Recommendations for starting hemodialysis in salicylate toxicity

June 30, 2015, 9:03 pm

Screen Shot 2015-06-30 at 5.55.50 PM★★★½☆

Extracorporeal Treatment for Salicylate Poisoning: Systematic Review and Recommendations From the EXTRIP Workgroup. Juurlink D et al. Ann Emerg Med 2015 May 8 [Epub ahead of print]


Aspirin is an especially dangerous poison for a number reasons:

  • • It’s easy to purchase over-the-counter in large quantities
  • • Even after a life-threatening acute ingestion of salicylate, a patient can present looking deceptively stable only to deteriorate catastrophically several hours later
  • • In chronic salicylate toxicity, the diagnosis can be easily missed

Ask many toxicologists about the poisons they fear the most, and aspirin will — more often than not — be high on the list.

This paper, from the Extracorporeal Treatments in Poisoning (ExTRIP) workgroup, reviewed the literature on salicylate toxicity to determine evidence- and consensus-based recommendations on indications for use of extracorporeal treatment (essentially hemodialysis) in these cases. The emphasis, as in the group’s papers on other poisons, is on consensus rather than evidence, since the group has consistently found that the level of evidence for use of hemodialysis in any poisoning is very poor, amounting to — their words, not mine — “just a guess.”

All of the recommendations presented here are rated as 1D — “1” representing a “strong recommendation,” “D” indicating that it is based on a “very low level of evidence.” I won’t even get into the group’s confusing distinction between a “recommendation” and a somewhat weaker “suggestion.”

I’ll just summarize the group’s recommendations for starting hemodialysis in salicylate toxicity:

  • Salicylate level > 100 mg/dL
  • Salicylate level > 90 mg/dL in presence of impaired kidney function*
  • Altered mental status
  • New hypoxemia requiring supplemental oxygen
  • Standard therapy (supportive measures, adequate volume repletion, bicarbonate, etc) fails (for example, rapidly increasing levels despite gastrointestinal decontamination and urinary alkalinization)

*Criteria for impaired kidney function include any of the following:

      1. estimated glomerular filtration rate < 45 mL/min per 1.73 m3
      2. creatinine > 2 mg/dL in adults or > 1.5 mg/dL in elderly or patients with low muscle mass
      3. oliguria/anuria for > 6 hours [NOTE: strangely, the recommendations say little about the importance of correcting volume status]

As we’ve noted before in reviewing the other ExTRIP papers, these parameters are really consensus opinions rather than evidence-based guidelines, but given the impressive multi-specialty composition of the workgroup, they are well worth considering, and the stated rationales are helpful. Since salicylate is such a dangerous ingestion, I completely agress with the concept of having a rather low bar for initiating hemodialysis, which will not only accelerate removal of salicylate but also help correct acidosis.

Related posts:

Excellent guidelines for managing salicylate overdose

Hemodialysis in metformin poisoning

Hemodialysis in acute methanol poisoning: is there really good evidence?

Hemodialysis in lithium poisoning: what is the evidence?

Must-read: consider hemodialysis in cases of massive acetaminophen overdose

What enhanced elimination techniques are useful in critical toxicology patients

Hemodialysis and other extracorporeal modalities in toxicology cases



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