[Effectiveness of pre-emptive hemodialysis with high-flux membranes for the treatment of life-threatening alcohol poisoning].
Alcohol intoxication (methanol, ethanol and ethylene glycol) may result in metabolic acidosis with increased anion gap, increased serum osmolal gap, and neurologic abnormalities ranging from drunkenness to coma, and death. The mortality and morbidity rates remain very high despite intensive care therapy. The toxicity of methanol and ethylene glycol is clearly correlated to the degree of metabolic acidosis. The established treatment of severe methanol and ethylene glycol intoxication is ethanol administration and hemodialysis (HD). By inhibiting the main metabolic pathway of methanol and ethylene glycol (alcohol dehydrogenase), ethanol prevents the formation of major toxic metabolites (formic acid, glycolic acid and oxalic acid). Conventional HD can reduce serum methanol, ethanol and ethylene glycol and its metabolites rapidly, but high-flux membranes should be capable of removing more toxic per hour of HD. In this report, we describe 14 cases of life-threatening alcohol intoxication (11 methanol, 1 ethanol, and 2 ethylene glycol) who were treated successfully with supportive care, ethanol infusion (methanol and ethylene glycol), and early HD with a high-flux dialyser. The median pH was 7.04 +/- 0.06 (range 6.60-7.33), median bicarbonate 9.9 +/- 1.9 mmol/l (range 1.4-25), and median base deficit 18.4 +/- 2.6 mmol/l (range 2-33). The median anion gap was 29.1 +/- 2.3 mmol/l (range 16-45) and the median osmolal gap was 119 +/- 47 mOsm/l (range 16-402). On admission there was an excellent linear correlation between the serum toxic alcohol concentrations and the osmolal gaps (R2 = 0.98, p = 0.0006). In all cases early HD corrected metabolic acidosis and osmolal abnormalities. The mortality was 7 % (1 from 14). We conclude that pre-emptive HD should be performed in severe intoxications to remove both the parent compound and its metabolites. The HD prescription should include a large surface area dialyser with high-flux membrane, a blood flow rate in excess of 250 ml/min, a modified bicarbonate bath enriched with phosphorus and potassium, and a long time session. The phosphorus and potassium-enriched bicarbonate-based dialysis solution used in patients with normal phosphorus and potassium serum levels avoided HD-induced hypophosphatemia and hypopotassemia. HD as implemented in these cases is a safe and very effective approach to the management of alcohol poisoning.
Peces
R
R
Servicio de Nefrología, Hospital Universitario La Paz, Madrid. cpeces@varnet.com
Fernández
R
R
Peces
C
C
González
E
E
Olivas
E
E
Renjel
F
F
Jiménez
M
M
Costero
O
O
Montero
A
A
Selgas
R
R
D000328:Adult; D004638:Emergency Treatment; D000431:Ethanol / Q000506:poisoning*; D019855:Ethylene Glycol / Q000506:poisoning*; D005260:Female; D006801:Humans; D008297:Male; D008567:Membranes, Artificial; D008659:Metabolic Diseases / Q000139:chemically induced / Q000628:therapy; D000432:Methanol / Q000506:poisoning*; D008875:Middle Aged; D011041:Poisoning / Q000628:therapy; D011446:Prospective Studies; D006435:Renal Dialysis
D008567:Membranes, Artificial; D000431:Ethanol; D019855:Ethylene Glycol; D000432:Methanol