{"id":177,"date":"2018-04-23T11:52:43","date_gmt":"2018-04-23T11:52:43","guid":{"rendered":"http:\/\/edren.org\/ren\/?page_id=177"},"modified":"2018-10-30T11:10:43","modified_gmt":"2018-10-30T11:10:43","slug":"poisoning","status":"publish","type":"page","link":"https:\/\/edren.org\/ren\/handbook\/unithdbk\/poisoning\/","title":{"rendered":"Poisoning"},"content":{"rendered":"<p>Haemodialysis is effective at removing a number of low molecular weight, water-soluble poisons with a low degree of protein binding. It is indicated when elimination by other routes is unacceptably slow, especially if renal failure is contributing to this. The following agents are usefully removed:<\/p>\n<table style=\"height: 882px; width: 100%;\" border=\"1\" width=\"100%\" cellspacing=\"0\" cellpadding=\"1\">\n<tbody>\n<tr style=\"height: 13px;\">\n<td style=\"height: 13px; background-color: #e6f7ed;\" valign=\"top\" bgcolor=\"#ffffcc\" width=\"100%\"><strong><span style=\"color: #993300;\">Inorganic acids\u00a0 (Acetic, Phosphoric, Formic)<\/span><\/strong><\/p>\n<p><strong><span style=\"color: #993300;\">Alcohols (ethanol, methanol*)<\/span><\/strong><\/p>\n<p><strong><span style=\"color: #993300;\">Barbiturates<\/span><\/strong><\/p>\n<p><strong><span style=\"color: #993300;\">Chloral Hydrate<\/span><\/strong><\/p>\n<p><strong><span style=\"color: #993300;\">Ethylene glycol*<\/span><\/strong><\/p>\n<p><strong><span style=\"color: #993300;\">Thallium<\/span><\/strong><\/td>\n<\/tr>\n<tr style=\"height: 344px;\">\n<td style=\"height: 344px; background-color: #e6f7ed;\" valign=\"top\" bgcolor=\"#ffffcc\" width=\"100%\"><strong><span style=\"color: #993300;\">Lithium<\/span> <\/strong>: is<b> <\/b>the ideal poison for removal by dialysis.\u00a0 Renal tubular reabsorption\u00a0 leads to a renal clearance of 10-40ml\/min when hydration is adequate, whereas haemodialysis can achieve clearances of up to 150ml\/min.\u00a0 Some suggested indications for dialysis are:<\/p>\n<ul style=\"list-style-type: disc;\">\n<li>Lithium\u00a0level of \u00c2\u00b3 4mM<\/li>\n<li>Lithium level of \u00c2\u00b3 2.5 with severe symptoms or in the presence of significant renal impairment or sodium retention (eg heart failure, liver disease)<\/li>\n<li>if the level is falling slowly<\/li>\n<\/ul>\n<p>Rebound is normal, because of intracellular stores and the fact that slow-release preparations are commonly responsible for poisoning.\u00a0 Try 6 hours of HD on a large kidney with maximal flow rates.\u00a0 Check levels 1-2h later.<\/td>\n<\/tr>\n<tr style=\"height: 263px;\">\n<td style=\"height: 263px; background-color: #e6f7ed;\" valign=\"top\" bgcolor=\"#ffffcc\" width=\"100%\"><strong><span style=\"color: #993300;\">Salicylates\u00a0<\/span> <\/strong>Although there is a high degree of protein binding at therapeutic levels, this is saturated at toxic doses, and salicylates\u00a0become more widely tissue distributed, extending half life 3 to 4-fold to 15-30h.\u00a0\u00a0 Alkalinization of plasma and urine are beneficial.<\/p>\n<p>Dialysis should be considered when<\/p>\n<ul>\n<li>salicylate levels are &gt;800mg\/l<\/li>\n<li>impaired renal function or fluid overload<\/li>\n<li>serious toxicity (eg coma, or deterioration despite treatment)<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><strong><span style=\"color: #993300;\">* Fomepizole<\/span><\/strong> is now first line therapy for methanol and ethylene glycol poisoning, but will often need to be used together with haemodialysis in severe poisoining. Ethanol can be used to inhibit metabolism of these compounds to toxic intermediates. It is less expensive, but harder to use effectively.<\/p>\n<h5><strong><span style=\"color: #993300;\">Further information<\/span><\/strong><\/h5>\n<ul style=\"list-style-type: disc;\">\n<li><strong><span style=\"color: #993300;\">Extrip<\/span><\/strong> provides very useful information at expert level for management of drug toxicity where dialysis or other extracorporeal treatments are recommended. See the <a href=\"http:\/\/www.extrip-workgroup.org\/recommendations\">list of Extrip recommendations.<\/a><\/li>\n<li><strong><span style=\"color: #993300;\">Poisons Units<\/span><\/strong> will give detailed advice for specific drugs. <a href=\"http:\/\/www.toxbase.org\/\">TOXBASE<\/a> is invaluable for all types of poisoning. Using it requires registration. Contact A&amp;E departments or local poisons unit for help with access. Edinburgh Renal Unit users &#8211; look on your noticeboard or in your email.<\/li>\n<li><strong><span style=\"color: #993300;\">Haemoperfusion<\/span><\/strong> over activated charcoal is more effective if poisons that are protein-bound in the circulation bind to it well.\u00a0 This applies to (for instance), theophylline, some anticonvulsants, procainamide.\u00a0 Practically this is now so rarely undertaken that obtaining the charcoal cartridge may be difficult.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt; color: #808080;\"><strong>Acknowledgements:\u00a0\u00a0<\/strong> Richard Phelps and Jane Goddard were the main authors for this page. The last modified date is shown in the footer.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Haemodialysis is effective at removing a number of low molecular weight, water-soluble poisons with a low degree of protein binding. It is indicated when elimination by other routes is unacceptably slow, especially if renal failure is contributing to this. The following agents are usefully removed: Inorganic acids\u00a0 (Acetic, Phosphoric, Formic)\u2026<\/p>\n<p> <a class=\"continue-reading-link\" href=\"https:\/\/edren.org\/ren\/handbook\/unithdbk\/poisoning\/\"><span>Continue reading<\/span><i class=\"crycon-right-dir\"><\/i><\/a> <\/p>\n","protected":false},"author":2,"featured_media":0,"parent":19,"menu_order":217,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"class_list":["post-177","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/177","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/comments?post=177"}],"version-history":[{"count":3,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/177\/revisions"}],"predecessor-version":[{"id":1915,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/177\/revisions\/1915"}],"up":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/19"}],"wp:attachment":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/media?parent=177"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}