Poisoning hemoperfusion

A variety of therapies for thallium poisoning have been suggested by neutralising thallium in the intestinal tract, hastening excretion after resorption, or decreasing absorption. Berlin-Blue (fertihexacyanate) and sodium iodide in a 1 wt % solution have been recommended. Forced diuresis hemoperfusion and hemodialysis in combination results in the elimination of up to 40% of the resorbed thaHous sulfate (39). 

Pond, S.M., S.C. Johnston, D.D. Schoof, E.C. Hampson, M. Bowles, D.M. Wright, and JJ. Petrie. 1987. Repeated hemoperfusion and continuous arteriovenous hemofiltration in a paraquat poisoned patient. Clin. Toxicol. 25 305-316. 

Hemoperfusion is like hemodialysis except that blood is circulated extracorporeally through a column with adsorbent material like resin or charcoal, which binds molecules electrostatically. The molecules likely to be removed are characterized as poorly dialyzable, lipid-soluble, protein bound. Among the indications for hemoperfusion in the management of poisoning include the presence of a poison in a patient with impairment of excretory system (i.e. damaged kidneys), intoxication of a drug known to produce delayed toxicity or metabolized to a more toxic metabolite (i.e. paraquat or methotrexate), deterioration of the clinical state of the poisoned patient despite conservative therapy (i.e. convulsions or cardiac arrhythmias following theophylline intoxication), or development of coma as a complication. 

Cutler RE, Forland SC, Hammond, P, and Evans, JR. Extracorporeal removal of drugs and poisons by hemodialysis and hemoperfusion. Annu Rev Pharmacol Toxicol 1987 27 169-191. 

Diazinon is rapidly metabolized, with an estimated mammalian biological half-life of 12-15 hours (Iverson et al. 1975 Mucke et al. 1970). Consequently, efforts at reducing body burdens of poisoned persons may not be critical to the outcome. Dialysis and hemoperfusion are not indicated in organophosphate poisonings because of the extensive tissue distribution of the absorbed doses (Mucke et al. 1970 Poklis et al. 1980). 

Hemoperfusion and hemodialysis may be used in very severely poisoned patients. 

Table 59-3. Indications for Hemodialysis (HD) and Hemoperfusion (HP) in Drug Poisoning. ...

Hemoperfusion The process by which a drug is removed from the blood of a poisoned patient by allowing it to be absorbed by activated charcoal or a resin while the blood is pumped through a special machine. 

Gary NE, Byra WM, Eisinger RP. Carbamazepine poisoning treatment by hemoperfusion. Nephron 1981 27(4-5) 202-3. 

Boereboom FT, Ververs FF, Meulenbelt J, van Dijk A. Hemoperfusion is ineffectual in severe chloroquine poisoning. Crit Care Med 2000 28(9) 3346-50. 

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. 

Koppel C, Martens F, Schirop T, Ibe K. Hemoperfusion in acute camphor poisoning. Intensive Care Med 1988 14(4) 431-3. 

Berlinger WG, Spector R, Flanigan MJ, Johnson GF, Groh MR. Hemoperfusion for phenylbutazone poisoning. Ann Intern Med 1982 96(3) 334-5. 

Hemodialysis, hemofiltration, and hemodiafiltration Apparatus and principles Factors governing drug removal Hemodialysis in poisoning Hemofiltration and hemodiafiltration in poisoning Hemoperfusion ... 

The nephrologist is often consulted in poisoning cases. Although management may involve attention to incident renal failure or electrolyte and acid-hase disorders, hlood purification may also be necessary [1]. The application of dialysis therapies or hemoperfusion to enhance clearance of intoxicants is an essential task for the nephrologist. 

Hemoperfusion is infrequently used to treat acute intoxication. A survey of major New York City hospitals showed two-thirds to be unequipped to perform acute hemoperfusion [33]. However, for some ingestions hemoperfusion provides superior drug clearance, and advances in technology may increase the utility of adsorptive clearance in the treatment of poisoning. 

Some poisonings for which hemoperfusion is preferred are theophylline [35], lipid-soluble drugs, barbiturates [36], and other types of hypnotics/sedatives/tranquilizers. For example, the extraction ratio [inflow concentration - outflow concentration h- inflow concentration] of theophylline is 99 percent with hemoperfusion and only 50 percent with hemodialysis. It should be noted that high extraction ratios may not predict improved clinical outcomes, and there are no controlled studies of hemoperfusion in poisoned patients. 

There is limited evidence to recommend combined chelation and blood purification therapy for other heavy metal poisonings, such as copper, mercury, arsenic, and thalhum. There are case reports, however, outlining several such attempts. Treatment of cupric sulfate ingestion by dimercaprol and penicillamine chelation followed by hemoperfusion and hemodia-filtration has been reported [57]. An interesting case of inorganic mercury poisoning treated with DMPS chelation and continuous venous-venous hemodiafiltration (CVVHDF) was also reported [58]. It should be noted that treatment continued for 14 days with a hmited total removal of mercury (<13% of the ingested dose) in... 

Hemodialysis is recommended for acutely poisoned patients with salicylate levels greater than 80-lOOmg/ dL, acidosis, CNS dysfunction, or pulmonary edema. Chronic intoxication with levels >60 mg/ dL is a further indication. While hemoperfusion is also effective, hemodialysis is preferred to correct acid-base and electrolyte disturbances. 

Mullins ME, Horowitz BZ. The futility of hemoperfusion and hemodialysis in Amanita phalloides poisoning. Vet Hum Toxicol... 

Chen LL, Fang JT, Lin JL. Chronic renal disease patients with severe star fruit poisoning hemoperfusion may be an effective alternative therapy. 2005 43 181 -183... 

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

Management of lindane poisoning is symptomatic. Diazepam or phenobarbital is used to control convulsions. Cholestyramine or activated charcoal has been utilized to inhibit lindane uptake after ingestion. In more severe poisonings, the serum levels of lindane may be lowered by hemoperfusion over Am-berlite XAD-4. 

Liver. The liver performs a wide variety of chemical reactions in the body and is the main locus of detoxification. Successful liver transplantation is somewhat rare, and no true artificial liver seems likely in the near future. The process of hemoperfusion, which is sometimes termed an artificial liver, can be used to supplement or relieve the normal liver functions for short time periods. In this technique, the patient s blood is passed through a column or bed of some sorbent material that removes toxic chemicals from the blood. This technique is often used in cases of drug overdose, poisoning, and acute hepatitis. The sorbent material can be charcoal, ion-exchange resins, immobilized hepatic material, or liver material enclosed in artificial cells (microcapsules, usually made from a polyamide). The column is usually a plastic material, and plastic tubing is used to direct the blood flow to and from the device ( 1, 57, M). 

Hemodialysis or hemoperfusion usually has limited use in the treatment of intoxication with chemicals. However, under certain circumstances, such procedures can be lifesaving. The utility of dialysis depends on the amount of poison in the blood relative to the total-body burden. Thus, if a poison has a large volume of distribution, as is the case for the tricyclic antidepressants, the plasma will contain too little of the compound for effective removal by dialysis. Extensive binding of the compound to plasma proteins impairs dialysis greatly. The elimination of a toxicant by dialysis also depends on dissociation of the compound from binding sites in tissues for some chemicals, this rate may be slow and limiting. 

Passage of blood through a column of charcoal or adsorbent resin (hemoperfusion) is a technique for the extracorporeal removal of a poison. Because of the high adsorptive capacity and affinity of the material in the column, some chemicals that are bound to plasma proteins can be removed. The principal side effect of hemoperfusion is depletion of platelets. 

More than one million poisonings occur annually in the United States (1 ) and in 1975 over 26,000 people died from intake of medicinal and non-medicinal substances ( ). Common current treatment methods include support of heart and lung function and removal of unabsorbed drug by stomach lavage. However, any drug absorbed into the bloodstream can be removed only by hemodialysis or hemoperfusion O). These processes are expensive, require highly trained personnel, and are usually available only at large urban medical centers. 

The liver Is the main detoxification organ in the body and therefore comes Into contact with nearly every poison and toxin that enters the body. These materials could occur in case of poisoning, drug overdose, acute hepatitis, and allergies. While no true artificial liver has been developed, and transplantation is rare and difficult, several approaches have been attempted to replace and/or assist the function of the liver. The most common method is hemoperfusion in which the blood is passed through a column or bed of some sorbent material which can remove the poisons. The sorbents that have been used include charcoal, ion-exchange resins, affinity chromatography resins, immobilized enzymes and hepatic material or pieces of liver enclosed in artificial cells (9, 52). 

Adapted in part from Pond SM Diuresis, diaiysis, and hemoperfusion indications and benefits. Emerg Med Clin North Am 1984 2 29 and Cutier RE et ai Extracorporeai removai of drugs and poisons by hemodiaiysis and hemoperfusion. Ann Rev Pharmacol 7b co/1987 27 169. 

Winchester JF Dialysis and hemoperfusion in poisoning. Adv Ren Replace Ther 2002 9(1) 26-30. [PMID 11927904] (Review with list of potentially dialyzable substances.)... 

D. Enhanced elimination. There is no role for dialysis or hemoperfusion in acute azide poisoning. 

Hemodialysis and hemoperfusion have not been evaluated In the treatment of serious barium poisoning. Hemodialysis might be helpful In correcting severe electrolyte disturbances. 

---