A case of accidental ingestion of a salbutamol sulfate inhalant, Venetlin®

Pediatricians examine increasing numbers of children with bronchial asthma every year. In Japan, medical institutions can provide standardized therapies according to the Japanese Pediatric Guideline for the Treatment and Management of Asthma 2005. Inhalation therapy is highly beneficial, and a substantial proportion of patients choose to purchase inhalators and practice inhalation therapy at home. Recently, we experienced a case of accidental ingestion of a salbutamol sulfate inhalant by a non-asthmatic child, which reminded us anew of the importance of managing the medicines for asthma. We also recognized the need to educate patients and their families on the knowledge of these medicines. In this report, we analyze the case and discuss measures that pediatricians can implement to avoid accidental inhalant ingestion by children.

Salbutamol intoxication: is salbutamol a drug-inducing fever? A case report and treatment strategy

A four-year-old female with salbutamol intoxication was referred to our paediatric emergency medicine unit, due to agitation, tremulousness, sinus tachycardia, mild hypokalaemia and hyperglycaemia. On admission the child was agitated and had a noticeable tremor, an axillary temperature of 38 degrees C and a pulse rate of 185 beats/min. She had no identifiable focus of infection on physical examination to explain her fever. Gastric lavage, activated charcoal, intravenous hydration and electrocardiogram (ECG) monitoring were performed. Her plasma potassium level, blood sugar and QT interval were closely monitored during her hospital stay. Her fever, tachycardia and serum potassium and glucose levels returned to normal and she was discharged in good condition 24 h after admission. The difference of this case from prior cases of salbutamol intoxication was the observation of fever in the absence of evidence of infection. Since the cause of fever was not a reaction to the medication used in the treatment or related to environmental factors, it is assumed that salbutamol is a fever-inducing drug.

[Salbutamol intoxication]

A 20-year-old asthmatic woman who ingested 300 mg of salbutamol (Albuterol) and 30 g of paracetamol is presented. She had sinus tachycardia up to 160/min, hypotension (80/50 mmHg), tremor, hypokalemia (2.1 mEq/l) and hyperglycemia (12.1 mEq/l). Treatment was by gastric lavage, fluids, potassium and N-acetylcysteine. Symptoms resolved in 24 hours.

Unintentional albuterol ingestion in children

This study was designed to determine the threshold dose for toxicity, the potential for serious medical complications, and the medical care required after unintentional albuterol ingestion in children. This study was prospective and descriptive. Data were obtained on pediatric albuterol ingestions evaluated emergently as reported to three regional poison control centers. Data elements included dose ingested, physical findings, medical treatment, and outcome. During 18 months, 78 patients who ingested albuterol and who received urgent medical evaluation were identified. Mean age was 2.8 years. The amount ingested ranged from 0.2 to 8.8 mg/kg. The most commonly reported signs of toxicity were tachycardia (57%, 44/78), widened pulse pressure (50%, 27/54), hyperglycemia (50%, 12/24), agitation (45%, 35/78), low serum carbon dioxide (42%, 10/24), vomiting (26%, 20/78), and hypokalemia (26%, 9/35). We found a threshold dose o 1 mg/kg for three or more signs of toxicity (P < 0.01). No patient required any specific treatment for toxicity. Seventy-two percent of patients were discharged from medical care within six hours of ingestion. Albuterol overdose in children causes a variety of cardiovascular, neuromuscular, and metabolic effects that are usually benign. The threshold dose for the development of three or more signs of toxicity is 1 mg/kg or three to 10 times the recommended daily dose. Toxicity is short-lived and does not require specific therapy or hospital admission in most cases.

Occupational asthma in salbutamol process workers

Occupational asthma after exposure to salbutamol in the pharmaceutical industry has not been previously reported. The occurrence of occupational asthma is described in two pharmaceutical process workers who were likely to have inhaled doses appreciably in excess of the therapeutic dose range. The findings do not lead to an unequivocal conclusion on the mechanism of the asthma but it was probably a pharmacological consequence of high exposure.

Hypokalemia after pediatric albuterol overdose: a case series

Sympathomimetic use results in a triad of hypokalemia, hyperglycemia, and elevated white blood cell count. Transient hypokalemia results from activation of the Na+/K+ pump and transport of potassium intracellularly. Increased serum glucose and insulin may also contribute to the intracellular shift of potassium after sympathomimetic use. Four cases of accidental pediatric albuterol ingestion with significant hypokalemia are reported. Four children between 1 and 6 years of age presented to the emergency department within 5 hours of ingesting 3.0, 1.1, 3.7, and 1.7 mg/kg albuterol, respectively. All four presented alert and oriented in no apparent distress. The most common findings were vomiting, sinus tachycardia, and hypokalemia (2.3, 2.5, 2.8, and 2.5 mmol/L, respectively). Each child received a single dose of activated charcoal and intravenous potassium replacement. All patients recovered uneventfully within 12 to 24 hours with supportive care only. These cases demonstrated that significant depressions in serum potassium can occur after pediatric albuterol overdose. Although transient, the dose-response relationship and duration of effect is unknown. Although significant hypokalemia can occur after ingestion of oral sympathomimetics, replacement should be managed on an individual basis until further studies are completed.

A two-year retrospective study of accidental pediatric albuterol ingestions

A two-year retrospective review of accidental albuterol ingestions in children less than 12 years old was performed to assess overdose toxicity and to investigate a dose-effect relationship. One hundred twelve exposures were located. Seventeen cases were excluded owing to coingestants, leaving 95 cases for evaluation. Twenty-nine children (30%) remained at home without intervention or telephone followup because of an ingestion of less than 0.6 mg/kg. Twenty-eight patients (30%) were followed at home by telephone (12 of whom received ipecac). Dosages ranged from 1 to 27 mg, with dose/weight ratios of 0.1 to 1.9 mg/kg. Two children experienced transient mild symptoms (irritability, brief nausea, and vomiting). The remaining 26 children were asymptomatic. Thirty eight cases (40%) were treated in an emergency department. Ingestions ranged from 2 to 96 mg, with dose/weight ratios of 0.3 to 6.3 mg/kg. Ages ranged from one to 11 years. Transient restlessness or irritability was observed in 16 patients, tachycardia in 15, tremors in six, and a widened pulse pressure in one. No serious events occurred in this series, and no patient required treatment beyond gastrointestinal decontamination. For ingestions of 0.6 mg/kg or less, treatment at home with observation may be sufficient. For larger ingestions, eg, greater than 0.6 mg/kg, consideration should be given to direct medical evaluation and gastrointestinal decontamination.

Propranolol treatment of albuterol poisoning in two asthmatic patients

The cases of two asthmatic adolescents who overdosed on albuterol are presented. Both patients were tremulous, tachycardic, and hypokalemic. Both were treated successfully with IV propranolol. Neither patient developed bronchospasm. The toxicity of albuterol overdoses and its treatment are discussed.

Simultaneous determination of salbutamol and terbutaline at overdose levels in human plasma by high performance liquid chromatography with electrochemical detection

A multidimensional column chromatographic method involving electrochemical detection using a carbon fibre microelectrode flow cell was optimized and successfully applied to the simultaneous determination of salbutamol and terbutaline in plasma at overdose levels. This method performs, in a single step, an efficient extraction and clean-up of salbutamol and terbutaline from human plasma. The calibration graphs over three days were linear over the calibration range 20-100 ng/mL plasma with a limit of detection of 1 ng and 0.8 ng/mL plasma for salbutamol and terbutaline, respectively. The intra- and inter-assay coefficients of variation were less than 8% and the recoveries ranged from 94 to 96%. The accuracy of the assay, which was defined as the percentage difference between the mean concentration found and the theoretical concentration, was 7% or better. The proposed method combines the advantages of being simple, reproducible and selective in the presence of other sympathomimetic and commonly ingested drugs and is suitable for routine analyses to obtain valuable information about the clinical effects and treatment of overdose with these drugs. The whole procedure takes ca. 10 min and compares favourably with detection at a conventional glassy carbon electrode.

Albuterol overdose: a case report and differential diagnosis

The increase in the use of selective beta 2 agonists as first-choice agents in the therapy of asthma has resulted in a concomitant increase in overdoses and other therapeutic misadventures. This case describes a 22-month-old child who ingested a large overdose of albuterol, resulting in an acute syndrome consisting of agitation, tremulousness, marked hyperglycemia of > 320 mg/dl (17.8 mmol/L), ketonuria, and hypokalemia. Such toxicity has generally been reported only in diabetics or pregnant patients. These findings and a brief review of the pharmacology and toxicology of beta 2 agonists are detailed, with special emphasis on the differential diagnosis of overdoses characterized by hyperglycemia, hypokalemia, agitation, and tremulousness. A system of ordering the relative toxicity of these (and other) drugs is proffered using the exposure-case fatality rate (ECFR) as a crude measure of clinical toxicity (while delineating its shortcomings). Applying the ECFR (using American Association of Poison Control Centers' data base) to beta 2 agonist overdoses indicates that the resulting clinical syndrome, while troublesome, generally results in a benign outcome.

Laboratory and clinical features of self-poisoning with salbutamol and terbutaline

A method has been developed for the simultaneous determination of the sympathomimetic drugs salbutamol and terbutaline in the plasma of poisoned patients, using ion-pair high-performance liquid chromatography with amperometric detection. Plasma concentrations of the drugs, measured in 8 poisoned patients, were well above the therapeutic range. The clinical and metabolic effects of overdose with these drugs were considerably less severe than those seen in patients with plasma theophylline concentrations elevated to the same degree.

Rhabdomyolysis and acute renal failure in chronic alcoholics with myopathy, unrelated to acute alcohol ingestion

Rhabdomyolysis leading to acute renal failure necessitating hemodialysis is described in three chronic alcoholics. In each case an acute medical or surgical event, but not alcoholic intoxication, was implicated. Renal biopsies demonstrated acute tubular necrosis with intraluminal deposits consisting of Tamm-Horsfall protein and myoglobin. After recovery all three patients were demonstrated to have proximal muscle weakness with similar electromyographic abnormalities but nerve-conduction was impaired in only two. Muscle biopsies showed mixed, but predominantly type II fiber atrophy and reduced muscle phosphorylase levels. In the one patient tested the lactate response to forearm muscle ischemia was abnormal. It is postulated that chronic alcoholics may be predisposed to rhabdomyolysis and acute renal failure following acute medical and surgical stress as well as acute alcohol abuse. The muscle damage in these patients may be due to impaired intra cellular glycogen metabolism.

Hypokalaemia due to salbutamol overdosage

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