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McMartin K, Jacobsen D, Hovda KE. Antidotes for poisoning by alcohols that form toxic metabolites. Br J Clin Pharmacol 2025; 91:662-671. [PMID: 39234820 DOI: 10.1111/bcp.16232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Revised: 08/08/2024] [Accepted: 08/13/2024] [Indexed: 09/06/2024] Open
Abstract
The alcohols methanol, ethylene glycol and diethylene glycol share many characteristics. The most important is that the compounds themselves are relatively nontoxic but are metabolized, initially by alcohol dehydrogenase, to various toxic intermediates. These compounds are readily available worldwide in commercial products as well as in homemade alcoholic beverages, both of which lead to most of the poisonings, from either unintentional or intentional ingestion. Although relatively infrequent, toxic alcohol poisonings do unfortunately occur in outbreaks and can result in severe morbidity and mortality. These poisonings have traditionally been treated with ethanol since it competes for the active site of alcohol dehydrogenase and decreases the formation of toxic metabolites. Although ethanol can be an effective antidote, there are substantial practical problems with its use. Therefore fomepizole, a potent competitive inhibitor of alcohol dehydrogenase, was developed for a hopefully better treatment for metabolically toxic alcohol poisonings. Fomepizole has few side effects and is easy to use in practice and it may obviate the need for haemodialysis in some, but not all, patients. Hence, fomepizole has largely replaced ethanol as the toxic alcohol antidote in many countries. Nevertheless, ethanol remains an important alternative because access to fomepizole can be limited, the cost may appear excessive or the physician may prefer ethanol due to experience.
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Affiliation(s)
- Kenneth McMartin
- Department of Pharmacology, Toxicology & Neuroscience, Louisiana State University Health Sciences Center-Shreveport, Shreveport, Louisiana, USA
| | - Dag Jacobsen
- Department of Acute Medicine, Division of Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- The National Poison Information Centre, National Institute of Health, Oslo, Norway
| | - Knut Erik Hovda
- Department of Acute Medicine, Division of Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- The National Poison Information Centre, National Institute of Health, Oslo, Norway
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2
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Cole JB, Kouri AM, King JD, Olives TD, Scott NL, Oakland CL. Comparison of children receiving extracorporeal treatments for poisoning at United States centers with and without a pediatric nephrologist. Clin Toxicol (Phila) 2025:1-4. [PMID: 39911112 DOI: 10.1080/15563650.2025.2456109] [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: 12/03/2024] [Revised: 01/05/2025] [Accepted: 01/11/2025] [Indexed: 02/07/2025]
Abstract
BACKGROUND Pediatric nephrologists are rare in the United States; many children with poisoning needing extracorporeal treatments may not have timely access to care. This study compared outcomes in children receiving extracorporeal treatments for poisoning at centers with and without a pediatric nephrologist. METHODS This was a retrospective cohort study of all patients aged ≤17 years reported to an American poison center covering three upper midwestern states during 2000-2024. RESULTS We identified 72 patients: 54 received extracorporeal treatments at a hospital with pediatric nephrologists, and 18 patients aged 14-17 years (minimum weight, 35 kg) received extracorporeal treatments at hospitals staffed solely by adult nephrologists. The most common responsible poisons were toxic alcohols (10/18, 55%) and salicylates (4/18, 22%). Children receiving extracorporeal treatments from adult nephrologists more commonly (P <0.001) received intermittent hemodialysis (18/18, 100%) compared to pediatric nephrologists (31/54, 57%). Conversely, children treated by pediatric nephrologists more commonly (P <0.05) received continuous kidney replacement therapy (28/54, 52%) compared to adult nephrologists (0/18). We found no difference (P = 0.1) in mortality between the children treated by pediatric nephrologists (9/54, 17%) compared to those treated by adult nephrologists (0/18). DISCUSSION Teenage children commonly received hemodialysis from adult nephrologists for poisoning and had similar outcomes to those treated by pediatric nephrologists. CONCLUSIONS These data suggest adult nephrologists can successfully perform extracorporeal treatments for poisoning in teenage children.
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Affiliation(s)
- Jon B Cole
- Minnesota Regional Poison Center, Minneapolis, MN, USA
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Anne M Kouri
- Department of Pediatrics, Division of Nephrology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Joshua D King
- Department of Medicine, Division of Nephrology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Travis D Olives
- Minnesota Regional Poison Center, Minneapolis, MN, USA
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Nathaniel L Scott
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
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Marino R, Sidlak A, Scoccimarro A, Flickinger K, Pizon A. Ethanol and the Limitations of the Osmol Gap. Ann Emerg Med 2025:S0196-0644(24)01303-9. [PMID: 39864007 DOI: 10.1016/j.annemergmed.2024.12.022] [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: 08/01/2024] [Revised: 12/15/2024] [Accepted: 12/20/2024] [Indexed: 01/27/2025]
Abstract
STUDY OBJECTIVE The osmol gap can help detect and manage those with toxic alcohol exposure, and it is altered by all alcohols including ethanol. The optimal correction for ethanol that would allow accurate detection of an alternative alcohol is unclear. METHODS We conducted a prospective cohort study to assess baseline variations in osmol gap, and then to assess the validity of 2 commonly used coefficients (correction factors) for ethanol. Twenty-two healthy volunteers received a body mass-based dose of oral ethanol that targeted an estimated peak blood ethanol concentration >200 mg/dL. We measured laboratory values prior to ethanol administration and at 2, 4, and 6 hours after ingestion. We considered an osmol gap >10 or <-10 abnormal and an osmol gap of >10 after correction as a false positive. RESULTS Four of the 22 subjects (18%) had an osmol gap >10 at baseline. Following ethanol ingestion and across 66 timepoints (N=66), there were 14 abnormal osmol gap tests (21%) when corrected with an ethanol coefficient of 4.6, and 31 (47%) abnormal tests when corrected using the Purssell ethanol coefficient of 3.7. The mean difference between the baseline and the post-ethanol corrected osmol gap was lower with the molecular weight correction factor of 4.6 compared with the Purssell correction factor of 3.7 (0.2 versus 11.0; P<.001). CONCLUSION Our data show that the osmol gap is occasionally elevated absent ingestion of any alcohol, and using an ethanol correction coefficient of 4.6 produced a better clinical osmol gap input albeit still with some variation.
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Affiliation(s)
- Ryan Marino
- Division of Toxicology and Addiction Medicine, University Hospitals, Cleveland, OH; Division of Medical Toxicology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Alexander Sidlak
- Division of Medical Toxicology, University of Pittsburgh School of Medicine, Pittsburgh, PA; Emergency Department, Inova Fairfax Medical Campus, Falls Church, VA.
| | - Anthony Scoccimarro
- Division of Medical Toxicology, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Emergency Medicine, Jacobi Medical Center, Bronx, NY; and
| | - Kathryn Flickinger
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Anthony Pizon
- Division of Medical Toxicology, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Sobhi N, Abdollahi M, Arman A, Mahmoodpoor A, Jafarizadeh A. Methanol Induced Optic Neuropathy: Molecular Mysteries, Public Health Perspective, Clinical Insights and Treatment Strategies. Semin Ophthalmol 2025; 40:18-29. [PMID: 38804878 DOI: 10.1080/08820538.2024.2358310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 05/14/2024] [Accepted: 05/17/2024] [Indexed: 05/29/2024]
Abstract
Methanol-induced optic neuropathy (MION) represents a critical public health issue, particularly prevalent in lower socioeconomic populations and regions with restricted alcohol access. MION, characterized by irreversible visual impairment, arises from the toxic metabolization of methanol into formaldehyde and formic acid, leading to mitochondrial oxidative phosphorylation inhibition, oxidative stress, and subsequent neurotoxicity. The pathogenesis involves axonal and glial cell degeneration within the optic nerve and potential retinal damage. Despite advancements in therapeutic interventions, a significant proportion of affected individuals endure persistent visual sequelae. The study comprehensively investigates the pathophysiology of MION, encompassing the absorption and metabolism of methanol, subsequent systemic effects, and ocular impacts. Histopathological changes, including alterations in retinal layers and proteins, Müller cell dysfunction, and visual symptoms, are meticulously examined to provide insights into the disease mechanism. Furthermore, preventive measures and public health perspectives are discussed to highlight the importance of awareness and intervention strategies. Therapeutic approaches, such as decontamination procedures, ethanol and fomepizole administration, hemodialysis, intravenous fluids, electrolyte balance management, nutritional therapy, corticosteroid therapy, and erythropoietin (EPO) treatment, are evaluated for their efficacy in managing MION. This comprehensive review underscores the need for increased awareness, improved diagnostic strategies, and more effective treatments to mitigate the impact of MION on global health.
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Affiliation(s)
- Navid Sobhi
- Nikookari Eye Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mirsaeed Abdollahi
- Nikookari Eye Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ali Arman
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ata Mahmoodpoor
- Research Center for Integrative Medicine in Aging, Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Anesthesiology and Intensive care, Faculty of Medicine, Tabriz University of Medical Science, Tabriz, Iran
| | - Ali Jafarizadeh
- Nikookari Eye Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Hayman CV, Pires KD, Cohen ET, Biary R, Su MK, Hoffman RS. Elevated osmol gaps in patients with alcoholic ketoacidosis. Clin Toxicol (Phila) 2024; 62:609-614. [PMID: 39222325 DOI: 10.1080/15563650.2024.2397053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Revised: 08/06/2024] [Accepted: 08/21/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION The use of the osmol gap as a surrogate marker of toxic alcohol poisoning is common. Unfortunately, many patients with alcoholic ketoacidosis have elevated osmol gaps and are misdiagnosed with toxic alcohol poisoning. We aimed to characterize the range of osmol gaps in patients with alcoholic ketoacidosis. METHODS This was a retrospective poison center study. Data from 24 years were reviewed using the following case definition of alcoholic ketoacidosis: (1) documented alcohol use disorder; (2) presence of urine or serum ketones or an elevated blood beta-hydroxybutyrate concentration; (3) an anion gap ≥14 mmol/L. Potential cases of alcoholic ketoacidosis that failed to fulfill all three criteria were adjudicated by three toxicologists. Exclusion criteria included (1) detectable toxic alcohol concentration, (2) hemodialysis and/or multiple doses of fomepizole, (3) no osmol gap documented, (4) other diagnoses that lead to a metabolic acidosis. Demographics, pH, anion gap, lactate concentration, and osmol gap were extracted. RESULTS Of 1,493 patients screened, 55 met criteria for alcoholic ketoacidosis. Sixty-four percent were male, and their median age was 52 years. The median osmol gap was 27 [IQR 18-36]. The largest anion gap was 57 mmol/L, and the lowest pH was 6.8. Forty-five (82%) of the patients with alcoholic ketoacidosis had osmol gaps >10; 38 (69%) had osmol gaps >20; 24 (44%) had osmol gaps >30; 11 (20%) had osmol gaps > 40. DISCUSSION The large range of osmol gaps in patients with alcoholic ketoacidosis often reaches values associated with toxic alcohol poisoning. The study is limited by the potential for transcribing errors and the inability to identify the cause of the osmol gap. CONCLUSIONS In this retrospective study, patients with alcoholic ketoacidosis had a median osmol gap of 27. Given that alcoholic ketoacidosis is easily and inexpensively treated, proper identification may prevent costly and invasive treatment directed at toxic alcohol poisoning.
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Affiliation(s)
- Chelsea V Hayman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Kyle D Pires
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Emily T Cohen
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Rana Biary
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Mark K Su
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
- New York City Poison Center, New York, NY, USA
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
- New York City Poison Center, New York, NY, USA
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Siebeneck M, Abu-Tair M. [Emergencies in nephrology]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:798-807. [PMID: 39012350 DOI: 10.1007/s00108-024-01739-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/04/2024] [Indexed: 07/17/2024]
Abstract
Emergencies in nephrology are mainly acute life-threatening situations for patients. Furthermore, one needs to consider constellations that are so damaging to the kidneys that the need for permanent dialysis develops within a short period of time. Acute kidney failure as an immediate consequence is categorized using the Acute Kidney Injury Network (AKIN) stages and is pathophysiologically subdivided into pre-, intra- and post-renal. This leads to changes in volume status, acid base and electrolytes, while the terms nephrotic and nephritic describe the amount of kidney damage and help to choose diagnostic steps wisely. Patients that are already undergoing dialysis treatment or have received a kidney transplant are a further specific group in the case of emergencies.
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Affiliation(s)
- Mareike Siebeneck
- Abteilung für Innere Medizin und Nephrologie, Ev. Klinikum Bethel (EvKB), Schildescher Str. 99, 33611, Bielefeld, Deutschland.
| | - Mariam Abu-Tair
- Abteilung für Innere Medizin und Nephrologie, Ev. Klinikum Bethel (EvKB), Schildescher Str. 99, 33611, Bielefeld, Deutschland
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Katsuki H, Kamijo Y, Kyan R, Abe H. The efficacy of intermittent hemodialysis in severe bromovalerylurea poisoning. Am J Emerg Med 2024; 79:231.e1-231.e2. [PMID: 38521712 DOI: 10.1016/j.ajem.2024.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 03/25/2024] Open
Abstract
Bromvalerylurea (BVU) is a sedative-hypnotic drug with a high risk of acute poisoning. In the present case, hemodialysis (HD) was introduced in a patient with severe BVU poisoning who later demonstrated respiratory arrest, and then HD clearances (CLHD) were assessed in detail. A 20-year-old female was transported to the emergency department by ambulance, an estimated two to four hours after orally ingesting 144 tablets of Utto® (12,000 mg BVU) in a suicide attempt. The patient was comatose on arrival. After intratracheal intubation, 50 g of activated charcoal was administered through nasogastric tube. She was then transferred to the intensive care unit. Ten hours after arrival at the hospital, her light reflex, contralateral light reflex, corneal reflex, and spontaneous respiration disappeared, resulting in an introduction of HD 16 h after arrival. Eighteen hours after arrival, her light reflex, contralateral light reflex, and corneal reflexes had recovered. Twenty-one hours after arrival, her consciousness level improved and the patient was weaned from HD. During HD treatment, blood samples were collected pre-HD and post-HD every hour. Serum BVU concentrations were determined using liquid chromatography-tandem mass spectrometry (LC-MS/MS). The median CLHD was 133.61 mL/min, and the systemic clearance (CLSYS) was 117.77 mL/min. Higher CLHD of BVUs over CLSYS suggests that HD may play an important role in the treatment of severe BVU poisoning.
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Affiliation(s)
- Hironori Katsuki
- Clinical Toxicology Center, Saitama Medical University Hospital, 38, Hongo, Moroyama-machi, Iruma-gun, Sitama 350-0495, Japan; Emergency and Critical Care Center, Iizuka Hospital, 3-38, Yoshiomachi, Iizukashi, Fukuoka 820-0018, Japan.
| | - Yoshito Kamijo
- Clinical Toxicology Center, Saitama Medical University Hospital, 38, Hongo, Moroyama-machi, Iruma-gun, Sitama 350-0495, Japan
| | - Ryoko Kyan
- Clinical Toxicology Center, Saitama Medical University Hospital, 38, Hongo, Moroyama-machi, Iruma-gun, Sitama 350-0495, Japan
| | - Hiroko Abe
- Emergency and Critical Care Center, Iizuka Hospital, 3-38, Yoshiomachi, Iizukashi, Fukuoka 820-0018, Japan; Bio Design Inc, 3-25-15, Nishiikebukkuro, Toyoshimaku, Tokyo 171-0021, Japan
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Alrobaian M, Alkhuraiji A, Almohanna R, Alshehri M, Alyahya B. Visual outcome of methanol toxic optic neuropathy after erythropoietin treatment in Riyadh, Saudi Arabia. Saudi J Ophthalmol 2024; 38:41-46. [PMID: 38628402 PMCID: PMC11017006 DOI: 10.4103/sjopt.sjopt_174_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/29/2023] [Accepted: 03/07/2023] [Indexed: 04/19/2024] Open
Abstract
PURPOSE The purpose of this study is to evaluate the visual response of methanol-induced optic neuropathy to management with erythropoietin (EPO) along with conventional therapy. METHODS This retrospective case series examines the ophthalmological data of patients diagnosed with methanol-induced optic neuropathy between 2020 and 2021 at two centers, Riyadh, Saudi Arabia. Patients' characteristics and the results of initial and final ophthalmological examinations were documented and compared between patients who received EPO in addition to conventional management and those who received only conventional management. RESULTS A total of nine cases were reviewed, of which eight (88.9%) were males and one was female (11.1%). The mean age was 37.7 years. At presentation, funduscopic examination revealed optic disc edema in four eyes (two patients), and 14 eyes had normal appearance (seven patients). Among the nine patients who received conventional management, 5 (55.6%) additionally received intravenous EPO during the treatment course. There was no clinically or statistically significant difference in terms of visual outcome between the two groups. The mean visual acuity at the final presentation was 1.32 ± 0.79 logarithm of the minimum angle of resolution (LogMAR) in the EPO group and 1.36 ± 0.85 LogMAR in the non-EPO group. Optical coherence tomography indicated that the EPO group had an average retinal nerve fiber layer thickness of 48.13μm (±6.2), at the final assessment. CONCLUSION Managing the visual impairments in individuals with methanol-induced optic neuropathy using intravenous EPO resulted in similar final visual outcomes compared to conventional management.
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Affiliation(s)
- Malek Alrobaian
- Department of Ophthalmology, Ministry of the National Guard – Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Arwa Alkhuraiji
- Department of Ophthalmology, Ministry of the National Guard – Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Rema Almohanna
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Surgery, Ministry of the National Guard – Health Affairs, Riyadh, Saudi Arabia
| | - Mohammed Alshehri
- Department of Emergency Medicine, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - Bader Alyahya
- Department of Emergency Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Sadeghi M, Fakhar M, Hoseininejad SM, Zakariaei Z, Sadeghi A. The clinico-epidemiological, diagnostic and therapeutic aspects of methanol poisoning: A five-year retrospective study, northern Iran. Drug Alcohol Depend 2023; 253:111024. [PMID: 38006673 DOI: 10.1016/j.drugalcdep.2023.111024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 10/23/2023] [Accepted: 11/03/2023] [Indexed: 11/27/2023]
Abstract
INTRODUCTION Methanol poisoning (MP) is a serious health issue that has become more prevalent in recent years and has resulted in numerous deaths. Early detection and timely treatment are critical for preventing fatalities and reducing the incidence of neurological complications. PATIENTS AND METHODS This study was designed as a retrospective investigation with the purpose of analyzing the clinico-epidemiological, diagnostic, and therapeutic aspects of patients who were admitted to two training hospitals in northern Iran due to MP. The selection of samples for this study was based on a pre-defined checklist. Following the completion of the treatment period in the hospital, the patients were categorized into three groups based on their clinical outcome. All relevant variables for each group were recorded and reported separately, using the SciPy library in the Python programming language. RESULTS The majority of the patients (88.12%) were male (P=0.012), the average age was 41.46, and mostly (82.18%) lived in urban regions (P=0.025). The primary clinical complaint reported was visual disorders, accounting for 75.25% of the cases, followed by nervous, gastrointestinal, respiratory, and chest pain accordingly. The average hospitalization length for the patients was 5.065 days. Out of the 101 patients, 65 (64.36%) were discharged without any complications, 17 (16.83%) were discharged with complications, and unfortunately, 19 (18.81%) were died. CONCLUSION A decreased level of consciousness and severe metabolic acidosis are commonly associated with unfavorable outcomes in MP. The use of systemic corticosteroids as a treatment method has a significant association with reducing mortality rates.
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Affiliation(s)
- Mahdieh Sadeghi
- Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mahdi Fakhar
- Iranian National Registry Center for Lophomoniasis and Toxoplasmosis, Mazandaran University of Medical Sciences, Sari, Iran
| | | | - Zakaria Zakariaei
- Toxicology and Forensic Medicine Division, Mazandaran Registry Center for Opioids Poisoning, Antimicrobial Resistance Research Center, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran.
| | - Alireza Sadeghi
- Intelligent Mobile Robot Lab (IMRL), Department of Mechatronics Engineering, Faculty of New Sciences and Technologies, University of Tehran, Tehran, Iran
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Ghannoum M, Roberts DM. Management of Poisonings and Intoxications. Clin J Am Soc Nephrol 2023; 18:1210-1221. [PMID: 37097121 PMCID: PMC10564369 DOI: 10.2215/cjn.0000000000000057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 12/21/2022] [Indexed: 01/22/2023]
Abstract
Poisoning occurs after exposure to any of a number of substances, including medicines, which can result in severe toxicity including death. The nephrologist may be involved in poisonings that cause kidney disease and for targeted treatments. The overall approach to the poisoned patient involves the initial acute resuscitation and performing a risk assessment, whereby the exposure is considered in terms of the anticipated severity and in the context of the patient's status and treatments that may be required. Time-critical interventions such as gastrointestinal decontamination ( e.g. , activated charcoal) and antidotes are administered when indicated. The nephrologist is usually involved when elimination enhancement techniques are required, such as urine alkalinization or extracorporeal treatments. There is increasing data to guide decision making for the use of extracorporeal treatments in the poisoned patient. Principles to consider are clinical indications such as whether severe toxicity is present, anticipated, and/or will persist and whether the poison will be significantly removed by the extracorporeal treatment. Extracorporeal clearance is maximized for low-molecular weight drugs that are water soluble with minimal protein binding (<80%) and low endogenous clearance and volume of distribution. The dosage of some antidotes ( e.g. , N-acetylcysteine, ethanol, fomepizole) should be increased to maintain therapeutic concentrations once the extracorporeal treatment is initiated. To maximize the effect of an extracorporeal treatment, blood and effluent flows should be optimized, the filter with the largest surface area selected, and duration tailored to remove enough poison to reduce toxicity. Intermittent hemodialysis is recommended in most cases when an extracorporeal treatment is required because it is the most efficient, and continuous kidney replacement therapy is prescribed in some circumstances, particularly if intermittent hemodialysis is not readily available.
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Affiliation(s)
- Marc Ghannoum
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, University of Montreal, Montreal, Quebec, Canada, and Department of Nephrology and Hypertension, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Darren M. Roberts
- New South Wales Poisons Information Centre, Sydney Children's Hospitals Network, Westmead, and Edith Collins Centre, Drug Health Services, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Kobylarz D, Noga M, Frydrych A, Milan J, Morawiec A, Glaca A, Kucab E, Jastrzębska J, Jabłońska K, Łuc K, Zdeb G, Pasierb J, Toporowska-Kaźmierak J, Półchłopek S, Słoma P, Adamik M, Banasik M, Bartoszek M, Adamczyk A, Rędziniak P, Frączkiewicz P, Orczyk M, Orzechowska M, Tajchman P, Dziuba K, Pelczar R, Zima S, Nyankovska Y, Sowińska M, Pempuś W, Kubacka M, Popielska J, Brzezicki P, Jurowski K. Antidotes in Clinical Toxicology-Critical Review. TOXICS 2023; 11:723. [PMID: 37755734 PMCID: PMC10534475 DOI: 10.3390/toxics11090723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/11/2023] [Accepted: 08/20/2023] [Indexed: 09/28/2023]
Abstract
Poisoning and overdose are very important aspects in medicine and toxicology. Chemical weapons pose a threat to civilians, and emergency medicine principles must be followed when dealing with patients who have been poisoned or overdosed. Antidotes have been used for centuries and modern research has led to the development of new antidotes that can accelerate the elimination of toxins from the body. Although some antidotes have become less relevant due to modern intensive care techniques, they can still save lives or reduce the severity of toxicity. The availability of antidotes is crucial, especially in developing countries where intensive care facilities may be limited. This article aims to provide information on specific antidotes, their recommended uses, and potential risks and new uses. In the case of poisoning, supportive therapies are most often used; however, in many cases, the administration of an appropriate antidote saves the patient's life. In this review, we reviewed the literature on selected antidotes used in the treatment of poisonings. We also characterised the antidotes (bio)chemically. We described the cases in which they are used together with the dosage recommendations. We also analysed the mechanisms of action. In addition, we described alternative methods of using a given substance as a drug, an example of which is N-acetylcysteine, which can be used in the treatment of COVID-19. This article was written as part of the implementation of the project of the Polish Ministry of Education and Science, "Toxicovigilance, poisoning prevention, and first aid in poisoning with xenobiotics of current clinical importance in Poland", grant number SKN/SP/570184/2023.
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Affiliation(s)
- Damian Kobylarz
- Department of Regulatory and Forensic Toxicology, Institute of Medical Expertises, Łódź, ul. Aleksandrowska 67/93, 91-205 Łódź, Poland
| | - Maciej Noga
- Department of Regulatory and Forensic Toxicology, Institute of Medical Expertises, Łódź, ul. Aleksandrowska 67/93, 91-205 Łódź, Poland
| | - Adrian Frydrych
- Laboratory of Innovative Toxicological Research and Analyzes, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland
| | - Justyna Milan
- Laboratory of Innovative Toxicological Research and Analyzes, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland
| | - Adrian Morawiec
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Agata Glaca
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Emilia Kucab
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Julia Jastrzębska
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Karolina Jabłońska
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Klaudia Łuc
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Gabriela Zdeb
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Jakub Pasierb
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Joanna Toporowska-Kaźmierak
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Szczepan Półchłopek
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Paweł Słoma
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Magdalena Adamik
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Mateusz Banasik
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Mateusz Bartoszek
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Aleksandra Adamczyk
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Patrycja Rędziniak
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Paulina Frączkiewicz
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Michał Orczyk
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Martyna Orzechowska
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Paulina Tajchman
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Klaudia Dziuba
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Rafał Pelczar
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Sabina Zima
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Yana Nyankovska
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Marta Sowińska
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Wiktoria Pempuś
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Maria Kubacka
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Julia Popielska
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Patryk Brzezicki
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland (E.K.); (G.Z.); (M.B.); (M.O.)
| | - Kamil Jurowski
- Department of Regulatory and Forensic Toxicology, Institute of Medical Expertises, Łódź, ul. Aleksandrowska 67/93, 91-205 Łódź, Poland
- Laboratory of Innovative Toxicological Research and Analyzes, Institute of Medical Studies, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland
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12
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Alqurashi GI, Alqurashi FS, Alhusayni KM, Falemban AH, Alhindi YZ, Alsanosi SM, Alzahrani AR, Al-Ghamdi SS, Ayoub N. Case Reports Study on Methanol Poisoning in King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia. J Clin Med 2023; 12:4282. [PMID: 37445316 DOI: 10.3390/jcm12134282] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 05/28/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
Methanol poisoning is a challenging issue due to its inducing acute multiple organ failures, and especially due to a lack of preparedness, available antidotes, and management protocols. The current study presents six cases of methanol poisoning that attended the emergency department of King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia, between March and November 2022. All of the patients suffered from severe metabolic acidosis and visual impairment following the ingestion of homemade alcoholic beverages and colonia. Three patients were comatose, suffered from post-cardiac pulmonary arrest, and, finally, died, while the other three were non-comatose and discharged from the ICU after improvement. Management was based on clinical symptoms and other laboratory findings due to a shortage of methanol level measurement resources. The antidote, fomepizole, was not given to all of the cases due to its deficiency, and ethanol was given only to one patient due to difficulties in administering it without monitoring its concentration. Methanol poisoning and its outbreak provide insights into the dangers of hazardous homemade alcohol and other pharmaceutical preparations that might be adulterated with methanol, particularly to the shortage of suitable diagnostic testing and antidotes in addition to poor resources for management of intoxicated patients in some regions of Saudi Arabia.
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Affiliation(s)
- Ghadi I Alqurashi
- Pharmacy Department, King Abdulaziz Hospital, Taif 26521, Saudi Arabia
- Saudi Toxicology Society, Umm Al-Qura University (UQU), Makkah 21955, Saudi Arabia
| | - Fahad S Alqurashi
- Pharmacy Department, King Abdulaziz Hospital, Taif 26521, Saudi Arabia
| | | | - Alaa H Falemban
- Saudi Toxicology Society, Umm Al-Qura University (UQU), Makkah 21955, Saudi Arabia
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University (UQU), Makkah 21955, Saudi Arabia
| | - Yosra Z Alhindi
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University (UQU), Makkah 21955, Saudi Arabia
| | - Safaa M Alsanosi
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University (UQU), Makkah 21955, Saudi Arabia
| | - Abdullah R Alzahrani
- Saudi Toxicology Society, Umm Al-Qura University (UQU), Makkah 21955, Saudi Arabia
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University (UQU), Makkah 21955, Saudi Arabia
| | - Saeed S Al-Ghamdi
- Saudi Toxicology Society, Umm Al-Qura University (UQU), Makkah 21955, Saudi Arabia
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University (UQU), Makkah 21955, Saudi Arabia
| | - Nahla Ayoub
- Saudi Toxicology Society, Umm Al-Qura University (UQU), Makkah 21955, Saudi Arabia
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University (UQU), Makkah 21955, Saudi Arabia
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13
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Kabli AO, Felemban AM, Nasri AK, Aljedani FA, Bedairi AM, Alghamdi MM, Alghamdi AS, Ogran SY. Outcome of Methanol Toxicity Outbreak In Saudi Arabia: Case Series Study. Cureus 2023; 15:e41108. [PMID: 37519541 PMCID: PMC10382281 DOI: 10.7759/cureus.41108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
Introduction Methanol poisoning is an acute medical emergency. If not recognized in time and treated properly, it can lead to a considerable magnitude of morbidity as well as mortality. This article aims to report cases of methanol toxicity, focusing on clinical presentation, management, and outcomes. Method Nine ICU-admitted patients with confirmed positive serum methanol levels were analyzed in a case series at King Fahad General Hospital in Jeddah, Saudi Arabia, between November 2022 and January 2023. Results Among the nine patients admitted to the ICU due to methanol poisoning, the majority were middle-aged males, with two females included. Gastrointestinal symptoms were seen in two-thirds of patients, while three patients required immediate mechanical ventilation due to a low Glasgow Coma Scale. Severe metabolic acidosis was observed in most cases. All patients received sodium bicarbonate and hemodialysis, with six patients also receiving fomepizole. However, two patients in the study with low initial low Glasgow Coma Scale (GCS), severe metabolic acidosis, and diffuse brain edema, did not survive. One patient reported acute complete vision loss. Conclusion This case series highlights the importance of promptly recognizing and managing methanol toxicity in ICU settings. The clinical presentation of methanol toxicity can be challenging, and early diagnosis and treatment are crucial to prevent irreversible damage.
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Affiliation(s)
| | | | - Alanoud K Nasri
- Internal Medicine, Dr. Soliman Fakeeh Hospital (DSFH), Jeddah, SAU
| | | | | | | | | | - Saeed Y Ogran
- Intensive Care Unit, King Fahad General Hospital, Jeddah, SAU
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14
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Bagshaw SM, Neyra JA, Tolwani AJ, Wald R. Debate: Intermittent Hemodialysis versus Continuous Kidney Replacement Therapy in the Critically Ill Patient: The Argument for CKRT. Clin J Am Soc Nephrol 2023; 18:647-660. [PMID: 39074305 PMCID: PMC10278790 DOI: 10.2215/cjn.0000000000000056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
Continuous kidney replacement therapy (CKRT) is well entrenched as one of the dominant KRT modalities in modern critical care practice. Since its introduction four decades ago, there have been considerable innovations in CKRT machines that have improved precision, safety, and simplicity. CKRT is the preferred KRT modality for critically ill patients with hemodynamic instability. Early physical therapy and rehabilitation can be feasibly and safely provided to patients connected to CKRT, thus obviating concerns about immobility. Although randomized clinical trials have not shown a mortality difference when comparing CKRT and intermittent hemodialysis, CKRT allows precision delivery of solute and fluid removal that can be readily adjusted in the face of dynamic circumstances. Accumulated evidence from observational studies, although susceptible to bias, has shown that CKRT, when compared with intermittent hemodialysis, is associated with better short- and long-term kidney recovery and KRT independence. Critical care medicine encompasses a wide range of sick patients, and no single KRT modality is likely to ideally suit every patient in every context and for every condition. The provision of KRT represents a spectrum of modalities to which patients can flexibly transition in response to their evolving condition. As a vital tool for organ support in the intensive care unit, CKRT enables the personalization of KRT to meet the clinical demands of patients during the most severe phases of their illness.
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Affiliation(s)
- Sean M. Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, Alberta, Canada
| | - Javier A. Neyra
- Division of Nephrology, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ashita J. Tolwani
- Division of Nephrology, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ron Wald
- Division of Nephrology, St. Michael's Hospital and the University of Toronto and the Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
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15
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Wang C, Hiremath S, Sikora L, Kanji S, Bugeja A, Samaha D, Sood MM, Kong JWY, Clark EG. Kidney outcomes after methanol and ethylene glycol poisoning: a systematic review and meta-analysis. Clin Toxicol (Phila) 2023; 61:326-335. [PMID: 37293897 DOI: 10.1080/15563650.2023.2200547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 03/28/2023] [Accepted: 04/03/2023] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Ingestions with methanol, ethylene glycol, diethylene glycol, propylene glycol, and isopropanol are rare yet exceedingly dangerous conditions that may require emergent management with kidney replacement therapy. Little is known regarding short- and long-term kidney outcomes post-ingestion. OBJECTIVES To comprehensively synthesize existing evidence regarding short- and long-term kidney and other outcomes of adult patients following these poisonings. METHODS We developed a search strategy in MEDLINE via OVID and then translated it into other databases including EMBASE (via OVID), PubMed, CENTRAL (via OVID). The databases were searched from their dates of inception to 29 July 2021. A grey literature search was conducted in the International Traditional Medicine Clinical Trial Registry and ClinicalTrials.gov. All interventional and observational studies and case series with ≥ five participants that reported on the outcomes of toxic alcohol (methanol, ethylene glycol, diethylene glycol, propylene glycol and isopropanol) poisonings in adult patients ≥18 years old were included. Studies that reported mortality, kidney outcomes and/or complications attributed to toxic alcohol poisoning were eligible. RESULTS The search strategy identified 1,221 citations. Sixty-seven studies (13 retrospective observational studies, one prospective observational study, 53 case series) met inclusion criteria (total N = 2,327 participants). No randomized controlled trials were identified per our prespecified criteria. Generally, included studies had small sample sizes (median of 27 participants) and were of low quality. Methanol and/or ethylene glycol poisoning made up 94.1% of included studies, whereas one study reported on isopropanol and none reported on propylene glycol. Results of the 13 observational studies of methanol and/or ethylene glycol poisoning were pooled for meta-analyses. The pooled in-hospital mortality estimates amongst patients with methanol and ethylene glycol poisoning were 24 and 11%, respectively. A more recent year of publication, female sex and mean age were associated with lower in-hospital mortality amongst individuals with ethylene glycol poisoning. Although hemodialysis was the most frequently employed kidney replacement therapy, the indications for initiation of this therapy were not reported in the majority of studies. At hospital discharge, kidney recovery occurred in 64.7-96.3% of patients with ethylene glycol poisoning. In studies of methanol and/or ethylene glycol poisoning, 2-3.7% of individuals required ongoing dialysis. Only one study reported post-discharge mortality. Furthermore, long-term toxic alcohol-mediated sequelae, such as visual and neurologic outcomes, were scarcely reported. DISCUSSION Ingestions of methanol and ethylene glycol were associated with a significant short-term risk of mortality. Although a wealth of literature in the form of case reports and case series exists, high-quality evidence regarding kidney outcomes after these poisonings is lacking. We identified a paucity of standardized reporting in clinical presentations, therapeutics and outcomes amongst adults with toxic alcohol poisoning. Amongst the included studies, there was substantial heterogeneity encompassing study type, outcomes, duration of follow-up and treatment modalities. These sources of heterogeneity restricted our ability to perform comprehensive meta-analyses of all outcomes of interest. An additional limitation is the lack of studies pertaining to propylene glycol and the paucity of data on isopropanol. CONCLUSIONS The indications for hemodialysis, long-term kidney recovery and long-term mortality risk vary widely in these poisonings and are inconsistently reported in the literature. This highlights the need for further research with standardized reporting of baseline kidney function, indications for initiation of kidney replacement therapy and short-term and long-term kidney outcomes. REGISTRATION This systematic review protocol is registered at PROSPERO, CRD42018101955.
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Affiliation(s)
- Carol Wang
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
| | - Swapnil Hiremath
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Lindsey Sikora
- Health Sciences Library, University of Ottawa Library, University of Ottawa, Ottawa, ON, Canada
| | - Salmaan Kanji
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Ann Bugeja
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Daniel Samaha
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Manish M Sood
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jennifer W Y Kong
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Edward G Clark
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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Vafapour F, Jahangiri-Mehr S, Hassanzadeh S. Delayed reversal of methanol-induced blindness in an adult by a combination of erythropoietin and a high dose of methylprednisolone: a case report. J Med Case Rep 2023; 17:181. [PMID: 37076901 PMCID: PMC10116800 DOI: 10.1186/s13256-023-03899-w] [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: 02/27/2023] [Accepted: 03/09/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND The clinical manifestation following methanol toxicity accounts for a life-threatening problem that contributes to metabolic disorders, neurological complications, blindness, and even death. There is no completely effective treatment to retain the patient's vision. Herein, we apply a new therapeutic strategy for the recovery of bilateral blindness in a patient who had ingested methanol. CASE PRESENTATION A 27-year-old Iranian man with complete bilateral blindness was referred 3 days after accidental ingestion of methanol to the poisoning center at Jalil Hospital, Yasuj, Iran, in 2022. After taking his medical history, performing neurologic and ophthalmologic examinations, and routine laboratory tests, ordinary management was undertaken and counterpoisons were given for 4-5 days; however, the blindness did not reverse. Following the 4-5 days of unsuccessful standard management, he was given ten doses of subcutaneous erythropoietin 10,000 IU/12 hours twice daily, folinic acid 50 mg/12 hours, and methylprednisolone 250 mg/6 hours for 5 days. After five days, vision of both eyes recovered, reaching 1/10 in the left and 7/10 in the right eye. He remained under daily supervision until his release from the hospital, and he was discharged from the hospital 15 days post admission. In outpatient follow-up, his visual acuity was improved without having any side effects at 2 weeks after discharge. CONCLUSION A combination of erythropoietin and a high dose of methylprednisolone were useful for relieving the critical optic neuropathy and improved the optical neurological disorder following methanol toxicity.
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Affiliation(s)
- Fatemeh Vafapour
- Department of Internal Medicine, School of Medicine, Yasuj University of Medical Sciences, Shahid Dr. Ghorban Ali Jalil Street, Yasuj, Iran
| | - Sajad Jahangiri-Mehr
- Department of Ophtalmology, School of Medicine, Yasuj University of Medical Sciences, Yasuj, Iran
| | - Sajad Hassanzadeh
- Department of Internal Medicine, School of Medicine, Yasuj University of Medical Sciences, Shahid Dr. Ghorban Ali Jalil Street, Yasuj, Iran.
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17
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Allata Y, Chouhani BA, El Bardai G, Kabbali N, Sqalli Houssaini T. The Role of Nephrologists in the Management of Methanol Poisoning. Cureus 2023; 15:e37471. [PMID: 37187623 PMCID: PMC10176525 DOI: 10.7759/cureus.37471] [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] [Accepted: 04/11/2023] [Indexed: 05/17/2023] Open
Abstract
Acute methanol poisoning is a rare but serious condition that can lead to significant morbidity and mortality. Toxic metabolites produced by methanol, primarily formaldehyde, can cause high anion gap metabolic acidosis, with the severity of clinical presentation ranging from mild symptoms to multi-organ failure. Nine people died and four patients needed treatment at our university hospital following a collective intoxication caused by the consumption of homemade alcoholic beverages in the central region of Morocco. The four patients presented to the emergency department with varying clinical symptoms, such as decreased visual acuity, severe agitation, and dyspnea. The laboratory tests confirmed high anion gap metabolic acidosis and a subsequent toxicology screen revealed that they had consumed methanol-tainted alcohol. The treatment regimen involved inhibiting the formation of toxic metabolites using an antidote (ethanol or fomepizole), correcting metabolic acidosis, enhancing the elimination of toxic metabolites through prolonged hemodialysis, and administering adjunctive therapies. While two patients had favorable outcomes, the other two died from multi-organ failure. These findings highlight the importance of prompt diagnosis and treatment in cases of methanol poisoning.
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Affiliation(s)
- Yassine Allata
- Nephrology, Hemodialysis and Transplantation, Hassan II University Hospital, Fez, MAR
| | - Basmat Amal Chouhani
- Nephrology, Hemodialysis and Transplantation, Hassan II University Hospital, Fez, MAR
- Epidemiology and Health Sciences Research Laboratory, Faculty of Medicine, Pharmacy and Dentistry, Sidi Mohamed Ben Abdellah University, Fez, MAR
| | - Ghita El Bardai
- Nephrology, Hemodialysis and Transplantation, Hassan II University Hospital, Fez, MAR
- Epidemiology and Health Sciences Research Laboratory, Faculty of Medicine, Pharmacy and Dentistry, Sidi Mohamed Ben Abdellah University, Fez, MAR
| | - Nadia Kabbali
- Nephrology, Hemodialysis and Transplantation, Hassan II University Hospital, Fez, MAR
- Epidemiology and Health Sciences Research Laboratory, Faculty of Medicine, Pharmacy and Dentistry, Sidi Mohamed Ben Abdellah University, Fez, MAR
| | - Tarik Sqalli Houssaini
- Nephrology, Hemodialysis and Transplantation, Hassan II University Hospital, Fez, MAR
- Epidemiology and Health Sciences Research Laboratory, Faculty of Medicine, Pharmacy and Dentistry, Sidi Mohamed Ben Abdellah University, Fez, MAR
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Takahashi M, Kondo T, Yamasaki G, Sugimoto M, Yoshida H, Harada K, Matsumoto H, Asano M, Ueno Y. An Autopsy Case Report of Homicide by Methanol Intoxication With Pinkish Bilateral Putamina. Am J Forensic Med Pathol 2023; 44:55-58. [PMID: 36037297 DOI: 10.1097/paf.0000000000000790] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT Many deaths caused by methanol occur as a result of intentional suicide attempts or accidental ingestion, and several investigators have quantified methanol and formic acid in blood and organs. However, to the best of our knowledge, no reports have described regional differences in the concentration of methanol in the brain. A man in his 50s drank alcohol that had been deliberately contaminated with methanol by his wife, and he died of multiple-organ failure after 4 days of intensive medical treatment including hemodialysis. On medicolegal autopsy, cross sections of the brain showed scattered petechial hemorrhage in the brain stem and microscopic hemorrhage with congestion in the bilateral putamina, which showed pinkish discoloration. The concentrations of methanol, formic acid, and ethanol in autopsy samples were measured by headspace gas chromatography, revealing relatively high concentrations of residual methanol and formic acid in the brain (especially in the basal ganglia), although methanol had been eliminated from the blood. Even after 4 days of medical treatment, postmortem toxicological analysis of the brain tissue indicated methanol ingestion. The accumulation of formic acid and the consequent local metabolic acidosis may cause brain lesions.
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Affiliation(s)
- Motonori Takahashi
- From the Division of Legal Medicine, Department of Community Medicine and Social Health Science, Kobe University Graduate School of Medicine, Hyogo
| | - Takeshi Kondo
- From the Division of Legal Medicine, Department of Community Medicine and Social Health Science, Kobe University Graduate School of Medicine, Hyogo
| | - Gentaro Yamasaki
- From the Division of Legal Medicine, Department of Community Medicine and Social Health Science, Kobe University Graduate School of Medicine, Hyogo
| | - Marie Sugimoto
- From the Division of Legal Medicine, Department of Community Medicine and Social Health Science, Kobe University Graduate School of Medicine, Hyogo
| | | | | | - Hiroshi Matsumoto
- Department of Legal Medicine, Osaka University Graduate School of Medicine
| | - Migiwa Asano
- Department of Legal Medicine, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Yasuhiro Ueno
- From the Division of Legal Medicine, Department of Community Medicine and Social Health Science, Kobe University Graduate School of Medicine, Hyogo
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Kielstein JT. [Hemoperfusion and plasmapheresis in the intensive care unit]. WIENER KLINISCHES MAGAZIN : BEILAGE ZUR WIENER KLINISCHEN WOCHENSCHRIFT 2023; 26:1-6. [PMID: 37359739 PMCID: PMC9975843 DOI: 10.1007/s00740-023-00486-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
In addition to kidney replacement procedures, several other extracorporeal procedures are employed in the intensive care unit. Hemoperfusion with activated charcoal was the predominant treatment used for removal of toxins from the 1970s until the millennium. Nowadays, this treatment does no longer play a clinically meaningful role as even strongly protein-bound toxins can be removed by effective dialysis procedures in case poisoning. The concept of a cytokine adsorber was introduced 10 years ago, which is directed towards withstanding the cytokine storm. Despite negative data from prospective randomized controlled studies, its use is steadily increasing in Germany. A totally different treatment concept is the biomimetic pathogen adsorber, which removes bacteria, viruses and fungi from the bloodstream by binding to immobilized heparin. Whether this rapid reduction of the pathogen load translates into an improvement of clinically relevant endpoints is unclear, as prospective randomized controlled studies are lacking. For the early hours of septic shock a very old procedure, plasmapheresis, has recently regained interest. The results of two large randomized controlled studies in this setting from Europe and Canada will become available in 2025/2026. The rationale to use plasma exchange in early sepsis is that this procedure not only removes cytokines but also replenishes reduced levels of protective factors, such as angiopoietin‑1, a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS-13) and protein C, if fresh plasma is used as exchange fluid. All afore mentioned procedures do not only have a different mode of action but are also used at seperate time points of bloodstream infections and/or sepsis.
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Affiliation(s)
- Jan T. Kielstein
- Medizinische Klinik V (Nephrologie | Rheumatologie | Blutreinigungsverfahren), Städtisches Klinikum Braunschweig, Salzdahlumer Str. 90, 38126 Braunschweig, Deutschland
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20
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Subedi N, Pandey DP, Wagle A, Bhandari S, Paudel S, Karn M. Fatal toxicity due to locally produced unlabeled alcohol consumption: An illustrative case series from Nepal. SAGE Open Med Case Rep 2023; 11:2050313X231157985. [PMID: 36860306 PMCID: PMC9969422 DOI: 10.1177/2050313x231157985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/31/2023] [Indexed: 02/26/2023] Open
Abstract
Locally prepared liquor, which is not standardized or regulated, though cheap can contain various toxic ingredients and even may be fatal. We report a case series of four adult males who died within 18.5 h due to the effect of local liquor consumption in a hilly district of Gandaki Province of Nepal. Methanol toxicity due to illicitly produced alcohol consumption should be managed with adequate supportive care and administration of specific antidotes such as ethanol or fomepizole. Liquor production should be standardized, and quality checks should be done before the sale for consumption.
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Affiliation(s)
- Nuwadatta Subedi
- Gandaki Medical College Teaching
Hospital and Research Center, Pokhara, Gandaki Province, Nepal,Nuwadatta Subedi, Gandaki Medical College
Teaching Hospital and Research Center, Pokhara, Gandaki Province, Nepal.
| | - Deb P. Pandey
- Research Center, Invention and
Innovation Center (RC-II), Pokhara, Gandaki University, Gandaki Province,
Nepal
| | - Abhishesh Wagle
- Gandaki Medical College Teaching
Hospital and Research Center, Pokhara, Gandaki Province, Nepal
| | - Shankar Bhandari
- Gandaki Medical College Teaching
Hospital and Research Center, Pokhara, Gandaki Province, Nepal
| | - Sabita Paudel
- Gandaki Medical College Teaching
Hospital and Research Center, Pokhara, Gandaki Province, Nepal
| | - Mitesh Karn
- Gandaki Medical College Teaching
Hospital and Research Center, Pokhara, Gandaki Province, Nepal
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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: 2] [Impact Index Per Article: 1.0] [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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22
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Hämoperfusion und Plasmapherese auf der Intensivstation. DIE NEPHROLOGIE 2022. [PMCID: PMC9768770 DOI: 10.1007/s11560-022-00620-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Neben Nierenersatzverfahren werden auf der Intensivstation mehrere andere extrakorporale Verfahren eingesetzt. In den 1970er- bis 2000er-Jahren stand die Hämoperfusion mit Aktivkohlekapseln zur Entfernung von Toxinen im Vordergrund. Dies ist mittlerweile aufgrund der effektiven Dialyseverfahren, die im Vergiftungsfall auch stark proteingebundene Toxine entfernen, fast bedeutungslos geworden. Vor 10 Jahren erlebte ein Zytokinadsorber die Markteinführung, der darauf gerichtet ist, den „Zytokinsturm“ zu überstehen. Dieser erfreut sich trotz ernüchternder Daten aus prospektiven, randomisierten, kontrollierten Studien wachsender Beliebtheit. Ein gänzlich anderes Therapiekonzept ist der biomimetische Pathogenadsorber, der Bakterien, Viren und Pilze durch Bindung an immobilisiertes Heparin aus dem Blutstrom entfernt. Ob sich diese schnelle Reduktion der Pathogenlast in eine Verbesserung klinisch relevanter Endpunkte übersetzt, ist unklar, da hier prospektive, randomisierte und kontrollierte Studien gänzlich fehlen. Für ein sehr altes Verfahren, nämlich die Plasmapherese, werden wir für die Frühphase der Sepsis bis zum Jahr 2025/2026 Ergebnisse aus 2 großen randomisierten, kontrollierten Studien aus Europa und Kanada erhalten. Neben der Entfernung von Zytokinen erhofft man sich durch die Verwendung von Frischplasma als Austauschflüssigkeit auch das Wiederauffüllen reduzierter protektiver Faktoren wie Angiopoietin 1, ADAMTS13 („a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13“) und Protein C. Alle genannten Verfahren funktionieren nicht nur unterschiedlich, sondern werden auch zu unterschiedlichen Zeitpunkten der Blutstrominfektion/Sepsis eingesetzt.
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Orhan U, Gulen M, Satar S, Acehan S, Nazik H, Unlu N, Gediklioglu M, Isikber C, Sonmez A, Sonmez GO. Hemodialysis treatment for poisoning patients in the emergency department. Ther Apher Dial 2022; 27:580-586. [PMID: 36504481 DOI: 10.1111/1744-9987.13960] [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: 09/27/2022] [Revised: 11/30/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION We aimed to evaluate the hemodialysis (HD) use in adult patients after acute poisoning in the emergency department. METHODS The study was performed as a retrospective observational cohort study. We analyzed hospital electronic data system and patient files. RESULTS A total of 55 patients were included in the study. Among the 10 toxins exposed, the most common were methanol and metformin. The most common indications for HD treatment were: 67.3% (n = 37) for toxin elimination, 20% (n = 11) for treatment-resistant metabolic acidosis, hemodynamic disorder. The most common complication (50.9%) in all patients was central nervous system depression. Ten patients died from ingestion of methanol, one of aluminum phosphide, and one of opioid-sympathomimetic-hallucinogen agents. CONCLUSION HD is the most commonly used extracorporeal treatment method in the treatment of poisoning patients. HD should be considered without any delay in treating poisoned patients if there is no response to conventional treatments.
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Affiliation(s)
- Ugur Orhan
- Department of Emergency Medicine, Bitlis State Hospital, Bitlis, Turkey
| | - Muge Gulen
- Department of Emergency Medicine, Adana City Training and Research Hospital, Adana, Turkey
| | - Salim Satar
- Department of Emergency Medicine, Adana City Training and Research Hospital, Adana, Turkey
| | - Selen Acehan
- Department of Emergency Medicine, Adana City Training and Research Hospital, Adana, Turkey
| | - Hakan Nazik
- Department of Gynecology and Obstetrics, Adana Middle East Hospital, Adana, Turkey
| | - Nurdan Unlu
- Department of Anesthesiology and Intensive Care, Adana City Training and Research Hospital, Adana, Turkey
| | - Mustafa Gediklioglu
- Department of Emergency Medicine, Adana City Training and Research Hospital, Adana, Turkey
| | - Cem Isikber
- Department of Emergency Medicine, Adana City Training and Research Hospital, Adana, Turkey
| | - Ahmet Sonmez
- Department of Emergency Medicine, Adana City Training and Research Hospital, Adana, Turkey
| | - Gökben Oral Sonmez
- Department of Emergency Medicine, Adana City Training and Research Hospital, Adana, Turkey
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24
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Stanton MT. Part
II
: Interactive case: Toxicology and poison control. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022. [DOI: 10.1002/jac5.1725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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AYDIN H, DOĞANAY F, ERDOĞAN M, DOĞAN H, BEŞTEMİR A, TUNCAR A. Risk factors associated with mortality in patients with methanol poisoning: a retrospective study. ACTA MEDICA ALANYA 2022. [DOI: 10.30565/medalanya.1184894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Aim: Methanol poisoning (MP) is an essential medical problem worldwide, and despite advances in diagnosis and treatment, the mortality rate in these cases is high. This study aimed to evaluate the clinical and laboratory factors to determine in-hospital mortality in patients with MP.
Methods: This single-center, retrospective, observational study was conducted with adult 65 MP cases visiting the emergency department (ED) of a tertiary training and research hospital between January 01, 2017, and February 01, 2022. Data were statistically compared between survivors and non-survivors.
Results: The in-hospital mortality rate was 41.5%. The rate of cases with respiratory distress, low Glasgow coma scale (GCS) (≤8), and delayed arrival to the hospital (>24 hours) was higher in the group of non-survivors compared to the group of survivors. Non-survivors had a higher anion gap (30.5 mEq/L vs. 25.5mEq/L), base excess (-25.0 mmol/L vs. -18.6 mmol/L), lactate (10.2 mmol/L vs. 2.2 mmol/L) levels, and lower pH (6.76 vs. 7.14) and bicarbonate (6.3 mmol/L vs. 10.3 mmol/L) levels than survivors (p
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Affiliation(s)
- Hakan AYDIN
- University of Health Sciences, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of Emergency Medicine
| | - Fatih DOĞANAY
- University of Health Sciences, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of Emergency Medicine
| | - Mehmet ERDOĞAN
- University of Health Sciences, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of Emergency Medicine
| | - Halil DOĞAN
- University of Health Sciences, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of Emergency Medicine
| | | | - Alpay TUNCAR
- The Minister of Health, Department of Medical Specialty Board
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26
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McEnery B, Scalzo A, Maliakkal J. Methanol toxicity in a pediatric patient treated with fomepizole and hemodialysis. CEN Case Rep 2022; 12:195-199. [PMID: 36307578 PMCID: PMC10151443 DOI: 10.1007/s13730-022-00744-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 10/03/2022] [Indexed: 11/07/2022] Open
Abstract
Methanol toxicity is an important cause of toxic alcohol exposure resulting in morbidity and mortality in both adult and pediatric populations. Methanol is metabolized into formaldehyde and formic acid: toxic metabolites that can cause altered mental status, visual disturbances, multisystem organ failure, and death. Recognition of methanol intoxication and rapid treatment are critical for the prevention of long-term sequelae. We present the case of a 16-year-old male with a past medical history of depression who intentionally ingested windshield wiper fluid containing methanol. Based on the patient's osmolal gap, he was estimated to have a serum methanol level of 374 mg/dL; a send-out laboratory measurement later revealed a serum methanol level of 436 mg/dL. Therapy included two hemodialysis treatments as well as fomepizole and supportive care. The patient recovered remarkably with no long-term sequelae. This case demonstrates the effectiveness of swift recognition and treatment of methanol ingestion. Optimization of methods of measuring serum methanol and evidence-based guidelines for therapy are needed to improve the care of patients with methanol intoxication.
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Li J, Feng ZJ, Liu L, Ma YJ. Acute methanol poisoning with bilateral diffuse cerebral hemorrhage: A case report. World J Clin Cases 2022; 10:6571-6579. [PMID: 35979299 PMCID: PMC9294890 DOI: 10.12998/wjcc.v10.i19.6571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 04/04/2022] [Accepted: 05/07/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute methanol poisoning (AMP) is a systemic disease that mainly affects the central nervous system and is characterized by ocular damage and metabolic acidosis. If appropriate treatments are inadequate or delayed, the mortality can exceed 40%. As the most serious complication, cerebral hemorrhage is rare with reported prevalence of 7%-19%.
CASE SUMMARY A 62-year-old man drank liquor mixed with 45% methanol and 35% alcohol. His vision blurred 10 h later and he fell into coma in another 9 h. Serum toxicological tests were performed immediately, and continuous renal replacement therapy (CRRT) was carried out as the lactic acid exceeded 15 mmol/L and blood pH was 6.78. In addition, the toxicological report revealed 1300.5 μg/mL of methanol in serum and 1500.2 μg/mL in urine. After 59 h of CRRT, the methanol level decreased to 126.0 μg/mL in serum and 151.0 μg/mL in urine. However, the patient was still unconscious and his pupillary light reflex was slow. Computed tomography showed hemorrhage in the left putamen. After 16 d of life support treatment, putamen hemorrhage developed into diffuse symmetric intracerebral hemorrhage. In the end, his family gave up and the patient was discharged, and died in a local hospital.
CONCLUSION Cerebral hemorrhage requires constant vigilance during the full course of treatment for severe cases of AMP.
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Affiliation(s)
- Jin Li
- Department of Critical Care Medicine, Air Force Medical Center, PLA, Beijing 100142, China
| | - Zhi-Juan Feng
- Department of Critical Care Medicine, Air Force Medical Center, PLA, Beijing 100142, China
| | - Lei Liu
- Department of Critical Care Medicine, Air Force Medical Center, PLA, Beijing 100142, China
| | - Yu-Jie Ma
- Department of Critical Care Medicine, Air Force Medical Center, PLA, Beijing 100142, China
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Wu X, Gu M, Wang W, Zhang H, Tang Z. Case Report: Early Recognition, Treatment, and Occupational Safety Protection are Crucial for Methanol Toxicity. Front Med (Lausanne) 2022; 9:918812. [PMID: 35774994 PMCID: PMC9237385 DOI: 10.3389/fmed.2022.918812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/24/2022] [Indexed: 11/16/2022] Open
Abstract
Background Despite significant progress in treating methanol poisoning, the lack of training, hazard communication, and occupational safety protection education contributes to the risk of occupational exposure and methanol toxicity. In addition, early diagnosis and timely medical care are essential to reduce the risk of morbidity and mortality, yet it remains a challenging procedure. Case Report A 35-year-old man working in a fireworks factory came to our emergency department with acute mental change and progressive disturbance of consciousness. The patient's vital signs were stable, and he presented with enlargement of both pupils with a weak reaction to light. Head computed tomography showed low signal intensities in the bilateral basal ganglia. He was admitted to the neurologic intensive care unit, where additional laboratory workup showed high anion-gap metabolic acidosis. Methanol poisoning was thus considered. Before being treated with sodium bicarbonate infusion, hemodialysis, folate, and high-dose vitamin B, the blood and urine samples were collected for toxicity tests, which turned out to be methanol poisoning. After 8 hours of hemodialysis, the patient's consciousness recovered, but he complained of a complete loss of vision in both eyes. Brain and optic nerve magnetic resonance images showed bilateral symmetric putamen lesions and optic neuropathy. Ophthalmic tests indicated visual pathway impairment and optic disc swelling but no fluorescein leakage. The right eye's vision was partially restored on the third day, but he could only count fingers at 20 cm. Unfortunately, his eyesight ceased to improve during the 6 months of follow-up. Conclusions Early diagnosis and prompt treatment will improve the prognosis of methanol poisoning in terms of vision and patient survival. Awareness and supervision of commercial alcohol use are indispensable for similar industrial processes.
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Affiliation(s)
- Xiaomei Wu
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Meifeng Gu
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Wei Wang
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Hainan Zhang
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Zhenchu Tang
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Tumor Models and Individualized Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
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DOĞAN M. Examination of patients admitted to a university hospital with methanol intoxication. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2022. [DOI: 10.32322/jhsm.1107285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objective: The aim of this study is to evaluate the demographic data, clinical features and laboratory findings of patients followed up with methanol poisoning in our internal medicine clinic. In addition, to examine the data of the patients followed in our intensive care unit and to contribute to the literature in this direction.
Material and Method: In this study, 21 patients diagnosed with methanol intoxication who were hospitalized in the internal medicine clinic of our hospital between 01.01.2019 and 01.04.2022 were included. Demographic information of the patients, initial complaints, accompanying symptoms, laboratory results, blood gas values, intensive care unit requirements, mechanical ventilation needs, length of hospital stay and whether they received hemodialysis treatment were recorded from the hospital automation system.
Results: 21 patients were included in the study. The mean time for patients to apply to the hospital after drinking alcohol was calculated as 31.42±4.27 hours. The mean hospital stay was 3.0±1.02 days. While 12 patients were followed up in the intensive care unit, it was found that 6 patients needed mechanical ventilation and 9 patients needed hemodialysis. Glucose, creatinine, acetyl aminotransferase (AST), partial carbon dioxide pressure (PaCO2), lactate, anion gap and base gap were found to be statistically significantly higher in the group treated in the intensive care unit (p
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Affiliation(s)
- Murat DOĞAN
- Çorum Hitit Üniversitesi EAH İç Hastalıkları
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Fatal intoxication due to home distillation of methanol: Report of three cases. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2022. [DOI: 10.1016/j.toxac.2022.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Kuusela E, Järvisalo MJ, Hellman T, Uusalo P. Mortality and associated risk factors in patients with severe methanol or ethylene glycol poisoning treated with dialysis: a retrospective cohort study. J Int Med Res 2022; 50:3000605221081427. [PMID: 35209742 PMCID: PMC8891871 DOI: 10.1177/03000605221081427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To compare the initial clinical course and data on 90-day mortality in adults with methanol (MET) or ethylene glycol (EG) poisoning treated with dialysis. Methods Data on patient demographics and clinical parameters at intensive care unit (ICU) admission and for the first 24 hours after dialysis initiation were collected, and 90-day outcome data were collected for patients with MET (n = 15) or EG (n = 13) poisoning treated with dialysis in this retrospective cohort study. Results In univariate analysis, patients with EG poisoning were older and they had lower hourly urine output during the first 24 hours after the initiation of dialysis. Six (46%) patients with MET poisoning and three (20%) patients with EG poisoning died within 90 days of ICU admission. A larger anion gap and lower pH, bicarbonate levels, base excess, and Glasgow Coma Scale scores on admission, as well as the need for mechanical ventilation, were associated with 90-day mortality. Conclusions Metabolic acidosis, a large anion gap, and an altered mental status on admission appear to be associated with mortality in MET or EG poisoning, and EG poisoning may be linked to lower urine output.
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Affiliation(s)
- Emma Kuusela
- Department of Anaesthesiology and Intensive Care, Turku University Hospital and University of Turku, Turku, Finland
| | - Mikko J Järvisalo
- Department of Anaesthesiology and Intensive Care, Turku University Hospital and University of Turku, Turku, Finland.,Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Tapio Hellman
- Kidney Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Panu Uusalo
- Department of Anaesthesiology and Intensive Care, Turku University Hospital and University of Turku, Turku, Finland.,Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital and University of Turku, Turku, Finland
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Scanlon M, Marino R, Sidlak A. Folic acid in methanol toxicity: a retrospective cohort study. TOXICOLOGY COMMUNICATIONS 2021. [DOI: 10.1080/24734306.2021.1997013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Matthew Scanlon
- Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ryan Marino
- Division of Toxicology, Department of Emergency Medicine, University Hospital, Cleveland, OH, USA
| | - Alexander Sidlak
- Department of Emergency Medicine, Inova Fairfax Medical Center, Great Falls, VA, USA
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Hoyte C, Schimmel J, Hadianfar A, Banerji S, Nakhaee S, Mehrpour O. Toxic alcohol poisoning characteristics and treatments from 2000 to 2017 at a United States regional poison center. Daru 2021; 29:367-376. [PMID: 34709587 DOI: 10.1007/s40199-021-00418-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 09/30/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Toxic alcohol exposures are an ongoing concern in the United States. In the US, few studies characterize the local epidemiology of toxic alcohols over time. OBJECTIVES The objective was to examine the incidence of toxic alcohol ingestions and changes in management over time. METHODS This retrospective cohort study evaluates toxic alcohol ingestion phone calls to a regional poison center in the United States covering four states. Data were queried for this poison center from the National Poison Data System (NPDS) using generic codes for each toxic alcohol. Inclusion criteria were ingestion of toxic alcohol, age ≥ 13 years, from January 1, 2000 to Dec 31, 2017. Exclusion criteria were unrelated effects coded in the medical outcome, duplicate data, or incomplete demographic data. RESULTS Of 926 subjects (adults and teenagers), 71.5% were male, and the mean age was 34.5 years. Toxic alcohol ingestion was more common in individuals younger than 40 years, with a significant relationship between age and intentional abuse or misuse (p = 0.001). There was also a significant relationship between age and reason for ingestion, with younger patients more likely to be suicidal (p < 0.001). Ethyleneglycol was the most common toxic alcohol. There was no change in the incidence of toxic alcohol ingestions over the study period. The mortality rate was 1.7%, and 31.2%of patients were hospitalized in a critical care unit. Major effects and death were more common in younger patients (p < 0.001). There was a significant difference in medical outcomes based on the type of toxic alcohol(p = 0.03). Fomepizole was the most common treatment. A Poisson regression model found no change in fomepizole use during the study period (p = 0.1). Ethanol administration over the study period increased (p = 0.02), while hemodialysis decreased (p = 0.02). CONCLUSION Data obtained from a single regional United States poison center showed low mortality related to toxic alcohol ingestions. The most prevalent toxic alcohol was Ethylene glycol. In all cases, toxic alcohol ingestion was higher in the 20-29-year-old age group. Reasons for ingestion, in most cases, were suicidal. Fomepizole was the most common treatment, ethanol administration as an antidote is rising, and hemodialysis utilization is decreasing. Data may not be nationally representative.
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Affiliation(s)
| | - Jonathan Schimmel
- Department of Emergency Medicine, Division of Medical Toxicology, Mount Sinai Hospital Icahn School of Medicine, New York, NY, USA
| | - Ali Hadianfar
- Department of Biostatistics, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Shireen Banerji
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA
| | - Samaneh Nakhaee
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences (BUMS), Birjand, Iran
| | - Omid Mehrpour
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA. .,Scientific Unlimited horizon, Tucson, AZ, USA.
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El Gharbi F, El Bèze N, Jaffal K, Sutterlin L, Mora P, Malissin I, Deye N, Voicu S, Mégarbane B. Does the ICU Requirement Score allow the poisoned patient to be safely managed without admission to the intensive care unit? - a validation cohort study. Clin Toxicol (Phila) 2021; 60:298-303. [PMID: 34378997 DOI: 10.1080/15563650.2021.1961145] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The Intensive care unit (ICU) Requirement Score (IRS) has been defined as identifying poisoned patients on hospital admission who do not require ICU referral, in an effort to reduce health expenses. However, this score has been poorly validated. We aimed to evaluate the IRS in a large cohort of poisoned patients. METHODS We performed a single-center retrospective cohort study. IRS was calculated using clinical parameters obtained on admission including age, systolic blood pressure, heart rate, Glasgow coma score, intoxication type, co-morbidities (i.e., arrhythmia, cirrhosis, and respiratory insufficiency), and the combination of the intoxication with another reason for ICU admission. We evaluated the ability of IRS < 6 determined on admission to predict the lack of need for ICU treatment, defined as the need for mechanical ventilation, vasopressors, and/or renal replacement therapy in the first 24 h post-admission and/or death during the hospital stay. This score was compared to the usual prognostic scores, i.e., SAPS II and III, SOFA score, and PSS. RESULTS During the 10-year study period, 2,514 poisoned patients were admitted, 1,011 excluded as requiring ICU treatment on admission, and 1,503 included. Among these patients, 232 met the endpoint whereas only 23/510 patients with IRS < 6 (4.5%) presented the endpoint and one patient died. The area under the curve of the IRS ROC curve was 0.736 (95% confidence interval (CI), 0.702-0.770). The negative predictive value of IRS < 6 was 95% (95% CI, 93-97), sensitivity 89% (95% CI, 85-93), specificity 38% (95% CI, 36-41), and positive predictive value 21% (95% CI, 18-24). IRS performance was similar to those of the other tested scores, which are however not readily available on admission. CONCLUSION Our data demonstrate the excellent negative predictive value of the IRS, allowing the exclusion of ICU requirements for poisoned patients with IRS < 6. IRS usefulness should be confirmed based on a prospective multicenter cohort study before extensive routine use.
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Affiliation(s)
- Foued El Gharbi
- Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, Paris, France
| | - Nathan El Bèze
- Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, Paris, France
| | - Karim Jaffal
- Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, Paris, France
| | - Laetitia Sutterlin
- Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, Paris, France
| | - Pierre Mora
- Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, Paris, France
| | - Isabelle Malissin
- Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, Paris, France.,University of Paris, Inserm UMRS-1144, Paris, France
| | - Nicolas Deye
- Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, Paris, France
| | - Sebastian Voicu
- Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, Paris, France.,University of Paris, Inserm UMRS-1144, Paris, France
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Federation of Toxicology APHP, Lariboisière Hospital, Paris, France.,University of Paris, Inserm UMRS-1144, Paris, France
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Illescas AC, Argyropoulos CP, Combs SA, Shaffi SK, Xu ZQ, Aragon MA, Teixeira JP. Severe methanol poisoning treated with a novel hemodialysis system: a case report, analysis, and review. RENAL REPLACEMENT THERAPY 2021; 7:43. [PMID: 34367669 PMCID: PMC8330177 DOI: 10.1186/s41100-021-00362-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 07/15/2021] [Indexed: 11/10/2022] Open
Abstract
In May and June 2020, an outbreak of methanol poisoning arose in the southwest United States linked to ingestion of contaminated hand sanitizer imported during the coronavirus disease 2019 pandemic, ultimately resulting in over a dozen hospitalizations and at least four deaths in New Mexico and Arizona. In this report, we describe one of these cases in which profound methanol intoxication was successfully treated with the Tablo® Hemodialysis System, the first reported case of toxic alcohol poisoning treated with this novel device. We carry out a formal regression analysis of the serial methanol levels obtained in this case to conservatively estimate that intermittent hemodialysis with Tablo achieved a clearance of methanol of 239 mL/min (95% confidence interval, 173–305 mL/min), a clearance that is well within the previously published standard of care. We conclude by reviewing both the treatment of toxic alcohol poisoning and the determinants of small molecule clearance with hemodialysis, emphasizing the importance of optimizing the dialytic treatment of intoxications with extended treatment times and the use of high-efficiency dialyzers.
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Affiliation(s)
- Alisa C Illescas
- Department of Internal Medicine, University of New Mexico School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM 87131 USA
| | - Christos P Argyropoulos
- Department of Internal Medicine, University of New Mexico School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM 87131 USA.,Division of Nephrology, University of New Mexico School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM 87131 USA
| | - Sara A Combs
- Department of Internal Medicine, University of New Mexico School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM 87131 USA.,Division of Nephrology, University of New Mexico School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM 87131 USA
| | - Saeed K Shaffi
- Department of Internal Medicine, University of New Mexico School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM 87131 USA.,Division of Nephrology, University of New Mexico School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM 87131 USA
| | - Zhi Q Xu
- Department of Internal Medicine, University of New Mexico School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM 87131 USA.,Division of Nephrology, University of New Mexico School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM 87131 USA
| | | | - J Pedro Teixeira
- Department of Internal Medicine, University of New Mexico School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM 87131 USA.,Division of Nephrology, University of New Mexico School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM 87131 USA.,Division of Pulmonary, Critical Care, & Sleep Medicine, University of New Mexico School of Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM 87131 USA
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36
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Hadipourzadeh M, Ebrahimi S, Ziaeefar P, Zamani N, Falahaty H, Robert D, Hassanian-Moghaddam H. Comparing the Clinical Characteristics, Laboratory Findings, and Outcomes between Epidemic and Episodic Methanol Poisoning Referrals; a Cross-sectional Study. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2021; 9:e46. [PMID: 34223191 PMCID: PMC8221550 DOI: 10.22037/aaem.v9i1.1278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Introduction: Due to illegal manufacturing and sales of alcoholic beverages, epidemic outbreaks of methanol poisoning may occur. The aim of this study was to determine if there were differences in the severity, course of poisoning, and outcomes between methanol-poisoned patients admitted during an outbreak versus those who were admitted following episodic exposures. Methods: The present retrospective study was performed in a single referral poisoning center between March 2018 and March 2019 in patients with confirmed methanol poisoning. During this time, in addition to episodic cases of methanol intoxication, there were three methanol poisoning outbreaks. Outbreaks were characterized by an unexpected increase in the number of methanol-poisoned patients in a short period of time, which impacted resources and decision-making. The two groups were compared regarding their severity of poisoning, sessions of hemodialysis, and clinical outcomes. Results: Outbreak cases had a higher level of methanol than episodic cases. Odds of being dialyzed more than once was 5.4 times higher in the cases presenting during an outbreak (95% CI 2.1-14.0; p=0.001). Mean hospital stay, intubation/mechanical ventilation, and death were similar between the two groups. An evaluation of the alcoholic beverage samples available in the Iranian black market during the outbreak showed a 7-percent methanol concentration with no ethanol content. Conclusions: Poisoning risk may be higher during methanol outbreaks due to the higher methanol concentrations, requiring more hemodialysis sessions for persistent metabolic acidosis. In addition to alcohol dehydrogenase blockade, careful risk assessment of all methanol poisonings can assist with stratifying the priority for, and duration of, hemodialysis to optimize outcomes.
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Affiliation(s)
- Mehdi Hadipourzadeh
- Department of Clinical Toxicology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sara Ebrahimi
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Pardis Ziaeefar
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nasim Zamani
- Department of Clinical Toxicology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hassan Falahaty
- Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Darren Robert
- Departments of Clinical Pharmacology and Toxicology, and Renal Medicine and Transplantation, St Vincent's Hospital, Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Hossein Hassanian-Moghaddam
- Department of Clinical Toxicology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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37
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Nekoukar Z, Zakariaei Z, Taghizadeh F, Musavi F, Banimostafavi ES, Sharifpour A, Ebrahim Ghuchi N, Fakhar M, Tabaripour R, Safanavaei S. Methanol poisoning as a new world challenge: A review. Ann Med Surg (Lond) 2021; 66:102445. [PMID: 34141419 PMCID: PMC8187162 DOI: 10.1016/j.amsu.2021.102445] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 05/21/2021] [Accepted: 05/23/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Methanol poisoning (MP) occurs often via ingestion, inhalation, or dermal exposure to formulations containing methanol in base. Clinical manifestations of MP include gastrointestinal symptoms, central nervous system (CNS) suppression, and decompensated metabolic acidosis occurred with blurred vision and early or late blindness. OBJECTIVE This study reviewed the clinical manifestations, laboratory and radiology findings, and treatment approaches in MP. DISCUSSION Methanol is usually rapidly absorbed after ingestion and metabolized by alcohol dehydrogenase (ADH), then distributed to the body water to reach a volume distribution approximately equal to 0.77 L/kg. It is also eliminated from the body as unchanged parent compounds. Clinical manifestations of MP alone initiate within 0.5-4 h after ingestion and include gastrointestinal symptoms and CNS suppression. After a latent period of 6-24 h, depending on the absorbed dose, decompensated metabolic acidosis occurs with blurred vision and early or late blindness. Blurred vision with normal consciousness is a strong suspicious sign of an MP. The mortality and severity of intoxication are well associated with the severity of CNS depression, hyperglycemia, and metabolic acidosis, but not with serum methanol concentration. After initial resuscitation, the most important therapeutic action for patients with known or suspected MP is correction of acidosis, inhibition of ADH, and hemodialysis. CONCLUSION Since MP is associated with high morbidity and mortality, it should be considered seriously and instantly managed. Delay in treatment may cause complications, permanent damage, and even death.
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Affiliation(s)
- Zahra Nekoukar
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Zakaria Zakariaei
- Toxoplasmosis Research Center, Communicable Diseases Institute, Iranian National Registry Center for Lophomoniasis and Toxoplasmosis, Mazandaran University of Medical Sciences, Sari, Iran
- Toxicology and Forensic Medicine Division, Orthopedic Research Center, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran
| | - Fatemeh Taghizadeh
- Psychiatry and Behavioral Sciences Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Fatemeh Musavi
- Toxicology and Forensic Medicine Division, Orthopedic Research Center, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran
| | - Elham Sadat Banimostafavi
- Toxoplasmosis Research Center, Communicable Diseases Institute, Iranian National Registry Center for Lophomoniasis and Toxoplasmosis, Mazandaran University of Medical Sciences, Sari, Iran
| | - Ali Sharifpour
- Toxoplasmosis Research Center, Communicable Diseases Institute, Iranian National Registry Center for Lophomoniasis and Toxoplasmosis, Mazandaran University of Medical Sciences, Sari, Iran
- Pulmonary and Critical Care Division, Imam Khomeini Hospital, Iranian National Registry Center for Lophomoniasis (INRCL), Mazandaran University of Medical Sciences, Sari, Iran
| | - Nasrin Ebrahim Ghuchi
- Knowledge and Information Science, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mahdi Fakhar
- Toxoplasmosis Research Center, Communicable Diseases Institute, Iranian National Registry Center for Lophomoniasis and Toxoplasmosis, Mazandaran University of Medical Sciences, Sari, Iran
| | - Rabeeh Tabaripour
- Toxoplasmosis Research Center, Communicable Diseases Institute, Iranian National Registry Center for Lophomoniasis and Toxoplasmosis, Mazandaran University of Medical Sciences, Sari, Iran
| | - Sepideh Safanavaei
- Toxoplasmosis Research Center, Communicable Diseases Institute, Iranian National Registry Center for Lophomoniasis and Toxoplasmosis, Mazandaran University of Medical Sciences, Sari, Iran
- Pulmonary and Critical Care Division, Imam Khomeini Hospital, Iranian National Registry Center for Lophomoniasis (INRCL), Mazandaran University of Medical Sciences, Sari, Iran
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38
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Mowry JB, Shepherd G, Hoffman RS, Lavergne V, Gosselin S, Nolin TD, Vijayan A, Kielstein JT, Roberts DM, Ghannoum M. Extracorporeal treatments for isoniazid poisoning: Systematic review and recommendations from the EXTRIP workgroup. Pharmacotherapy 2021; 41:463-478. [PMID: 33660266 DOI: 10.1002/phar.2519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/15/2021] [Accepted: 02/17/2021] [Indexed: 11/11/2022]
Abstract
Isoniazid toxicity from self-poisoning or dosing errors remains common in regions of the world where tuberculosis is prevalent. Although the treatment of isoniazid poisoning is centered on supportive care and pyridoxine administration, extracorporeal treatments (ECTRs), such as hemodialysis, have been advocated to enhance elimination of isoniazid. No systematic reviews or evidence-based recommendations currently exist on the benefit of ECTRs for isoniazid poisoning. The Extracorporeal Treatments in Poisoning (EXTRIP) workgroup systematically collected and rated the available evidence on the effect of and indications for ECTRs in cases of isoniazid poisoning. We conducted a systematic review of the literature, screened studies, extracted data on study characteristics, outcomes, and measurement characteristics, summarized findings, and formulated recommendations following published EXTRIP methods. Forty-three studies (two animal studies, 34 patient reports or patient series, and seven pharmacokinetic studies) met inclusion criteria. Toxicokinetic or pharmacokinetic analysis was available for 60 patients, most treated with hemodialysis (n = 38). The workgroup assessed isoniazid as "Moderately Dialyzable" by hemodialysis for patients with normal kidney function (quality of evidence = C) and "Dialyzable" by hemodialysis for patients with impaired kidney function (quality of evidence = A). Clinical data for ECTR in isoniazid poisoning were available for 40 patients. Mortality of the cohort was 12.5%. Historical controls who received modern standard care including appropriately dosed pyridoxine generally had excellent outcomes. No benefit could be extrapolated from ECTR, although there was evidence of added costs and harms related to the double lumen catheter insertion, the extracorporeal procedure itself, and the extracorporeal removal of pyridoxine. The EXTRIP workgroup suggests against performing ECTR in addition to standard care (weak recommendation, very low quality of evidence) in patients with isoniazid poisoning. If standard dose pyridoxine cannot be administered, we suggest performing ECTR only in patients with seizures refractory to GABAA receptor agonists (weak recommendation, very low quality of evidence).
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Affiliation(s)
- James B Mowry
- Division of Medical Toxicology, Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Greene Shepherd
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Valery Lavergne
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, University of Montreal, Montreal, Quebec, Canada
| | - Sophie Gosselin
- Centre Intégré de Santé et de Services Sociaux (CISSS) Montérégie-Centre Emergency Department, Hôpital Charles-Lemoyne, Greenfield Park, Quebec, Canada.,Department of Emergency Medicine, McGill University, Montreal, Quebec, Canada.,Centre Antipoison du Québec, Montréal, Quebec, Canada
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA.,Department of Medicine Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Anitha Vijayan
- Division of Nephrology, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Jan T Kielstein
- Medical Clinic V Nephrology, Rheumatology, Blood Purification, Academic Teaching Hospital Braunschweig, Braunschweig, Germany
| | - Darren M Roberts
- Departments of Renal Medicine and Transplantation and Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Drug Health Clinical Services, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Marc Ghannoum
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, University of Montreal, Montreal, Quebec, Canada
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Holzman SD, Larsen J, Kaur R, Smelski G, Dudley S, Shirazi FM. Death by hand sanitizer: syndemic methanol poisoning in the age of COVID-19. Clin Toxicol (Phila) 2021; 59:1009-1014. [PMID: 33755514 DOI: 10.1080/15563650.2021.1895202] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The advent of COVID-19 increased attention to hand hygiene in prevention of disease transmission. To meet the increased demand for hand sanitizer during the pandemic, the US FDA issued an Emergency Use Authorization allowing new manufacturers and importers to enter the market. Some of the newly introduced hand sanitizer products contained methanol in lieu of ethanol or isopropanol. We describe five patients with fatal methanol poisoning resulting from hand sanitizers improperly containing methanol. CASE SUMMARY Comparing a 5-month period from 2019 to the same time frame in 2020, the Arizona Poison and Drug Information Center has seen an increase of 124% in exposures to hand sanitizer. Of these cases, 28% involved methanol-contaminated hand sanitizer. Five of these patients died from methanol poisoning. All five cases had similar clinical features with severe high anion gap metabolic acidosis and, in four patients, elevated osmolal gap. Methanol concentrations were consistently very elevated, but these results were not available before the patients succumbed. Four of the patients received fomepizole and adjunctive care. Two patients received emergency extracorporeal therapy. All five died despite maximal treatment efforts. CONCLUSION During the pandemic in 2020, there was a proliferation of alcohol-based hand sanitizers which contained methanol. Exposure to these products, which failed to meet regulatory standards, led to increased harm and death. Challenges to treatment of methanol poisoning, especially in rural areas, include lack of access to timely laboratory measurement of methanol concentrations and lack of available emergency hemodialysis without transfer of the patient.
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Affiliation(s)
- Sarah Denise Holzman
- Arizona Poison and Drug Information Center, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Jaiva Larsen
- Arizona Poison and Drug Information Center, University of Arizona College of Pharmacy, Tucson, AZ, USA.,Department of Emergency Medicine, Banner University Medical Center South, Tucson, AZ, USA.,Department of Emergency Medicine, Southern Arizona VA Health Care System, Tucson, AZ, USA
| | - Ramandeep Kaur
- Arizona Poison and Drug Information Center, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Geoffrey Smelski
- Arizona Poison and Drug Information Center, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Steven Dudley
- Arizona Poison and Drug Information Center, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Farshad Mazda Shirazi
- Arizona Poison and Drug Information Center, University of Arizona College of Pharmacy, Tucson, AZ, USA.,Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ, USA.,Department of Medical Pharmacology, University of Arizona College of Medicine, Tucson, AZ, USA.,Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, USA
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40
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Wong A, Hoffman RS, Walsh SJ, Roberts DM, Gosselin S, Bunchman TE, Kebede S, Lavergne V, Ghannoum M. Extracorporeal treatment for calcium channel blocker poisoning: systematic review and recommendations from the EXTRIP workgroup. Clin Toxicol (Phila) 2021; 59:361-375. [PMID: 33555964 DOI: 10.1080/15563650.2020.1870123] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Calcium channel blockers (CCBs) are commonly used to treat conditions such as arterial hypertension and supraventricular dysrhythmias. Poisoning from these drugs can lead to severe morbidity and mortality. We aimed to determine the utility of extracorporeal treatments (ECTRs) in the management of CCB poisoning. METHODS We conducted systematic reviews of the literature, screened studies, extracted data, summarized findings, and formulated recommendations following published EXTRIP methods. RESULTS A total of 83 publications (6 in vitro and 1 animal experiments, 55 case reports or case series, 19 pharmacokinetic studies, 1 cohort study and 1 systematic review) met inclusion criteria regarding the effect of ECTR. Toxicokinetic or pharmacokinetic data were available on 210 patients (including 32 for amlodipine, 20 for diltiazem, and 52 for verapamil). Regardless of the ECTR used, amlodipine, bepridil, diltiazem, felodipine, isradipine, mibefradil, nifedipine, nisoldipine, and verapamil were considered not dialyzable, with variable levels of evidence, while no dialyzability grading was possible for nicardipine and nitrendipine. Data were available for clinical analysis on 78 CCB poisoned patients (including 32 patients for amlodipine, 16 for diltiazem, and 23 for verapamil). Standard care (including high dose insulin euglycemic therapy) was not systematically administered. Clinical data did not suggest an improvement in outcomes with ECTR. Consequently, the EXTRIP workgroup recommends against using ECTR in addition to standard care for patients severely poisoned with either amlodipine, diltiazem or verapamil (strong recommendations, very low quality of the evidence (1D)). There were insufficient clinical data to draft recommendation for other CCBs, although the workgroup acknowledged the low dialyzability from, and lack of biological plausibility for, ECTR. CONCLUSIONS Both dialyzability and clinical data do not support a clinical benefit from ECTRs for CCB poisoning. The EXTRIP workgroup recommends against using extracorporeal methods to enhance the elimination of amlodipine, diltiazem, and verapamil in patients with severe poisoning.
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Affiliation(s)
- Anselm Wong
- Austin Toxicology Unit and Emergency Department, Victorian Poisons Information Centre, Austin Health, Heidelberg, Victoria, Australia.,Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.,Centre for Integrated Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Steven J Walsh
- Department of Emergency Medicine, Division of Medical Toxicology, The Poison Control Center at Children's Hospital of Philadelphia, Einstein Healthcare Network, Philadelphia, PA, USA
| | - Darren M Roberts
- Departments of Renal Medicine and Transplantation and Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia.,St. Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia.,Drug Health Clinical Services, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Sophie Gosselin
- Montérégie-Centre Emergency Department, Centre Intégré de Santé et de Services Sociaux (CISSS), Hôpital Charles-Lemoyne, Greenfield Park, QC.,Department of Emergency Medicine, McGill University, Montreal.,Centre Antipoison du Québec, Quebec, Canada
| | - Timothy E Bunchman
- Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, USA
| | - Sofia Kebede
- School of Medicine, St. Peter`s Specialized Hospital Poison Center, Addis Ababa University, Addis Ababa, Ethiopia
| | - Valery Lavergne
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, QC, Canada
| | - Marc Ghannoum
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, QC, Canada
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41
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Drick N, Schmidt JJ, Wiesner O, Kielstein JT. [Fomepizole, ethanol or dialysis in the case of life-threatening ethylenglycol intoxication?]. Med Klin Intensivmed Notfmed 2020; 116:698-701. [PMID: 32820350 DOI: 10.1007/s00063-020-00718-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 05/25/2020] [Accepted: 07/04/2020] [Indexed: 11/29/2022]
Abstract
The EXTRIP (EXtracorporeal Treatments In Poisoning) workgroup is a collaborative international effort of pharmacologists, toxicologists, critical care physicians and nephrologists reviewing all available evidence in extracorporeal procedures for the treatment of intoxications in a standardized way to distill treatment recommendations for the physician at the bedside. The second round of guidelines will include recommendations for ethylenglycol intoxication. The case reported here is of a 60-year old man with a body weight of 65 kg who ingested approximately half a bottle (500 mL) of Aral Antifreeze in a suicidal attempt and presented around 12 h later with severe metabolic acidosis (venous blood gas analysis: pH 7.13; lactate 30 mmol/l, anion gap 23.3 mmol/l). As fomepizole, the inhibitor of the alcohol dehydrogenase, was not readily available, therapy with intermittent hemodialysis was started, as well as ethanol infusion. The first available ethylenglycol concentration before prolonged intermittent hemodialysis was 1230 mg/L. The total removed amount of ethylenglycol during intermittent hemodialysis, as well as following prolonged intermittent renal replacement therapy, was quantified (102 and 65 g). Based on this case report, the new EXRIP recommendations for the role of extracorporeal treatment in the case of ethylenglycol intoxication are discussed.
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Affiliation(s)
- N Drick
- Klinik für Pneumologie, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - J J Schmidt
- Klinik für Nephrologie, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - O Wiesner
- Klinik für Pneumologie, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - J T Kielstein
- Medizinische Klinik V, Nephrologie
- Rheumatologie
- Blutreinigungsverfahren, Städtisches Klinikum Braunschweig, Braunschweig, Deutschland
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42
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Gouda AS, Khattab AM, Mégarbane B. Lessons from a methanol poisoning outbreak in Egypt: Six case reports. World J Crit Care Med 2020; 9:54-62. [PMID: 32844091 PMCID: PMC7416361 DOI: 10.5492/wjccm.v9.i3.54] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/08/2020] [Accepted: 07/19/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Mass methanol poisonings are challenging, especially in regions with no preparedness, management guidelines and available antidotes.
CASE SUMMARY Six Ukrainian patients were referred to our emergency department in Cairo, Egypt several hours after drinking an alcoholic beverage made of 70%-ethanol disinfectant bought from a local pharmacy. All patients presented with severe metabolic acidosis and visual impairments. Two were comatose. Management was based on the clinical features and chemistry tests due to deficient resources for methanol leveling. No antidote was administered due to fomepizole unavailability and the difficulties expected to obtain ethanol and safely administer it without concentration monitoring. One patient died from multiorgan failure, another developed blindness and the four other patients rapidly improved.
CONCLUSION This methanol poisoning outbreak strongly highlights the lack of safety from hazardous pharmaceuticals sold in pharmacies and limitations due to the lack of diagnostic testing, antidote availability and staff training in countries with limited-resources such as Egypt.
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Affiliation(s)
- Ahmed S Gouda
- National Egyptian Center of Environmental and Toxicological Research, Faculty of Medicine, Cairo University, Cairo 11562, Egypt
| | - Amr M Khattab
- Department of Forensic Medicine and clinical Toxicology, Faculty of Medicine, Cairo University, Cairo 11562, Egypt
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, Paris 75010, France
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Reisinger A, Rabensteiner J, Hackl G. Diagnosis of acute intoxications in critically ill patients: focus on biomarkers - part 2: markers for specific intoxications. Biomarkers 2020; 25:112-125. [PMID: 32011177 DOI: 10.1080/1354750x.2020.1725787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
In medical intensive care units, acute intoxications contribute to a large proportion of all patients. Epidemiology and a basic overview on this topic were presented in part one. The purpose of this second part regarding toxicological biomarkers in the ICU setting focuses on specific poisons and toxins. Following the introduction of anion and osmol gap in part one, it's relevance in toxic alcohols and other biomarkers for these poisonings are presented within this publication. Furthermore, the role of markers in the blood, urine and cerebrospinal fluid for several intoxications is evaluated. Specific details are presented, amongst others, for cardiovascular drug poisoning, paracetamol (acetaminophen), ethanol, pesticides, ricin and yew tree intoxications. Detailed biomarkers and therapeutic decision tools are shown for carbon monoxide (CO) and cyanide (CN-) poisoning. Also, biomarkers in environmental toxicological situations such as mushroom poisoning and scorpion stings are presented.
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Affiliation(s)
- Alexander Reisinger
- Intensive Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Jasmin Rabensteiner
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Gerald Hackl
- Intensive Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Šejvl J, Barták M, Gavurová B, Mašlániová M, Petruželka B, Rogalewicz V, Zacharov S, Miovský M. Public health response to methanol mass poisoning in the Czech Republic in 2012: a case study. Cent Eur J Public Health 2020; 27 Suppl:S29-S39. [PMID: 31901190 DOI: 10.21101/cejph.a5764] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 08/08/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The study focuses on the 2012 methanol outbreak in the Czech Republic. The main goal of the present study was to apply analytical and descriptive tools to selected qualitative and quantitative processes related to the 2012 methanol outbreak in the Czech Republic. The secondary goal was to study and evaluate in detail their potential for creating integrated conceptual national policies aimed at eliminating the risk of methanol poisoning in the future. METHODS The presented qualitative analysis focused on the content of documents published by Czech public authorities - the Ministry of Health, the Ministry of the Interior, the Czech Agriculture and Food Inspection Authority, and the Regional Public Health Authorities - as well as the content of the relevant legal regulations. Moreover, statistical data concerning the number of hospitalisations and deaths due to the methanol intoxication were used to provide a background to a detailed description of the relevant facts. RESULTS In procedural terms, most of the analysed measures focused on a strongly restrictive regulation of sales, regular information channels designed to protect consumers on the national as well as international level, and elimination of further health and economic risks stemming from the dangerous alcoholic products that had already entered distribution networks. The health, social and economic consequences of such activities are quantified at a highly aggregated level. The analysed institutional ties are evaluated also in the context of international documents: the European Action Plan to Reduce Harmful Use of Alcohol 2012-2020 and the Global Strategy to Reduce Harmful Use of Alcohol, and their current potential for steering public policies is assessed. CONCLUSION The analysis and evaluation of procedural activities carried out after the methanol outbreak have laid the foundations for a multidimensional study that can contribute to integrated national policy concepts aimed at preventing these and similar negative health, societal and economic consequences. Six years after the methanol outbreak, national and regional health policies have reflected no findings concerning the experience of patients whose health was impaired due to methanol, and the economic cost of the event has not been calculated. The quality of life of these patients has greatly decreased due to permanent or partial incapacity and serious upheavals of their and their families' economic and social conditions. This opens the question of researching and evaluating multiple aspects of health, social and economic impacts of harmful use of alcohol and setting up processes to mitigate these impacts.
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Affiliation(s)
- Jaroslav Šejvl
- Department of Addictology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Miroslav Barták
- Department of Addictology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Beáta Gavurová
- Department of Addictology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Miroslava Mašlániová
- Department of Addictology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Benjamin Petruželka
- Department of Addictology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Vladimír Rogalewicz
- Department of Addictology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Sergej Zacharov
- Department of Occupational Medicine with Toxicological Information Centre, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Michal Miovský
- Department of Addictology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
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Rulisek J, Waldauf P, Belohlavek J, Balik M, Kotikova K, Hlusicka J, Vaneckova M, Seidl Z, Diblik P, Bydzovsky J, Heissigerova J, Urban P, Miovsky M, Sejvl J, Pelclova D, Zakharov S. Health-related quality of life determinants in survivors of a mass methanol poisoning outbreak: six-year prospective cohort study. Clin Toxicol (Phila) 2020; 58:870-880. [PMID: 31913708 DOI: 10.1080/15563650.2019.1702994] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Purpose: The effect of acute methanol poisoning on the follow-up quality of life of survivors in mass poisoning outbreaks is not known. The objective of this is to study the impact of visual and central nervous system (CNS) sequelae of methanol poisoning on long-term health-related quality of life (QoL) of survivors, its clinical determinants, and dynamics.Materials and methods: A total of 54 patients with confirmed methanol poisoning (mean age 46.7 ± 13.4 years, 9 females) were examined consequently three times within six-year prospective cohort study and compared to 23 controls with the history of chronic alcohol abuse. The following tests were performed: SF-36 QoL questionnaire, visual evoked potentials (VEP) of optic nerve, ocular examination with retinal nerve fiber layer (RNFL) thickness measurement, brain magnetic resonance imaging (MRI), and biochemical and toxicological tests.Results: Acute methanol poisoning led to significant decrease in physical component summary (PCS) compared to PCS of age-adjusted controls (mean score with SD 46.8 ± 11.0 versus 52.3 ± 9.4 points; p = .003). In 17/40 (42.5%) patients with three rounds of examination, signs of severe disability (≤30 points in at least one score) were present six years after discharge, with negative dynamics of PCS score during the observation period. The patients with abnormal RNFL thickness had lower PCS (mean difference 10.5 points; 95%CI 3.5-17.5, p = .004) and mental component summary score (9.5 points; 95%CI 1.9-17.1, p = .015) compared to the patients with normal RNFL. Signs of physical and mental adaptation to long-term visual sequelae were registered with gradual reduction of difference in most of physical and mental components scores compared to the patients with normal RNFL during six years of observation. Signs of hemorrhagic brain lesions were associated with permanent decrease of PCS score (mean difference 7.4 points; 95%CI 0.6-14.0; p = .033), bodily pain (8.7 points; 95%CI 1.6-17.6; p = .018), and social functioning (8.2 points; 95%CI 3.0-17.4; p = .005) six years after discharge. No effect of type of antidote (fomepizole versus ethanol) and extracorporeal enhanced elimination modality (intermittent hemodialysis versus continuous renal replacement therapy) applied in hospital on long-term QoL was found (all p > .05).Conclusion: Acute methanol poisoning was associated with a significant decrease of health-related quality of life of survivors persisting for at least six years after discharge. The more pronounced decrease in QoL scores was observed in the patients with hemorrhagic brain lesions and visual sequelae of poisoning with abnormal RNFL thickness.
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Affiliation(s)
- Jan Rulisek
- Department of Anesthesia and Intensive Care, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Petr Waldauf
- Department of Anesthesia and Intensive Care, Third Faculty of Medicine, Charles University and Royal Vinohrady Teaching Hospital, Prague, Czech Republic
| | - Jan Belohlavek
- Department of Cardiology and Angiology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Martin Balik
- Department of Anesthesia and Intensive Care, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Katerina Kotikova
- Department of Occupational Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Toxicological Information Centre, General University Hospital, Prague, Czech Republic
| | - Jiri Hlusicka
- Department of Occupational Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Toxicological Information Centre, General University Hospital, Prague, Czech Republic
| | - Manuela Vaneckova
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Zdenek Seidl
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Pavel Diblik
- Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jan Bydzovsky
- Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jarmila Heissigerova
- Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Pavel Urban
- Department of Occupational Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Toxicological Information Centre, General University Hospital, Prague, Czech Republic
| | - Michal Miovsky
- Department of Addictology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jaroslav Sejvl
- Department of Addictology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Daniela Pelclova
- Department of Occupational Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Toxicological Information Centre, General University Hospital, Prague, Czech Republic
| | - Sergey Zakharov
- Department of Occupational Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Toxicological Information Centre, General University Hospital, Prague, Czech Republic
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Harbord N. Common Toxidromes and the Role of Extracorporeal Detoxification. Adv Chronic Kidney Dis 2020; 27:11-17. [PMID: 32146996 DOI: 10.1053/j.ackd.2019.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 08/25/2019] [Indexed: 01/12/2023]
Abstract
Extracorporeal modalities have been used for detoxification for decades, with hemodialysis the preferred and most commonly used modality. Salicylates, lithium, methanol, and ethylene glycol are the most common poisonings treated with dialysis. For each of these common poisonings, a description of the toxidrome including pharmacokinetics, clinical presentation, an overview of treatment, and the role and application of dialysis is outlined. Inhibition of alcohol dehydrogenase to prevent the formation of toxic metabolites in methanol and ethylene glycol is discussed in detail, including the use of fomepizole and ethanol to complement and in some cases prevent the need for hemodialysis. Hemodialysis has been attempted to treat many poisonings, often without success. A description of EXTRIP (Extracorporeal Treatments in Poisoning), a multidisciplinary project examining the evidence for extracorporeal treatments in poisoning, is also described. Recommendations for poisoning with acetaminophen, baclofen, barbiturates, carbamazepine, digoxin, metformin, phenytoin, thallium, theophylline, tricyclic antidepressants, and valproic acid are provided in a comprehensive table.
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Jaffe TA, Boyer EW, Erickson TB, Studley H, Hayes BD, Chai PR. Acute and delayed toxicity from co-ingestion of methylene chloride and methanol. TOXICOLOGY COMMUNICATIONS 2019; 3:79-84. [PMID: 31745533 PMCID: PMC6863342 DOI: 10.1080/24734306.2019.1685222] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Methylene chloride is a volatile, chlorinated hydrocarbon and colorless solvent found in multiple industrial products including paint strippers, metal cleaners, automotive products, pesticides and aerosol containers. Occupational exposure to methylene chloride is reported in automotive technicians, painters, and other industrial workers with adverse health effects including gastrointestinal, neurological, as well as hepato-renal injuries. International Agency for Research on Cancer (IARC) classifies methylene chloride as a 2 A carcinogen. Through a series of reactions catalyzed by cytochrome P450 2E1 (CYP2E1), metabolism of methylene chloride leads to the formation of formyl chloride, and ultimately carbon monoxide (CO). Most reports of methylene chloride toxicity are due to dermal and inhalational exposure in occupational settings. Ingestion of methylene chloride is uncommon, yet can lead to significant toxicity and prolonged CO toxicity. Methylene chloride is frequently formulated with methanol; individuals who intentionally ingest methylene chloride can experience concomitant methanol toxicity. We present a case of acute ingestion of paint stripper containing methanol and methylene chloride. We discuss the clinical presentation, key management decisions, relevant pathophysiology and biochemistry, as well as the clinical course and management.
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Affiliation(s)
- Todd A Jaffe
- Harvard Affiliated Emergency Medicine Residency at Massachusetts General Hospital and Brigham and Women's Hospital, Boston, MA, USA
| | - Edward W Boyer
- Division of Medical Toxicology, Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Behavioral Science Research Program, The Fenway Institute, Boston, MA, USA
| | - Timothy B Erickson
- Division of Medical Toxicology, Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Harvard Humanitarian Initiative, Harvard University, Cambridge, MA, USA
| | - Heather Studley
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bryan D Hayes
- Clinical Pharmacist, Emergency Medicine and Toxicology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Peter R Chai
- Division of Medical Toxicology, Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Behavioral Science Research Program, The Fenway Institute, Boston, MA, USA.,Koch Institute for Integrated Cancer Research, Massachusetts Institute of Technology, Boston, MA, USA
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Jung B, Martinez M, Claessens YE, Darmon M, Klouche K, Lautrette A, Levraut J, Maury E, Oberlin M, Terzi N, Viglino D, Yordanov Y, Claret PG, Bigé N. Diagnostic et Prise en Charge de l’Acidose Métabolique Recommandations formalisées d’experts communes Société de réanimation de langue française (SRLF) – Société française de médecine d’urgence (SFMU). ANNALES FRANCAISES DE MEDECINE D URGENCE 2019. [DOI: 10.3166/afmu-2019-0162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
L’acidose métabolique est un trouble fréquemment rencontré en médecine d’urgence et en médecine intensive réanimation. La littérature s’étant enrichie de nouvelles données concernant la prise en charge de l’acidose métabolique, la Société de Réanimation de Langue Française (SRLF) et la Société Française de Médecine d’Urgence (SFMU) ont élaboré des recommandations formalisées d’experts selon la méthodologie GRADE. Les champs de la stratégie diagnostique, de l’orientation et de la prise en charge thérapeutique ont été traités et vingt-neuf recommandations ont été formulées : quatre recommandations fortes (Grade 1), dix recommandations faibles (Grade 2) et quinze avis d’experts. Toutes ont obtenu un accord fort. L’application des méthodes d’Henderson-Hasselbalch et de Stewart pour le diagnostic du mécanisme de l’acidose métabolique est discutée et un algorithme diagnostique est proposé. L’utilisation de la cétonémie et des lactatémies veineuse et capillaire est également traitée. L’intérêt du pH, de la lactatémie et de sa cinétique pour l’orientation des patients en pré-hospitalier et aux urgences est envisagé. Enfin, les modalités de l’insulinothérapie au cours de l’acidocétose diabétique, les indications de la perfusion de bicarbonate de sodium et de l’épuration extra-rénale ainsi que les modalités de la ventilation mécanique au cours des acidoses métaboliques sévères sont traitées dans la prise en charge thérapeutique.
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Sun X, Chen X, Lu J, Tao Y, Zhang L, Dong L. Extracorporeal treatment in children with acute severe poisoning. Medicine (Baltimore) 2019; 98:e18086. [PMID: 31764843 PMCID: PMC6882618 DOI: 10.1097/md.0000000000018086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 08/06/2019] [Accepted: 10/23/2019] [Indexed: 02/01/2023] Open
Abstract
Acute poisoning in children is a clinical emergency. Prompt and effective treatment is critical for life-threatening poisoning. Extracorporeal treatment (ECTR) is a practical option for enhancing the elimination of poisons.We conducted a retrospective observational study on 338 children with severe acute poisoning who received ECTR during hospitalization from January 2010 to December 2017. The poisonous substances, utilization of ECTR, adverse reactions to ECTR, and outcomes were recorded.The top 3 poisoning categories, in order of frequency, were found to be pesticides (57.99%), biotoxins (25.15%), and pharmaceuticals (14.20%). Paraquat (35.21%), an organic heterocyclic herbicide with high toxicity to humans, was the most common toxic substance. The main modalities of ECTR use were hemoperfusion (50.59%) and therapeutic plasma exchange (42.60%), followed by continuous renal replacement therapy (4.44%) and hemodialysis (1.18%). There were also 4 patients (1.18%) with a combination of ECTR performed. Adverse events of ECTR included errhysis and hematomas around the catheter exit site, oral cavity bleeding, allergic reactions, hypothermia, hypotension, and blood coagulation. The adverse reactions were mostly mild to moderate and were manageable. During the study period, there were 295 patients (87.28%) who were cured, 9 (2.66%) who experienced some improvement, and 34 (10.06%) who died.ECTR modalities were found to be clinically effective approaches to the treatment of poisoning by pesticides, biotoxins, and pharmaceuticals, indicating they are important modalities in toxicology and treatment, and are well tolerated by children.
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Affiliation(s)
- Xiaomei Sun
- Department of Pediatrics
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiuying Chen
- Department of Pediatrics
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jing Lu
- Department of Pediatrics
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yuhong Tao
- Department of Pediatrics
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lijuan Zhang
- Department of Pediatrics
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Liqun Dong
- Department of Pediatrics
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
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50
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Raina R, Grewal MK, Blackford M, Symons JM, Somers MJG, Licht C, Basu RK, Sethi SK, Chand D, Kapur G, McCulloch M, Bagga A, Krishnappa V, Yap HK, de Sousa Tavares M, Bunchman TE, Bestic M, Warady BA, de Ferris MDG. Renal replacement therapy in the management of intoxications in children: recommendations from the Pediatric Continuous Renal Replacement Therapy (PCRRT) workgroup. Pediatr Nephrol 2019; 34:2427-2448. [PMID: 31446483 DOI: 10.1007/s00467-019-04319-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 06/28/2019] [Accepted: 07/24/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Intentional or unintentional ingestions among children and adolescents are common. There are a number of ingestions amenable to renal replacement therapy (RRT). METHODS We systematically searched PubMed/Medline, Embase, and Cochrane databases for literature regarding drugs/intoxicants and treatment with RRT in pediatric populations. Two experts from the PCRRT (Pediatric Continuous Renal Replacement Therapy) workgroup assessed titles, abstracts, and full-text articles for extraction of data. The data from the literature search was shared with the PCRRT workgroup and two expert toxicologists, and expert panel recommendations were developed. RESULTS AND CONCLUSIONS We have presented the recommendations concerning the use of RRTs for treatment of intoxications with toxic alcohols, lithium, vancomycin, theophylline, barbiturates, metformin, carbamazepine, methotrexate, phenytoin, acetaminophen, salicylates, valproic acid, and aminoglycosides.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Akron Children's Hospital, Akron, OH, USA. .,Akron Nephrology Associates/Cleveland Clinic Akron General, 224 W. Exchange St., Akron, OH, 44302, USA.
| | - Manpreet K Grewal
- Akron Nephrology Associates/Cleveland Clinic Akron General, 224 W. Exchange St., Akron, OH, 44302, USA
| | - Martha Blackford
- Division of Clinical Pharmacology & Toxicology, Akron Children's Hospital, Akron, OH, USA
| | - Jordan M Symons
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | | | - Christoph Licht
- Division of Nephrology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Rajit K Basu
- Department of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Sidharth Kumar Sethi
- Pediatric Nephrology & Pediatric Kidney Transplantation, Kidney and Urology Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Deepa Chand
- Division of Pediatric Nephrology, Washington University School of Medicine, St. Louis, MO, USA
| | - Gaurav Kapur
- Department of Pediatric Nephrology, Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | - Mignon McCulloch
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Arvind Bagga
- Division of Paediatric Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Vinod Krishnappa
- Akron Nephrology Associates/Cleveland Clinic Akron General, 224 W. Exchange St., Akron, OH, 44302, USA
| | - Hui-Kim Yap
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Timothy E Bunchman
- Pediatric Nephrology & Transplantation, Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, VA, USA
| | - Michelle Bestic
- Division of Clinical Pharmacology & Toxicology, Akron Children's Hospital, Akron, OH, USA
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, MO, USA
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