Single-pass albumin dialysis in a child aged six months with phenobarbital poisoning

Abstract

A girl aged six months was hospitalized because of resistant seizures and was discharged with phenobarbital and carbamazepine therapy. She was admitted to a state hospital with symptoms of inability to waken and difficulty in breathing. It was learned that phenobarbital had been used incorrectly and the patient was sent to our pediatric intensive care unit because of severe phenobarbital overdose. The decision was taken for hemodialysis. Single-pass albumin dialysis was planned because phenobarbital can bind to high levels of plasma protein. The process was undertaken with 1% albumin-containing dialysate, which was prepared manually. After 6 hours of dialysis, the phenobarbital blood level measured 62 mcg/mL (>140 mcg/mL on admission) and the patient's clinical findings were markedly regressed. There are no case reports about phenobarbital overdose treated with single-pass albumin dialysis in the literature. We conclude that single-pass albumin dialysis may be a useful treatment, especially with intoxications of drugs that bind protein at high levels. (Turk Pediatri Ars 2016; 51: 228-30)

The Use of Peritoneal Dialysis in Phenobarbitone Toxicity in a Critically Unwell Neonate

“…In situations of severe barbiturate intoxication, MDAC is recommended as the first-line intervention to enhance intestinal clearance [5], and it has been used in infants [6,7]. Extra-corporeal elimination therapies that enhance adult PB clearance have technical limitations and an increased risk in neonates [5,8].…”

Antiepileptic drugs: Role in paediatric poisoning

“…Focusing on the paediatric population, PB is a relatively rare cause of intoxication. Most reported cases have involved newborns inadvertently given a dose higher than that prescribed …”

“…Forced diuresis is another possible treatment, but its efficacy may be low if protein binding is high . Urine alkalinisation is suggested in cases of PB poisoning . Extracorporeal techniques, including haemodialysis, peritoneal dialysis, plasma exchange, charcoal haemoperfusion, albumin‐enhanced continuous venovenous haemodialysis and continuous venovenous haemodiafiltration, should be reserved for severe poisonings.…”

“…31 PB poisoning can be life-threatening, manifesting with miosis, lack of pupil and corneal reflexes, nystagmus, ataxia, pulmonary oedema, apnoea, respiratory failure, hypotension, hypothermia, mixed acidosis, areflexia and disorders of consciousness ranging from drowsiness to coma. 7,31 Hypersensitivity to PB may lead to severe hepatitis and massive hepatic necrosis. 32 Tiagabine Tiagabine (TGB) is a new AED prescribed at a dose of 4-32 mg/ kg/day; T max is 0.5-2 h, and therapeutic plasma concentration is 0.02-0.2 mg/L.…”

“…48 Urine alkalinisation is suggested in cases of PB poisoning. 31 Extracorporeal techniques, including haemodialysis, peritoneal dialysis, plasma exchange, charcoal haemoperfusion, albumin-enhanced continuous venovenous haemodialysis and continuous venovenous haemodiafiltration, should be reserved for severe poisonings. Reviews and recommendations of extracorporeal treatment for CBZ and VPA poisoning have recently been published by the EXtracorporeal TReatments In Poisoning (EXTRIP) workgroup; however, no specific paediatric guidelines are currently available.…”