title: Extracorporeal Treatment for Lithium Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup.
abstract: The Extracorporeal Treatments in Poisoning Workgroup was created to provide evidence-based recommendations on the use of extracorporeal treatments in poisoning. Here, the EXTRIP workgroup presents its recommendations for lithium poisoning. After a systematic literature search, clinical and toxicokinetic data were extracted and summarized following a predetermined format. The entire workgroup voted through a two-round modified Delphi method to reach a consensus on voting statements. A RAND/UCLA Appropriateness Method was used to quantify disagreement, and anonymous votes were compiled and discussed in person. A second vote was conducted to determine the final workgroup recommendations. In total, 166 articles met inclusion criteria, which were mostly case reports, yielding a very low quality of evidence for all recommendations. A total of 418 patients were reviewed, 228 of which allowed extraction of patient-level data. The workgroup concluded that lithium is dialyzable (Level of evidence=A) and made the following recommendations: Extracorporeal treatment is recommended in severe lithium poisoning (1D). Extracorporeal treatment is recommended if kidney function is impaired and the [Li(+)] is >4.0 mEq/L, or in the presence of a decreased level of consciousness, seizures, or life-threatening dysrhythmias irrespective of the [Li(+)] (1D). Extracorporeal treatment is suggested if the [Li(+)] is >5.0 mEq/L, significant confusion is present, or the expected time to reduce the [Li(+)] to <1.0 mEq/L is >36 hours (2D). Extracorporeal treatment should be continued until clinical improvement is apparent or [Li(+)] is <1.0 mEq/L (1D). Extracorporeal treatments should be continued for a minimum of 6 hours if the [Li(+)] is not readily measurable (1D). Hemodialysis is the preferred extracorporeal treatment (1D), but continuous RRT is an acceptable alternative (1D). The workgroup supported the use of extracorporeal treatment in severe lithium poisoning. Clinical decisions on when to use extracorporeal treatment should take into account the [Li(+)], kidney function, pattern of lithium toxicity, patient's clinical status, and availability of extracorporeal treatments.
authors.affiliation: Due to the number of contributing authors, the affiliations are provided in the Supplemental Material.
authors.forename: Brian S
authors.initials: BS
authors.lastname: Decker
authors.affiliation: Due to the number of contributing authors, the affiliations are provided in the Supplemental Material.
authors.forename: David S
authors.initials: DS
authors.lastname: Goldfarb
authors.affiliation: Due to the number of contributing authors, the affiliations are provided in the Supplemental Material.
authors.forename: Paul I
authors.initials: PI
authors.lastname: Dargan
authors.affiliation: Due to the number of contributing authors, the affiliations are provided in the Supplemental Material.
authors.forename: Marjorie
authors.initials: M
authors.lastname: Friesen
authors.affiliation: Due to the number of contributing authors, the affiliations are provided in the Supplemental Material.
authors.forename: Sophie
authors.initials: S
authors.lastname: Gosselin
authors.affiliation: Due to the number of contributing authors, the affiliations are provided in the Supplemental Material.
authors.forename: Robert S
authors.initials: RS
authors.lastname: Hoffman
authors.affiliation: Due to the number of contributing authors, the affiliations are provided in the Supplemental Material.
authors.forename: Valéry
authors.initials: V
authors.lastname: Lavergne
authors.affiliation: Due to the number of contributing authors, the affiliations are provided in the Supplemental Material.
authors.forename: Thomas D
authors.initials: TD
authors.lastname: Nolin
authors.affiliation: Due to the number of contributing authors, the affiliations are provided in the Supplemental Material. marcghannoum@gmail.com.
authors.forename: Marc
authors.initials: M
authors.lastname: Ghannoum
mesh_terms: D018692:Antimanic Agents / Q000494:pharmacology / Q000506:poisoning*; D032921:Consensus; D003697:Delphi Technique; D062787:Drug Overdose / Q000628:therapy*; D019317:Evidence-Based Medicine; D006801:Humans; D008094:Lithium / Q000506:poisoning*; D018020:Lithium Compounds / Q000494:pharmacology / Q000506:poisoning*; D006435:Renal Dialysis
chemical_list: D018692:Antimanic Agents; D018020:Lithium Compounds; D008094:Lithium
keywords: acute dialysis; intoxication; overdose; pharmacokinetics