Antifreeze Ingestion Research Articles

Minding the osmol gap: a sentinel event and subsequent laboratory investigation

Introduction Many hospitals are unable to determine toxic alcohol concentrations in a clinically meaningful time frame. Thus, clinicians use surrogate markers when evaluating potentially poisoned patients. Index case A patient presented after an intentional antifreeze (ethylene glycol) ingestion with an osmol gap of −10.6 that remained stable one hour later. Further investigation revealed that the serum osmolality was calculated and not measured. The true osmol gap was 16.4, which correlated to a measured ethylene glycol concentration of 808 mg/L (80.8 mg/dL, 13.0 mmol/L). Survey A telephone survey of hospital laboratories in our catchment area was performed to investigate the potential for similar events. Results Thirty-eight (47 percent) hospitals responded. No laboratories were able to test for toxic alcohols. One hospital (2.6 percent) reported routinely calculating osmolality based on chemistries, while two hospitals (5.3 percent) reported scenarios in which this might occur. Thirty-five (92.1 percent) hospitals could directly measure osmolality. Two hospitals (5.3 percent) were reliant on outside laboratories for osmolality measurement. Limitations The 47 percent response rate and one geographic area are significant limitations. Discussion Over 10 percent of hospitals that responded could have significant difficulty assessing patients with toxic alcohol ingestion. Conclusions Until the standard of rapidly obtaining toxic alcohol concentrations is broadly implemented, we recommend that policies and procedures be put in place to minimize errors associated with the determination of the osmol gap.

Combined Ethylene Glycol Poisoning with Methemoglobinemia Due to Antifreeze Ingestion

BackgroundAntifreeze poisoning is potentially life-threatening and often requires multiple antidotal therapies and hemodialysis. Ethylene or propylene glycol toxicity is commonly caused by antifreeze ingestion. However, ingestion of antifreeze is typically not associated with methemoglobinemia. Currently, only one other case of antifreeze ingestion causing combined ethylene glycol poisoning and methemoglobinemia has been reported. Case ReportA 56-year-old man presented after a witnessed, intentional, large-volume antifreeze ingestion. Evaluation revealed dark brown blood and significantly elevated methemoglobin and ethylene glycol levels. He was successfully treated with methylene blue, fomepizole, and hemodialysis. No other potential cause for methemoglobinemia was elucidated, and further research indicated that minor components of the specific antifreeze product served as an oxidizing agent. Why Should an Emergency Physician Be Aware of This?This case highlights the impact of minor, unreported product components that may significantly contribute to clinical toxicity, as well as the need to remain vigilant when reviewing product information and potential limitations therein.

Poisons affecting the kidney

The kidney has an essential role in maintaining normal physiological functions but it can be affected by various drugs and chemicals. A common seasonal cause of renal failure in cats is ingestion of antifreeze containing ethylene glycol. It is not the ethylene glycol itself which causes renal failure but toxic metabolites which result in deposition of calcium oxalate crystals in the renal tubules. Various non-steroidal anti-inflammatory drugs, particularly those used in human medicine such as ibuprofen, flurbiprofen and naproxen, cause renal effects through inhibition of prostaglandin synthesis which results in reduced renal blood flow and disruption of normal renal function and homeostatic mechanisms. For some common substances, such as lilies in cats and grapes and their dried fruit in dogs, kidney injury occurs through unknown mechanisms. Management of poison-induced kidney injury is supportive with monitoring and support of renal function. Although haemodialysis and other extracorporeal techniques can be used, they are rarely available in veterinary medicine and therefore preventive measures are used. This includes aggressive intravenous fluid therapy before onset of signs for lily and grape poisoning and early use of the antidote (ethanol) in ethylene glycol poisoning to prevent formation of toxic metabolites, allowing excretion of the parent compound. In most cases, once kidney injury is advanced, prognosis is poor.

Poisons affecting the kidney

The kidney has an essential role in maintaining normal physiological functions but it can be affected by various drugs and chemicals. A common seasonal cause of renal failure in cats is ingestion of antifreeze containing ethylene glycol. It is not the ethylene glycol itself which causes renal failure but toxic metabolites which result in deposition of calcium oxalate crystals in the renal tubules. Various non-steroidal anti-inflammatory drugs (NSAIDs), particularly those used in human medicine such as ibuprofen, flurbiprofen and naproxen, cause renal effects through inhibition of prostaglandin synthesis which results in reduced renal blood flow and disruption of normal renal function and homeostatic mechanisms. For some common substances, such as lilies in cats and grapes and their dried fruit in dogs, kidney injury occurs through unknown mechanisms. Management of poison-induced kidney injury is supportive with monitoring and support of renal function. Although haemodialysis and other extracorporeal techniques can be used, they are rarely available in veterinary medicine and therefore preventive measures are used. This includes aggressive intravenous fluid therapy before onset of signs for lily and grape poisoning and early use of the antidote (ethanol) in ethylene glycol poisoning to prevent formation of toxic metabolites, allowing excretion of the parent compound. In most cases, once kidney injury is advanced, prognosis is poor.

Ethylene glycol poisoning

Ethylene glycol poisoning

Case Report of a Fatal Antifreeze Ingestion with a Record High Level and Impressive Renal Crystal Deposition.

Ethylene glycol, methanol, and diethylene glycol are readily available in many household and commercially available products. While these alcohols are relatively nontoxic themselves, their acidic metabolites are toxic and can result in significant morbidity and mortality. Herein we report a lethal case of massive ethylene glycol ingestion in a suicide with a record high level (1254 mg/dL) and images of the histologic examination of the kidneys revealing impressive calcium oxalate crystal deposition. Autopsy findings also showed evidence of mild cerebral edema.

CONCOMITANT INGESTION OF ETHYLENE GLYCOL AND ETHANOL: A DIAGNOSIS TRAP?

Ethylene glycol is one of the most toxic alcohols; it may be accidentally or intentionally consumed as a substitute for ethanol or related to suicidal attempts. Ingestion of ethylene glycol causes a severe metabolic acidosis with increased anion and osmotic gap due to its toxic metabolites, leading to a clinical picture of central nervous system depression, cardiovascular and renal impairment. A 16-year-old boy was admitted with clinical and biological signs of ethylene glycol poisoning after simultaneous ingestion of antifreeze and ethanol. The patient had mild anion gap metabolic acidosis only at the debut, rapidly corrected with one dose of sodium bicarbonate; further evaluation did not reveal acidosis, even if the subsequent evolution included acute renal failure requiring hemodialysis. Due to the absence of a positive history and of a persistent metabolic acidosis, the diagnosis of ethylene glycol poisoning was delayed until it was confirmed by serum toxicological test. Conclusions: concomitant ingestion of ethanol may mask the symptoms of ethylene glycol poisoning; the absence of persistent metabolic acidosis does not rule out the diagnosis.

Effectiveness of High-Flux Hemodialysis for the Reduction of Serum Urea and Creatinine Levels in Life Threatening Ethylene Glycol Poisoning in Dogs - Case Report

The main problem of ethylene glycol consumption and intoxication is acute tubular necrosis and consecutive acute renal failure. In our case a 3,5 years Bucovina Shepard female dog presented with acute renal failure following antifreeze ingestion. The dog was subjected to three HF hemodialysis treatments which dramatically reduced the urea creatinine levels and also the metabolic derangements.

The Case Files

The Case Files

Etilenglikol (Antifiriz) entoksikasyonuna bağlı metabolik ensefalopati: Bir olgu sunumu

Ethylene glycol (EG) intoxication seems rarely in our country. It is a colorless, odourless, sweety substance which a member of dihydric alchols and dissolves with water. Metabolic asidosis, central nervous system depression and acute renal failure occure after accidental or for suicidal intake. We wrote about a EG intoxcication with methabolic asidosis and ensephalopathy after antifreeze ingestion accidentally.

Methabolic ensephalopathy with Ethylene glycol antifreeze intoxication: A case report

Ethylene glycol (EG) intoxication seems rarely in our country. It is a colorless, odourless, sweety substance which a member of dihydric alchols and dissolves with water. Metabolic asidosis, central nervous system depression and acute renal failure occure after accidental or for suicidal intake. We wrote about a EG intoxcication with methabolic asidosis and ensephalopathy after antifreeze ingestion accidentally.

Efficacy Study of Dolichos biflorus in the Management of Nephrotoxicity

ObjectiveEthylene glycol is widely used as a solvent and automobile antifreeze agent. Therefore, there have been a number of cases of human exposure from accidental or intentional ingestion of antifreeze, with the kidney being the most sensitive target organ. This study was designed to investigate the protective effect of seeds of Dolichos biflorus (Fabaceae), on ethylene glycol induced nephrotoxicity in adult female Wistar rats. MethodsThe hydro-methanolic (30:70, v/v) extract of D. biflorus was orally administrated at doses of 150 and 300 mg/kg body weight/day along with ethylene glycol (0.75% v/v) for 28 days. The results were compared with a parallel study conducted with standard marketed drug cystone under identical dosage conditions. The ionic chemistry was measured in urine and serum. Statistical differences and linear regression analysis were performed using GraphPad prism 5 software. ResultsEthylene glycol induced a significant elevation in the creatinine, uric acid, urea levels in urine as well as in serum and urinary electrolytes (sodium and potassium) excretion levels. D. biflorus significantly (P<0.001) protected the elevated levels of urine and serum parameters. Moreover, D. biflorus shows higher renoprotective index than cystone at identical dose levels. ConclusionsThese results provided an evidence of the significant protective effect of D. biflorus towards hyperuricemic and nephrotoxicity and thus can be used as potent dietary food.

The usefulness of urine fluorescence for suspected antifreeze ingestion in children

Purpose To evaluate urine fluorescence as a diagnostic tool. Procedures Using a Wood lamp, 60 physicians, assigned to group 1 or 2, independently rated 150 urine specimens from nonpoisoned children as fluorescent or nonfluorescent. Interobserver and intraobserver agreements were assessed. Physician ratings were compared with fluorometry results. The prevalence of urine fluorescence was determined by fluorometry. Main Findings Group 1 reported fluorescence in 80.7% (95% CI 73.4%-86.6%) of urine specimens; group 2 reported fluorescence in 69.3% (95% CI 61.3%-76.5%). Interrater agreement was poor (72.5%, κ = 0.25, 95% CI 0.13-0.37); intrarater agreement was good (physician group 1: 97.9%, κ = 0.93, 95% CI 0.77-1.00; physician group 2: 93.3%, κ = 0.85, 95% CI 0.69-1.00). The prevalence of urine fluorescence was 100% (95% CI 98.1%-100%). Conclusion Our data suggest that determination of urine fluorescence using a Wood lamp is a poor screening tool for suspected antifreeze ingestion in children.

Does fluorescent urine indicate antifreeze ingestion by children?

Fluorescent urine has been reported to indicate antifreeze ingestion. Recently, we evaluated a child who was suspected of ethylene glycol ingestion. Although she had fluorescent urine, subsequent studies showed that she had not ingested antifreeze. We tested whether fluorescent urine indicates antifreeze ingestion by children. A convenience sample of urine specimens from 30 hospitalized children was obtained. All of the patients had been hospitalized for reasons unrelated to poisoning. The specimens were viewed with a Wood's lamp, and the samples were identified as fluorescent or not fluorescent. A second convenience sample of urine specimens from a group of 16 healthy children was obtained, and these specimens were identified as fluorescent or not fluorescent in a similar manner. The majority of urine specimens obtained from children are fluorescent. There is variation in the interpretation of urine fluorescence among observers. The type of container used may influence the finding of fluorescence. Fluorescent urine is not an indicator of ethylene glycol antifreeze ingestion by children.

Complete Recovery After Massive Ethylene Glycol Ingestion

We treated a 64-year-old man who recovered completely from a massive antifreeze ingestion with ethylene glycol levels well above those of previously described survivors. Rapid and aggressive treatment of the patient with recognized methods, including hemodialysis, resulted in the favorable outcome.

Urine fluorescence using a wood's lamp to detect the antifreeze additive sodium fluorescein: A qualitative adjunctive test in suspected ethylene glycol ingestions

Antifreeze ingestions require rapid and accurate differential diagnosis to prevent fatal outcomes. Sodium fluorescein is added to some commercial antifreeze preparations (ethylene glycol) to a final concentration of approximately 20 micrograms/mL as a colorant to aid in detection of automobile cooling-system leaks. For an adult human being, a potentially toxic volume of antifreeze is 30 mL, which contains 0.4 to 0.6 mg sodium fluorescein. Six male volunteers were given a 0.6-mg oral bolus of sodium fluorescein on an empty stomach. Urine was collected at two-hour intervals. Using a Wood's lamp, visually detectable fluorescence was seen with 100% reliability for two hours and 60% reliability for four hours. A second group of male volunteers was given the same dose of sodium fluorescein, and fluorescence was measured with a fluorometer during a six-hour period. Detectable fluorescence was present in all samples except the zero time point, including those with no fluorescence present by visual examination. We conclude that exposing urine to a Wood's lamp may be a useful adjunctive diagnostic test for early evaluation of patients with suspected antifreeze ingestion while awaiting definitive quantitative analysis of serum ethylene glycol concentration. A prospective clinical trial is needed to evaluate the frequency of false-positives and false-negatives.