Assessment of Extracorporeal Treatments in Poisoning criteria for the decision of extracorporeal toxin removal in lithium poisoning

Abstract

Aims To assess recommendations provided by the EXtracorporeal TReatments In Poisoning (EXTRIP) workgroup on extracorporeal toxin removal (ECTR) in lithium poisoning. Methods Retrospective assessment in a 128 lithium‐poisoned patient cohort previously used to identify ECTR initiation criteria that could improve outcome (Paris criteria). ECTR requirement using EXTRIP criteria was compared to the actual practice or if Paris criteria were used. The potential impact on outcome if these different criteria were used was investigated. Results Using the recommended (Rec‐EXTRIP) or recommended + suggested (All‐EXTRIP) EXTRIP criteria, ECTR would have been indicated in more patients than was actually done (P < .001), or if Paris criteria were used (P < .01). The non‐actually ECTR‐treated patients fulfilling Rec‐EXTRIP or All‐EXTRIP criteria had shorter intensive care unit stay (P < .05) and no significant increase in fatalities and neurological impairment on discharge in comparison to the actually ECTR‐treated patients. ECTR requirements using EXTRIP vs Paris criteria were not concordant (P < .001). In the non‐actually ECTR‐treated patients, 31/106 and 55/106 patients fulfilled Rec‐EXTRIP or All‐EXTRIP but not Paris criteria, respectively. Those patients had longer stay (P < .01) but no worse neurological impairment on discharge than the patients not fulfilling any of these criteria (50/106 and 26/106, respectively). In the non‐actually ECTR‐treated patients, 7/106 fulfilled Paris but not Rec‐EXTRIP criteria. Those patients had longer stay (P < .05) and worse neurological impairment on discharge (P < .01) than the 50/106 patients not fulfilling any of these criteria. Conclusion In this cohort of lithium poisonings, EXTRIP criteria may lead to more ECTR than actually performed or if the Paris criteria were used, with no demonstrated improvement in outcome.

Identifying lithium‐poisoned patients who may benefit from haemodialysis remains highly challenging

“…3 The 'decreased level of consciousness' criterion was interpreted as a Glasgow coma score (GCS) of <15 in Buckley's study 1 but as GCS of <12 in ours. 2 The 'confusion' criterion was construed as onset of confusion in Buckley's study 1 but as GCS of 12-13 in ours. 2 The 'serum lithium concentration expected to be >1 mmol/L at 36 h with optimal management' criterion was determined in Buckley's study 1 using the Ct = Co à e − 0:161ÃeGFR + 6:47…”

“…2 The 'confusion' criterion was construed as onset of confusion in Buckley's study 1 but as GCS of 12-13 in ours. 2 The 'serum lithium concentration expected to be >1 mmol/L at 36 h with optimal management' criterion was determined in Buckley's study 1 using the Ct = Co à e − 0:161ÃeGFR + 6:47…”

“…Ãt equation but in ours 2 Comparison of the two study cohorts of lithium-poisoned patients Note: Data are given as medians (range) or counts (%).…”

Lithium Poisoning Update in Diagnosis and Treatment

“…The clinical characteristics of the drug, for example, its small molecular weight, low binding to plasma proteins, low volume of distribution, and poor endogenous clearance, make hemodialysis the therapeutic strategy of greatest evidence and use in the context of lithium poisoning [39,40]. The goals of hemodialysis are to decrease high concentrations of lithium in toxic behaviors, such as the central nervous system, and to favor a concentration gradient that allows lithium to diffuse into plasma for its subsequent elimination [41].…”

Evidence‐based recommendations for haemodialysis in lithium‐poisoned patients: Getting from where we are to where we want to be

“…In addition to periodic review over time, significant new data, a change in outcomes of interest, or development of new resources or therapies should trigger rapid revision.12 Two recent papers in the Journal add to the evidence for ECTR in lithium poisoning by comparing locally derived decision rules to the EXTRIP criteria. In the first paper, Vodovar et al performed a retrospective analysis of lithium-poisoned patients from a single ICU in Paris 13. They derived a simple set of clinical criteria and suggest that these new criteria outperform the EXTRIP criteria.…”