Charcoal hemoperfusion

Consider forced diuresis, urine acidification, or alkalinization if specific antidotes are not available Hemodialysis or charcoal hemoperfusion may be appropriate for rapid elimination if antidotes are not available... 

Various CNS adverse effects have been reported with CBZ and include sedation, dizziness, ataxia/clumsiness, blurred vision/diplopia, and impaired task performance. Although uncommon, fatal CBZ toxicity does occur. CBZ overdose is characterized by neurological symptoms such as diplopia, dysarthria, ataxia, vertigo, nystagmus, and coma. Infrequently, cyclic coma with biphasic fluctuations of consciousness, seizures, respiratory depression, cardiac conduction defects, and the need for artificial ventilation may occur. Plasma levels are only moderately correlated to severity, but as noted earlier, more than 15 pg/ml in children or 20 pg/ml in adults should be considered serious. Charcoal hemoperfusion or gastric lavage with activated charcoal has been used in such cases, whereas benefit from plasmapheresis is controversial (77, 114, 368). 

Hemoperfusion has been used to treat digitalis overdose (SEDA-5, 174) but once a cardiac glycoside has been distributed to the body tissues hemoperfusion is unlikely to be of benefit. For digitoxin, which has a lower apparent volume of distribution than digoxin, charcoal hemoperfusion may be more valuable. 

Aoyama N, Sasaki T, Yoshida M, Suzuki K, Matsuyama K, Aizaki T, Izumi T, Kondo R, Kamijo Y, Soma K, Ohwada T. Effect of charcoal hemoperfusion on clearance of cibenzoline succinate (cifenline) poisoning. J Toxicol Clin Toxicol 1999 37(4) 505-8. 

A 35-year-old woman took diphenhydramine 16 g and developed hypertension and QRS prolongation charcoal hemoperfusion and hemodialysis were used successfully (12). 

Mullins ME, Pinnick RV, Terhes JM. Life-threatening diphenhydramine overdose treated with charcoal hemoperfusion and hemodialysis. Ann Emerg Med 1999 33(l) 104-7. 

When serum methotrexate concentrations are high, leu-covorin (folinic acid) rescue may protect against renal damage. Methotrexate concentrations are only transiently lowered by hemoperfusion, and they are unaffected by peritoneal dialysis once there is acute renal insufficiency. Sustained reductions in drug concentrations and recovery of renal function have been reported after charcoal hemoperfusion followed by hemodialysis (63,64). 

The only alternatives to glutathione donors are charcoal hemoperfusion and hemodialysis, which can be effective up to 18 hours after dosage. However, the longer the time from ingestion to treatment, the less likely the condition is to be reversible and the more likely a fatal outcome. 

The apparent effectiveness of charcoal hemoperfusion has been reported in a 19-year-old woman who took about 5 g of phenytoin (68). The plasma concentrations of total and unbound phenjdoin fell rapidly, from 160 and 14 pmol/l to 65 and 6 pmol/l respectively, after 3 hours of hemoperfusion. The total phenytoin half-life was 3.9 hours. The protein-bound fraction was constant (91%) throughout. 

Kawasaki C, Nishi R, Uekihara S, Hayano S, Otagiri M. Charcoal hemoperfusion in the treatment of phenytoin overdose. Am J Kidney Dis 2000 35(2) 323-6. 

In acute overdosage the chief effect of quinidine is profound hypotension, due to the combination of peripheral vasodilatation, and a negative inotropic effect on the heart (68,69). Charcoal hemoperfusion has been successfully used in the treatment of quinidine overdose (70). 

However, charcoal hemoperfusion is now regarded as the recommended method for rapid reduction of serum theophylhne concentrations, if necessary, although access to this technique is limited in most hospitals. Venovenous hemofiltration, which is readily avaUable in many hospitals, appears to be a reaUstic and practical alternative to charcoal hemoperfusion, in combination with oral activated charcoal, particularly in the hemodynamically unstable patient with severe theophylhne toxicity without anticoagulation (40,41). A higher extraction ratio in neonates than in adults has also been described (41). 

A 14-month-old girl with chronic renal insufficiency due to renal dysplasia was empirically treated with ceftazidime and vancomycin for fever. Her calculated creatinine clearance was 10 ml/minute/1.73 m. She erroneously received vancomycin 1.5 g in 3 doses 6 hours apart. Her serum creatinine concentration increased and her vancomycin concentrations remained markedly high (338 mg/1 5 hours after the third dose). The half-Ufe of vancomycin was 145 hours. Hearing loss developed. Continued charcoal hemoperfusion and hemodialysis were used to treat the disorder. Thrombocytopenia was noted as significant consequence of hemoperfusion. The patient did not fully recover her previous renal function and became dialysis dependent. The audiogram normalized by 6 months. 

Environmental and iatrogenic exposure can result in aluminum overload in dialysis patients and evident osteomalacia, anemia and dementia [46]. Furthermore, acute intoxication with aluminum can lead to encephalopathy and death [47]. Hemoperfusion, hemodialysis, or hemofiltration combined with desferoxamine (DFO) can effectively remove aluminum [48]. Hemodialysis with a high flux dialyzer and hemofiltration are likely superior to charcoal hemoperfusion [48, 49]. In aluminum intoxicated dialysis patients, improvements in osteomalacia [50], anemia [51], and dementia [52] have been demonstrated with chelation. 

Kawasaki Cl, Nishi R, Uekihara S, et al. Howtightly can a drug be bound to a protein and still be removable by charcoal hemoperfusion in overdose cases Clin Toxicol. 2005 43 95-99... 

Weiss LG, Danielson BG, Fellstrom B, et al. Aluminum removal with hemodialysis, hemofiltration and charcoal hemoperfusion in uremic patients after desferrioxamine infusion. A comparison of efficiency. Nephron. 1989 51 325-329... 

Bouchard NC, Malostovker I, Harbord N, et al. Acute aluminum encephalopathy aluminum extraction with high flux hemodialysis is superior to charcoal hemoperfusion (abstract). Clin Toxicol. 2005 43 677-678... 

Endre ZH, Charlesworth JA, Macdonald GJ, Wood bridge L. Successful treatment of acute dapsone intoxication using charcoal hemoperfusion. Australian and New Zealand journal of medicine. 1983 Oct l 3(5) 509-l 2. 

Fall in glomerular filtration rate in a rapid and dose related fashion if dose >1 g/m Charcoal hemoperfusion and sequential hemodialysis if severe renal toxicity (significant clearance of methotrexate can be achieved with high-flux dialyzers... 

Molina R, Fabian C, Cowley B. Use of charcoal hemoperfusion wih sequential hemodialysis to reduce serum methotrexate levels in a patient with acute renal insufficiency. Am J Med. 1987.82 350-352. 

Whilst hemodialysis does remove paraquat, it is far less efficient than charcoal hemoperfusion, which... 

Chen LL et al [18] reported one severe case of a patient who started hemodialysis 3 days after admission. His state of consciousness did not modify with hemodialysis. Charcoal hemoperfusion was performed during 6 hours and his consciousness improved progressively. About 24 hours after the 6 hours session of hemoperfusion, his consciousness returned to normal without subsequent mental confusion. 

Christiansen RG, Klaman JS. Successful treatment of phenol poisoning with charcoal hemoperfusion. Vet Hum Toxicol 1996 38 27-28. 

No specific treatment is available for chloramphenicol exposure. Hemodialysis is ineffective. Charcoal hemoperfusion or whole blood exchange transfusion has been recommended in infants with serum concentrations of >50pgmH. Management is primarily supportive. 

Dilution may be accomplished with water or with demulcent fluids such as milk. Gastric lavage is indicated in certain circumstances. Hemodialysis and charcoal hemoperfusion may be employed in the event of renal failure. Fluid balance should be monitored and supportive measures taken as indicated. 

Quinine The antimalarial agent quinine is derived from the bark of the cinchona tree along with several other alkaloids and salicylate (aspirin). Many of these agents produce similar toxic features (cinchon-ism) in patients with excessive intake, but only quinine produces blindness. Cinchonism consists of abdominal pain and vomiting, ringing in the ears (tinnitus), and confusion. Visual loss after quinine overdose is due to direct retinal toxicity, although until recently it was believed to be due to spasm of the arterial blood supply to the retina. Treatment is difficult, but limited evidence suggests charcoal hemoperfusion may be beneficial (hemoperfusion is similar to hemodialysis, except in place of a semi-permeable membrane to filter the toxin from the blood, charcoal is used to bind the toxin). 

For acute exposure, ipecac should be administered and lavage performed. The use of single- or multiple-dose activated charcoal is supported by in vitro binding experiments and some animal data, and charcoal hemoperfusion may be a useful adjunct. Forced potassium diuresis appears to be harmful. Flemodial-ysis is also recommended with potassium administration. Since calcium metabolism is disturbed, supplementary calcium is indicated. The use of traditional metal chelators such as dimercaprol (British antilewisite) and penicillamine is not supported by the available evidence. In fact, the use of penicillamine may lead to redistribution of thallium into the central nervous system. Multiple animal studies have found evidence of enhanced elimination and improved survival with Prussian blue however, despite the fact that many humans have been treated with Prussian blue, the data presented are insufficient to judge its true efficacy. Despite this, one publication notes that... 

Multiple-dose oral activated charcoal, charcoal hemoperfusion... 

Activated charcoal is effective in decreasing theophylline absorption from the gastrointestinal tract, and whole bowel irrigation is especially useful for decontamination of orally administered sustained-release formulations of the drug. Hypotension is often managed by saline infusion, though vasopressors may be required. The blood levels of theophylline are decreased by charcoal hemoperfusion or by hemodialysis. Ipecac fluid extract contains cardiotoxic alkaloids and should never be used as an emetic. The answer is (D). 

Epoprostenol sodium (prostacyclin) is a naturally occurring prostaglandin indicated for the preservation of platelet function during cardiopvdmonary bypass, prevention of platelet aggregation during charcoal hemoperfusion of patients in hepatic failure, euid as an alternative to heparin during rened dialysis. 

Based on the data in Figure 6 we have calculated a hexobarbital clearance rate of 0.8 ml/hr in plasma. Simple extrapolation to a clinical size hollow fiber (e.g., 10,000 cm surface area) containing 17 mg pS protein/0.5 ml pS suspension (total of 4 grams of pS protein yields a theoretical clearance of 8.4 ml/ min. This figure approaches the hemodialysis clearance of 15 ml/ min reported for secobarbital (18), but is significantly slower than the 50 ml/min achieved using charcoal hemoperfusion (19). 

Charcoal hemoperfusion effectively removes chloramphenicol and is indicated after a severe overdose with a high serum level and metabolic acidosis. 

D. Enhanced elimination. Repeat-dose activated charcoal (see p 57) may enhance caffeine elimination. Seriously intoxicated patients (with multiple seizures, significant tachyarrhythmias, or intractable hypotension) may require hemodialysis or charcoal hemoperfusion (see p 55). 

Charcoal hemoperfusion can reduce the half-life to 1.5 hours and might be considered in a severe intoxication unresponsive to conventional treatment. Hemodialysis is ineffective because dapsone and its metabolites are highly protein bound. 

Charcoal hemoperfusion may be effective for phenylbutazone overdose, although there are limited clinical data to support its use. 

D. Enhanced elimination. Diuresis and hemodialysis are not useful because thyroid hormones are extensively protein bound. Charcoal hemoperfusion may be effective, but iimited data are available. Exchange transfusion has been performed in chiidren and adults, but data on its efficacy are limited. 

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