Case files of the Children’s Hospital of Michigan Regional Poison Control Center: The use of carnitine for the management of acute valproic acid toxicity

Katiyar, Abhishek; Aaron, Cynthia K.

doi:10.1007/bf03160923

Cited by 7 publications

(6 citation statements)

References 80 publications

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“…1,4 Ayrıca hiperamonyeminin stupor, koma ve nöbet gelişmesinin nedeni olduğu düşünülmektedir. 9 VA zehirlenmelerinde halen destek tedavisi öncelikli seçenektir. Ağız yoluyla VA alımı sonrasında yapılan mide yıkama işlemi ve tekrarlayan aktif kömür uygulanması ilacın emilimini azaltarak kan VA düzeyini azaltabilmektedir.…”

Section: öZ Abstractunclassified

Severe Valproic Acid Intoxication Responding to Hemodialysis

Arslanköylü¹,

Alakaya²,

Akyılmaz³

et al. 2017

cayd

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Valproik asit (VA), epilepsi hastası çocuklarda yaygın olarak kullanılan ve terapötik aralığının dar olması nedeniyle kolaylıkla zehirlenmelere neden olabilen anti-epileptik bir ilaçtır. VA zehirlenmesi hafif bilinç bozukluğu ve letarjiden koma ve ölüme kadar farklı klinik tablolara neden olabilir. VA'nın gastrointestinal sisteme olan yan etkileri arasında bulantı, diyare, kusma, pankreatit, metabolik etkiler arasında lökopeni, anemi, trombositopeni, kanama, hipofibrinojenemi, 'yüksek anyon açıklı metabolik asidoz, hiperosmolarite, hipernatremi, hipokalsemi, hipoglisemi, methemoglobinemi, rabdomiyoliz, akut böbrek yetmezliği, solunum yetmezliği, hipotermi, hipotansiyon, taşikardi sayılabilir. 1-3 Tedavinin temelini destek tedavisi oluşturur. VA zehirlenmesinin özgül bir antidotu veya tedavi rehberi yoktur. Ancak bazı çalışmalarda klinik sonuçları net olmasa da, VA alımına ikincil gelişen hiperamonyemi, karaciğer yetmezliği, koma varlığında, ağızdan verilen L-karnitin antidot olarak kullanılabileceği bildirilmiştir. 1,2,4 VA zehirlenmesinde hemodiyalizin etkili olduğuna dair nadir olgu sunumları bulunmaktadır. 5,6 Bu olgu sunumunda amacımız ağır VA zehirlenmesinde destek tedavisine yanıt vermeyen çocuk hastalarda hemodiyalizin etkin olduğu bir olgu sunarak ağır Valproic acid is a commonly used antiepileptic drug which causes intoxication easily due to its narrow therapeutic window. Here, we present a child with valproic acid poisoning who responded to hemodialysis. A 14-year-old male patient with epilepsy and mental motor retardation was admitted to the pediatric intensive care unit due to valproic acid intoxication. Plasma valproic acid level was 710 µg/mL. The patient's vital signs were stable and a decrease was observed in the valproic acid and ammonia levels with supportive treatment at the beginning. On the third day of the admission, hemodynamic and mental status of the patient deteriorated, plasma ammonia and lactate levels elevated, thus, we decided to perform hemodialysis. After hemodialysis, the patient's hemodynamic status and mental function improved in conjunction with the reduction in valproic acid, ammonia and lactate levels. Thus he was transferred to the pediatric ward. Hemodialysis may be considered an effective treatment choice for severe valproic acid intoxication. Here, it was shown that hemodialysis may also be effective in patients with deteriorated general status under supportive treatment in the late phase of valproic acid intoxication.

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Section: öZ Abstractunclassified

Severe Valproic Acid Intoxication Responding to Hemodialysis

Arslanköylü¹,

Alakaya²,

Akyılmaz³

et al. 2017

cayd

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“…The anticonvulsant properties of VPA derive from its ability to increase γ-aminobutyric acid (GABA) availability via inhibition of GABA transaminase and succinic semialdehyde dehydrogenase, to attenuate N-methyl-Daspartate (NMDA)-type glutamate receptor excitatory effects, and to slow the rate of recovery from sodium channel inactivation [201][202][203]. Additionally, VPA appears to affect inositol levels similar to lithium.…”

Section: L-carnitinementioning

confidence: 99%

Drugs and pharmaceuticals: management of intoxication and antidotes

Smith

2010

Experientia Supplementum

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The treatment of patients poisoned with drugs and pharmaceuticals can be quite challenging. Diverse exposure circumstances, varied clinical presentations, unique patientspecific factors, and inconsistent diagnostic and therapeutic infrastructure support, coupled with relatively few definitive antidotes, may complicate evaluation and management. The historical approach to poisoned patients (patient arousal, toxin elimination, and toxin identification) has given way to rigorous attention to the fundamental aspects of basic life supportairway management, oxygenation and ventilation, circulatory competence, thermoregulation, and substrate availability. Selected patients may benefit from methods to alter toxin pharmacokinetics to minimize systemic, target organ, or tissue compartment exposure (either by decreasing absorption or increasing elimination). These may include syrup of ipecac, orogastric lavage, activated single-or multi-dose charcoal, whole bowel irrigation, endoscopy and surgery, urinary alkalinization, saline diuresis, or extracorporeal methods (hemodialysis, charcoal hemoperfusion, continuous venovenous hemofiltration, and exchange transfusion). Pharmaceutical adjuncts and antidotes may be useful in toxicant-induced hyperthermias. In the context of analgesic, anti-inflammatory, anticholinergic, anticonvulsant, antihyperglycemic, antimicrobial, antineoplastic, cardiovascular, opioid, or sedative-hypnotic agents overdose, N-acetylcysteine, physostigmine, L-carnitine, dextrose, octreotide, pyridoxine, dexrazoxane, leucovorin, glucarpidase, atropine, calcium, digoxin-specific antibody fragments, glucagon, high-dose insulin euglycemia therapy, lipid emulsion, magnesium, sodium bicarbonate, naloxone, and flumazenil are specifically reviewed. In summary, patients generally benefit from aggressive support of vital functions, careful history and physical examination, specific laboratory analyses, a thoughtful consideration of the risks and benefits of decontamination and enhanced elimination, and the use of specific antidotes where warranted. Data supporting antidotes effectiveness vary considerably. Clinicians are encouraged to utilize consultation with regional poison centers or those with toxicology training to assist with diagnosis, management, and administration of antidotes, particularly in unfamiliar cases.

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“…VPA poisonings in childhood frequently develop due to overdosing or suicidal use. Central nervous system (CNS) depression, cerebral edema, hyperammoniemia, hepatotoxicity, hemorrhagic pancreatitis, bone marrow suppression and death are among the clinical findings it causes (8)(9)(10)(11). Treatment is supportive in valproic acid poisoning.…”

Section: Introductionmentioning

confidence: 99%

2010–2016 yılları arasında çocuk acil polikliniğinde valproik asit intoksikasyonu nedeniyle takip ve tedavi edilen olguların değerlendirilmesi

Fidancı¹,

Güzel²

2017

Konuralp Tıp Dergisi

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Objective: Our aim was to determine prognostic factors effecting clinical course of the patients referring to the Child Emergency Service in our hospital with valproic acid (VPA) poisoning. Methods: Patients who had VPA poisoning diagnoses between 2010 and 2016 in our Child Emergency Service were retrospectively examined. Demographical characteristics, clinical findings, laboratory results, treatment methods and effective factors for prognosis were evaluated for the patients. Results: The study were included 114 patients whose avarage age is 9.91±4.69 years Sixty-six of the patients were female and forty-eight were male. The most common reason for inclusion has been overdosing (100 patients, 87.72%). Fourteen patients (12.28%) had pure VPA poisoning. VPA serum level median value was 141.80 µ/mL (min-max; 102.20 -640.38 µ/mL). Central nervous system depression was the most common clinical finding (six patients, 5.2%). Thrombocytopenia was detected in sixteen patients (14.0%) and hyperammoniemia in eighteen patients (15.8%). Average follow-up duration for the patients was 16.14 hours. L-carnitine treatment was applied for six patients (5.3%). Conclusions:In long-term VPA usage, the importance of thrombocytopenia and ammonia level should not be forgotten during prognosis. Supportive treatment still maintains its importance in VPA intoxication and intensive care follow-up and treatment was necessary for two patients in our study and L carnitine was started for patients with suitable indications and preserves its importance in treatment. Yöntem: Çocuk Acil Servisimize 2010-2016 yılları arasında VPA zehirlenme tanısı alan hastalar geriye dönük incelendi. Hastaların, demografik özellikleri, klinik bulguları, laboratuar sonuçları, tedavi yöntemleri ve prognozda etkili faktörler değerlendirildi. Bulgular: Çalışmaya 114 hasta dahil edildi. Hastaların yaş ortalaması 9,91±4,69 yıl idi. Hastaların 66'sı kız ve 48'i erkekti. Alım nedenleri arasında en sık neden doz aşımı (100 hasta, %87,72) idi. 14 hasta (%12,28) ise suisidal saf VPA zehirlenmesi idi. VPA serum düzeyi ortanca değeri 141,80 µ/mL (min-max; 102,20 -640,38 µ/mL) idi. En sık klinik bulgu (6 hasta, %5,2) santral sinir sistemi depresyonu mevcuttu. On altı hastada (%14,0) trombostopeni ve 18 hastada (%15,8) hiperamonyemi tespit edildi. Hastaların ortalama takip süresi 16,14 saat idi. Altı hastaya (% 5,3) L-karnitin tedavisi uygulandı. Sonuç: Uzun dönem VPA kullanımında trombositopeni ve amonyak seviyesininde prognozdaki yeri unutulmamalıdır. VPA intoksikasyonunda destekleyici tedavi halen önemini korumakta olup çalışmamızda 2 hastamızda yoğun bakım takip ve tedavisi gerekmiş olup, L carnitin uygun endikasyonlu hastalara başlandı ve tedavide yerini korumaktadır.

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Case files of the Children’s Hospital of Michigan Regional Poison Control Center: The use of carnitine for the management of acute valproic acid toxicity

Cited by 7 publications

References 80 publications

Severe Valproic Acid Intoxication Responding to Hemodialysis

Severe Valproic Acid Intoxication Responding to Hemodialysis

Drugs and pharmaceuticals: management of intoxication and antidotes

2010–2016 yılları arasında çocuk acil polikliniğinde valproik asit intoksikasyonu nedeniyle takip ve tedavi edilen olguların değerlendirilmesi

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