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Extracorporeal Substance Removal

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Critical Care Toxicology

Abstract

Along with active supportive care, judicious gastrointestinal decontamination, and antidotal therapy, elimination enhancement techniques should be considered in the comprehensive management of any poisoned patient. Elimination enhancement techniques are defined as any procedure that accelerates the endogenous clearance of poison already absorbed and located either in the blood or tissue compartment. Corporal techniques provide their effects inside the body and include multiple-dose activated charcoal (MDAC), resins, and urine pH manipulation, as discussed elsewhere. Extracorporeal treatments (ECTRs) occur in a circuit outside the body (with the exception of peritoneal dialysis) and include hemodialysis, hemoperfusion, hemofiltration, and plasma exchange [1]. As the prognosis of most toxic exposures remains excellent with supportive measures alone, only a small minority of poisonings benefit from active elimination enhancement; for example, MDAC, urine alkalinization, and hemodialysis were only used in 0.06%, 0.5%, and 0.1%, respectively, of patients reported to the US poison control centers. Although the large proportion of the literature reviewing the efficacy of elimination enhancement techniques is derived from human case reports, evidence-based and consensus-based recommendations are now available for extracorporeal treatments [2–15].

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Author information

Authors and Affiliations

  1. Department of Nephrology, University of Montreal, Verdun Hospital, Verdun, QC, Canada

    Monique J. Cormier & Marc Ghannoum

Authors
  1. Monique J. Cormier
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  2. Marc Ghannoum
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Corresponding authors

Correspondence to Monique J. Cormier or Marc Ghannoum .

Editor information

Editors and Affiliations

  1. Department of Medicine, Division of Clinical Pharmacology and Toxicology, University of Colorado, School of Medicine, Aurora, Colorado, USA

    Jeffrey Brent

  2. FDA, Office of New Drugs/Immediate Office, Center for Drug Evaluation and Research, Silver Spring, Maryland, USA

    Keith Burkhart

  3. Clinical Toxicology, St Thomas’ Hospital, Silver Spring, Maryland, USA

    Paul Dargan

  4. Toxicology Associates, University of Colorado, School of Medicine, Denver, Colorado, USA

    Benjamin Hatten

  5. Medical Toxicological Intensive Care Unit, Lariboisiere Hospital, Paris-Diderot University, Paris, France

    Bruno Megarbane

  6. Toxicology Associates, University of Colorado, School of Medicine, Denver, Colorado, USA

    Robert Palmer

  7. Toxinology Department, Women’s and Children’s Hospital, North Adelaide, South Australia, Australia

    Julian White

Grading System for Levels of Evidence Supporting Recommendations in Critical Care Toxicology, 2nd Edition

  1. I

    Evidence obtained from at least one properly randomized controlled trial.

  2. II-1

    Evidence obtained from well-designed controlled trials without randomization.

  3. II-2

    Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.

  4. II-3

    Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence.

  5. III

    Opinions of respected authorities, based on clinical experience, descriptive studies and case reports, or reports of expert committees.

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Cormier, M.J., Ghannoum, M. (2017). Extracorporeal Substance Removal. In: Brent, J., et al. Critical Care Toxicology. Springer, Cham. https://doi.org/10.1007/978-3-319-17900-1_81

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