODS Seven asymptomatic volunteers who were unexposed to cyanide had baseline heart rate (HR), blood pressure (BP), and oximeter measurements recorded followed by an infusion of five grams of hydroxocobalamin over 15 minutes. The above parameters were subsequently recorded at: 5, 10, 15, 30 and 60 minutes post infusion. Data were analyzed by calculating the area under the curve (AUC) for each variable and comparing the results to expected values by paired t tests. Expected AUC values were calculated by extrapolating baseline values across the entire time period. RESULTS The mean differences from baseline values with 95% confidence intervals and t tests of mean difference were: SBP: 11 mm Hg (95% CI, 0-22; P = .051); HR: -9 (95% CI, -15 to -3; P = .01); Hb: -0.1 (95% CI, -0.7 to 0.4; P = .57); O2Hb: 0 g/dL (95% CI, -1 to 1; P = .41); COHb: -1 (95% CI, -3 to 1; P = .25); MetHb: -0.2 (95% CI, -0.3 to 0; P = .03). DISCUSSION After infusion of hydroxocobalamin there was a significant elevation of systolic blood pressure and decrease in heart rate. There were no significant differences in Hb, O2Hb, and COHb. Although percent methemoglobin concentrations were statistically lower, the authors feel this difference is of trivial clinical significance. CONCLUSION The administration of hydroxocobalamin does not significantly impact noninvasive oximetry.
Collapse
|
16
|
Abstract
INTRODUCTION On theoretical grounds, hydroxocobalamin is an attractive antidote for cyanide poisoning as cobalt compounds have the ability to bind and detoxify cyanide. This paper reviews the pharmacokinetic and pharmacodynamic aspects of hydroxocobalamin, its efficacy in human cyanide poisoning and its adverse effects. METHODS PubMed was searched for the period 1952 to April 2012. A total of 71 papers were identified in this way; and none was excluded. PHARMACOKINETICS AND PHARMACODYNAMICS: Pharmacokinetic studies in dogs and humans suggest a two-compartment model, with first order elimination kinetics. Pharmacodynamic studies in animals suggest that hydroxocobalamin would be a satisfactory antidote for human cyanide poisoning. EFFICACY IN HUMAN POISONING: There is limited evidence that hydroxocobalamin alone is effective in severe poisoning by cyanide salts. The evidence for the efficacy of hydroxocobalamin in smoke inhalation is complicated by lack of evidence for the importance of cyanide exposure in fires and the effects of other chemicals as well as confounding effects of other therapeutic measures, including hyperbaric oxygen. Evidence that hydroxocobalamin is effective in poisoning due to hydrogen cyanide alone is lacking; extrapolation of efficacy from poisoning by ingested cyanide salts may not be valid. The rate of absorption may be greater with inhaled hydrogen cyanide and the recommended slow intravenous administration of hydroxocobalamin may severely limit its clinical effectiveness in these circumstances. ADVERSE EFFECTS Both animal and human data suggest that hydroxocobalamin is lacking in clinically significant adverse effects. However, in one human volunteer study, delayed but prolonged rashes were observed in one-sixth of subjects, appearing 7 to 25 days after administration of 5 g or more of hydroxocobalamin. Rare adverse effects have included dyspnoea, facial oedema, and urticaria. CONCLUSIONS Limited data on human poisonings with cyanide salts suggest that hydroxocobalamin is an effective antidote; data from smoke inhalation are less clear-cut. Although clinically important reactions to hydroxocobalamin have not been seen, some, non-life threatening, adverse reactions can occur.
Collapse
Affiliation(s)
- John P Thompson
- Wales College of Medicine, Cardiff University, University Hospital of Wales, Heath Park, Cardiff, UK
| | | |
Collapse
|
17
|
Sutter ME, Clarke ME, Cobb J, Daubert GP, Rathore VS, Aston LS, Poppenga RH, Ford JB, Owen KP, Albertson TE. Blood leak alarm interference by hydoxocobalamin is hemodialysis machine dependent. Clin Toxicol (Phila) 2012; 50:892-5. [DOI: 10.3109/15563650.2012.744031] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
18
|
|
19
|
Marraffa JM, Cohen V, Howland MA. Antidotes for toxicological emergencies: a practical review. Am J Health Syst Pharm 2012; 69:199-212. [PMID: 22261941 DOI: 10.2146/ajhp110014] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Appropriate therapies for commonly encountered poisonings, medication overdoses, and other toxicological emergencies are reviewed, with discussion of pharmacists' role in ensuring their ready availability and proper use. SUMMARY Poisoning is the second leading cause of injury-related morbidity and mortality in the United States, with more than 2.4 million toxic exposures reported each year. Recently published national consensus guidelines recommend that hospitals providing emergency care routinely stock 24 antidotes for a wide range of toxicities, including toxic-alcohol poisoning, exposure to cyanide and other industrial agents, and intentional or unintentional overdoses of prescription medications (e.g., calcium-channel blockers, β-blockers, digoxin, isoniazid). Pharmacists can help reduce morbidity and mortality due to poisonings and overdoses by (1) recognizing the signs and symptoms of various types of toxic exposure, (2) guiding emergency room staff on the appropriate use of antidotes and supportive therapies, (3) helping to ensure appropriate monitoring of patients for antidote response and adverse effects, and (4) managing the procurement and stocking of antidotes to ensure their timely availability. CONCLUSION Pharmacists can play a key role in reducing poisoning and overdose injuries and deaths by assisting in the early recognition of toxic exposures and guiding emergency personnel on the proper storage, selection, and use of antidotal therapies.
Collapse
Affiliation(s)
- Jeanna M Marraffa
- Upstate New York Poison Center, 750 East Adams Street, Syracuse, NY 13210, USA.
| | | | | |
Collapse
|
20
|
Abstract
Enclosed-space smoke inhalation is the fifth most common cause of all unintentional injury deaths in the United States. Increasingly, cyanide has been recognized as a significant toxicant in many cases of smoke inhalation. However, it cannot be emergently verified. Failure to recognize the possibility of cyanide toxicity may result in inadequate treatment. Findings suggestive cyanide toxicity include: (1) a history of an enclosed-space fire scene in which smoke inhalation was likely; (2) the presence of oropharyngeal soot or carbonaceous expectorations; (3) any alteration of the level of consciousness, and particularly, otherwise inexplicable hypotension (systolic blood pressure ≤90 mmHg in adults). Prehospital studies have demonstrated the feasibility and safety of empiric treatment with hydroxocobalamin for patients with suspected smoke inhalation cyanide toxicity. Although United States Food and Drug Administration (FDA)-approved since 2006, the lack of efficacy data has stymied the routine use of this potentially lifesaving antidote. Based on a literature review and on-site observation of the Paris Fire Brigade, emergency management protocols to guide empiric and early hydroxocobalamin administration in smoke inhalation victims with high-risk presentations are proposed.
Collapse
|
21
|
Abdelmalek J, Thornton S, Nizar J, Schneir A, Sanchez AP. Successful use of continuous renal replacement therapy after hydroxocobalamin administration. ACTA ACUST UNITED AC 2011. [DOI: 10.1002/dat.20572] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|
22
|
Levine M, Brooks DE, Truitt CA, Wolk BJ, Boyer EW, Ruha AM. Toxicology in the ICU. Chest 2011; 140:795-806. [DOI: 10.1378/chest.10-2548] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
|
23
|
Carlsson CJ, Hansen HE, Hilsted L, Malm J, Ødum L, Szecsi PB. An evaluation of the interference of hydroxycobalamin with chemistry and co-oximetry tests on nine commonly used instruments. Scandinavian Journal of Clinical and Laboratory Investigation 2011; 71:378-86. [DOI: 10.3109/00365513.2011.573573] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Christian J. Carlsson
- Department of Clinical Biochemistry, Gentofte Hospital, University of Copenhagen,
Hellerup, Denmark
| | - Heidi E. Hansen
- Department of Clinical Biochemistry, Vendsyssel Hospital,
Hjørring, Denmark
| | - Linda Hilsted
- Department of Clinical Biochemistry,
Rigshospitalet, Copenhagen, Denmark
| | - Johan Malm
- Department of Clinical Chemistry, Malmö University Hospital,
Malmö, Sweden
| | - Lars Ødum
- Department of Clinical Biochemistry, Roskilde Hospital,
Roskilde, Denmark
| | - Pal B. Szecsi
- Department of Clinical Biochemistry, Gentofte Hospital, University of Copenhagen,
Hellerup, Denmark
| |
Collapse
|
24
|
Sutter M, Tereshchenko N, Rafii R, Daubert GP. Hemodialysis complications of hydroxocobalamin: a case report. J Med Toxicol 2010; 6:165-7. [PMID: 20352539 PMCID: PMC2919685 DOI: 10.1007/s13181-010-0067-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Hydroxocobalamin is a new antidote approved by the FDA for the treatment of cyanide poisoning. Our report describes a patient with cyanide poisoning who survived after treatment with hydroxocobalamin and complications we encountered with hemodialysis. A 34-year-old female presented to the emergency department after a syncopal event and seizures. Her systolic blood pressure was 75 mmHg, her QRS complex progressively widened, and pulses were lost. She was intubated and resuscitated with fluids, sodium bicarbonate for her QRS widening and vasopressors. Venous blood gas demonstrated a pH of 6.36 with an O2 saturation of 99%. Due to the acidemia with a normal pulse oximetry, simultaneous venous and arterial blood gases were obtained. Venous gas demonstrated a pH of 6.80 with a PO2 of 222 mmHg, an O2 saturation of 99%. The arterial blood gas showed a pH of 6.82, a PO2 518 mmHg, an O2 saturation of 100%. Cyanide was suspected and hydroxocobalamin and sodium thiosulfate were given. Within 40 min of hydroxocobalamin administration, vasopressors were discontinued. Initially, nephrology attempted dialysis for metabolic acidosis; however, the dialysis machine repeatedly shut down due to a “blood leak”. This was an unforeseen effect attributed to hydroxocobalamin. Cyanide level, drawn 20 min after the antidote was completed, was elevated at 22 mcg/dL. Her urinary thiocyanate level could not be analyzed due to an “interfering substance”. Hydroxocobalamin is an effective antidote. However, clinicians must be aware of its effects on hemodialysis machines which could delay the initiation of this important treatment modality in the severely acidemic patient.
Collapse
Affiliation(s)
- Mark Sutter
- Department of Emergency Medicine, University of California, Davis Medical Center, Sacramento, CA 95817, USA.
| | | | | | | |
Collapse
|
25
|
|
26
|
Jang DH, Nelson LS, Hoffman RS. Hydroxocobalamin and Sodium Thiosulfate versus Sodium Nitrite and Sodium Thiosulfate in Acute Cyanide Toxicity. Ann Emerg Med 2010; 55:582; author reply 582-3. [DOI: 10.1016/j.annemergmed.2009.12.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Revised: 12/21/2009] [Accepted: 12/28/2009] [Indexed: 10/19/2022]
|
27
|
Time Standing Still: Adding Realism to Tabletop Exercises. Prehosp Disaster Med 2010. [DOI: 10.1017/s1049023x00023062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
28
|
Abstract
Cyanide has several antidotes, with differing mechanisms of action and diverse toxicological, clinical, and risk-benefit profiles. The international medical community lacks consensus about the antidote or antidotes with the best risk-benefit ratio. Critical assessment of cyanide antidotes is needed to aid in therapeutic and administrative decisions that will improve care for victims of cyanide poisoning (particularly poisoning from enclosed-space fire-smoke inhalation), and enhance readiness for cyanide toxic terrorism and other mass-casualty incidents. This paper reviews preclinical and clinical data on available cyanide antidotes and considers the profiles of these antidotes relative to properties of a hypothetical ideal cyanide antidote. Each of the antidotes shows evidence of efficacy in animal studies and clinical experience. The data available to date do not suggest obvious differences in efficacy among antidotes, with the exception of a slower onset of action of sodium thiosulfate (administered alone) than of the other antidotes. The potential for serious toxicity limits or prevents the use of the Cyanide Antidote Kit, dicobalt edetate, and 4-dimethylaminophenol in prehospital empiric treatment of suspected cyanide poisoning. Hydroxocobalamin differs from these antidotes in that it has not been associated with clinically significant toxicity in antidotal doses. Hydroxocobalamin is an antidote that seems to have many of the characteristics of the ideal cyanide antidote: rapid onset of action, neutralizes cyanide without interfering with cellular oxygen use, tolerability and safety profiles conducive to prehospital use, safe for use with smoke-inhalation victims, not harmful when administered to non-poisoned patients, easy to administer.
Collapse
Affiliation(s)
- Alan H Hall
- Toxicology Consulting and Medical Translating Services, Inc., Laramie, WY 82072, USA.
| | | | | |
Collapse
|
29
|
Emergency: Poison Control Therapy. Am J Nurs 2009; 109:42-5. [DOI: 10.1097/01.naj.0000365184.22158.43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
30
|
Beckerman N, Leikin SM, Aitchinson R, Yen M, Wills BK. Laboratory interferences with the newer cyanide antidote: hydroxocobalamin. Semin Diagn Pathol 2009; 26:49-52. [DOI: 10.1053/j.semdp.2008.12.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
31
|
Denninghoff K, Walter FG, Langa A, He Y, Chipman RA. Spectrophotometry of hydroxocobalamin and hemoglobin reveals production of an unanticipated methemoglobin variant. Clin Toxicol (Phila) 2009; 46:545-50. [DOI: 10.1080/15563650701846270] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
32
|
Uhl W, Nolting A, Golor G, Rost KL, Kovar A. Safety of Hydroxocobalamin in Healthy Volunteers in a Randomized, Placebo-Controlled Study. Clin Toxicol (Phila) 2008; 44 Suppl 1:17-28. [PMID: 16990190 DOI: 10.1080/15563650600811755] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION This randomized, double-blind, placebo-controlled, ascending-dose study was conducted in healthy volunteers to evaluate the safety of the investigational cyanide antidote hydroxocobalamin. METHODS Four ascending dosing groups received intravenous doses of 2.5, 5, 7.5 or 10 g hydroxocobalamin over 7.5 to 30 minutes at a constant infusion rate. Volunteers (n = 136) randomized 3:1 to receive hydroxocobalamin or placebo underwent a 4-day in-house observation after infusion on Day 1 and follow-up visits on Days 8, 15, and 28. RESULTS The most common drug-related adverse events were asymptomatic and self-limiting chromaturia and reddening of the skin, which are attributed to the red color of hydroxocobalamin. Other adverse events included pustular/papular rash, headache, erythema at the injection site, decrease in lymphocyte percentage, nausea, pruritus, chest discomfort, and dysphagia. Hydroxocobalamin was associated with an increase in blood pressure in some volunteers. Blood pressure changes peaked toward the end of hydroxocobalamin infusion and typically returned to baseline levels by 4 hours postinfusion. Maximum mean changes from baseline in systolic blood pressure ranged from 22.6 to 27.0 mmHg across hydroxocobalamin doses compared with 0.2 to 6.7 mmHg in the corresponding placebo groups. Maximum mean change from baseline in diastolic blood pressure ranged from 14.3 to 25.4 mmHg across hydroxocobalamin doses compared with -3.0 to 3.8 mmHg in the corresponding placebo groups. Two allergic reactions that occurred within minutes after start of the 5- and 10-g hydroxocobalamin infusions were successfully managed with dexamethasone and/or dimethindene maleate. CONCLUSION Timely intervention for acute cyanide poisoning could entail administration of an antidote in the prehospital setting based on a presumptive diagnosis. Results of this placebo-controlled study in healthy volunteers corroborate previous studies and French postmarketing experience in cyanide-exposed patients in suggesting that the safety profile of hydroxocobalamin is consistent with prehospital or hospital use.
Collapse
|
33
|
Dart RC. Hydroxocobalamin for Acute Cyanide Poisoning: New Data from Preclinical and Clinical Studies; New Results from the Prehospital Emergency Setting. Clin Toxicol (Phila) 2008; 44 Suppl 1:1-3. [PMID: 16990188 DOI: 10.1080/15563650600811607] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
34
|
Fortin JL, Ruttimann M, Capellier G, Bigorie A, Ferlicot S, Thervet E. Successful organ transplantation after treatment of fatal cyanide poisoning with hydroxocobalamin. Clin Toxicol (Phila) 2008; 45:468-71. [PMID: 17503248 DOI: 10.1080/15563650701338179] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Cyanide-poisoned patients are potential organ donors provided that organs are not damaged by the poison or by antidotal treatment. CASE STUDY A patient with third-degree burns and smoke inhalation-associated cyanide poisoning confirmed by measurements of whole blood cyanide was found in cardiac arrest and administered epinephrine and hydroxocobalamin (5 g + 5 g). Cardiac activity resumed, but the patient was declared brain dead on the third day of hospitalization when coma deteriorated to a shock state with refractory hypoxemia. Kidneys, heart, and liver were removed and transplanted into four patients. Gross pre-transplantation inspection of the donor organs and renal histology showed no evidence that hydroxocobalamin caused organ toxicity. Donor organs functioned normally through follow-up periods of several months. CONCLUSION Anoxic cardiac arrest following acute cyanide poisoning treated with hydroxocobalamin (5 g + 5 g) was not a contraindication to organ transplantation after confirmed encephalic death in this patient.
Collapse
Affiliation(s)
- J L Fortin
- Emergency Medical Service of the Paris Fire Brigade,Paris, France.
| | | | | | | | | | | |
Collapse
|
35
|
Fortin JL, Waroux S, Giocanti JP, Capellier G, Ruttimann M, Kowalski JJ. Hydroxocobalamin for poisoning caused by ingestion of potassium cyanide: a case study. J Emerg Med 2008; 39:320-4. [PMID: 18554843 DOI: 10.1016/j.jemermed.2008.04.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2006] [Revised: 05/04/2007] [Accepted: 08/08/2007] [Indexed: 10/21/2022]
Abstract
Hydroxocobalamin, a precursor of vitamin B12, has a history of use in the prehospital setting in France for cyanide poisoning, particularly that associated with smoke inhalation. Because cyanide poisoning by ingestion is less common than smoke inhalation-associated cyanide poisoning, less information is available on prehospital use of hydroxocobalamin to treat cyanide poisoning by ingestion. This report describes a case of prehospital use of hydroxocobalamin for poisoning by ingestion of cyanide. The case supports the efficacy of hydroxocobalamin for acute cyanide poisoning caused by ingestion of a cyanide salt. No adverse events attributed to hydroxocobalamin were observed.
Collapse
|
36
|
Eckstein M. Enhancing public health preparedness for a terrorist attack involving cyanide. J Emerg Med 2007; 35:59-65. [PMID: 17976798 DOI: 10.1016/j.jemermed.2007.03.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2005] [Revised: 12/09/2005] [Accepted: 08/09/2006] [Indexed: 11/18/2022]
Abstract
The US government considers cyanide to be among the most likely agents of chemical terrorism. Cyanide differs from many other biological or chemical agents for which little or no defense is available because its individual and public health effects are largely remediable through appropriate preparedness and response. Because the toxicity of the cyanide antidote currently available in the United States renders it ill-suited for use in terrorist incidents and other situations requiring rapid out-of-hospital treatment, hydroxocobalamin--an effective and safe cyanide antidote being used in other countries--has been introduced in the United States. Unlike the other available cyanide antidote, hydroxocobalamin can be administered at the scene of a cyanide disaster, and it need not be reserved for cases of confirmed cyanide poisoning but can be administered in cases of suspected poisoning. Both of these attributes facilitate the rapid intervention necessary for saving lives. To realize the potential benefits of hydroxocobalamin, progress also needs to be realized in other aspects of readiness, including but not limited to developing plans for ensuring local and regional availability of antidote, educating emergency responders and health care professionals in the recognition and management of cyanide poisoning, and raising public awareness of the potential for a chemical weapons attack and of how to respond.
Collapse
Affiliation(s)
- Marc Eckstein
- Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, University of Southern California Medical Center, Los Angeles, California 90033, USA
| |
Collapse
|
37
|
Borron SW, Baud FJ, Mégarbane B, Bismuth C. Hydroxocobalamin for severe acute cyanide poisoning by ingestion or inhalation. Am J Emerg Med 2007; 25:551-8. [PMID: 17543660 DOI: 10.1016/j.ajem.2006.10.010] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2006] [Accepted: 10/26/2006] [Indexed: 12/14/2022] Open
Abstract
This chart review was undertaken to assess efficacy and safety of hydroxocobalamin for acute cyanide poisoning. Hospital records of the Fernand Widal and Lariboisière Hospitals were reviewed for intensive care unit admissions with cyanide poisoning for which hydroxocobalamin was used as first-line treatment from 1988 to 2003. Smoke inhalation cases were excluded. Hydroxocobalamin (5-20 g) was administered to 14 consecutive patients beginning a median 2.1 hours after cyanide ingestion or inhalation. Ten patients (71%) survived and were discharged. Of the 11 patients with blood cyanide exceeding the typically lethal threshold of 100 micromol/L, 7 survived. The most common hydroxocobalamin-attributed adverse events were chromaturia and pink skin discoloration. Severe cyanide poisoning of the nature observed in most patients in this study is frequently fatal. That 71% of patients survived after treatment with hydroxocobalamin suggests that hydroxocobalamin as first-line antidotal therapy is effective and safe in acute cyanide poisoning.
Collapse
Affiliation(s)
- Stephen W Borron
- University of Texas Health Science Center, San Antonio, TX 78229, USA
| | | | | | | |
Collapse
|
38
|
Borron SW, Baud FJ, Barriot P, Imbert M, Bismuth C. Prospective Study of Hydroxocobalamin for Acute Cyanide Poisoning in Smoke Inhalation. Ann Emerg Med 2007; 49:794-801, 801.e1-2. [PMID: 17481777 DOI: 10.1016/j.annemergmed.2007.01.026] [Citation(s) in RCA: 134] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2006] [Revised: 01/15/2007] [Accepted: 01/29/2007] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE To assess outcomes in patients treated with hydroxocobalamin at the fire scene or in the ICU for suspected smoke inhalation-associated cyanide poisoning. METHODS Adult smoke inhalation victims with suspected cyanide poisoning as determined by soot in the face, mouth, or nose or expectorations and neurologic impairment received an intravenous infusion of hydroxocobalamin 5 g (maximum 15 g) at the fire scene or in the ICU in this observational case series conducted from 1987 to 1994. Blood cyanide specimens were collected before administration of hydroxocobalamin. The threshold for cyanide toxicity was predefined as greater than or equal to 39 micromol/L. RESULTS The sample included 69 patients (mean age 49.6 years; 33 men), of whom 39 were comatose. Out-of-hospital deaths were excluded. Fifty of the 69 patients (72%) admitted to the ICU survived after administration of hydroxocobalamin. In the group in which cyanide poisoning was confirmed a posteriori (n=42), 67% (28/42) survived after administration of hydroxocobalamin. The most common adverse events were chromaturia (n=6), pink or red skin discoloration (n=4), hypertension (n=3), erythema (n=2), and increased blood pressure (n=2). No serious adverse events were attributed to hydroxocobalamin. Laboratory tests revealed transient alterations in renal and hepatic function consistent with the critical condition of the patients and mild anemia consistent with progressive hemodilution. CONCLUSION Empiric administration of hydroxocobalamin was associated with survival among 67% of patients confirmed a posteriori to have had cyanide poisoning. Hydroxocobalamin was well tolerated irrespective of the presence of cyanide poisoning. Hydroxocobalamin appears to be safe for the out-of-hospital treatment of presumptive cyanide poisoning from smoke inhalation.
Collapse
Affiliation(s)
- Stephen W Borron
- Division of Emergency Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | | | | | | | | |
Collapse
|
39
|
Lee J, Mukai D, Kreuter K, Mahon S, Tromberg B, Brenner M. Potential Interference by Hydroxocobalamin on Cooximetry Hemoglobin Measurements During Cyanide and Smoke Inhalation Treatments. Ann Emerg Med 2007; 49:802-5. [PMID: 17210205 DOI: 10.1016/j.annemergmed.2006.11.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2006] [Revised: 11/10/2006] [Accepted: 11/15/2006] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVE Concentrated aqueous solutions of hydroxocobalamin (OHCob) are administered intravenously for cyanide poisoning victims, many of whom also have concurrent smoke inhalation. Because of its intense light absorbance in visible wavelengths (absorption peak at 532 nm), we investigate potential interference effects of OHCob on total hemoglobin concentration (tHb), carboxyhemoglobin (COHb), methemoglobin (MetHb), and oxyhemoglobin (Hb-O2) cooximetry measurement values in blood. METHODS In vivo cooximetry measurements were conducted with 3 specific pathogen-free white New Zealand rabbits (3.80+/-0.21 kg) during the intravenous infusion of OHCob (625 mg during a 100-minute period). Resultant changes in tHb, Hb-O2, COHb, and MetHb values were measured and correlated with respect to estimated in vivo OHCob concentrations. In vitro measurements were conducted with rabbit blood to confirm in vivo measurements. RESULTS The introduction of OHCob clearly interfered with the cooximetry measurements of each of the hemoglobin component fractions in whole blood and resulted in altered measurement values from the baseline values. The presence of OHCob in blood interferes with cooximetry measurements of COHb, MetHb, and Hb-O2. The increase in measured COHb fraction with increasing concentrations of OHCob was most notable. CONCLUSION The presence of OHCob in blood interferes with cooximetry measurements of COHb, MetHb, and Hb-O2. These effects need to be considered during OHCob treatment of cyanide poisoning, particularly in smoke inhalation victims with potential for concurrent carbon monoxide exposure, because it may lead to potentially erroneous reported COHb levels.
Collapse
Affiliation(s)
- Jangwoen Lee
- Laser Microbeam and Medical Program, Beckman Laser Institute, University of California, Irvine, CA, USA
| | | | | | | | | | | |
Collapse
|
40
|
Hall AH, Dart R, Bogdan G. Sodium Thiosulfate or Hydroxocobalamin for the Empiric Treatment of Cyanide Poisoning? Ann Emerg Med 2007; 49:806-13. [PMID: 17098327 DOI: 10.1016/j.annemergmed.2006.09.021] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2006] [Revised: 08/31/2006] [Accepted: 09/25/2006] [Indexed: 11/21/2022]
Abstract
Cyanide poisoning must be seriously considered in victims of smoke inhalation from enclosed space fires; it is also a credible terrorism threat agent. The treatment of cyanide poisoning is empiric because laboratory confirmation can take hours or days. Empiric treatment requires a safe and effective antidote that can be rapidly administered by either out-of-hospital or emergency department personnel. Among several cyanide antidotes available, sodium thiosulfate and hydroxocobalamin have been proposed for use in these circumstances. The evidence available to assess either sodium thiosulfate or hydroxocobalamin is incomplete. According to recent safety and efficacy studies in animals and human safety and uncontrolled efficacy studies, hydroxocobalamin seems to be an appropriate antidote for empiric treatment of smoke inhalation and other suspected cyanide poisoning victims in the out-of-hospital setting. Sodium thiosulfate can also be administered in the out-of-hospital setting. The efficacy of sodium thiosulfate is based on individual case studies, and there are contradictory conclusions about efficacy in animal models. The onset of antidotal action of sodium thiosulfate may be too slow for it to be the only cyanide antidote for emergency use. Hydroxocobalamin is being developed for potential introduction in the United States and may represent a new option for emergency personnel in cases of suspected or confirmed cyanide poisoning in the out-of-hospital setting.
Collapse
Affiliation(s)
- Alan H Hall
- Toxicology Consulting and Medical Translating Services, Inc., Elk Mountain, WY 82324, USA.
| | | | | |
Collapse
|
41
|
Abstract
There is well-founded concern that a chemical or radioactive agent will at some point be used as a weapon of terror. There are several antidotes that, if used correctly in a timely fashion, can help lessen the harm caused by these agents. This article is meant to introduce the clinician to several such agents, along with the antidotes useful in the management of exposure to these. It covers the indications, administration, and precautions for using these antidotes.
Collapse
Affiliation(s)
- David T Lawrence
- Blue Ridge Poison Center, Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia, Charlottesville, VA 22908-0774, USA.
| | | |
Collapse
|
42
|
Fortin JL, Giocanti JP, Ruttimann M, Kowalski JJ. Prehospital administration of hydroxocobalamin for smoke inhalation-associated cyanide poisoning: 8 years of experience in the Paris Fire Brigade. Clin Toxicol (Phila) 2006; 44 Suppl 1:37-44. [PMID: 16990192 DOI: 10.1080/15563650600811870] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION This article reports the results of a retrospective study of 8 years of experience of the Paris Fire Brigade with the prehospital use of hydroxocobalamin. METHODS The head physician at the Paris Fire Brigade extracted and summarized data from standardized forms completed at the fire scene and, when available, hospital reports to assess survival status and clinical parameters associated with the use of hydroxocobalamin for each patient who received it for smoke inhalation-associated cyanide poisoning from 1995 to 2003. RESULTS Of the 101 patients administered hydroxocobalamin, 30 survived, 42 died (17 at the fire scene and 25 at the intensive-care unit), and survival status was not known in the remaining 29 patients. Among the 72 patients for whom survival status was known, survival rate was 41.7% after the administration of hydroxocobalamin. Of the 38 patients found in cardiac arrest, 21 had a return of spontaneous circulation during prehospital care. Of the 12 patients who were initially hemodynamically unstable (systolic blood pressure 0 to < or =90 mmHg), 9 recovered systolic blood pressure an average of 30.6 minutes after the start of hydroxocobalamin infusion. Among nonsedated patients in the sample as a whole (n = 52), mean (SD) Glasgow coma scale score improved from 7.9 (5.4) initially to 8.5 (5.7) after administration of hydroxocobalamin. Among nonsedated patients who were initially neurologically impaired (n = 18), Glasgow coma scale score improved in 9 patients, did not change in 8 patients, and worsened in 1 patient. Two adverse events--red or pink coloration of urine or skin (n = 5) and cutaneous rash (n = 1)--were assessed as being possibly related to hydroxocobalamin. CONCLUSION Hydroxocobalamin has a risk:benefit ratio rendering it suitable for prehospital use in the management of acute cyanide poisoning caused by smoke inhalation.
Collapse
Affiliation(s)
- Jean-Luc Fortin
- Emergency Department, Military Hospital Legouest, Metz, France.
| | | | | | | |
Collapse
|
43
|
Geller RJ, Barthold C, Saiers JA, Hall AH. Pediatric cyanide poisoning: causes, manifestations, management, and unmet needs. Pediatrics 2006; 118:2146-58. [PMID: 17079589 DOI: 10.1542/peds.2006-1251] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Confirmed cases of childhood exposure to cyanide are rare despite multiple potential sources including inhalation of fire smoke, ingestion of toxic household and workplace substances, and ingestion of cyanogenic foods. Because of its infrequent occurrence, medical professionals may have difficulty recognizing cyanide poisoning, confirming its presence, and treating it in pediatric patients. The sources and manifestations of acute cyanide poisoning seem to be qualitatively similar between children and adults, but children may be more vulnerable than adults to poisoning from some sources. The only currently available antidote in the United States (the cyanide antidote kit) has been used successfully in children but has particular risks associated with its use in pediatric patients. Because hemoglobin kinetics vary with age, methemoglobinemia associated with nitrite-based antidotes may be excessive at standard adult dosing in children. A cyanide antidote with a better risk/benefit ratio than the current agent available in the United States is desirable. The vitamin B12 precursor hydroxocobalamin, which has been used in Europe, may prove to be an attractive alternative to the cyanide antidote kit for pediatric patients. In this article we review the available data on the sources, manifestations, and treatment of acute cyanide poisoning in children and discuss unmet needs in the management of pediatric cyanide poisoning.
Collapse
Affiliation(s)
- Robert J Geller
- Department of Pediatrics and the Medical Toxicology Fellowship Program, Emory University School of Medicine, Atlanta, Georgia, USA.
| | | | | | | |
Collapse
|
44
|
Affiliation(s)
- Stephen W Borron
- Division of Emergency Medicine, University of Texas Health Science Center, San Antonio, TX 78229, USA.
| |
Collapse
|
45
|
Guidotti T. Acute cyanide poisoning in prehospital care: new challenges, new tools for intervention. Prehosp Disaster Med 2006; 21:s40-8. [PMID: 16771011 DOI: 10.1017/s1049023x00015892] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Effective management of cyanide poisoning from chemical terrorism, inhalation of fire smoke, and other causes constitutes a critical challenge for the prehospital care provider. The ability to meet the challenge of managing cyanide poisoning in the prehospital setting may be enhanced by the availability of the cyanide antidote hydroxocobalamin, currently under development for potential introduction in the United States. This paper discusses the causes, recognition, and management of acute cyanide poisoning in the prehospital setting with emphasis on the emerging profile of hydroxocobalamin, an antidote that may have a risk:benefit ratio suitable for empiric, out-of-hospital treatment of the range of causes of cyanide poisoning. If introduced in the U.S., hydroxocobalamin may enhance the role of the U.S. prehospital responder in providing emergency care in a cyanide incident.
Collapse
Affiliation(s)
- Tee Guidotti
- Division of Occupational Medicine and Toxicology, Department of Medicine, School of Medicine and Health Sciences, The George Washington University Medical Center, Washington, DC, USA.
| |
Collapse
|
46
|
|
47
|
Abstract
Although some antidotes are rarely used, they have an important, potentially life-saving role in the treatment of toxic exposures. The timely and judicious use of an antidote can prevent death and shorten hospitalization as well as reduce the patient's pain and suffering. Although their importance is recognized, sufficient stocking of antidotes remains a problem.
Collapse
Affiliation(s)
- Nicole L Ries
- Rocky Mountain Poison and Drug Center, Denver Health, Denver, CO 80204, USA
| | | |
Collapse
|
48
|
Abstract
Cyanide is a likely weapon for terrorists due to its notoriety, lethality, and availability. Poisoning results in central nervous system and cardiovascular dysfunction due to inhibition of oxidative phosphorylation. Laboratory findings of anion gap metabolic acidosis and hyperlactemia aid in confirming the diagnosis. Treatment for significant poisonings includes aggressive supportive care and administration of antidotes such as sodium nitrite, sodium thiosulfate, and hydroxocobalamin. Survivors of significant poisonings can have long-term neurologic dysfunction.
Collapse
Affiliation(s)
- Anthony P Morocco
- Guam Memorial Hospital, Department of Emergency Medicine, 850 Gov. Carlos Camacho Road, Oka, Tamuning, Guam
| |
Collapse
|
49
|
Abstract
The United States is under the constant threat of a mass casualty cyanide disaster from industrial accidents, hazardous material transportation incidents, and deliberate terrorist attacks. The current readiness for cyanide disaster by the emergency medical system in the United States is abysmal. We, as a nation, are simply not prepared for a significant cyanide-related event. The standard of care for cyanide intoxication is the cyanide antidote kit, which is based on the use of nitrites to induce methemoglobinemia. This kit is both expensive and ill suited for out-of-hospital use. It also has its own inherent toxicity that prevents rapid administration. Furthermore, our hospitals frequently fail to stock this life-saving antidote or decline to stock more than one. Hydroxocobalamin is well recognized as an efficacious, safe, and easily administered cyanide antidote. Because of its extremely low adverse effect profile, it is ideal for out-of-hospital use in suspected cyanide intoxication. To effectively prepare for a cyanide disaster, the United States must investigate, adopt, manufacture, and stockpile hydroxocobalamin to prevent needless morbidity and mortality.
Collapse
Affiliation(s)
- S W Sauer
- US Army Medical Corps, Honolulu, HI, USA
| | | |
Collapse
|
50
|
Abstract
Seven cases of hydrogen cyanide gas poisoning which occurred in an industrial building in Hong Kong are presented here. Two of them were more severely injured and required specific antidotal treatment. The other five were mild and responded to supportive treatment alone. All except one patient recovered completely. Cyanide poisoning is relatively uncommon in urbanized area, so high index of suspicion is important for early diagnosis and treatment. We believe that prevention of cyanide poisoning can be achieved by proper storage of chemicals, and by enforcing rescuers to wear special chemical protective clothing to avoid systemic poisoning because of dermal absorption of hydrogen cyanide gas. As there are newer and safer cyanide antidotes available, each emergency department should have a stock of updated products such as hydroxocobalamin.
Collapse
Affiliation(s)
- K K Lam
- Accident and Emergency Department, United Christian Hospital, Kwun Tong, Kowloon, Hong Kong
| | | |
Collapse
|