Successful treatment of carbamazepine poisoning with hemodialysis: A case report and review of the literature

Abstract

A 48-year-old man was brought to the emergency room after ingesting an unknown amount of carbamazepine. He was unconscious and not responding to the noxious stimuli. He was intubated and was placed on mechanical ventilation because of respiratory insufficiency. Primary detoxification was performed with a gastric lavage and charcoal instillation. His serum carbamazepine level was 25.6 mcg/mL at the time of admission. His computed tomography of the brain was normal. He was managed conservatively but there was no improvement in his neurological status in the next 24 hours. Serum carbamazepine level was repeated and reported to be 28.3 mcg/mL. As there was no improvement in his sensorium and the serum carbamazepine levels remained persistently high, extracorporeal removal of carbamazepine was attempted. As the facility to carry out hemoperfusion was not available immediately, the decision to initiate hemodialysis was taken. After 3 sessions of hemodialysis, his sensorium improved markedly and the carbamazepine level at this time was within the therapeutic range. He was discharged after psychiatry consultation and counseling. We review the literature regarding extra corporeal techniques for the removal of carbamazepine and discuss them in this article.

Severe Carbamazepine Intoxication in Children: Analysis of a 40-Case Series

“…Despite significant improvements in hemodialysis technology and continuous venovenous hemofiltration, evidence supporting extracorporeal removal of a CBZ overdose is limited to case series studies [10,12,36–39]. The Extracorporeal Treatments in Poisoning Workgroup recommends extracorporeal removal of CBZ for severely intoxicated cases that progressively worsened despite administration of maximum supportive care (such as patients with multiple refractory seizures, hemodynamic imbalances requiring vasopressors, or life-threatening arrhythmias) [8].…”

“…Although there are no antidotes for CBZ intoxication, treatment options include gastric lavage, administration of activated charcoal, hemodynamic support, and close monitoring. Recently, it has been reported that hemodialysis or hemoperfusion are effective ways to treat severe cases of CBZ intoxication [2,8–10]. It has been demonstrated that serum levels of CBZ in adults are correlated with the severity of the patient’s neurological condition and prognosis [11].…”

Blood Purification for Intoxications and Drug Overdose

“…Highly protein bound toxins, depending on the affinity to the charcoal, in CH will competitively separate from the protein and adsorb to the charcoal for removal. [6][7][8] The use of CH in veterinary medicine is still applicable and is often combined with other RRT modalities. In this modality, as the free toxin crosses the membrane to bind with albumin in the dialysate, the concentration gradient will change and more toxin will dissociate from the albumin in the blood and will contribute to a greater clearance of toxin.…”

Combined Hemoperfusion and Continuous Veno-Venous Hemofiltration for Carbamazepine Intoxication

“…This workgroup recommends the application of extracorporeal removal techniques in cases of severe CBZ overdose with intermittent hemodialysis as the preferred option. However, dialysis is associated with rebound increases in CBZ levels if applied acutely and for a limited period because its removal of CBZ from the blood at a high speed does not allow equilibration of tissue concentration with serum concentrations and loses efficiency of mass removal after a short time [6]. Moreover, hemodialysis does not deal with the delayed absorption and delayed peaks in CBZ concentration in patients with a CBZ overdose and may be unsafe if a patient has taken other drugs that create hemodynamic instability.…”