Extracorporeal Treatment in Phenytoin Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup

The Extracorporeal Treatments in Poisoning (EXTRIP) Workgroup conducted a systematic literature review using a standardized process to develop evidence-based recommendations on the use of extracorporeal treatment (ECTR) in patients with phenytoin poisoning. The authors reviewed all articles, extracted data, summarized findings, and proposed structured voting statements following a predetermined format. A 2-round modified Delphi method was used to reach a consensus on voting statements, and the RAND/UCLA Appropriateness Method was used to quantify disagreement. 51 articles met the inclusion criteria. Only case reports, case series, and pharmacokinetic studies were identified, yielding a very low quality of evidence. Clinical data from 31 patients and toxicokinetic grading from 46 patients were abstracted. The workgroup concluded that phenytoin is moderately dialyzable (level of evidence = C) despite its high protein binding and made the following recommendations. ECTR would be reasonable in select cases of severe phenytoin poisoning (neutral recommendation, 3D). ECTR is suggested if prolonged coma is present or expected (graded 2D) and it would be reasonable if prolonged incapacitating ataxia is present or expected (graded 3D). If ECTR is used, it should be discontinued when clinical improvement is apparent (graded 1D). The preferred ECTR modality in phenytoin poisoning is intermittent hemodialysis (graded 1D), but hemoperfusion is an acceptable alternative if hemodialysis is not available (graded 1D). In summary, phenytoin appears to be amenable to extracorporeal removal. However, because of the low incidence of irreversible tissue injury or death related to phenytoin poisoning and the relatively limited effect of ECTR on phenytoin removal, the workgroup proposed the use of ECTR only in very select patients with severe phenytoin poisoning

Experts Consensus Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults

Objective: To provide a management approach for adults with calcium channel blocker poisoning. Data Sources, Study Selection, and Data Extraction: Following the Appraisal of Guidelines for Research & Evaluation II instrument, initial voting statements were constructed based on summaries outlining the evidence, risks, and benefits. Data Synthesis: We recommend 1) for asymptomatic patients, observation and consideration of decontamination following a potentially toxic calcium channel blocker ingestion (1D); 2) as first-line therapies (prioritized based on desired effect), IV calcium (1D), high-dose insulin therapy (1D-2D), and norepinephrine and/or epinephrine (1D). We also suggest dobutamine or epinephrine in the presence of cardiogenic shock (2D) and atropine in the presence of symptomatic bradycardia or conduction disturbance (2D); 3) in patients refractory to the first-line treatments, we suggest incremental doses of high-dose insulin therapy if myocardial dysfunction is present (2D), IV lipid-emulsion therapy (2D), and using a pacemaker in the presence of unstable bradycardia or high-grade arteriovenous block without significant alteration in cardiac inotropism (2D); 4) in patients with refractory shock or who are periarrest, we recommend incremental doses of high-dose insulin (1D) and IV lipid-emulsion therapy (1D) if not already tried. We suggest venoarterial extracorporeal membrane oxygenation, if available, when refractory shock has a significant cardiogenic component (2D), and using pacemaker in the presence of unstable bradycardia or high-grade arteriovenous block in the absence of myocardial dysfunction (2D) if not already tried; 5) in patients with cardiac arrest, we recommend IV calcium in addition to the standard advanced cardiac life-support (1D), lipid-emulsion therapy (1D), and we suggest venoarterial extracorporeal membrane oxygenation if available (2D). Conclusion: We offer recommendations for the stepwise management of calcium channel blocker toxicity. For all interventions, the level of evidence was very low

Preparing for venomous snake bites in Europe.

The most common venomous snake in Europe is the Vipera berus or common European adder, while no extremely venomous snakes are free-living in nature. At present, exotic venomous snakes are in Europe only found in captivity (zoo or as a pet). Toxicity by venomous snakes can be characterized by three major features are as follows: cytotoxic (swelling and tissue damage in the bite area), neurotoxic (paralysis or other nervous system injuries) or hemotoxic (blood clot disturbances).[...

Are Belgian emergency nurses prepared for chemical and nuclear incidents?

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Belgian cost-effectiveness analysis of hydroxocobalamin (Cyanokit) in known or suspected cyanide poisoning

Background: No published burden of illness or cost-effectiveness studies on cyanide (CN) poisoning exist. A health economic model has therefore been developed to determine the cost-effectiveness of hydroxocobalamin (Cyanokit) in suspected and known CN poisoning. Objectives: To assess the cost-effectiveness of hydroxocobalamin versus standard treatment in known or suspected CN poisoning in Belgium. Methods: Probabilities for neurological sequelae and mortality were applied based on phase III trials, literature data and the hydroxocobalamin preclinical trial. Since no cost and utility data for CN poisoning exist, costs and utilities of very comparable or related diseases derived from publicly available Belgian sources and literature were applied. Direct medical costs from the public healthcare payer's perspective were used. The time horizon was 1 year. Sensitivity analyses were performed to assess the robustness of the results. Results: Base-case analyses versus standard treatment revealed cost-effective results (incremental cost-effectiveness ratio= 9921(sic)/QALY) in suspected CN poisoning and dominance (more effective and cost-saving) in known CN poisoning. It was determined that 17 lives could be saved and one sequel prevented per year on a national level using hydroxocobalamin treatment. One-way sensitivity analyses varying efficacy, costs, utilities and time horizon demonstrated the robustness of the results. The results were most sensitive to the probability of death and neurological sequelae, but remained within acceptable limits of cost-effectiveness. Furthermore, it was shown that a longer time frame (5 or 10 years) leads to even more favourable cost-effective results. Conclusions: Hydroxocobalamin appears cost-effective to dominant compared with standard treatment in CN poisoning from a healthcare payer's perspective

Are dutch hospitals prepared for chemical, biological or radionuclear incidents?

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