Severe ethylene glycol toxicity — did therapeutic* vodka really contribute to the good outcome?

April 17, 2011, 8:38 pm

★½☆☆☆

Cooling in the tropics: ethylene glycol overdose. Holyoak AL et al. Crit Care Resus 2011;13:28-32.

Abstract

This case report, from Australia, is remarkable — or probably would be so if one had enough data to make any sense of it.  A 23-year-old male is brought to the emergency department unresponsive after an apparent suicidal ingestion of ethylene glycol.  On arrival he had a metabolic acidosis (anion gap = 31) and a pH of 6.83.  Serum bicarbonate was 3 mmol/L and serum ethanol less than 3 mmol/L (< 10 mg/dL).  No serum osmolality is reported, and no ethylene glycol level was obtained.  Because fomepizole was not available, he was given intravenous alcohol with a goal of maintaining a serum ethanol level of 26-39 mmol/L (120-180 mg/dL).  The hospital quickly ran out of its supply of ethanol for infusion and he was switched to vodka by nasojejeunal tube. He was also started on continuous venovenous haemodiafiltration (CVVHDF).

After a difficult hospital course that included bilateral pneumonia and renal insufficiency, the patient recovered and is reported to have “returned to his previous level of function and health, with only minimal residual renal dysfunction”.  The authors conclude that their case “demonstrates that good outcomes may be achieved with simple and readily available therapies”.

I’m not so sure.  For one thing, CVVHDF is not a “simple and readily available therapy”, although it was most likely a key intervention here (the patient’s pH normalized 18 hours after admission. In addition, it is not clear at what stage of ethylene glycol poisoning the patient presented. Since the acidosis was so profound, most likely he had metabolized almost all of the poison to its toxic metabolites, and the attempt to block this conversion by administering ethanol was not a factor in his recovery. It is apparent from Table 2 that the target ethanol level was achieved only briefly.

This is a very interesting case, but a less-than-great case report. Still a very impressive save considering the limitations.

*The original headline mistakenly referred to “parenteral” vodka.  Since the alcohol was delivered directly to the jejunum, the route was of course enteral, not parenteral.

6 Comments:

  1. Vamsi Balakrishnan Says:

    So, theoretically, if they had run out of ethanol like this, but were giving iv supplementation for ethylene poisoning, could they have switched to literal iv vodka, bought from a supermarket or nearby store?

  2. Leon Says:

    Vamsi:

    Thank you for your comment that gives me the opportunity to correct an editing error on my part. The original headline for this post referred to “parenteral vodka”. Since the vodka was given by nasojejeunal tube, it was administered by the enteral — not parenteral — route. Theoretically, this could be effective in maintaining a desired ethanol level, since absorption should be rapid. However, from the data presented in this paper it does not seem that the target ethanol level was maintained for very long. As I commented in the post, by the time the patient presented it is likely essentially all of the ethylene glycol had been converted to toxic metabolites, and that ethanol did not contribute to the good outcome.

  3. Vamsi Balakrishnan Says:

    @Leon

    No, what I meant was, theoretically (not necessarily addressed in the article), were someone to have taken methanol at this moment, and neither fomepizole nor “ethanol” was available, could someone (theoretically) walk to a super market, pick up some “Greygoose”, etc. and administer it by IV? Or is it always given by PO? I guess I could check uptodate about this…but I’m at home at the moment 😀

    (I tried looking up alcohol infusion IV…except…I kept getting articles about flavor infusion…no literaly parenteral entry)

  4. Leon Says:

    Vamsi:

    I doubt there is any study of this and it would — of course — be extremely inadvisable to administer vodka intravenously. In addition, it would not be necessary — ethanol given by the enteral route is extremely well-absorbed and could be titrated. If nothing else were available and blocking alcohol dehydrogenase was indicated, I would not hesitate to give enteral ethanol.

  5. Lil-frog Says:

    Leon,

    You make some interesting and valid points. I suspect the point of the article is that despite the severe intoxication, the patient made an excellent recovery in the context of a) no fomipazole b) potentially late presentation c) no IV alcohol. Perhaps this calls into question current recommendations.

    I think you’re being nitpicky about the CRRT – available in any self-respecting ICU in the western world…

  6. Leon Says:

    Lil-frog:

    You’re right, perhaps I did get too focused on the most unusual part of the case, which was the vodka therapy. the article’s abstract also emphasized the role of enteral ethanol and did not mention CRRT. I still feel that the vodka was unnecessary in what was undoubtedly a late presentation. For the same reason, the unavailability of fomepizole most likely was a non-issue in this case. The authors would have been better off stressing the option of CRRT in situations where hemodialysis wasn’t available. Nevertheless, as I said in the discussion, a great save.

    Thanks for the note. I hope you are finding TPR helpful and informative.