Serious Toxicity in a Young Child Due to Ibuprofen

Abstract

Abstract. An 18-month-old male presented to the emergency department (ED) for evaluation of lethargy and apnea. Four hours before presentation, the patient was found with an empty bottle of ibuprofen, an ingestion of as much as 7.2 grams (600 mg/kg). The ED course was remarkable for a 30-second tonic-clonic seizure. Laboratory analysis was notable for metabolic acidosis. Four-hour and 7.5-hour serum ibuprofen levels were 640 and 39 g/mL, respectively. Following treatment, the patient improved and was extubated the next morning. While metabolic acidosis has been frequently described at doses exceeding 400 mg/kg, seizures occurring early in the course of ibuprofen toxicity have been rarely noted. Key words: ibuprofen; poisoning; pediatrics. ACADEMIC EMERGENCY MEDICINE 2000; 7:821-823 Ibuprofen is a commonly used overthe-counter nonsteroidal anti-inflammatory analgesic derived from propionic acid. In general, overdoses of ibuprofen result in mild effects. These effects include abdominal pain, nausea, vomiting, lethargy, headache, tinnitus, and ataxia.1 Serious toxicity, including coma, apnea, metabolic acidosis, hypotension, bradycardia, and renal and hepatic dysfunction, has been observed in ingestions of more than 400 mg/kg. Symptoms usually develop within four hours of ingestion. CASE REPORTAn 18-month-old, 12-kg male with an unremarkable past medical history was brought to the emergency department (ED) for evaluation of lethargy. According to the parents, the patient was found approximately four hours prior to presentation with an empty bottle of ibuprofen, and with pill fragments in his mouth. The patient had two episodes of emesis; one spontaneous and the other manually induced by a grandparent. After a brief period of relatively normal behavior, the parents noted that the patient became limp and was not easily aroused. The patient subsequently became apneic, prompting the parents to bring him to the ED. The patient's past medical history included eczema and otitis media. His parents indicated that he was occasionally given pseudoephedrine but was not given any in the last 24 hours. Further, it was discovered that his grandmother took lisinopril, for which all tablets were accounted.Later investigation indicated a potential ingestion of as much as 7.2 grams of ibuprofen (600 mg/kg).On presentation to the ED, the patient was lethargic. Vital signs were temperature (rectal) 96.8ЊF, respiratory rate 16 breaths/min, heart rate 123 beats/min, and blood pressure 118/48 mm Hg. The patient's vital signs remained in this range throughout his ED course. Physical exam was significant for an intact gag reflex, reactive pupils (3 mm), and withdrawal from painful stimuli. He received, in increments, a total of 600 mL of normal saline and 1 mg of naloxone without response. A short time later the patient sustained a 30-second tonicclonic seizure, which resolved with lorazepam 1 mg IV push. The patient then became apneic, requiring endotracheal intubation. Subsequent lavage with a 12-Fr nasogastric tube and 300 mL of norm...

Capillary electrophoresis and the clinical laboratory

“…Toxic doses of ibuprofen can cause gastrointestinal dysfunction and acute renal failure [170] while toxic levels of paracetamol can result in liver failure [171]. Recently, Heitmeier and Blaschke [172] described the CZE analysis of paracetamol in urine and serum.…”

“…In addition to being used to study the pharmacokinetics of drugs, CE has also been used to monitor the levels of a number of antibiotics and analgesics, nonsteroidal antiinflammatory drugs [142][143][144][145][146][147][148]. However, since HPLC and immunoassays have been extensively validated and are relatively easy to perform it is unlikely that their replacement by CE in the general clinical laboratory will occur.…”

Polyuria, Acidosis, and Coma Following Massive Ibuprofen Ingestion

“…In their case, a 4-h ibuprofen level was 640 mg/L. The child survived without long-term sequelae [7]. Lastly, Holubek and colleagues described two fatal ibuprofen ingestions.…”

Nonsteroidal Anti-Inflammatory Drug Toxicity in Children

“…28 Significant NSAID ingestions may result in life-threatening symptoms including metabolic acidosis, apnea, and generalized tonic-clonic seizures. 29,30 Acute kidney injury associated with NSAID use may occur in up to 2.7% of hospitalized children. 31 In particular, children hospitalized for gastroenteritis and dehydration may be at increased risk of acute kidney injury with NSAID use, although most cases resolve without specific therapy.…”