Clinical toxicology : the official journal of the American Academy of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxicologists
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Clin Toxicol (Phila) · Nov 2013
ReviewWhat is the clinical significance of 5-oxoproline (pyroglutamic acid) in high anion gap metabolic acidosis following paracetamol (acetaminophen) exposure?
Paracetamol (acetaminophen) ingestion is the most frequent pharmaceutical overdose in the developed world. Metabolic acidosis sometimes occurs, but the acidosis is infrequently persistent or severe. A growing number of case reports and case series describe high anion gap metabolic acidosis (HAGMA) following paracetamol exposure with subsequent detection or measurement of 5-oxoproline (also called pyroglutamic acid) in blood, urine, or both. Typically 5-oxoprolinuria or 5-oxoprolinemia occurs in the setting of inborn genetic errors in glutathione metabolism. It is unknown whether 5-oxoprolinemia in the setting of paracetamol exposure reflects an acquired or transient derangement of glutathione metabolism or previously unrecognized genetic defects. ⋯ In rare cases, HAGMA in the setting of paracetamol exposure is attributable to 5-oxoprolinemia. Clinicians should first exclude commoner and treatable causes of HAGMA, such as lactic acidosis, co-ingested drug administration, and ketoacidosis. It is likely that the propensity for HAGMA following paracetamol exposure may be genetically determined. The effects of acetylcysteine on 5-oxoproline concentrations or clinical outcome are unknown. When HAGMA is diagnosed, the 5-oxoproline concentration and the glutathione synthetase activity should be measured.
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Clin Toxicol (Phila) · Nov 2013
Case ReportsAntidote removal during haemodialysis for massive acetaminophen overdose.
Haemodialysis is sometimes used for patients with massive acetaminophen overdose when signs of "mitochondrial paralysis" (lactic acidosis, altered mental status, hypothermia and hyperglycaemia) are present. The role of haemodialysis is debated, in part because the evidence base is weak and the endogenous clearance of acetaminophen is high. There is also concern because the antidote acetylcysteine is also dialyzable. We prospectively measured serum acetylcysteine concentrations during haemodialysis in three such cases. ⋯ When massive acetaminophen ingestion is accompanied by coma and lactic acidosis, emergency haemodialysis can result in rapid biochemical improvement. As expected, haemodialysis more than doubles the clearance of both acetaminophen and acetylcysteine. Because acetylcysteine dosing is largely empirical, we recommend doubling the dose during haemodialysis, with an additional half-load when dialysis exceeds 6 h.
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Clin Toxicol (Phila) · Nov 2013
Comparative StudyCharacterizing risk factors for pediatric lamp oil product exposures.
Poisonings from lamp oil ingestion continue to occur worldwide among the pediatric population despite preventive measures such as restricted sale of colored and scented lamp oils. This suggests that optimal prevention practices for unintentional pediatric exposures to lamp oil have yet to be identified and/or properly implemented. ⋯ Lamp oil product exposures are most common among young children (around 2 years of age) while at home, not alone and likely as a result of the product being in a child-accessible location. Increasing parental awareness about potential health risks to children from these products and teaching safe storage and handling practices may help prevent both exposures and associated illness. These activities may be of greater benefit in Midwestern states and during summer months (including the period around the July 4th holiday).
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Clin Toxicol (Phila) · Nov 2013
A 13-year review of lisinopril ingestions in children less than 6 years of age.
Lisinopril is an angiotensin converting enzyme inhibitor used for treatment of hypertension, congestive heart failure, and acute myocardial infarction. Reports of clinical experience with pediatric ingestions are minimal. ⋯ The lowest estimated dose of lisinopril to cause hypotension was 50 mg or 3.9 mg/kg. Although continued evaluation of pediatric lisinopril ingestions is essential to determine more specific thresholds of toxicity, the lack of effect on blood pressure in children with exact-dose ingestions indicate that pediatric lisinopril ingestions (for ages > 9 months) ≤ 4 mg/kg up to 40 mg total may be safely managed at home.
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Clin Toxicol (Phila) · Nov 2013
Case ReportsProlonged lipemia and pancreatitis due to extended infusion of lipid emulsion in bupropion overdose.
Lipid emulsion is gaining popularity as an antidote for lipophilic drug overdose, and is generally considered safe at doses recommended for antidotal therapy. We report a case of asymptomatic pancreatitis following extended infusion lipid emulsion. ⋯ Large doses of lipid emulsion may result in lipemia, severe hypertriglyceridemia, interference in laboratory analyses, and pancreatitis. This is the third reported adverse event due to lipid emulsion therapy used for overdose.