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Ghannoum M, Gosselin S, Hoffman RS, Lavergne V, Mégarbane B, Hassanian-Moghaddam H, Rif M, Kallab S, Bird S, Wood DM, Roberts DM, Anseeuw K, Berling I, Bouchard J, Bunchman TE, Calello DP, Chin PK, Doi K, Galvao T, Goldfarb DS, Hoegberg LCG, Kebede S, Kielstein JT, Lewington A, Li Y, Macedo EM, MacLaren R, Mowry JB, Nolin TD, Ostermann M, Peng A, Roy JP, Shepherd G, Vijayan A, Walsh SJ, Wong A, Yates C. Extracorporeal treatment for ethylene glycol poisoning: systematic review and recommendations from the EXTRIP workgroup. Crit Care 2023; 27:56. [PMID: 36765419 PMCID: PMC9921105 DOI: 10.1186/s13054-022-04227-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/18/2022] [Indexed: 02/12/2023] Open
Abstract
Ethylene glycol (EG) is metabolized into glycolate and oxalate and may cause metabolic acidemia, neurotoxicity, acute kidney injury (AKI), and death. Historically, treatment of EG toxicity included supportive care, correction of acid-base disturbances and antidotes (ethanol or fomepizole), and extracorporeal treatments (ECTRs), such as hemodialysis. With the wider availability of fomepizole, the indications for ECTRs in EG poisoning are debated. We conducted systematic reviews of the literature following published EXTRIP methods to determine the utility of ECTRs in the management of EG toxicity. The quality of the evidence and the strength of recommendations, either strong ("we recommend") or weak/conditional ("we suggest"), were graded according to the GRADE approach. A total of 226 articles met inclusion criteria. EG was assessed as dialyzable by intermittent hemodialysis (level of evidence = B) as was glycolate (Level of evidence = C). Clinical data were available for analysis on 446 patients, in whom overall mortality was 18.7%. In the subgroup of patients with a glycolate concentration ≤ 12 mmol/L (or anion gap ≤ 28 mmol/L), mortality was 3.6%; in this subgroup, outcomes in patients receiving ECTR were not better than in those who did not receive ECTR. The EXTRIP workgroup made the following recommendations for the use of ECTR in addition to supportive care over supportive care alone in the management of EG poisoning (very low quality of evidence for all recommendations): i) Suggest ECTR if fomepizole is used and EG concentration > 50 mmol/L OR osmol gap > 50; or ii) Recommend ECTR if ethanol is used and EG concentration > 50 mmol/L OR osmol gap > 50; or iii) Recommend ECTR if glycolate concentration is > 12 mmol/L or anion gap > 27 mmol/L; or iv) Suggest ECTR if glycolate concentration 8-12 mmol/L or anion gap 23-27 mmol/L; or v) Recommend ECTR if there are severe clinical features (coma, seizures, or AKI). In most settings, the workgroup recommends using intermittent hemodialysis over other ECTRs. If intermittent hemodialysis is not available, CKRT is recommended over other types of ECTR. Cessation of ECTR is recommended once the anion gap is < 18 mmol/L or suggested if EG concentration is < 4 mmol/L. The dosage of antidotes (fomepizole or ethanol) needs to be adjusted during ECTR.
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Affiliation(s)
- Marc Ghannoum
- grid.14848.310000 0001 2292 3357Research Center, CIUSSS du Nord-de-l’île-de-Montréal, University of Montreal, Montreal, QC Canada ,grid.137628.90000 0004 1936 8753Nephrology Division, NYU Langone Health, NYU Grossman School of Medicine, New York, NY USA ,grid.5477.10000000120346234Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sophie Gosselin
- grid.420748.d0000 0000 8994 4657Centre Intégré de Santé et de Services Sociaux (CISSS) de la Montérégie-Centre Emergency Department, Hôpital Charles-Lemoyne, Greenfield Park, QC Canada ,grid.86715.3d0000 0000 9064 6198Faculté de Médecine et Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Canada ,Centre Antipoison du Québec, Quebec, QC Canada
| | - Robert S. Hoffman
- grid.137628.90000 0004 1936 8753Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY USA
| | - Valery Lavergne
- grid.14848.310000 0001 2292 3357Research Center, CIUSSS du Nord-de-l’île-de-Montréal, University of Montreal, Montreal, QC Canada
| | - Bruno Mégarbane
- grid.411296.90000 0000 9725 279XDepartment of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM UMRS-1144, Paris Cité University, Paris, France
| | - Hossein Hassanian-Moghaddam
- grid.411600.2Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran ,grid.411600.2Department of Clinical Toxicology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Siba Kallab
- grid.411323.60000 0001 2324 5973Department of Internal Medicine-Division of Nephrology, Lebanese American University - School of Medicine, Byblos, Lebanon
| | - Steven Bird
- Department of Emergency Medicine, U Mass Memorial Health, U Mass Chan Medical School, Worcester, MA USA
| | - David M. Wood
- grid.13097.3c0000 0001 2322 6764Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, and Clinical Toxicology, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Darren M. Roberts
- grid.430417.50000 0004 0640 6474New South Wales Poisons Information Centre, Sydney Children’s Hospitals Network, Westmead, NSW Australia ,grid.413249.90000 0004 0385 0051Drug Health Services, Royal Prince Alfred Hospital, Sydney, NSW Australia
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Inman B, Maddry JK, Ng PC, Koyfman A, Long B. High risk and low prevalence diseases: Toxic alcohol ingestion. Am J Emerg Med 2023; 67:29-36. [PMID: 36796238 DOI: 10.1016/j.ajem.2023.01.048] [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: 11/07/2022] [Revised: 01/26/2023] [Accepted: 01/26/2023] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Toxic alcohol ingestion is a rare but serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of toxic alcohol ingestion, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Toxic alcohols include ethylene glycol, methanol, isopropyl alcohol, propylene glycol, and diethylene glycol. These substances can be found in several settings including hospitals, hardware stores, and the household, and ingestion can be accidental or intentional. Toxic alcohol ingestion presents with various degrees of inebriation, acidemia, and end-organ damage depending on the substance. Timely diagnosis is critical to prevent irreversible organ damage or death and is based primarily on clinical history and consideration of this entity. Laboratory evidence of toxic alcohol ingestion includes worsening osmolar gap or anion-gap acidemia and end organ injury. Treatment depends on the ingestion and severity of illness but includes alcohol dehydrogenase blockade with fomepizole or ethanol and special considerations for the initiation of hemodialysis. CONCLUSIONS An understanding of toxic alcohol ingestion can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
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Affiliation(s)
- Brannon Inman
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Joseph K Maddry
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Patrick C Ng
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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3
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Prashek J, Mohamed A, Barnes TE, Schlachter AB. Continuous renal replacement therapy combined with fomepizole is effective in the clearance of ethylene glycol: a case report. TOXICOLOGY COMMUNICATIONS 2021. [DOI: 10.1080/24734306.2021.1973818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Jamie Prashek
- University of Missouri Health Care, Columbia, MO, USA
| | - Adham Mohamed
- Saint Luke’s Hospital of Kansas City, Kansas City, MO, USA
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D'Netto ME, Archibald WJ, Cajigas HR. 44-Year-Old Woman With Altered Mental Status and Tachypnea. Mayo Clin Proc 2021; 96:776-781. [PMID: 33673925 DOI: 10.1016/j.mayocp.2020.07.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/24/2020] [Accepted: 07/02/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Michael E D'Netto
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - William J Archibald
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Hector R Cajigas
- Advisor to residents and Consultant in Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
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Sidlak AM, Marino RT, Van Meerbeke JP, Pizon AF. Single versus continued dosing of fomepizole during hemodialysis in ethylene glycol toxicity. Clin Toxicol (Phila) 2020; 59:106-110. [PMID: 32452214 DOI: 10.1080/15563650.2020.1770780] [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] [Indexed: 10/24/2022]
Abstract
BACKGROUND In cases of ethylene glycol (EG) toxicity requiring hemodialysis (HD), fomepizole is dosed every four hours. HD efficiently clears EG and its toxic metabolites, and it's unclear if multiple doses (MD) of fomepizole improve patient outcomes or whether a single dose (SD) prior to initiation of HD is sufficient. METHODS We reviewed cases of EG toxicity at a toxicology referral center from 2008 to 2018. Patients treated with HD with EG levels greater than 20 mg/dL were included. Duration of dialysis, creatinine at discharge, hospital length of stay (LOS), and complications were analyzed. We compared patients who received a single dose of fomepizole prior to HD to those who received continued dosing during and after HD. RESULTS Twenty-five patient encounters were identified (MD: 20; SD: 5). Initial bicarbonate (11 [SD] vs. 9 mg/dL [MD]) and pH (7.1 vs. 7.1) were similar between the groups; however, there was a trend toward a greater proportion of patients with renal dysfunction in the MD group: 11 (55%) vs. 1 (20%). HD was initiated a median interval of 5.2 h [SD] vs. 5.7 h [MD] after a dose of fomepizole. There was one death in the MD group and none in the SD group. Median creatinine on the day of discharge was 0.7 mg/dL (IQR: 0.57-3.8) in the SD group and 2.0 mg/dL (0.90-7.0) in the MD group. LOS was similar (5.8 days [95% CI 3.6-8.0] vs. 7.6 days [5.3-9.9]) (p = .61). CONCLUSION Patients with moderately severe EG toxicity (acidosis and no initial renal dysfunction) treated with a single dose of fomepizole prior to HD had similar outcomes to those receiving continued dosing of fomepizole during or after HD. This raises the possibility that a single dose of fomepizole may be sufficient if HD is initiated quickly.
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Affiliation(s)
- Alexander M Sidlak
- Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ryan T Marino
- Division of Medical Toxicology, Department of Emergency Medicine, University Hospitals, Cleveland, OH, USA
| | - James P Van Meerbeke
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anthony F Pizon
- Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Greenwald KE, Peak DA, Wittels K, Wilcox SR. Acute Intoxication. J Emerg Med 2019; 57:387-389. [PMID: 31296353 DOI: 10.1016/j.jemermed.2019.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/19/2019] [Indexed: 06/09/2023]
Affiliation(s)
- Kelsy E Greenwald
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - David A Peak
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kathleen Wittels
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Susan R Wilcox
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
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A Case Report of Massive Acetaminophen Poisoning Treated with a Novel "Triple Therapy": N-Acetylcysteine, 4-Methylpyrazole, and Hemodialysis. Case Rep Emerg Med 2019; 2019:9301432. [PMID: 30956824 PMCID: PMC6425342 DOI: 10.1155/2019/9301432] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 01/25/2019] [Accepted: 02/13/2019] [Indexed: 01/01/2023] Open
Abstract
Massive acetaminophen (N-acetyl-p-aminophenol; APAP) ingestion is characterized by a rapid onset of mitochondrial dysfunction, including metabolic acidosis, lactemia, and altered mental status without hepatotoxicity which may not respond to the standard doses of N-acetylcysteine (NAC). A 64-year-old woman without medical history presented comatose after an ingestion of 208 tablets of Tylenol PM™ (APAP 500 mg and diphenhydramine 25 mg). The initial APAP concentration measured 1,017 µg/mL (therapeutic range 10-30 µg/mL), and elevated anion gap metabolic acidosis, lactemia, and 5-oxoprolinemia were detected. High-dose intravenous (IV) NAC, 4-methylpyrazole (4-MP), and hemodialysis (HD) were initiated. She was transferred to a liver transplant center and continued both NAC and HD therapies until complete resolution of metabolic acidosis and coma without developing hepatitis. She was discharged without sequelae. This is the fourth highest APAP concentration recorded in a surviving patient. Moreover, this is the first report of a novel “triple therapy” using NAC, 4-MP, and HD in the setting of massive APAP ingestion that presents with coma, elevated anion gap metabolic acidosis, and lactemia. Emergency physicians should recognize these critically ill patients and consider high-dose NAC, 4-MP, and HD to be initiated in the emergency department (ED).
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8
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Prediction and validation of the duration of hemodialysis sessions for the treatment of acute ethylene glycol poisoning. Kidney Int 2017; 92:453-460. [DOI: 10.1016/j.kint.2017.02.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 02/13/2017] [Accepted: 02/16/2017] [Indexed: 11/18/2022]
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9
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Sugunaraj JP, Thakur LK, Jha KK, Bucaloiu ID. Sequential episodes of ethylene glycol poisoning in the same person. BMJ Case Rep 2017; 2017:bcr-2017-220108. [PMID: 28551601 DOI: 10.1136/bcr-2017-220108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Ethylene glycol is a common alcohol found in many household products such as household hard surface cleaner, paints, varnish, auto glass cleaner and antifreeze. While extremely toxic and often fatal on ingestion, few cases with early presentation by the patient have resulted in death; thus, rapid diagnosis is paramount to effectively treating ethylene glycol poisoning. In this study, we compare two sequential cases of ethylene glycol poisoning in a single individual, which resulted in strikingly different outcomes.
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Affiliation(s)
- Jaya Prakash Sugunaraj
- Pulmonary & Critical Care Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
| | | | - Kunal Kishor Jha
- Critical Care Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Ion Dan Bucaloiu
- Nephrology, Geisinger Medical Center, Danville, Pennsylvania, USA
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10
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Kim Y. Plotting of Ethylene Glycol Blood Concentrations Using Linear Regression before and during Hemodialysis in a Case of Intoxication and Pharmacokinetic Review. Case Rep Nephrol 2015; 2015:359101. [PMID: 26346463 PMCID: PMC4543587 DOI: 10.1155/2015/359101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 07/22/2015] [Indexed: 11/24/2022] Open
Abstract
Introduction. As blood concentration measurement of commonly abused alcohol is readily available, the equation was proposed in previous publication to predict the change of their concentration. The change of ethylene glycol (EG) concentrations was studied in a case of intoxication to estimate required time for hemodialysis (HD) using linear regression. Case Report. A 55-year-old female with past medical history of seizure disorder, bipolar disorder, and chronic pain was admitted due to severe agitation. The patient was noted to have metabolic acidosis with elevated anion gap and acute kidney injury, which prompted blood concentration measurement of commonly abused alcohol. Her initial EG concentration was 26.45 mmol/L. Fomepizole therapy was initiated, soon followed by HD to enhance clearance. Discussion. Plotting of natural logarithm of EG concentrations over time showed that EG elimination follows first-order kinetics and predicts the change of its concentration well. Pharmacokinetic review revealed minimal elimination of EG by alcohol dehydrogenase (ADH) which could be related to genetic predisposition for ADH activity and home medications as well as presence of propylene glycol. Pharmacokinetics of EG is relatively well studied with published parameters. Consideration and application of pharmacokinetics could assist in management of EG intoxication including HD planning.
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Affiliation(s)
- Youngho Kim
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, 901 University Boulevard SE, Suite 150, MSC 04-2785, Albuquerque, NM 87106, USA
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11
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Abstract
ABSTRACT
The management of ethylene glycol poisoning is reviewed, with a focus on the use of the new antidote fomepizole. Ethylene glycol is a widely used industrial agent that is also easily obtained commercially, usually as radiator antifreeze. Ingestion of as little as 30 to 60 mL can result in death or serious permanent disability. Traditional management of poisoning includes the use of ethanol, with or without hemodialysis. Activated charcoal is not indicated, and gastric lavage may be beneficial only in the first hour after ingestion. Cofactors such as pyridoxine and thiamine may be beneficial in patients deficient in these vitamins. A new antidote, fomepizole, has recently been approved for use in Canada. Like ethanol, it is a competitive inhibitor of alcohol dehydrogenase. Potential benefits of fomepizole include its ease of administration and lack of serious adverse effects. Fomepizole may be recommended over ethanol in situations in which avoidance of ethanol-induced side effects is imperative or when ethanol is not readily available. Further studies are required to verify its comparative efficacy and cost-effectiveness compared to ethanol.
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Affiliation(s)
- Tammy L Hall
- Pharmacy Department, The Ottawa Hospital -- Civic Campus, Ottawa, Ontario, Canada
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12
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Mégarbane B, Résière D. [Toxicological analysis is mandatory to interpret elevation in blood lactate concentration in toxic alcohol poisoning]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2014; 33:368-369. [PMID: 24857017 DOI: 10.1016/j.annfar.2014.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- B Mégarbane
- Inserm U1144, réanimation médicale et toxicologique, hôpital Lariboisière, université Paris-Diderot, 2, rue Ambroise-Paré, 75010 Paris, France.
| | - D Résière
- Réanimation polyvalente, CHU de Fort-De-France, Fort-De-France, Martinique
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13
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Ghannoum M, Hoffman RS, Mowry JB, Lavergne V. Trends in Toxic Alcohol Exposures in the United States from 2000 to 2013: A Focus on the Use of Antidotes and Extracorporeal Treatments. Semin Dial 2014; 27:395-401. [DOI: 10.1111/sdi.12237] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Marc Ghannoum
- Department of Nephrology; Verdun Hospital; University of Montreal; Montreal Quebec Canada
| | - Robert S. Hoffman
- Division of Medical Toxicology; Departments of Medicine and Emergency Medicine; New York University School of Medicine; New York City New York
| | - James B. Mowry
- Indiana University Health; Indiana Poison Center; Indianapolis Indiana
| | - Valery Lavergne
- Department of Medical Biology Sacré-Coeur Hospital; University of Montreal; Montreal Quebec Canada
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14
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McQuade DJ, Dargan PI, Wood DM. Challenges in the diagnosis of ethylene glycol poisoning. Ann Clin Biochem 2013; 51:167-78. [DOI: 10.1177/0004563213506697] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Ethylene glycol poisoning, while uncommon, is clinically significant due to the associated risk of severe morbidity or lethality and it continues to occur in many countries around the world. The clinical presentation of ethylene glycol toxicity, while classically described in three phases, varies widely and when combined with the range of differential diagnoses that must be considered makes diagnosis challenging. Early and accurate detection is important in these patients, however, as there is a need to start antidotal treatment early to prevent serious harm. In this article, we will review the literature and provide guidance regarding the diagnosis of ethylene glycol poisoning. While gas chromatography is the gold standard, the usefulness of this test is hampered by delays in access due to availability. Consequently, there are several surrogate markers that can give an indication of ethylene glycol exposure but these must be interpreted with caution and within the clinical context. An in-depth review of these tests, particularly the detection of a raised osmolar gap or an raised anion gap acidosis, will form the main focus of this article.
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Affiliation(s)
- David J McQuade
- Emergency Department, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, London, UK
- Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, London, UK
- King’s College London, London, UK
| | - David M Wood
- Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, London, UK
- King’s College London, London, UK
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15
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Murphy CM, Vitto MJ, Dulaney AR. Detectable serum ethylene glycol levels after subcutaneous injection of antifreeze. Clin Toxicol (Phila) 2013; 51:908-9. [PMID: 24032467 DOI: 10.3109/15563650.2013.834534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Christine M Murphy
- Department of Emergency Medicine, Carolinas Medical Center , Charlotte, NC , USA
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16
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Abstract
Ethylene glycol poisoning is a medical emergency that presents challenges for clinicians and clinical laboratories. If left untreated, it may cause morbidity and death, but effective therapy is available if diagnosed in time. The diagnosis of ethylene glycol poisoning is not always straightforward and the commonly quoted 'plasma osmolar gap' is not sufficiently sensitive to exclude a small ingestion and has been reported to be normal in a number of serious exposures. The 'plasma osmolar gap' cannot distinguish among ethanol, isopropyl alcohol, methanol or ethylene glycol. Thus, the measurement of serum ethylene glycol and, ideally, glycolic acid, its major toxic metabolite in serum, is definitive. This also holds true for methanol and its metabolite formic acid. Ethylene glycol metabolites target the kidney and lead to reversible oliguric or anuric injury, which in turn slows the elimination of ethylene glycol. The therapeutic options include reversal of metabolic acidosis, inhibition of alcohol dehydrogenase and early haemodialysis.
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Affiliation(s)
- Alok Arora
- Frenchay Hospital, North Bristol Hospitals NHS trust, Bristol, UK.
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17
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Beatty L, Green R, Magee K, Zed P. A systematic review of ethanol and fomepizole use in toxic alcohol ingestions. Emerg Med Int 2013; 2013:638057. [PMID: 23431453 PMCID: PMC3574646 DOI: 10.1155/2013/638057] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Accepted: 12/25/2012] [Indexed: 11/26/2022] Open
Abstract
Objectives. The optimal antidote for the treatment of ethylene glycol or methanol intoxication is not known. The objective of this systematic review is to describe all available data on the use of ethanol and fomepizole for methanol and ethylene glycol intoxication. Data Source. A systematic search of MEDLINE and EMBASE was conducted. Study Selection. Published studies involving the use of ethanol or fomepizole, or both, in adults who presented within 72 hours of toxic alcohol ingestion were included. Our search yielded a total of 145 studies for our analysis. There were no randomized controlled trials, and no head-to-head trials. Data Extraction. Variables were evaluated for all publications by one independent author using a standardized data collection form. Data Synthesis. 897 patients with toxic alcohol ingestion were identified. 720 (80.3%) were treated with ethanol (505 Me, 215 EG), 146 (16.3%) with fomepizole (81 Me, 65 EG), and 33 (3.7%) with both antidotes (18 Me, 15 EG). Mortality in patients treated with ethanol was 21.8% for Me and 18.1% for EG. In those administered fomepizole, mortality was 17.1% for Me and 4.1% for EG. Adverse events were uncommon. Conclusion. The data supporting the use of one antidote is inconclusive. Further investigation is warranted.
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Affiliation(s)
- Lorri Beatty
- Department of Emergency Medicine, Dalhousie University, Room 377, Bethune Building, 1276 South Park Street, Halifax, NS, Canada B3H 2Y9
| | - Robert Green
- Department of Emergency Medicine, Dalhousie University, Room 377, Bethune Building, 1276 South Park Street, Halifax, NS, Canada B3H 2Y9
- Division of Critical Care Medicine, Department of Anesthesia, Dalhousie University, Room 377, Bethune Building, 1276 South Park Street, Halifax, NS, Canada B3H 2Y9
| | - Kirk Magee
- Department of Emergency Medicine, Dalhousie University, Room 377, Bethune Building, 1276 South Park Street, Halifax, NS, Canada B3H 2Y9
| | - Peter Zed
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada V6T 1Z3
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Besenhofer LM, Cain MC, Dunning C, McMartin KE. Aluminum citrate prevents renal injury from calcium oxalate crystal deposition. J Am Soc Nephrol 2012; 23:2024-33. [PMID: 23138489 DOI: 10.1681/asn.2012040357] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Calcium oxalate monohydrate crystals are responsible for the kidney injury associated with exposure to ethylene glycol or severe hyperoxaluria. Current treatment strategies target the formation of calcium oxalate but not its interaction with kidney tissue. Because aluminum citrate blocks calcium oxalate binding and toxicity in human kidney cells, it may provide a different therapeutic approach to calcium oxalate-induced injury. Here, we tested the effects of aluminum citrate and sodium citrate in a Wistar rat model of acute high-dose ethylene glycol exposure. Aluminum citrate, but not sodium citrate, attenuated increases in urea nitrogen, creatinine, and the ratio of kidney to body weight in ethylene glycol-treated rats. Compared with ethylene glycol alone, the addition of aluminum citrate significantly increased the urinary excretion of both crystalline calcium and crystalline oxalate and decreased the deposition of crystals in renal tissue. In vitro, aluminum citrate interacted directly with oxalate crystals to inhibit their uptake by proximal tubule cells. These results suggest that treating with aluminum citrate attenuates renal injury in rats with severe ethylene glycol toxicity, apparently by inhibiting calcium oxalate's interaction with, and retention by, the kidney epithelium.
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Affiliation(s)
- Lauren M Besenhofer
- Department of Pharmacology, Toxicology, and Neuroscience, Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA 71130-3932, USA
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Head JM. Ethylene glycol ingestion masked by concomitant ethanol intoxication. BMJ Case Rep 2012; 2012:bcr.12.2011.5326. [PMID: 22605713 DOI: 10.1136/bcr.12.2011.5326] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
An obtunded male with a history of alcohol abuse presented to the emergency department with metabolic acidosis, an osmolar gap and lactic acidosis. The patient was initially treated for alcohol intoxication due to an extremely high blood alcohol level. Following respiratory failure and intubation, a large volume of dark green liquid was removed via nasogastric suction; bedside fluorescence for ethylene glycol was negative. Twenty-four hours later, the patient's glomerular filtration rate decreased significantly, serum osmolality was 807, the osmolar gap was 407, complete metabolic panel showed pH of 6.8, sodium of 156 mmol/l, potassium of 7.3 mmol/l, chloride of 116, CO(2) of 3.9 and anion gap of 30.7. Blood lactic acid was >56 mmol/l. The patient received emergency haemodialysis. Four days after presentation, the patient began to respond to voice commands and was extubated. Currently, the patient still receives haemodialysis due to ongoing renal failure, but no long-term neurologic complications are evident.
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Affiliation(s)
- Justin M Head
- Lincoln Memorial University-DeBusk College of Osteopathic Medicine, Harrogate, Tennessee, USA.
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McClain J, Uemura T, Sathishkumar S, Kadry Z. Liver donation after ethylene glycol overdose: when is it safe? Transpl Int 2012; 25:e55-7. [PMID: 22340516 DOI: 10.1111/j.1432-2277.2012.01436.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Levine M, Curry SC, Ruha AM, Pizon AF, Boyer E, Burns J, Bikin D, Gerkin RD. Ethylene glycol elimination kinetics and outcomes in patients managed without hemodialysis. Ann Emerg Med 2012; 59:527-31. [PMID: 22226175 DOI: 10.1016/j.annemergmed.2011.12.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Revised: 11/20/2011] [Accepted: 12/02/2011] [Indexed: 10/14/2022]
Abstract
STUDY OBJECTIVE Ethylene glycol remains an important toxic cause of metabolic acidosis and acute renal failure. Traditionally, inhibition of alcohol dehydrogenase along with hemodialysis has been used for treatment. Because of reported long elimination half-life of ethylene glycol during alcohol dehydrogenase inhibition, hemodialysis has been used in patients who are otherwise doing well to clear ethylene glycol. We study ethylene glycol elimination kinetics in patients treated with fomepizole, but without hemodialysis. METHODS This was a retrospective, multicenter cohort study of patients older than 15 years who were treated at one of 3 medical centers during an 8-year period. Inclusion criteria were peak serum ethylene glycol concentration greater than 20 mg/dL, lack of renal failure on admission, treatment with fomepizole but without hemodialysis, and availability of serial serum ethylene glycol concentrations, allowing calculation of elimination half-life. The primary outcome variable was ethylene glycol elimination half-life; mortality and onset of renal failure were secondary outcome variables. RESULTS During the study period, 85 patients were treated for ethylene glycol toxicity, of whom 40 met inclusion criteria. The mean serum ethylene glycol elimination half-life was 14.2 hours (SD=3.7 hours; 95% confidence interval 13.1 to 15.3 hours). One patient presented with metabolic acidosis on admission and developed mild transient renal insufficiency but did not require hemodialysis. No patient died. CONCLUSION The mean elimination half-life of ethylene glycol in this population was shorter than previously reported without hemodialysis, and this select group of patients did well without enhanced elimination by hemodialysis.
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Affiliation(s)
- Michael Levine
- Department of Medical Toxicology, Banner Good Samaritan Medical Center, Phoenix, AZ, USA.
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Buller GK, Moskowitz CB. When is It appropriate to treat ethylene glycol intoxication with fomepizole alone without hemodialysis? Semin Dial 2011; 24:441-2. [DOI: 10.1111/j.1525-139x.2011.00930.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Green TJ, Sivilotti MLA, Langmann C, Yarema M, Juurlink D, Burns MJ, Johnson DW. When do the aminotransferases rise after acute acetaminophen overdose? Clin Toxicol (Phila) 2010; 48:787-92. [PMID: 20969501 DOI: 10.3109/15563650.2010.523828] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Thomas J Green
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
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Mégarbane B. Treatment of patients with ethylene glycol or methanol poisoning: focus on fomepizole. Open Access Emerg Med 2010; 2:67-75. [PMID: 27147840 PMCID: PMC4806829 DOI: 10.2147/oaem.s5346] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Ethylene glycol (EG) and methanol are responsible for life-threatening poisonings. Fomepizole, a potent alcohol dehydrogenase (ADH) inhibitor, is an efficient and safe antidote that prevents or reduces toxic EG and methanol metabolism. Although no study has compared its efficacy with ethanol, fomepizole is recommended as a first-line antidote. Treatment should be started as soon as possible, based on history and initial findings including anion gap metabolic acidosis, while awaiting measurement of alcohol concentration. Administration is easy (15 mg/kg-loading dose, either intravenously or orally, independent of alcohol concentration, followed by intermittent 10 mg/kg-doses every 12 hours until alcohol concentrations are <30 mg/dL). There is no need to monitor fomepizole concentrations. Administered early, fomepizole prevents EG-related renal failure and methanol-related visual and neurological injuries. When administered prior to the onset of significant acidosis or organ injury, fomepizole may obviate the need for hemodialysis. When dialysis is indicated, 1 mg/kg/h-continuous infusion should be provided to compensate for its elimination. Side-effects are rarely serious and with a lower occurrence than ethanol. Fomepizole is contraindicated in case of allergy to pyrazoles. It is both efficacious and safe in the pediatric population, but is not recommended during pregnancy. In conclusion, fomepizole is an effective and safe first-line antidote for EG and methanol intoxications.
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Affiliation(s)
- Bruno Mégarbane
- Réanimation Médicale et Toxicologique, Hôpital Lariboisière and Université Paris-Diderot, Paris, France
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Buchanan JA, Alhelail M, Cetaruk EW, Schaeffer TH, Palmer RB, Kulig K, Brent J. Massive ethylene glycol ingestion treated with fomepizole alone-a viable therapeutic option. J Med Toxicol 2010; 6:131-4. [PMID: 20422336 PMCID: PMC3550287 DOI: 10.1007/s13181-010-0061-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Fomepizole is used to treat and prevent toxicity from ethylene glycol poisoning. Treatment with fomepizole without hemodialysis in massive ethylene glycol ingestion has been rarely reported in the literature; however, published literature and practice guidelines recommend considering dialysis for ethylene glycol levels >50 mg/dL. We report a case of massive ethylene glycol ingestion resulting in the highest serum ethylene glycol concentration in a patient without ethanol co-ingestion who was treated with fomepizole and was not hemodialyzed. A 48-year-old male presented to the emergency department after reportedly ingesting >1 liter of antifreeze in an attempt at self-harm. He denied concomitant ethanol consumption. His initial presenting serum ethylene glycol level was 700 mg/dL, with normal renal function, and a metabolic acidosis with a high anion gap. One hour after presentation, he was started on intravenous fomepizole. Treatment with fomepizole continued until the patient's plasma ethylene glycol concentration was 16 mg/dL. His metabolic acidosis quickly resolved, he had no adverse reactions to the treatment, and his renal function remained normal. Ultimately, he was discharged to a psychiatric unit without sequelae. Published literature and practice guidelines suggests considering hemodialysis initiation in patients with an ethylene glycol level > 50 mg/dL. This recommendation is anecdotally, rather than evidence, based. With the potential risks inherent in hemodialysis, our case provides evidence that treatment with fomepizole without hemodialysis appears to be a viable alternative option in patients with even extremely high plasma ethylene glycol concentrations as long as their renal function is intact.
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Fertel BS, Nelson LS, Goldfarb DS. Extracorporeal Removal Techniques for the Poisoned Patient: A Review for the Intensivist. J Intensive Care Med 2010; 25:139-48. [DOI: 10.1177/0885066609359592] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The kidney is able to rapidly eliminate many water-soluble xenobiotics (exogenous chemicals). However, in the face of extraordinary serum concentrations of these xenobiotics or renal dysfunction, alternative elimination techniques often become necessary. Extracorporeal removal (ECR) techniques are used to increase the clearance of xenobiotics. These techniques include hemodialysis (HD), charcoal hemoperfusion (HP), and modalities grouped under the heading of continuous renal replacement therapy (CRRT): continuous venovenous hemofiltration (CVVH) and continuous venovenous hemodiafiltration (CVVHDF). Extracorporeal removal is limited to patients with significant or potentially significant clinical poisoning because the resources required to perform ECR are great. Therefore, most patients who are treated with these techniques are being cared for in intensive care units (ICUs). Our goal in this review is to discuss the properties that make xenobiotics amenable to removal by ECR and the advantages and disadvantages of the individual techniques. We discuss xenobiotics that constitute clear indications for ECR, including the toxic alcohols, salicylates, and lithium. We review the use of CRRT, a modality for which clear indications for treatment of poisonings are currently lacking.
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Affiliation(s)
- Baruch S. Fertel
- Department of Emergency Medicine, University of Cincinnati, Ohio, USA
| | - Lewis S. Nelson
- Department of Emergency Medicine, New York University School of Medicine and New York City Poison Control Center, NY, USA
| | - David S. Goldfarb
- Nephrology Section, NY Harbor VA Medical Center and Nephrology Division, NYU School of Medicine, NY, USA,
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Ting SMS, Ching I, Nair H, Langman G, Suresh V, Temple RM. Early and late presentations of ethylene glycol poisoning. Am J Kidney Dis 2009; 53:1091-7. [PMID: 19272685 DOI: 10.1053/j.ajkd.2008.12.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2008] [Accepted: 12/12/2008] [Indexed: 12/15/2022]
Affiliation(s)
- Stephen M S Ting
- Renal Department, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, West Midlands, UK.
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Bestic M, Blackford M, Reed M. Fomepizole: a critical assessment of current dosing recommendations. J Clin Pharmacol 2008; 49:130-7. [PMID: 19004845 DOI: 10.1177/0091270008327142] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Fomepizole, 4-methylpyrazole (4-MP), is a competitive antagonist of alcohol dehydrogenase with a binding affinity >8000 times that of ethanol. The drug is currently labeled by the United States Food and Drug Administration for the treatment of adult patients with known or suspected ethylene glycol or methanol poisoning. Fomepizole's wide therapeutic dose range and safety profile confer several advantages over standard ethanol therapy for the treatment of toxic alcohol exposures, including the lack of ethanol-associated side effects. Published data and data obtained from the drug's manufacturer implies that the dose escalation after 48 hours is to compensate for fomepizole-induced increased body clearance resulting from autoinduction of the cytochrome P450 (CYP) drug metabolizing enzyme CYP2E1. However, we were unable to identify any evidence of fomepizole's metabolism occurring via CYP2E1 in humans while the data most frequently cited as evidence for induction do not appear to support this claim. Based on this data along with the apparent zero-order kinetics, the current dose increase recommendations may be unnecessary and considering the safety margin described for fomepizole, an extremely conservative constant higher dose administered every 12 hours would appear to assure efficacy and tolerability. Despite the evidence, dose changes should only be implemented after careful clinical trials.
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Affiliation(s)
- Michelle Bestic
- Department of Pharmacology and Critical Care, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Abstract
INTRODUCTION Ethylene glycol is a widely used chemical that is capable of causing significant injury if ingested. Treatment for ethylene glycol poisoning typically includes basic supportive care, alcohol dehydrogenase inhibition, and hemodialysis. Recent data have suggested that hemodialysis may not be necessary for cases of ethylene glycol poisoning that can be treated with fomepizole as blocking therapy before acidosis or renal dysfunction develops. CASE REPORT A 33-year-old man presented to the emergency department 1 hour after drinking approximately 1/2 gallon of ethylene glycol antifreeze and an unknown quantity of beer. On arrival he was mildly inebriated but otherwise displayed no other features of ethylene glycol poisoning. Fomepizole therapy was initiated and initial laboratory studies later revealed an osmol gap of 157 mOsm and an ethylene glycol concentration of 706 mg/dL. Nephrology and toxicology services were consulted. Over the next 3 days, fomepizole therapy was continued while the patient's acid-base status and renal function were closely monitored. No evidence of acid-base abnormalities or renal impairment was ever observed and the patient was discharged to psychiatric care on the fourth hospital day. DISCUSSION This report describes the case of a patient who presented soon after a massive ingestion of ethylene glycol with very high serum concentrations. He was successfully treated using fomepizole and basic supportive care. Our patient developed neither renal insufficiency nor metabolic acidosis. His concomitant ethanol consumption, early presentation, and treatment likely contributed to his favorable outcome. This case report underscores the effectiveness of supportive care and fomepizole in the treatment of ethylene glycol poisoning.
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Kraut JA, Kurtz I. Toxic alcohol ingestions: clinical features, diagnosis, and management. Clin J Am Soc Nephrol 2007; 3:208-25. [PMID: 18045860 DOI: 10.2215/cjn.03220807] [Citation(s) in RCA: 223] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Alcohol-related intoxications, including methanol, ethylene glycol, diethylene glycol, and propylene glycol, and alcoholic ketoacidosis can present with a high anion gap metabolic acidosis and increased serum osmolal gap, whereas isopropanol intoxication presents with hyperosmolality alone. The effects of these substances, except for isopropanol and possibly alcoholic ketoacidosis, are due to their metabolites, which can cause metabolic acidosis and cellular dysfunction. Accumulation of the alcohols in the blood can cause an increment in the osmolality, and accumulation of their metabolites can cause an increase in the anion gap and a decrease in serum bicarbonate concentration. The presence of both laboratory abnormalities concurrently is an important diagnostic clue, although either can be absent, depending on the time after exposure when blood is sampled. In addition to metabolic acidosis, acute renal failure and neurologic disease can occur in some of the intoxications. Dialysis to remove the unmetabolized alcohol and possibly the organic acid anion can be helpful in treatment of several of the alcohol-related intoxications. Administration of fomepizole or ethanol to inhibit alcohol dehydrogenase, a critical enzyme in metabolism of the alcohols, is beneficial in treatment of ethylene glycol and methanol intoxication and possibly diethylene glycol and propylene glycol intoxication. Given the potentially high morbidity and mortality of these intoxications, it is important for the clinician to have a high degree of suspicion for these disorders in cases of high anion gap metabolic acidosis, acute renal failure, or unexplained neurologic disease so that treatment can be initiated early.
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Affiliation(s)
- Jeffrey A Kraut
- Medical and Research Services, UCLA Membrane Biology Laboratory, VHAGLA Healthcare System, Los Angeles, CA 90073, USA.
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31
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Green R. The management of severe toxic alcohol ingestions at a tertiary care center after the introduction of fomepizole. Am J Emerg Med 2007; 25:799-803. [PMID: 17870485 DOI: 10.1016/j.ajem.2007.01.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2006] [Revised: 01/15/2007] [Accepted: 01/15/2007] [Indexed: 10/22/2022] Open
Abstract
INTRODUCTION Ethylene glycol and methanol ingestions are relatively uncommon but potentially lethal poisonings. Recent trials have demonstrated that fomepizole effectively blocks alcohol dehydrogenase (ADH) in toxic alcohol overdoses, and may eliminate the need for emergent hemodialysis and intensive care unit admission. However, controversy remains in the role of fomepizole in clinical practice. The purpose of this study was to describe the presentation, management and clinical course of toxic alcohol ingestions at a tertiary care referral center after the introduction of fomepizole to hospital formulary. METHODS Data was collected on all patents treated for toxic alcohol ingestions for a 1-year period in a tertiary care referral center. Patients who received fomepizole or ethanol infusions, or who underwent hemodialysis were identified by ED, pharmacy, hemodialysis and ICU databases. The patients' medical records were reviewed, and data was recorded on a predetermined computerized data collection form. RESULTS Overall, twenty (20) toxic ingestions (14 methanol; 6 ethylene glycol) were identified over the one year period. Fomepizole was used for ADH blockade in 12/20 cases; ETOH infusions in 15/20 cases (combined ETOH and fomepizole use in 7/20). The majority of toxic alcohol exposures were admitted to an intensive care unit (19/20) and received emergent hemodialysis (19/20). All patients were discharged from hospital alive. CONCLUSIONS Patients with methanol and ethylene glycol ingestions who presented to our centers had significant toxicity and received both HD and ICU admission. Further research is required to determined if the method of ADH blockade affects the need for hemodialysis or ICU admission in toxic alcohol ingestions.
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Affiliation(s)
- Robert Green
- Department of Emergency Medicine, Division of Critical Care Medicine, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS B3H 2Y9.
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Velez LI, Gracia R, Neerman MF. Ethylene Glycol Poisoning: Current Diagnostic and Management Issues. J Emerg Nurs 2007; 33:342-5. [PMID: 17643796 DOI: 10.1016/j.jen.2006.12.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2006] [Revised: 12/13/2006] [Accepted: 12/21/2006] [Indexed: 11/19/2022]
Affiliation(s)
- Larissa I Velez
- Division of Emergency Medicine, Toxicology Section, The University of Texas Southwestern Medical Center, Dallas, Tex, USA
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Pizon AF, Brooks DE. Hyperosmolality: another indication for hemodialysis following acute ethylene glycol poisoning. Clin Toxicol (Phila) 2006; 44:181-3. [PMID: 16615677 DOI: 10.1080/15563650500514582] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
When given early, fomepizole has demonstrated an effective role in the treatment of ethylene glycol (EG) intoxication, often eliminating the need for hemodialysis (HD). Many indications for HD have been suggested for EG intoxication. We present a case of EG intoxication with the second highest reported EG concentration. Despite early treatment with fomepizole and without the development of acidosis or renal insufficiency, the patient required HD for hyperosmolality and subsequent electrolyte imbalances. Indications for HD following EG intoxication are discussed.
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Affiliation(s)
- Anthony F Pizon
- Department of Medical Toxicology, Good Samaritan Regional Medical Center, Phoenix, Arizona 85006, USA.
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Caravati EM, Erdman AR, Christianson G, Manoguerra AS, Booze LL, Woolf AD, Olson KR, Chyka PA, Scharman EJ, Wax PM, Keyes DC, Troutman WG. Ethylene glycol exposure: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila) 2005; 43:327-45. [PMID: 16235508 DOI: 10.1080/07313820500184971] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In 2002, poison centers in the US reported 5816 human exposures to ethylene glycol. A guideline that effectively determines the threshold dose for emergency department referral and need for pre-hospital decontamination could potentially avoid unnecessary emergency department visits, reduce health care costs, optimize patient outcome, and reduce life disruption for patients and caregivers. An evidence-based expert consensus process was used to create this guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the primary author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments. The objective of this guideline is to assist poison center personnel in the out-of-hospital triage and initial management of patients with a suspected exposure to ethylene glycol by (1) describing the process by which the exposure might be evaluated, (2) identifying the key decision elements in managing the case, (3) providing clear and practical recommendations that reflect the current state of knowledge, and (4) identifying needs for research. This guideline is based on an assessment of current scientific and clinical information. The panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and health professionals providing care, considering all of the circumstances involved. Recommendations are in chronological order of likely clinical use. The grade of recommendation is in parentheses. (1) A patient with exposure due to suspected self-harm, misuse, or potentially malicious administration should be referred to an emergency department immediately regardless of the dose reported (Grade D). (2) Patients with inhalation exposures will not develop systemic toxicity and can be managed out-of-hospital if asymptomatic (Grade B). Patients with clinically significant mucous membrane irritation should be referred for evaluation (Grade D). (3) Decontamination of dermal exposures should include routine cleansing with mild soap and water. Removal of contact lenses and immediate irrigation with room temperature tap water is recommended for ocular exposures. All patients with symptoms of eye injury should be referred for an ophthalmologic exam (Grade D). (4) Patients with symptoms of ethylene glycol poisoning should be referred immediately for evaluation regardless of the reported dose (Grade C). (5) The absence of symptoms shortly after ingestion does not exclude a potentially toxic dose and should not be used as a triage criterion (Grade C). (6) Adults who ingest a "swallow" (10-30 mL), children who ingest more than a witnessed taste or lick, or if the amount is unknown of most ethylene glycol products should be referred immediately for evaluation. The potential toxic volume of dilute solutions (e.g., concentration <20%) is larger and can be estimated by a formula in the text (Grade C). (7) A witnessed taste or lick only by a child, or an adult who unintentionally drinks and then expectorates the product without swallowing, does not need referral (Grade C). (8) Referral is not needed if it has been >24 hours since a potentially toxic unintentional exposure, the patient has been asymptomatic, and no alcohol was co-ingested (Grade D). (9) Gastrointestinal decontamination with ipecac syrup, gastric lavage or activated charcoal is not recommended. Transportation to an emergency department should not be delayed for any decontamination procedures (Grade D). (10) Patients meeting referral criteria should be evaluated at a hospital emergency department rather than a clinic. A facility that can quickly obtain an ethylene glycol serum concentration and has alcohol or fomepizole therapy available is preferred. This referral should be guided by local poison center procedures and community resources (Grade D). (11) The administration of alcohol, fomepizole, thiamine, or pyridoxine is not recommended in the out-of-hospital setting (Grade D).
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Affiliation(s)
- E Martin Caravati
- American Association of Poison Control Centers, Washington, DC 20016, USA
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Mégarbane B, Borron SW, Baud FJ. Current recommendations for treatment of severe toxic alcohol poisonings. Intensive Care Med 2004; 31:189-95. [PMID: 15627163 DOI: 10.1007/s00134-004-2521-0] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2004] [Accepted: 11/08/2004] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ethylene glycol (EG) and methanol are responsible for accidental, suicidal, and epidemic poisonings, resulting in death or permanent sequelae. Toxicity is due to the metabolic products of alcohol dehydrogenase (ADH) and aldehyde dehydrogenase. Conventional management of these intoxications consists of ethanol and hemodialysis. Fomepizole, a potent ADH inhibitor, has largely replaced antidotal ethanol use in France and two recent prospective U.S. trials definitively established its efficacy. Fomepizole appears safer than ethanol and while no comparative study of efficacy exists, fomepizole is recommended as the first-line antidote. FOCUS Fomepizole, administered early in EG intoxication, prevents renal injury. In the absence of renal failure, EG clearance is rapid, avoiding the need for prolonged fomepizole administration. The long elimination half-life of methanol poisonings, with absent hemodialysis, necessitates prolonged administration of fomepizole. In the U.S. trials, patients were dialyzed when plasma EG or methanol concentrations were >/=0.5 g/l. However, EG-poisoned patients treated with fomepizole prior to the onset of significant acidosis may not require hemodialysis. Indeed, fomepizole may also obviate the need for hemodialysis in selected methanol-poisoned patients, in the absence of neurological and ocular impairment or severe acidosis. When dialysis is indicated, 1 mg.kg.h continuous infusion of fomepizole should be provided to compensate for its elimination. CONCLUSIONS Fomepizole is an effective and safe first-line recommended antidote for EG and methanol intoxication. In selected patients, fomepizole may obviate the need for hemodialysis.
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Affiliation(s)
- Bruno Mégarbane
- Réanimation Médicale et Toxicologique, Hôpital Lariboisière, 2 rue Ambroise Paré, 5010 Paris, France.
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Caravati EM, Heileson HL, Jones M. Treatment of severe pediatric ethylene glycol intoxication without hemodialysis. ACTA ACUST UNITED AC 2004; 42:255-9. [PMID: 15362591 DOI: 10.1081/clt-120037424] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND There is limited experience treating severe ethylene glycol poisoning in children without hemodialysis. The objective of this study was to describe the clinical course and outcome of severe pediatric ethylene glycol poisoning treated without hemodialysis. METHODS Patient records were identified retrospectively by hospital discharge diagnosis (ICD-9 code) of ethylene glycol poisoning from 1999 through 2002 at a pediatric medial center. Patients with initial serum ethylene glycol concentrations less than 50 mg/dL or those who received hemodialysis were excluded. RESULTS Six patients with an age range of 22 months to 14 years were admitted for treatment of ethylene glycol poisoning over a four-year period. Initial serum ethylene glycol concentrations ranged from 62 to 304 mg/dL (mean 174.0 mg/dL). The lowest-measured individual serum bicarbonates ranged from 4 to 17 mEq/L. All patients were initially admitted to intensive care. One patient received ethanol only, two patients received fomepizole only, and three patients received a loading dose of ethanol and then were converted to fomepizole therapy. None of the patients received hemodialysis. Treatment was continued until the serum ethylene glycol was less than 10 mg/dL. Metabolic acidosis resolved with intravenous fluid and supplemental bicarbonate within 24h. All patients had a normal creatinine upon presentation and at discharge. The mean length of stay in intensive care was 21h and on the ward was 33.7h. One episode of hypoglycemia occurred in a 22-month-old. All patients recovered without evidence of renal insufficiency or other major complications at discharge. CONCLUSION Six pediatric patients with severe ethylene glycol intoxication and normal renal function were successfully treated without hemodialysis.
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Affiliation(s)
- E Martin Caravati
- Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.
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Hess R, Bartels MJ, Pottenger LH. Ethylene glycol: an estimate of tolerable levels of exposure based on a review of animal and human data. Arch Toxicol 2004; 78:671-80. [PMID: 15372138 DOI: 10.1007/s00204-004-0594-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2004] [Accepted: 06/30/2004] [Indexed: 10/26/2022]
Abstract
Upon ingestion ethylene glycol (EG, monoethylene glycol) is rapidly absorbed from the gastrointestinal tract, and depending on the severity of exposure signs of toxicity may progress through three stages. Neurological effects characterize the first step consisting of central nervous depression (intoxication, lethargy, seizures, and coma). The second stage, usually 12-24 h after ingestion, is characterized by metabolic acidosis due to the accumulation of acidic metabolites of EG, primarily glycolic acid (GA), contributing to the ensuing osmolal and anion gaps. Stage 3, generally 24-72 h after ingestion, is determined mainly by oxalic acid excretion, nephropathy, and eventual renal failure. Because the toxicity of EG is mediated principally through its metabolites, adequate analytical methods are essential to provide the information necessary for diagnosis and therapeutic management. The severe metabolic acidosis and multiple organ failure caused by ingestion of high doses of EG is a medical emergency that usually requires immediate measures to support respiration, correct the electrolyte imbalance, and initiate hemodialysis. Since metabolic acidosis is not specific to EG, whenever EG intoxication is suspected, every effort should be made to determine EG as well as its major metabolite GA in plasma to confirm the diagnosis and to institute special treatment without delay. A number of specific and sensitive analytical methods (GC, GC-MS, or HPLC) are available for this purpose. Due to the rapid metabolism of EG, the plasma concentration of GA may be higher than that of EG already upon admission. As toxicity is largely a consequence of metabolism of EG to GA and oxalic acid, the simultaneous quantification of EG and GA is important. Formation of calcium oxalate monohydrate in the urine may be a useful indicator of developing oxalate nephrosis although urine crystals can result without renal injury. The pathways involved in the metabolism of EG are qualitatively similar in humans and laboratory animals, although quantitative differences have been reported. Comparison between species is difficult, however, because the information on humans is derived mainly from acute poisoning cases whereas the effects of repeated exposures have been investigated in animal experiments. Based on published data the minimum human lethal dose of EG has been estimated at approx. 100 ml for a 70-kg adult or 1.6 g/kg body weight (calculation of dose in ml/kg to mg/kg based in EG density=1.11 g/l). However, human data from case reports are generally insufficient for the determination of a clear dose-response relationship and quantification of threshold doses for systemic toxicity, in particular renal effects, is limited. As toxicity is largely a consequence of metabolism of EG to GA, it is important to note that no signs of renal injury have developed at initial plasma glycolate concentrations of up to 10.1 mM (76.7 mg/dl). Plasma EG levels of 3.2 mM (20 mg/dl) are considered the threshold of toxicity for systemic exposure, if therapeutic strategy is based on the EG concentration alone.
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Affiliation(s)
- Robert Hess
- Institut für Pathologie, University of Basel, 4056, Basel, Switzerland.
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Vasavada N, Williams C, Hellman RN. Ethylene Glycol Intoxication: Case Report and Pharmacokinetic Perspectives. Pharmacotherapy 2003; 23:1652-8. [PMID: 14695045 DOI: 10.1592/phco.23.15.1652.31968] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A 42-year-old man was brought to the emergency department with ethylene glycol intoxication. He was hemodynamically stable and had normal renal function. His serum ethylene glycol concentration was 284 mg/dl approximately 1 hour after ethylene glycol consumption. The patient was treated with fomepizole and forced diuresis. Elimination of ethylene glycol in this patient followed first-order pharmacokinetics. Elimination pharmacokinetics in this patient were compared with that in a patient who received fomepizole and hemodialysis. Fomepizole monotherapy can be given in patients without renal failure or metabolic acidosis even with serum ethylene glycol concentrations greater than 50 mg/dl. However, cost estimates based on this case suggest that if the patient is treated adequately with a single hemodialysis session and 24-hour hospitalization, then fomepizole monotherapy may be more expensive than the combination regimen of fomepizole and hemodialysis.
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Affiliation(s)
- Nina Vasavada
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.
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Woo MY, Greenway DC, Nadler SP, Cardinal P. Artifactual elevation of lactate in ethylene glycol poisoning. J Emerg Med 2003; 25:289-93. [PMID: 14585457 DOI: 10.1016/s0736-4679(03)00203-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The diagnosis of ethylene glycol poisoning is based on nonspecific clinical symptoms and signs and indirect and direct laboratory measurement. Few institutions have timely access to direct measurement of ethylene glycol. As a result, diagnosis sometimes can be delayed and therapy initiated late. We present two cases of ethylene glycol poisoning. These cases demonstrate the need to recognize the false elevation of lactate in some chemistry analyzers due to the interference of glycolic acid, a metabolite of ethylene glycol. Using the "lactate gap" in comparing the measurement of lactate with two commonly used chemical analyzers aids in differentiating ethylene glycol poisoning from lactic acidosis.
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Affiliation(s)
- Michael Y Woo
- Department of Emergency Medicine, The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada
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Mycyk MB, Aks SE. A visual schematic for clarifying the temporal relationship between the anion and osmol gaps in toxic alcohol poisoning. Am J Emerg Med 2003; 21:333-5. [PMID: 12898493 DOI: 10.1016/s0735-6757(03)00079-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Delayed treatment of ethylene glycol or methanol poisoning can result in life-threatening complications, but obtaining quantitative levels is delayed by several hours in most hospitals. Calculating the anion gap and the osmol gap are recommended to hasten identification and treatment in cases of suspected toxic alcohol poisoning. However, relying on the anion and osmol gap calculations without understanding the temporal relationship between these 2 gaps can lead to delayed identification and increased morbidity in cases of toxic alcohol poisoning. Our "Mountain" schematic illustrates the presence of an elevated osmol gap found early in toxic alcohol poisoning and the presence of an elevated anion gap found later in the course of poisoning. Using the "Mountain" diagram as a clarification of the temporal relationship between the anion and the osmol gap can improve the diagnostic use of these screening assays.
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Affiliation(s)
- Mark B Mycyk
- Division of Emergency Medicine, Northwestern University Medical School, 676 St. Clair, Suite 2125, Chicago, IL 60611, USA.
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Roy M, Bailey B, Chalut D, Senécal PE, Gaudreault P. What are the adverse effects of ethanol used as an antidote in the treatment of suspected methanol poisoning in children? JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 2003; 41:155-61. [PMID: 12733853 DOI: 10.1081/clt-120019131] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Ethanol used as an antidote is said to have various adverse effects, particularly in children. The rate of these adverse effects is not known. METHODS Twenty-one-year retrospective chart review (1980-2000) from suspected methanol poisoning patients treated with ethanol in two large pediatric tertiary care centers. RESULTS A total of 60 children (median age of 24 months) received ethanol for suspected methanol poisoning: 39 orally and 21 intravenously. Median initial methanol level was 4.16 mmol/L (13.3 mg/dL) (range 0 to 87.5 mmol/L or 0 to 280 mg/dL). Median duration of ethanol treatment was 16 hours (range 1.5 to 72 hours). None [0% (95% CI 0-5%)] of the 60 patients developed symptomatic hypoglycemia. Of the 50 patients that had a glucose level measured, none [(0% [95% CI 0-6%)] had a serum glucose concentration < 2.78 mmol/L (< 50 mg/dL). Eight patients [16% (95% CI 8-30%)] had at least one serum glucose concentration between 2.78-3.61 mmol/L (50-65 mg/dL), but none of those had symptoms compatible with hypoglycemia. A total of 42 patients [84% (95% CI 70-92%)] had all their serum glucose concentrations > 3.61mmol/L (> 65 mg/dL). There was no identifiable difference in the glucose intake between the serum glucose concentration groups. Six out of the 60 patients [10% (95% CI 4-21%)] were described as more drowsy after ethanol but none was comatose or needed intubation. No child showed signs of hypothermia [0/40 (95% CI 0-8%)] (rectal temperature < 35 degrees C), hepatotoxicity (0/12) (AST or ALT > 100 U/L) or even thrombophlebitis (0/21). None of the 22 patients with toxic levels of methanol (> or = 26.2 mmol/L- > or = 20 mg/dL) died or had ethanol-induced morbidity despite wide variation in ethanol levels. CONCLUSION The rate of clinically important adverse effects related to ethanol used as an antidote to treat methanol poisoning in children was either absent or low in a tertiary care pediatric hospital setting. There was no morbidity or mortality associated with ethanol when it was used despite wide variation in ethanol levels. These results suggest that with appropriate monitoring and intravenous glucose intake in a controlled environment such as a pediatric intensive care unit, ethanol therapy does not carry as many risks as currently believed.
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Affiliation(s)
- Michel Roy
- Division of Emergency Medicine, Department of Pediatrics, Hôpital Ste-Justine, Université de Montréal, Montréal, Quebec, Canada
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Affiliation(s)
- Jason Chu
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts-New England Medical Center, Boston, Massachusetts 02111, USA
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Abstract
OBJECTIVE To assess the use of fomepizole in the treatment of ethylene glycol poisoning in the absence of hemodialysis. DATA SOURCES A MEDLINE search (1966-May 2001) of English-language literature pertaining to the use of fomepizole in ethylene glycol poisoning was performed. Key search terms included fomepizole, ethylene glycol poisoning, and hemodialysis. References cited in those articles were also evaluated. DATA SYNTHESIS Results from a number of case reports and a prospective trial suggest that fomepizole is a safe and effective antidote in the treatment of ethylene glycol poisoning. CONCLUSIONS Case reports and 1 prospective trial have shown that, in the absence of both renal dysfunction and significant metabolic acidosis, the use of fomepizole should obviate the need for hemodialysis. However, the decision to add hemodialysis in the treatment of ethylene glycol poisoning based on plasma ethylene glycol concentrations is still debatable. A randomized, controlled trial is needed to determine the exact criteria for adding hemodialysis.
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Affiliation(s)
- Marisa Battistella
- University Health Network - Pharmacy Department ENG 260, 200 Elizabeth St., Toronto, Ontario M5G 2C4, Canada.
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Abstract
Intoxications frequently perturb acid-base and electrolyte status, intravascular volume, and renal function. In selected cases, extracorporeal techniques effectively restore homeostasis and augment intoxicant removal. The use of 4-methylpyrazole, an inhibitor of alcohol dehydrogenase, is a new and effective treatment for patients exposed to toxic alcohols. In this section, practical approaches to commonly encountered intoxicants and the use of extracorporeal techniques are critically reviewed.
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Affiliation(s)
- Steven C Borkan
- Department of Medicine, Boston University, Boston Medical Center, Renal Section, Boston, MA, USA.
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Druteika DP, Zed PJ, Ensom MHH. Role of fomepizole in the management of ethylene glycol toxicity. Pharmacotherapy 2002; 22:365-72. [PMID: 11899949 DOI: 10.1592/phco.22.5.365.33187] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To systematically review English-language articles on fomepizole administration in patients with ethylene glycol poisoning. DATA SOURCES MEDLINE, EMBASE, Current Contents, and PubMed. Search terms were fomepizole, 4-methylpyrazole, and ethylene glycol. The search was supplemented with a bibliographic review of all relevant articles. STUDY SELECTION All published reports of fomepizole administration in patients with ethylene glycol poisoning were reviewed, irrespective of study design. We identified one clinical trial and subsequent pharmacokinetic study, one case series, and 13 case reports. RESULTS Fomepizole has been investigated in 70 patients in open, unblinded studies. Most patients received an intravenous loading dose, with subsequent variable maintenance doses every 12 hours until plasma ethylene glycol levels became undetectable. Additional hemodialysis treatment generally was administered when patients had renal insufficiency or ethylene glycol levels above 50 mg/dl. Many patients had detectable ethanol levels either because of coadministration or as a result of adjunctive treatment at a referring center. Poorer patient outcomes, such as death and renal insufficiency, were associated with later clinical presentation time after ingestion. At therapeutic fomepizole levels (> 8.6 mg/ml), the half-life of ethylene glycol was prolonged to over 19 hours. Fomepizole appeared to be well tolerated by most patients. CONCLUSION Fomepizole is an effective alcohol dehydrogenase inhibitor that decreases production of ethylene glycol metabolites. Reduced mortality and morbidity are undetermined because of the small number of patients evaluated to date. Data on comparative efficacy of fomepizole versus ethanol and data on administration of fomepizole in children are limited.
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Affiliation(s)
- Deon P Druteika
- Division of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
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Affiliation(s)
- William A Watson
- South Texas Poison Center; Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
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