Dialyzing the Toxicology Patient

March 29, 2010, 11:17 am

★★★½☆

Dialysis in the poisoned patient.  Bayliss G.  Hemodialysis Int  2010 March 19 [Epub ahead of print]

Abstract

This is a helpful revieew of enhanced elimination techniques available for the management of toxicology patients.  Some key points emphasized in the article:

• Intermittent hemodialysis is ideal for low-molecular-weight, water-soluble toxins with small volumes of distribution and minimal binding to proteins or lipids.

Continuous renal replacement therapy(CRRT) should be considered for toxins that have large volumes of distribution or are likely to experience rebound, or in patients who are unstable and are unlikely to tolerate intermittent hemodialysis. 

• Charcoal hemoperfusion is an option for toxins that are highly bound to proteins or lipids.  This technique will not be successful for toxins that do not bind well to charcoal, such as toxic alcohols or lithium. 

• Basal ganglia infarction can be seen in methanol toxicity.  There is some evidence suggesting that use of heparin anticoagulation during dialysis can increase the risk of hemorrhagic transformation of these infarcts.

Although Dr. Bayliss specifically discusses the use of hemodialysis in cases of lithium, toxic alcohol, and salicylate toxicity, I would have appreciated a more thorough discussion of the role of enhanced elimination in other poisonings, such as valproic acid, carbamazepine, and metformin.

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