Theophylline hemoperfusion

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. 

The use of hemodialysis or hemoperfusion in the management of theophylline toxicity was initially controversial (SEDA-8, 11) (SEDA-9, 10) (SEDA-11, 5). In one study... 

Shannon MW. Comparative efficacy of hemodialysis and hemoperfusion in severe theophylline intoxication. Acad Emerg Med 1997 4(7) 674-8. 

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. 

D. Enhancement of Elimination Enhancement of elimination is possible for a number of toxins, including manipulation of urine pH to accelerate renal excretion of weak acids and bases. For example, alkaline diuresis is effective in toxicity due to fluoride, isoniazid, fluoroquinolones, phenobarbital, and salicylates. Urinary acidiflcation may be useful in toxicity due to weak bases, including amphetamines, nicotine, and phencyclidine, but care must be taken to avoid acidosis and renal failure in rhabdomyolysis. Hemodialysis or hemoperfusion enhances the elimination of many toxic compounds, including acetaminophen, ethylene glycol, formaldehyde, lithium, methanol, procainamide, quinidine, salicylates, and theophylline. Cathartics such as sorbitol (70%) may decrease absorption and hasten removal of toxins from the gastrointestinal tract. 

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). 

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