Episode #9: TPR Podcast on hemodialysis in poisonings

June 1, 2015, 5:05 pm

Episode 9: EXTRIP Review

 

Written by Theresa Kim, MD

 

Outline

  1. EXTRIP Guideline Methodology
  2. Methanol
  3. Theophylline
  4. Lithium
  5. Acetaminophen

 

  1. EXTRIP Guideline Methodology
  • Extracorporeal treatments (ie. hemodialysis, hemoperfusion) are commonly used in poisonings despite lack of formal human trials
  • Goal of the EXTRIP workgroup was to form an international collaboration among experts from nephrology, toxicology, critical care, pharmacology, and over 30 professional societies to form consensus recommendations and suggestions based on available research and expert opinion
  • Clinical evidence ranked using GRADE system A-D
    • A = high quality evidence
    • D = very poor quality evidence
  • Strength of consensus recommendations ranked on a 3 level scale:
    • Level 1: strong recommendation agreed upon by large majority of experts
    • Level 2: weak recommendation considered appropriate by majority of experts but with some disagreement
    • Level 3: neutral position considered appropriate in right context

 

NOTE: The following are summaries of the key points from the ExTRIP publications. For a more complete discussion of the group’s full recommendations and suggestions, follow links from the ExTRIP website.

 

Methanol

  • ECTR recommended in the following circumstances
    • Severe methanol poisoning (coma, seizure, vision deficits, metabolic acidosis pH<7.15, persistent acidosis, AND/OR anion gap > 24 mmol/L (1D)
    • Serum methanol concentrations
      • >70mg/dL in context of fomepizole therapy (1D), OR
      • >60mg/dL in context of ethanol treatment (1D), OR
      • >50mg/dL in absence of alcohol dehydrogenase blocker therapy (1D)
    • Impaired renal function (1D)
  • Additional recommendations
    • Intermittent hemodialysis preferred (1D)
    • Continue ADH inhibitors throughout ECTR (1D)
    • Can terminate ECTR when methanol concentration is < 20mg/dL and clinical improvement observed (1D)

 

Theophylline

  • ECTR recommended for theophylline poisoning in the following circumstances
    • Theophylline level >100mg/L in acute exposure (1C)
    • Seizures, life threatening dysrhythmias, or shock present (1D)
    • Rising theophylline level or clinical deterioration despite optimal therapy (1D)
  • Additional recommendations
    • Cessation of ECTR when clinical improvement or theophylline level < 15mg/L (1D)
    • Intermittent hemodialysis preferred method of ECTR (1C)
    • MDAC should be continued throughout ECTR (1D)

 

Lithium

  • ECTR recommended in the following circumstances

 

  • Impaired renal function* and lithium level > 4.0mEq/L (1D)
  • Seizures, decreased level of consciousness, OR life threatening dysrhythmias regardless of lithium level (1D)

 

[*NOTE: impaired renal function defined as serum creatinine > 2.0 mg/dL in adults, or > 1.5 mg/dL in the elderly]

 

  • Additional recommendations
    • Cessation of ECTR when lithium level < 1.0mEq/L, clinical improvement apparent, OR after minimum of 6 hours of ECTR if concentration of lithium is unavailable (1D)
    • After interruption of ECTR serial levels should be obtained over 12 hours to determine need for subsequent ECTR treatment (1D)
    • Intermittent hemodialysis preferred method of ECTR (1D)

 

Acetaminophen

  • ECTR suggested in cases whereN-acetylcysteine (NAC) is administered if:
    • Patient presents with early altered mental status or severe metabolic acidosis before onset of hepatic failure (1D)

 

[NOTE: ExTRIP “suggestions” reflect less agreement among the group than their stronger “recommendations”.]

 

 

Past Quizzlers

 

Q: What 1994 movie had 2 characters named ‘Snuffie’ and ‘Right Hand Man’ who were both glue sniffers?

A: Crooklyn

Winner: John Cook

 

Q: What is the real identity of the Stay-Puft Marshmallow Man in the movie Ghostbusters?

A: Gozer, the Gozerian

Also acceptable answers:

Gozer, the destructor

Volguus Zildrohar

Gozer, the traveler

Lord of the Sebouillia

Winner: Jon Smart

 

Current Quizzler

Posted at the end of the podcast

Submit responses and any feedback to toxtrivia@gmail.com

The first correct response wins a $10 amazon gift card and a Poison Review t-shirt

 

Comments

Thank you for listening. Please subscribe on iTunes and submit any comments via iTunes or email at toxtrivia@gmail.com

 

Bibliography

Decker, B.S., Goldfarb, D.S., Dargan, P.I., Friesen, M., Gosselin, S., Hoffman, R.S., Lavergne, V., Nolin, T.D., & Ghannoum, M. (2015, Jan). Extracorporeal treatment for lithium poisoning: systemic review and recommendations from the EXTRIP workgroup. Clinical Journal of the American Society of Nephrology.

 

Ghannoum, M., Wiegand, T.J., Liu, K.D., Calello, d.p., Godin, M., Lavergne, V., Gosselin, S., Nolin, T.D., & Hoffman, R.S. (2015, May). Extracorporeal treatment for theophylline poisoning: systemic review and recommendations from the EXTRIP workgroup. Clinical Toxicology,53(4): 215-29.

 

Gosselin, S., Juurlink, D.N., Kielstein, J.T., Ghannoum, M., Lavergne, V., Nolin, T.D., & Hoffman, R.S. (2014, Sep). Extracorporeal treatment for acetaminophen poisoning: recommendations from the EXTRIP workgroup. Clinical Toxicology,52(8): 856-67.

 

EXTRIP

 

Lavergne, V., Nolin, T.D., Hoffman, R.S., Roberts, D., Gosselin, S., Goldfarb, D.S., Kielstein, J.T., Mactier, R., Maclarent, R., Mowry, J.B., Bunchman, T.E., Jurrlink, D., Megarbane, B., Anseeuw, K., Winchester, J.F., Dargan, P.I., Liu, K.D., Hoegberg, L.C., Li, Y., Calello, D.P., Burdmann, E.A., Yates, C., Laliberte, M., Decker, B.S., Augusto Mello-Da-Silva, C., Lavonas, E., & Ghannoum, M. (2012, Jun). The EXTRIP (extracorporeal treatments in poisoning) workgroup: guideline methodology. Clinical Toxicology,50(5), 461-72.

 

Roberts, D.M., Yates, C., Megarbane, B., Winchester, J.F., Maclaren, R., Gosselin, S., Nolin, T.D., Lavergne, V., Hoffman, R.S., & Ghannoum, M. (2015, Feb). Recommendations for the role of extracorporeal treatments in the management of acute methanol poisoning: a systemic review and consensus statement. Critical Care Medicine,43(2): 461-72.

 

Shannon, M. (1999). Life-threatening events after theophylline overdose: a 10 year prospective analysis. Archives of Internal Med, 159(9),989-994.

 

Shannon, M., Lovejoy, F.H., Jr. Effect of acute versus chronic intoxication on clinical features of theophylline poisoning in children. Journal of Pediatrics, 121(1),125-130.

 

 

 

 

ADDITIONAL LINKS

 

ExTRIP Workgroup Website

 

Delphi Method (Wikipedia)

 

Likert Scale (Wikipedia)

 

RAND/UCLA Appropriateness Method

 

Should We All Take a Bit of Lithium? By Anna Fels, New York Times Sept. 13, 2014

 

Ghostbusters: The Stay Puft Marshmallow Man Scene (YouTube)

 

 

 

 

 

 

 

 

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2 Comments:

  1. Stephanie Says:

    This was a great review for me! We actually have a patient that may have SILENT, so I was able to have a productive discussion with our neurologist.

    Your blog/podcast is a great resource for me and I am getting my co-pharmacists addicted.

    Thanks!

  2. Leon Says:

    Stephanie:

    Thank you for the feedback. I very glad you are finding our posts useful!