CRRT and Extracorporeal Techniques in Exogenous Intoxications
Exogenous intoxications in the form of intentional and unintentional poisonings can lead to a high degree of morbidity and potential mortality. In the United States, around 2 million human exposures were reported to poison control centers in 2016 alone. While accidental poisoning may occur and include household cleaning products and cosmetics among others, medications such as analgesics, antidepressant, and other psychiatric medications are among the most frequently purposefully ingested substances.
Strategies to treat exogenous intoxications involve symptomatic care and support, metabolite level monitoring (when available), detoxification strategies including antidote administration, activated charcoal administration, fluid administration and urinary pH modification and in severe cases, the use of extracorporeal techniques to enhance clearance of the specific intoxicant.
The mainstays of extracorporeal approaches include intermittent hemodialysis and continuous renal replacement therapies. The majority of poisonings/intoxications, if treatable with extracorporeal approaches, can be accomplished using these more common techniques. The overall success with specific therapies is dependent on the extracorporeal approach used and the physical and distributive properties of the intoxicant.
In this chapter, we review and describe some of the extracorporeal approaches to treat intoxications. We also provide some specific evidence-based approaches as outlined by the Extracorporeal Treatment in Poisoning workgroup.
KeywordsIntoxications Poisoning IHD CRRT Albumin dialysis Extracorporeal
- 1.Gummin DD, Mowry JB, Spyker DA, Brooks DE, Fraser MO, Banner W. 2016 Annual report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 34th annual report. Clin Toxicol (Phila). 2017;55(10):1072–252. https://doi.org/10.1080/15563650.2017.1388087. Epub 2017 Nov 29.CrossRefGoogle Scholar
- 6.Winchester JF, et al. Use of dialysis and hemoperfusion in treatment of poisoning. Handbook of dialysis. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2007. p. 300–22.Google Scholar
- 10.Drexler K, Baustian C, Richter G, Ludwig J, Ramlow W, Mitzner S. Albumin dialysis molecular adsorbents recirculating system: impact of dialysate albumin concentration on detoxification efficacy. Ther Apher Dial. 2009;13(5):393–8. https://doi.org/10.1111/j.1744-9987.2009.00757.x.CrossRefPubMedGoogle Scholar
- 12.Bouchard J, Lavergne V, Roberts DM, Cormier M, Morissette G, Ghannoum M. Availability and cost of extracorporeal treatments for poisonings and other emergency indications: a worldwide survey. Nephrol Dial Transplant. 2017;32(4):699–706. https://doi.org/10.1093/ndt/gfw456.CrossRefPubMedGoogle Scholar
- 13.Juurlink DN, Gosselin S, Kielstein JT, Ghannoum M, Lavergne V, Nolin TD, Hoffman RS, EXTRIP Workgroup. Extracorporeal treatment for salicylate poisoning: systematic review and recommendations from the EXTRIP workgroup. Ann Emerg Med. 2015;66(2):165–81. https://doi.org/10.1016/j.annemergmed.2015.03.031. Epub 2015 May 15.CrossRefPubMedGoogle Scholar
- 14.Decker BS, Goldfarb DS, Dargan PI, Friesen M, Gosselin S, Hoffman RS, Lavergne V, Nolin TD, Ghannoum M, EXTRIP Workgroup. Extracorporeal treatment for lithium poisoning: systematic review and recommendations from the EXTRIP workgroup. Clin J Am Soc Nephrol. 2015;10(5):875–87. https://doi.org/10.2215/CJN.10021014. Epub 2015 Jan 12.CrossRefPubMedPubMedCentralGoogle Scholar
- 15.Ghannoum M, Yates C, Galvao TF, Sowinski KM, Vo TH, Coogan A, Gosselin S, Lavergne V, Nolin TD, Hoffman RS, EXTRIP workgroup. Extracorporeal treatment for carbamazepine poisoning: systematic review and recommendations from the EXTRIP workgroup. Clin Toxicol (Phila). 2014;52(10):993–1004. https://doi.org/10.3109/15563650.2014.973572. Epub 2014 Oct 30.CrossRefGoogle Scholar
- 16.Ghannoum M, Laliberté M, Nolin TD, MacTier R, Lavergne V, Hoffman RS, Gosselin S, Workgroup EXTRIP. Extracorporeal treatment for valproic acid poisoning: systematic review and recommendations from the EXTRIP workgroup. Clin Toxicol (Phila). 2015;53(5):454–65. https://doi.org/10.3109/15563650.2015.1035441.CrossRefGoogle Scholar
- 17.Anseeuw K, Mowry JB, Burdmann EA, Ghannoum M, Hoffman RS, Gosselin S, Lavergne V, Nolin TD, EXTRIP Workgroup. Extracorporeal treatment in phenytoin poisoning: systematic review and recommendations from the EXTRIP (extracorporeal treatments in poisoning) workgroup. Am J Kidney Dis. 2016;67(2):187–97. https://doi.org/10.1053/j.ajkd.2015.08.031. Epub 2015 Nov 11.CrossRefPubMedGoogle Scholar
- 18.Gosselin S, Juurlink DN, Kielstein JT, Ghannoum M, Lavergne V, Nolin TD, Hoffman RS, Workgroup E. Extracorporeal treatment for acetaminophen poisoning: recommendations from the EXTRIP workgroup. Clin Toxicol (Phila). 2014;52(8):856–67. https://doi.org/10.3109/15563650.2014.946994. Epub 2014 Aug 18.CrossRefGoogle Scholar
- 19.Calello DP, Liu KD, Wiegand TJ, Roberts DM, Lavergne V, Gosselin S, Hoffman RS, Nolin TD, Ghannoum M, Extracorporeal Treatments in Poisoning Workgroup. Extracorporeal treatment for metformin poisoning: systematic review and recommendations from the extracorporeal treatments in poisoning workgroup. Crit Care Med. 2015;43(8):1716–30. https://doi.org/10.1097/CCM.0000000000001002.CrossRefPubMedGoogle Scholar