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Paediatric clinical pharmacology
Published in Evelyne Jacqz-Aigrain, Imti Choonara, Paediatric Clinical Pharmacology, 2021
Evelyne Jacqz-Aigrain, Imti Choonara
Whole bowel irrigation [11] can be used to physically eliminate highly toxic substances that are not absorbed by activated charcoal and have a long gastrointestinal transit time. Treatment is based on the enteral administration of large quantities (30 ml/kg/hr) of osmotically balanced polyethylene glycol electrolyte solution to induce a liquid stool. Substances for which this technique may prove useful include iron and sustained-release or enteric-coated preparations.
Validation of a nomogram used to predict lithium concentration in overdose
Published in Clinical Toxicology, 2022
Khin Sam, Anselm Wong, Andis Graudins
Treatment of lithium toxicity is influenced by the severity of neurologic impairment and the extent of acute kidney injury (AKI). In addition to withholding lithium and nephrotoxic agents, serial clinical assessment, biochemical monitoring and intravenous rehydration are most important in the management of lithium toxicity [6,7]. Gastrointestinal decontamination by whole bowel irrigation may be performed in acute overdose with extended-release formulation [7]. Treatment may also include rehydration, correction of electrolyte abnormalities and extracorporeal treatment (ECTR) to enhance lithium clearance [6,7]. While ECTR is the key intervention in severely poisoned patients, the indications for this in the context of the abovementioned lithium toxicity scenarios are unclear and clinical practice is variable [7,8]. Furthermore, while ECTR removes lithium more rapidly in patients with AKI, the efficacy of ECTR in reducing morbidity for lithium poisoned patients is unclear [8].
Fatal lead encephalopathy following the ingestion of fishing weights (“sinkers”)
Published in Clinical Toxicology, 2022
Allister Vale, Nicola Barlow, Sally Bradberry
The outcome in this patient emphasizes the need for the urgent removal of lead fishing weights, particularly if the patient has evidence of lead poisoning. The first step is radiographic confirmation of the position of the weight/sinker. Secondly, the weight(s) should be removed as soon as possible. Whole bowel irrigation has variable effectiveness. and hence if the weight is within an area accessible by upper endoscopy, it should be removed urgently by this means. Thirdly, the blood lead concentration should be measured, and chelation treatment with intravenous sodium calcium edetate or succimer (oral or intravenous) should commence, if appropriate. In cases of severe lead poisoning/encephalopathy, we recommend intravenous sodium calcium edetate [5], especially if the patient is unable to take an oral antidote as in our case. It is possible that if the patient had agreed to these treatment measures when he first presented, he might have survived.
Clinical consequences related to a defective elimination of clobazam caused by homozygous mutated CYP2C19 allele
Published in Clinical Toxicology, 2019
David Boels, Stéphanie Chhun, Géraldine Meyer, Bénédicte Lelièvre, Vincent Souday
On day 7, the patient was finally admitted to the medical intensive care unit for fever associated with disturbances of alertness. He presented a GCS of 7/15 (E = 2, M = 3 and V = 2) without neurological localizing signs. Endotracheal intubation was performed. The initial tracheal aspiration found a Streptococcus agalactiae infection which was treated with amoxicillin (D10). The CLB plasma concentration was at the limit of quantification at 0.2 mg/L, whereas the plasma concentration of NCLB, its active metabolite, was very high (20 mg/L) 10 days after the last dose (Figure 2). The patient had normal renal function (serum creatinine 85 µmol/L). Initial treatment consisted of a continuous infusion of flumazenil. As a result, the patient’s neurological status improved; however, coma recurred when the flumazenil infusion was stopped. The patient was extubated (10 days of endotracheal intubation). On day 20, high levels of NCLB were still persistent. Whole bowel irrigation combined with activated charcoal was performed to eliminate a possible digestive reservoir. This treatment was ineffective, with concentrations of NCLB remaining high at 15.6 mg/L (Figure 2). The persistence of somnolence and a high concentration of NCLB suggested a lack of elimination. Persistence of high NCLB plasma concentration suggested impaired CYP2C19-mediated clearance. A genetic polymorphism of CYP2C19 was suspected.