P1104THE ROLE OF THERAPEUTIC PLASMA EXCHANGE COMBINED WITH HEMODIALYSIS IN MANAGEMENT OF POISONING AND INTOXICATION

Abstract

Abstract Background and Aims Background: Poisonings, intoxications, and drug overdoses are common occurrences and rapid lowering of the toxin level is key of all effective therapies. Therapeutic plasma exchange (TPE) has several unique characteristics that allow it to be a potentially effective therapy in rapidly achieving this goal with large molecular weight, protein-bound molecules that have a small volume of distribution. Ibuprofen is a commonly used anti-inflammatory, antipyretic, and analgesic drug. The number of reported ibuprofen overdoses (IO) has increased. Although the vast majority of IOs are not consequential, large ingestion can cause severe metabolic acidosis (MA) resulting in multi-organ failure and death. TPE has been reported as solo intervention in IO, however frequently with remaining renal dysfunction. We report two cases of massive IO that responded well to prompt combined TPE with continuous renal replacement therapy (CRRT). Method Literature and chart review of cases of IO in our institute treated with TPE+CRRT. Results Case 1: A 17 year old male presented to the Emergency Department (ED) following intentional IO in coma with serum pH of 7.09, cardiorespiratory failure and acute kidney injury (AKI). Urine drug screen was positive for only ibuprofen. He reportedly took 1381 mg/kg. Supportive care was unsuccessful, therefore TPE+CRRT was soon initiated. After two days of treatment the patient was able to be extubated, maintained normal cardiovascular status and renal function. The patient fully recovered. Case 2: A 17 year old female presented to the ED following intentional IO with serum pH of 6.9, cardiorespiratory failure, AKI, arrhythmia and bilateral leg compartment syndrome. Urine drug screen was positive for ibuprofen. The estimated ibuprofen exposure was above 2000 mg/kg. The initial ibuprofen serum plasma level was 330 µg/mL (therapeutic range is 10-50 µg/mL). Initial Supportive care was unsuccessful and TPE+CRRT was immediately started. Plasma ibuprofen level was normal after the 3rd TPE+CRRT. The patient fully recovered. Conclusion Intentional IO may result in major morbidity and mortality. TPE is more efficient in removing drugs with a high protein binding and/or a low volume of distribution, such as ibuprofen. In settings of massive overdose, hemodialysis may provide additional removal of unbound portion, as well corrects acidosis and allows provision of optimal nutrition. Combined TPE+CRRT is beneficial and may facilitate recovery. To our knowledge this is the first pediatric report of severe IO successfully treated with combined therapy.