To the Editor,
Standard treatment for severe ethanol poisoning consists of an aggressive treatment with cardiovascular and respiratory support, and close monitoring of the electrolytes, preventing hypothermia and hypoglycaemia. There are many cases of severe ethanol poisoning that have been successfully treated with conservative treatment. Haemodialysis is recommended for patients with signs of severe poisoning, and serum ethanol levels above 600mg/dl, (this figure is less for adolescents).1
We present the case of a patient with severe ethanol poisoning treated with haemodialysis, whose serum ethanol levels decreased rapidly.
The patient was a 57 year-old man, with epilepsy from 30 years of age, former alcoholic. He had experienced traumatic brain injury in 2008 as the result of an epileptic seizure. He was found unconscious in his home, with two empty whisky bottles and was suspected to have taken 4g of carbamazepine. In the examination we observed that he was in a state of coma, with slightly anisocoric pupils, pulse: 67 beats/min, blood pressure 80/50mm Hg, temperature 36.2ºC; and pulmonary auscultation revealed reduced vesicular murmur in the left haemothorax. There were no other significant findings.
He was haemodynamically unstable, and upon admission to the intensive care unit, vasopressor treatment and respiratory support were indicated. Toxic levels of ethanol (650mg/dl) were found. The biochemistry analysis showed: Na: 137mmol/l; K: 4mmol/l; Cl: 106mmol/l; glucose 173mg/dl; urea 42mg/dl; creatinine: 1.39mg/dl; anion gap: 18mOs/kg; osmolar gap: 126mOs/kg. Blood gasometry: pH: 7.05; HCO3: 16.6mmol/l; pCO2: 60mm Hg; pO2 : 47mm Hg. Due to instability and poor response to conservative treatment, haemodialysis was performed for 3 hours with a polysulfone dialyser at a blood flow of 250ml/min. After this session, serum ethanol levels reduced to 373mg/dl and metabolic acidosis was corrected.
The patient then had symptoms of bronchial aspiration and acute pancreatitis, which was resolved with antibiotic and conservative treatment.
Dialysis was recommended to treat severe ethanol poisoning for the first time in 1960, given that it is four times quicker than physiological elimination of ethanol.2 However, deciding which patients with severe poisoning are eligible to undergo haemodialysis is a controversial matter. Some authors suggest that it is sufficient with a conservative treatment,3 while others believe that haemodialysis should be considered for those patients with a serum level above 600mg/dl,4 given that it could reduce the length of the coma and the risk of bronchial aspiration, correct hypothermia and hypoglycaemia, improve metabolic acidosis, and reduce the risk of arrhythmia. Furthermore, that alcohol is easily eliminated by haemodialysis as it is a small, water-soluble molecule which does not bind to proteins. Its volume of distribution is also limited.
We recommend indicating haemodialysis as a therapeutic option for patients with signs of severe ethanol poisoning, whose clinical profile does not improve following conservative treatment, provided that the acute complications of haemodialysis are assessed.
