title: Lithium poisoning in the intensive care unit: predictive factors of severity and indications for extracorporeal toxin removal to improve outcome.
abstract: BACKGROUND
  Lithium is responsible for life-threatening poisoning, not consistently improved by extracorporeal toxin removal (ECTR).
  
  
  OBJECTIVE
  Our aim was to identify predictive factors on admission of poisoning severity and based on an evaluation of practice, report indications for ECTR susceptible to improve outcome Methods: We performed a retrospective cohort study including all lithium-poisoned patients admitted to the ICU in a university hospital. The usual clinical, biological and toxicological variables were collected. Poisoning severity was defined by seizures, catecholamine infusion, mechanical ventilation >48 h and/or fatality. Univariate followed by multiple logistic regression analyses were performed to identify prognosticators of poisoning severity and ECTR use.
  
  
  RESULTS
  From 1992 to 2013, 128 lithium-poisoned patients including acutely (10%), acute-on-chronically (63%) and chronically poisoned patients (27%) were included. The presumed ingested dose of lithium was 17.0 g [8.0-24.5] (median [25th-75th percentiles]). Serum lithium concentrations were 2.6 mmol/l [1.5-4.6], 2.8 mmol/l [1.8-4.5] and 2.8 mmol/l [2.1-3.0] on admission, peaking at 3.6 mmol/l [2.6; 6.2], 4.3 mmol/l [2.4; 6.2] and 2.8 mmol/l [2.1; 3.1] in the three groups, respectively. Severe poisoning occurred in 48 patients (38%) including four fatalities. Using the regression analysis, predictive factors of poisoning severity were Glasgow coma score ≤10 (Odds ratio (OR), 11.1; 95% confidence interval (CI), [4.1-33.3], p < 0.0001) and lithium concentration ≥5.2 mmol/l (OR, 6.0; CI, [1.7-25.5], p = 0.005). Ninety-eight patients (77%) developed acute kidney injury according to KDIGO criteria and 22 (17%) were treated with ECTR. Peak lithium concentration ≥5.2 mmol/l (OR, 22.4; CI, [6.4-96.4]; p < 0.0001) and peak creatinine concentration ≥200 μmol/l (OR, 5.0; CI, [1.4-19.2]; p = 0.01) were associated with ECTR use. Only 21/46 patients who presented one of these two criteria were actually treated with ECTR. More significant neurological impairment persisted on discharge in patients not treated with ECTR (p = 0.0007) despite not significantly shorter length of ICU stay.
  
  
  CONCLUSIONS
  Lithium poisoning is responsible for severe impairments but rare fatalities. Severity can be predicted on admission using Glasgow coma score and lithium concentration. Our results suggest that ECTR could be indicated if serum lithium ≥5.2 mmol/l or creatinine ≥200 μmol/l.
authors.affiliation: a Department of Medical and Toxicological Critical Care , Assistance Publique - Hôpitaux de Paris, Lariboisière Hospital , Paris , France ;|b Paris-Diderot University , Paris , France ;|c Research Unit 1144, Institut National de la santé et de la recherche médicale (INSERM) , Paris , France ;|d Paris-Descartes University , Paris , France ;
authors.forename: Dominique
authors.initials: D
authors.lastname: Vodovar
authors.affiliation: b Paris-Diderot University , Paris , France ;|c Research Unit 1144, Institut National de la santé et de la recherche médicale (INSERM) , Paris , France ;|d Paris-Descartes University , Paris , France ;|e Toxicology Laboratory , Assistance Publique - Hôpitaux de Paris, Lariboisière Hospital , Paris, France.
authors.forename: Souleiman
authors.initials: S
authors.lastname: El Balkhi
authors.affiliation: b Paris-Diderot University , Paris , France ;|c Research Unit 1144, Institut National de la santé et de la recherche médicale (INSERM) , Paris , France ;|d Paris-Descartes University , Paris , France ;
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Curis
authors.affiliation: a Department of Medical and Toxicological Critical Care , Assistance Publique - Hôpitaux de Paris, Lariboisière Hospital , Paris , France ;|b Paris-Diderot University , Paris , France ;
authors.forename: Nicolas
authors.initials: N
authors.lastname: Deye
authors.affiliation: a Department of Medical and Toxicological Critical Care , Assistance Publique - Hôpitaux de Paris, Lariboisière Hospital , Paris , France ;|b Paris-Diderot University , Paris , France ;|c Research Unit 1144, Institut National de la santé et de la recherche médicale (INSERM) , Paris , France ;|d Paris-Descartes University , Paris , France ;
authors.forename: Bruno
authors.initials: B
authors.lastname: Mégarbane
mesh_terms: D058186:Acute Kidney Injury / Q000139:chemically induced* / Q000628:therapy; D015331:Cohort Studies; D003422:Critical Care / Q000379:methods*; D015600:Glasgow Coma Scale; D006801:Humans; D007362:Intensive Care Units; D008094:Lithium / Q000097:blood / Q000506:poisoning*; D016015:Logistic Models; D011041:Poisoning / Q000175:diagnosis / Q000628:therapy; D011237:Predictive Value of Tests; D006435:Renal Dialysis; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016896:Treatment Outcome
chemical_list: D008094:Lithium
keywords: Acute kidney injury; hemodialysis; lithium; outcome; poisoning