Treatment Of Ethylene Glycol Poisoning Research Articles

SP2 Management of ethylene glycol poisoning in an adolescent: a clinical pearl

Situation16 year old girl admitted with suspected ingestion of ethylene glycol. She was treated with fomepizole and continuous renal replacement therapy (CRRT).How the Pharmacy Team ContributedEthanol was prescribed until fomepizole arrived. The volume of ethanol to be administered was calculated wrongly by the consultant due to confusion about the available strength. The Paediatric Intensive Care Unit (PICU) pharmacist intervened and the correct dosage information was given.PICU pharmacist used Toxbase to determine the correct treatment of ethylene glycol poisoning and advised on dosing regime, including adjustment due to CRRT. The pharmacist facilitated prescribing on the electronic system (added drug to system, set up administration instructions and assisted with prescribing – pharmacist was not an Independent Prescriber). This allowed medical staff to concentrate on resuscitation, monitoring cardiac function, inserting intravenous lines and obtaining access for CRRT.The PICU pharmacist and pharmacy technician co-ordinated initial supply of fomepizole. Fomepizole is usually ordered directly from the manufacturer during office hours. The patient presented in the early evening so further supply had to be obtained from a hospital hundreds of miles away after referring to the Rarely Used Medicines list. Pharmacist contacted appropriate on-call pharmacist and arranged for transfer of medicines via courier. Pharmacy technician arranged for further supply form the manufacturer the following day.Pharmacy technician arranged supply of additional dialysis fluids for CRRT due to the higher than usual administration rate.Without contribution from the pharmacy team the patient is likely to have been given the wrong dose of ethanol and fomepizole, and there would have been delay in initiation of treatment followed by an interruption, as it was wrongly assumed that it was kept as stock in the adjoining ‘adult hospital’ and subsequent supply from a local hospital would not have been sought by ward staff until original supply ran out.OutcomeEthylene glycol poisoning was confirmed on laboratory testing. Levels of ethylene glycol fell steadily over 36 hours, allowing CRRT and fomepizole to stop. Patient was discharged from PICU after 48 hours with no apparent long-lasting effects, but was referred to various specialities including renal, gastroenterology and psychology.Patient and family denied knowledge of intentional or accidental ingestion. Police investigation was inconclusive.Lessons to be LearnedLarger supplies of fomepizole are now kept in stock within Health Board. Supplies were missing from emergency cupboards when stock was needed, despite being on stock lists, necessitating courier fees to transfer stock from elsewhere. Procedures reviewed to ensure that stock is available in emergency cupboards at all times.This patient demonstrated that current (target) stock levels of fomepizole were inadequate for providing treatment during CRRT as the required doses are substantially higher (administered every four hours rather than every twelve hours) and would have lasted less than 12 hours for this average sized teenager. National Rarely Used Medicines list was updated to reflect actual stock levels and other hospitals increased their stockholding due to the realisation that existing stock was inadequate and that further supplies were hard to obtain out of working hours.

Ethylene glycol poisoning requiring critical care: Three case reports

Rapid diagnosis and treatment of ethylene glycol poisoning can be challenging and is critical for reducing the morbidity and the mortality of this intoxication. Cases from our center were retrospectively reviewed. From the 12 cases of ethylene glycol poisoning found since 2007, we present here three with significant toxicity and requiring critical care. Case 1 was an accidental intoxication in a 67 year-old male presenting dysarthria and altered level of consciousness. The patient mistakenly drank a bottle of beer containing a blue liquid 15 h before admission. Case 2 was a voluntary intoxication in a 56 year-old male with coma. The patient was found unconscious under a bridge with 9 wine bottles near him. An open bottle of car antifreeze was found at his home. Case 3 was a voluntary intoxication in a 46 year-old female presenting dyspnea. Ingestion amount was around 3 L of antifreeze 2 days before. Ethylene glycol plasma level was measured using liquid chromatography with ultraviolet detection after benzoyl chloride derivatization. At admission, case 1 showed metabolic acidosis (pH = 7.01) with very high serum lactate (> 20 mmol/L, acute renal failure (serum creatinine = 141 μmol/mL) and acute respiratory failure. The patient was transferred to an intensive care unit (ICU) where he was intubated and received renal replacement therapy (RRT). Ethylene glycol plasma level was 614 mg/L. Fomepizole was started 10 hours after admission. The patient was hospitalized for 35 days. Evolution was favorable but marked with an acute coronary syndrome. Cardiac function was recovered afterward. At admission in the ICU, case 2 was in a coma (Glasgow coma scale 3), and presented dyspnea, metabolic acidosis (pH = 6.90) with very high serum lactate (> 20 mmol/L), acute renal failure (serum creatinine = 141 μmol/mL) and hyperkaliemia (6.6 mmol/L). The patient was intubated and received RRT. Ethylene glycol plasma level was 402 mg/L. Fomepizole was started 18 h after admission. The patient was hospitalized for 21 days. Evolution was favorable except for a lower lip pressure ulcer and chronic kidney injury. Follow up at 2 months showed a partial recovery of renal function. Case 3 presented at admission metabolic acidosis (pH = 7.14) with high serum lactate (8.1 mmol/L), acute respiratory failure and acute renal failure (serum creatinine = 114 μmol/L). After transfer to the ICU, the patient was intubated and received RRT. Ethylene glycol plasma level was 607 mg/L. Fomepizole was started about 4 h after admission. The patient was hospitalized for 23 days. Evolution was marked by a ventilator-associated pneumonia but was favorable otherwise. These 3 cases have in common a severe acidosis associated with an acute renal failure and respiratory disorders. High serum lactate has to be interpreted with caution due to analytical interference [1] . Neurological toxicity was characterized for case 1 and 2. The long hospitalization duration (21 to 35 days) reflects the severity of the intoxications. Fomepizole antidote treatment must be started as soon as possible. Ethylene glycol plasma concentration should be obtained to confirm the diagnosis if available. Even though ethylene glycol poisoning is well known, cases are rare but nonetheless can currently be life-threatening. They require fast diagnostic and treatment to avoid morbidity [2] .

Unwell after drinking homemade alcohol – A case of ethylene glycol poisoning

Delayed treatment of ethylene glycol poisoning can have catastrophic consequences that may result in death. Three young men presented to the Emergency Centre (EC) with a main complaint of feeling unwell after consuming “homemade alcohol”. A fourth person had died at home an hour earlier. Blood analysis revealed a raised anion gap metabolic acidosis as well as a raised osmolar gap in all three patients. The clinical presentation of ethylene glycol and methanol poisoning is non-specific and can be difficult to differentiate from ethanol intoxication. Homemade alcohol preparations are commonly adulterated with ethylene glycol and methanol to improve their taste and sting. Toxic alcohol analysis is not routinely carried out by most laboratory services in South Africa, and when carried out, results are only made available a few days later. A high index of suspicion coupled with early blood gas analysis and a need for prompt and effective treatment whilst awaiting toxicology analysis may limit the associated high morbidity and mortality. Le retard de traitement des empoisonnement à l’éthylène glycol peut avoir des conséquences catastrophiques pouvant entraîner la mort. Trois jeunes hommes se sont présentés au centre de traitement des urgences en se plaignant essentiellement de se sentir malades après avoir consommé de l’”alcool artisanal”. Une quatrième personne était morte au domicile une heure plus tôt. Les analyses de sang ont révélé une acidose métabolique à trou anionique augmenté ainsi qu’un trou osmolaire augmenté chez les trois patients. La présentation clinique de l’empoisonnement à l’éthylène glycol et au méthanol n’est pas spécifique et peut être difficile à différencier d’une intoxication à l’éthanol. Les préparations artisanales sont couramment frelatées par l’ajout d’éthylène glycol et de méthanol destiné à en améliorer le goût et le piquant. Les analyses de la toxicité de l’alcool ne sont pas régulièrement réalisées par la plupart des services de laboratoire en Afrique du Sud, et quand elles le sont, les résultats ne sont transmis que quelques jours plus tard. Un indice élevé de suspicion associé à une analyse précoce des gaz du sang et la nécessité d’un traitement rapide et efficace dans l’attente de l’analyse toxicologique pourrait limiter la forte morbidité et mortalité associées.

Ethylene glycol ingestion treated only with fomepizole

Ethylene glycol is a widely used chemical that is capable of causing significant injury if ingested. Treatment for ethylene glycol poisoning typically includes basic supportive care, alcohol dehydrogenase inhibition, and hemodialysis. Recent data have suggested that hemodialysis may not be necessary for cases of ethylene glycol poisoning that can be treated with fomepizole as blocking therapy before acidosis or renal dysfunction develops. A 33-year-old man presented to the emergency department 1 hour after drinking approximately 1/2 gallon of ethylene glycol antifreeze and an unknown quantity of beer. On arrival he was mildly inebriated but otherwise displayed no other features of ethylene glycol poisoning. Fomepizole therapy was initiated and initial laboratory studies later revealed an osmol gap of 157 mOsm and an ethylene glycol concentration of 706 mg/dL. Nephrology and toxicology services were consulted. Over the next 3 days, fomepizole therapy was continued while the patient's acid-base status and renal function were closely monitored. No evidence of acid-base abnormalities or renal impairment was ever observed and the patient was discharged to psychiatric care on the fourth hospital day. This report describes the case of a patient who presented soon after a massive ingestion of ethylene glycol with very high serum concentrations. He was successfully treated using fomepizole and basic supportive care. Our patient developed neither renal insufficiency nor metabolic acidosis. His concomitant ethanol consumption, early presentation, and treatment likely contributed to his favorable outcome. This case report underscores the effectiveness of supportive care and fomepizole in the treatment of ethylene glycol poisoning.

Fomepizole as an antidote for ethylene glycol poisoning.

To assess the use of fomepizole in the treatment of ethylene glycol poisoning in the absence of hemodialysis. A MEDLINE search (1966-May 2001) of English-language literature pertaining to the use of fomepizole in ethylene glycol poisoning was performed. Key search terms included fomepizole, ethylene glycol poisoning, and hemodialysis. References cited in those articles were also evaluated. Results from a number of case reports and a prospective trial suggest that fomepizole is a safe and effective antidote in the treatment of ethylene glycol poisoning. Case reports and 1 prospective trial have shown that, in the absence of both renal dysfunction and significant metabolic acidosis, the use of fomepizole should obviate the need for hemodialysis. However, the decision to add hemodialysis in the treatment of ethylene glycol poisoning based on plasma ethylene glycol concentrations is still debatable. A randomized, controlled trial is needed to determine the exact criteria for adding hemodialysis.

Fomepizole in treatment of uncomplicated ethylene glycol poisoning

Fomepizole is an effective alternative to ethanol in the treatment of ethylene glycol poisoning. In a series of 38 acute poisonings without renal failure, fomepizole obviated the need for haemodialysis.

American Academy of Clinical Toxicology Practice Guidelines on the Treatment of Ethylene Glycol Poisoning

Fomepizole (4-methylpyrazole, 4-MP, Antizol) is a potent inhibitor of alcohol dehydrogenase that was approved recently by the US Food and Drug Administration (FDA) for the treatment of ethylene glycol poisoning. Although ethanol is the traditional antidote for ethylene glycol poisoning, it has not been studied prospectively. Furthermore, the FDA has not approved the use of ethanol for this purpose. Case reports and a prospective case series indicate that the intravenous (i.v.) administration of fomepizole every 12 hours prevents renal damage and metabolic abnormalities associated with the conversion of ethylene glycol to toxic metabolites. Currently, there are insufficient data to define the relative role of fomepizole and ethanol in the treatment of ethylene glycol poisoning. Fomepizole has clear advantages over ethanol in terms of validated efficacy, predictable pharmacokinetics, ease of administration, and lack of adverse effects, whereas ethanol has clear advantages over fomepizole in terms of long-term clinical experience and acquisition cost. The overall comparative cost of medical treatment using each antidote requires further study.

Hemodialysis‐Induced Hypophosphatemia in a Normophosphatemic Patient Dialyzed for Ethylene Glycol Poisoning: Treatment with Phosphorus‐Enriched Hemodialysis

Hypophosphatemia developed in a normophosphatemic patient after 9 h of hemodialysis therapy (using a phosphate-free dialysate) administered for the treatment of ethylene glycol poisoning. The hypophosphatemia was promptly improved with additional hemodialysis treatment using a phosphorus-enriched dialysate.

Low-dose ethanol in the treatment of ethylene glycol poisoning.

A pharmacokinetic study was conducted to determine the effectiveness of lower doses of ethanol in the treatment of ethylene glycol (EG) poisoning. Four dogs were maintained at serum ethanol concentrations of 0, 35 and 140 mg/dl prior to EG (i.v., 2 ml/kg) administration. The serum EG concentration-time data showed that the 35 mg/dl ethanol level provided as effective an inhibition of EG metabolism as did the 140 mg/dl level. The average urinary excretion rate of oxalic acid post EG administration was reduced to control levels by ethanol. The 35 mg/dl serum ethanol level reduced the total body clearance of EG from 93.9 to 50.0 ml/h/kg and increased the effective half-life from 5.78 to 11.4 h. Clinical testing was accomplished by giving the dogs 12 ml EG/kg body weight orally. One hour later, the dogs were either not treated or treated with a sodium bicarbonate-ethanol solution to obtain a serum ethanol concentration of 50 mg/dl. The clinical test performed in the ethanol-treated dogs showed little change from normal limits. Urine calcium oxalate crystals were seldom found. The dogs given EG (12 ml/kg) but not treated with ethanol were in a coma at 13 h and showed severe metabolic acidosis, dehydration, mild hepatocellular disease and acute renal damage. Urine calcium oxalate crystals were found in high numbers. The rapid death associated with EG poisoning appeared to be due to metabolic acidosis in combination with dehydration.

480. The answer to ethylene glycol poisoning: Peterson, D. I., Peterson, J. E., Hardinge, M. G. & Wacker, W. E. C. (1963). Experimental treatment of ethylene glycol poisoning. J. Amer. med. Ass.186, 955

480. The answer to ethylene glycol poisoning: Peterson, D. I., Peterson, J. E., Hardinge, M. G. & Wacker, W. E. C. (1963). Experimental treatment of ethylene glycol poisoning. J. Amer. med. Ass.186, 955