Therapeutic Monitoring of Adverse Drug Reactions (ADRs)
Frank A. Barile in Barile’s Clinical Toxicology, 2019
4. Enhancement of elimination of suspected chemical agents or drugs is accomplished using whole bowel irrigation. In adults, oral administration of polyethylene glycol (Golytely®, Colyte®), at a rate of 2 L/h, can flush ingested toxic agents through the bowel. Administration of the preparation is continued for 4–5 hours or until the bowel effluents are clear. The method is useful for enhanced elimination of sustained-release preparation of capsules or tablets, cellophane packets of street heroin or cocaine, and agents not effectively absorbed with charcoal.
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.
Intentional ingestion of elemental mercury requiring multi-step decontamination and prophylactic appendectomy: a case report and treatment proposal
Published in Clinical Toxicology, 2018
Andrea Michielan, Azzurra Schicchi, Roberto Cappuccio, Davide Lonati, Francesca Lamboglia, Alessandra Vitalba, Alessandro Caroli, Marta Crevani, Carlo A. Locatelli, Giorgio Betetto
Irrespective of the modality of ingestion, elemental mercury often remains trapped within the appendix. Indeed, foreign bodies heavier than the bowel content (such as elemental mercury or other metallic objects) usually stop in the lower portion of the cecum during transit and once they enter the appendix, they typically cannot be expelled by peristalsis [9,10]. After reviewing the literature, we have identified nine cases of appendiceal retention of elemental mercury (Table 1). All cases were treated with purgative agents except two patients who directly underwent appendectomy for acute appendicitis or during colostomy for obstructive rectosigmoid cancer [11,12]. After the use of mild laxatives, a more recent paper reported whole-bowel irrigation using polyethylene glycol (PEG 4000) up to 4 L [13]. Some authors also advocate positional manoeuvres (i.e., left lateral decubitus) to facilitate the expulsion of mercury from the appendix by gravity [2,3].
Related Knowledge Centers
- Activated Carbon
- Colonoscopy
- Gastrointestinal Tract
- Sodium Bicarbonate
- Surgery
- Osmoregulation
- Macrogol
- Nasogastric Intubation
- Electrolyte
- Lower Gastrointestinal Series