Extracorporeal Treatment for Barbiturate Poisoning: Recommendations From the EXTRIP Workgroup

Mactier, Robert; Laliberté, Martin; Mardini, Joëlle; Ghannoum, Marc; Lavergne, Valéry; Gosselin, Sophie; Hoffman, Robert S.; Nolin, Thomas D.

doi:10.1053/j.ajkd.2014.04.031

Cited by 56 publications

(54 citation statements)

References 74 publications

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“…As per EXTRIP intermittent hemodialysis is the preferred mode of treatment of severe barbiturate poisoning, continuous renal replacement modalities are valid alternatives, when clinical improvement is obvious cessation of hemodialysis or continuous veno-venous hemofiltration is indicated [10].…”

Section: Discussionmentioning

confidence: 99%

Effective Role of CVVH in Fatal Phenobarbital Overdose Clearance: A Case Report

Adeel¹,

Alan²,

J³

2018

J Clin Nephrol Ren Care

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We report affective utilization of continuous veno-venous hemofiltration for removal of phenobarbital in a patient who took twice amount of fatal dose and was hemodynamically stable. Historically treatment includes supportive care, activated charcoal and urinary alkalinisation along with the application of extracorporeal treatments such as charcoal haem perfusion or hemodialysis and continuous veno-venous hemodiafiltration are affective treatment for removal of drug. Early initiation of extracorporeal treatment and increasing blood flow rate effectively reduced half life of drug and improved patient outcome with fatal poisoning. known time. He was brought unconscious had GCS of 3 blood pressure 120/75 pulse 85 per minutes' respiratory rate 12 per minutes' and temperature of 36.5 °C was intubated and ventilated and transferred to intensive care unit. His medical background history includes bipolar disorder, deliberate self harm.His initial investigation showed positive blood and urine toxicology screen for barbiturates only and phenobarbital level of 160.5 mg/L, others investigation including full blood count, renal profile, liver function, arterial blood gases, calcium, phosphate, amylase, creatinine kinase and coagulation screen within normal limits (Table 1). His electrocardiogram showed prolonged QT. He remained hemodynamically stable without any inotropic support was started on supportive management with intravenous fluid and activated charcoal in intensive care unit as renal profile and acid base status remained within fair range with no evidence of renal failure. His repeat phenobarbital level after 48 hours was 221.8 mg/L likely due to redistribution of drug.

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Section: Discussionmentioning

confidence: 99%

Effective Role of CVVH in Fatal Phenobarbital Overdose Clearance: A Case Report

Adeel¹,

Alan²,

J³

2018

J Clin Nephrol Ren Care

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“…7 We considered using flumazenil, a non-specific competitive antagonist of the benzodiazepine (BZD) receptor, 8 Based on the recent Extracorporeal Treatments in Poisoning (EXTRIP) workgroup guidelines, our patient was suitable for extracorporeal treatment. 9 He was in a prolonged coma necessitating mechanical ventilation, with persistently elevated serum barbiturate concentrations. There have been multiple case reports regarding successful extracorporeal treatment in severe barbiturate intoxication.…”

Section: Discussionmentioning

confidence: 99%

“…There have been multiple case reports regarding successful extracorporeal treatment in severe barbiturate intoxication. 3,4,6,[9][10][11][12][13][14] Haemodialysis involves solute removal by diffusion whereas haemofiltration uses convection with hydrostatic pressure inducing plasma water filtration across the haemofilter. 6 Haemoperfusion is ideal in the removal of lipid soluble or highly protein bound drugs.…”

Section: Discussionmentioning

confidence: 99%

Successful haemofiltration therapy in severe phenobarbital overdose

Tan¹,

Moser²,

Duke³

2018

AMJ

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In the 19 th century, barbiturates were first-line treatment as hypnotic and anticonvulsants, then gradually replaced by agents with a safer clinical profile. However, its ongoing use in Australian veterinary medicine and steadfast prescriptions in developing countries/our migrant population, still contributes to overdoses.We present a case of a middle-aged man with a lifethreatening phenobarbital overdose. Haemofiltration was trialled, causing a rapid fall in phenobarbital levels and a speedy recovery. Through a review of the literature, treatment options of barbiturate overdose presentations will be discussed. It is imperative clinicians are aware of barbiturate's mechanism and its enhanced elimination through extracorporeal treatment. Key WordsPhenobarbital overdose, haemofiltration, extracorporeal treatment Implications for Practice: What is known about this subject?Barbiturates were once a very common cause of drug dependence and overdoses. Extracorporeal elimination has been trialled in low-quality evidence only, with positive conclusions. What new information is offered in this case study?Phenobarbital overdose of this prolonged period has rarely been reported in the literature. The trial of haemofiltration successfully eliminated the drug, facilitating early recovery. What are the implications for research, policy, or practice?In the absence of adequate phenobarbital elimination with forced alkaline diuresis, clinicians should consider extracorporeal treatment; so as to prevent prolonged hospital stay and complications.

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“…In an effort to improve the quality of data going into their evaluations, the EXTRIP workgroup recommended greater standardization of case reports to include details about the patient, the poison, the presentation, treatments other than extracorporeal therapy, type of extracorporeal therapy, poison sampling, toxicokinetic calculations, followup, time-line of significant events, discussion and conclusion [84]. So far, the workgroup has issued recommendations on extracorporeal treatment for poisoning from thallium [85], tricyclic antidepressants [86], barbiturates [87], acetaminophen [88], carbamazepine [89], methanol [90], lithium [91], theophylline [48] and salicylates [92].…”

Section: Extripmentioning

confidence: 99%