Haemodialysis management for salicylate intoxication
MANEJO HEMODIALÍTICO DE LA INTOXICACIÓN POR SALICILATOS
Nerio Quintero Parraa, Andrés Wurgaft Kirberga, Yessenia Valeska Orellana Arayaa, Javier Arellano Lorcaa, Loreto Rojas Wettiga, Jacqueline Pefaur Pennaa
a Departamento de Nefrología, Complejo Asistencial Barros Luco, Facultad de Ciencias Médicas, Universidad de Santiago de Chile, Santiago de Chile, Santiago de Chile, Chile,
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metabolic alterations and organ failure that can be fatal. <span class="elsevierStyleSup">1,2</span> Haemodialysis must be used appropriately in these cases.<span class="elsevierStyleSup">3,4 </span>We present a case where haemodialysis was used in a potentially lethal overdose of Acetylsalicylic Acid (ASA).</p><p class="elsevierStylePara">We describe the case of a 24 year old female patient, with no morbid history, that presented in the Emergency Room 18 hours after having ingested 50 pills of ASAof 500mg, 25g total or 400mg per kilogram of weight, with suicidal intention. When hospitalized, she presented lethargy, confusion, vomiting, hypoacusia and tinnitus. Vital signs were normal and there were no positive findings in the physical examination. Laboratory tests on admission included: arterial gasometry: pH: 7.42, PO2 115mmHg, PCO2 14mmHg, HCO3 9.2mmol/l. Creatininaemia: 0.89mg/dl, kalaemia: 2.1mEq/l, natraemia: 138mEq/l. The anion gap was 18. There were no alterations in liver function tests or in cardiac enzymes. A gastric lavage was performed, saline solution and sodium bicarbonate were administered. She was transferred to the Intermediate Care Unit with a salycilate level of 682mg/l.</p><p class="elsevierStylePara">Haemodialysis was carried out for four hours, with a polysulphone filter, and 39mEq/l bicarbonate, 3.5mEq/l of potassium and 140mEq/l of sodium bath. Fluid balance during haemodialysis was positive at 2,500cc. The patient was stable with progressive improvement of state of consciousness and slow correction of acidbase alterations. Salycilate levels of 99 and 1mg/l were obtained 12 to 20 hours after dialysis, respectively.</p><p class="elsevierStylePara">The ASA is absorbed in the stomach and small intestine as salicylic acid. It is conjugated in the liver and excreted in bile and urine. Therapeutic levels are of 100 to 300mg/l. The classic triad of intoxication by salicylate is hyperventilation, gastric irritation and tinnitus.1 There may be liver, kidney, central nervous system and cardiovascular organ damage. Salicylate, above therapeutic levels, stimulates the respiratory centre and causes respiratory alkalosis.<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara">The toxic levels also produce a separation in the oxidative phosphorylation and accumulation of lactic acid, resulting in metabolic acidosis.<span class="elsevierStyleSup">6</span> This mixed acid-base syndrome, with an increased anion gap, should lead one to suspect an intoxication by ASAin a patient where the antecedents of what has been ingested is unknown. The treatment of salycilate poisoning includes vital support, gastric lavage, the use of activated charcoal and alcalinization of the urine to encourage the excretion of the drug.<span class="elsevierStyleSup">3</span> Salicylate has a distribution volume of 150ml/k, a protein binding rate between 50 and 80% (which decreases when levels are high), and a molecular weight of 138.<span class="elsevierStyleSup">3 </span>These properties favour its elimination by haemodialysis, which is the indicated treatment in serious cases.</p>" "pdfFichero" => "P-E-S-A219-EN.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "O¿Malley G. Emergency department management of the salicylate-poisoned patient. Emerg Med Clin N Am 2007; 25:333¿346." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Chyka PA, Erdman AR, Christianson G, Wax PM, Booze LL, Manoguerra AS, Caravati EM, Nelson LS, Olson KR, Cobaugh DJ, Scharman EJ, Woolf AD, Troutman WG. Salicylate poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45 (2):95-131." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Wrathall G, Sinclair R, Moore A, Pogson D. Three case reports of the use of haemodiafiltration in the treatment of salicylate overdose. Hum Exp Toxicol 2001; 20; 491. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11776412" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Locket S. Haemodialysis in the treatment of acute poisoning. Proc roy Soc Med 1970;63:427-430. <a href="http://www.ncbi.nlm.nih.gov/pubmed/4916564" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Wood DM, Dargan PI, Jones AL. Measuring plasma salicylate concentrations in all patients with drug overdose or altered consciousness: is it necessary? Emerg Med J 2005;22:401-403. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15911944" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Krause DS, Wolf BA, Shaw LM. Acute aspirin overdose: mechanisms of toxicity. Ther Drug Monit 1992;14(6):441-51. <a href="http://www.ncbi.nlm.nih.gov/pubmed/1485363" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000002900000002/v0_201502091631/X2013251409005045/v0_201502091631/en/main.assets" "Apartado" => array:4 [ "identificador" => "35436" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000002900000002/v0_201502091631/X2013251409005045/v0_201502091631/en/P-E-S-A219-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251409005045?idApp=UINPBA000064" ]
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