Efficiency of acidemia correction on intermittent versus continuous hemodialysis in acute methanol poisoning.

CONTEXT: Acidemia is a marker of prognosis in methanol poisoning, as well as compounding formate-induced cytotoxicity. Prompt correction of acidemia is a key treatment of methanol toxicity and methods to optimize this are poorly defined. OBJECTIVE: We studied the efficiency of acidemia correction by intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT) in a mass outbreak of methanol poisoning. METHODS: The study was designed as observational cohort study. The mean time for an increase of 1 mmol/L HCO3-, 0.01 unit arterial blood pH, and the total time for correction of HCO3- were determined in IHD- and CRRT-treated patients. RESULTS: Data were obtained from 18 patients treated with IHD and 13 patients treated with CRRT. At baseline, CRRT group was more acidemic than IHD group (mean arterial pH 6.79 ± 0.10 versus 7.05 ± 0.10; p = 0.001). No association was found between the rate of acidemia correction and age, weight, serum methanol, lactate, formate, and glucose on admission. The time to HCO3- correction correlated with arterial blood pH (r= -0.511; p = 0.003) and creatinine (r = 0.415; p = 0.020). There was association between the time to HCO3- correction and dialysate/effluent and blood flow rates (r= -0.738; p < 0.001 and r= -0.602; p < 0.001, correspondingly). The mean time for HCO3- to increase by 1 mmol/L was 12 ± 2 min for IHD versus 34 ± 8 min for CRRT (p < 0.001), and the mean time for arterial blood pH to increase 0.01 was 7 ± 1 mins for IHD versus 11 ± 4 min for CRRT (p = 0.024). The mean increase in HCO3- was 5.67 ± 0.90 mmol/L/h for IHD versus 2.17 ± 0.74 mmol/L/h for CRRT (p < 0.001). CONCLUSIONS: Our study supports the superiority of IHD over CRRT in terms of the rate of acidemia correction.

[Effective bowel preparation before coloscopy - low-volume PEG in the divided dose regimen]. / Efektivní príprava streva pred koloskopií - nízkoobjemový PEG v deleném rezimu.

INTRODUCTION: The good and safe bowel cleansing is key to the success of coloscopy. The standard preparation involves 4 l polyethylene glycol (PEG). Now the combination of PEG and ascorbic acid (PEGA) of half the volume is available. Besides the type of product also the time factors which are not clarified, play a role during the bowel preparation. The aim of the study was to compare the efficiency and tolerance of both the agents and evaluate the effect of the time regimen of preparation. METHODS: 380 individuals were included in the evaluation in 4 cohorts which used 4 l PEG (Fortrans) in a single dose or split into 3 + 1 l and PEG + ascorbic acid (Moviprep) split into 1 + 1 l or 2 l one day before examination. RESULTS: There was no difference between the agents as to the quality of bowel preparation, when they were used in the same regimen. The bowel cleansing was better in both cases in the divided dose regimen (p < 0.001), and it was inversely proportional to the length of preparation (p = 0.003) and directly proportional to the length of time between the end of preparation and coloscopy (p < 0.001). PEGA was better tolerated (p < 0.028), regardless of the preparation regimen. CONCLUSION: PEG and PEGA are similarly efficient in the bowel preparation before coloscopy provided they are used in a similar regimen. The best results are reached when the preparation is divided into 2 days. PEGA is better tolerated than PEG, regardless of the used regimen. The quality of bowel cleansing is affected by the length of preparation (optimally up to 12 hours) and the time elapsed from the preparation until examination (up to 8 hours).

A single or split dose picosulphate/magnesium citrate before colonoscopy: comparison regarding tolerance and efficacy with polyethylene glycol. A randomized trial.

BACKGROUND & AIMS: To compare the efficacy and tolerance of sodium picosulphate/magnesium citrate (PMC) and polyethylene glycol (PEG) in a single or split dose regimen for colonoscopy bowel preparation. METHODS: A prospective, randomized, endoscopist-blinded, multicenter study. The patients were randomly assigned to receive PMC (PMC4/0) or PEG (PEG4/0) in a single dose 4L day before colonoscopy or a split dose 2+2L PMC (PMC2/2) or 3+1L PEG (PEG3/1) one day before and in the morning before the colonoscopy. Each patient was interviewed to determine his/her subjective tolerance of the preparation before the procedure. The quality of bowel cleansing was assessed in a blinded test performed by multiple endoscopists using the Aronchick scale. RESULTS: A total of 600 patients were enrolled, 88.2% were included in the analysis. Satisfactory bowel cleansing (Aronchick score 1 and 2) was significantly more frequent when a split dose was used irrespective of the solution type (81.6% PMC2/2, 87.3% PEG3/1 vs. 73.0% PEG4/0, p = 0.024). In single dose regimens, PMC performed better than PEG (82.6% vs. 73.0%). Single or split dose PMC preparations were comparable. A PMC based solution was generally better tolerated than PEG regardless of the regimen used (p < 0.001). Nausea was reported mostly after the 4L PEG (32.8%, p < 0.001), incontinence after a split PMC dose (34.4%, p = 0.002), and bloating after the 4L PEG (38.0%, p < 0.001). There was no significant difference in the prevalence of vomiting. CONCLUSION: Colonic preparation with PMC yields similar results as a split PEG dose, regardless of whether PMC is administered in single or separate doses. PMC is better tolerated than any PEG-based preparation. A single 4L PEG the day before the colonoscopy is less appropriate for bowel cleansing.

[Catheter related septic central venous thrombosis of the superior vena cava and right atrium]. / Septická trombóza horní duté zíly a pravé síne v souvislosti se zavedeným centrálním zilním katétrem.

Catheter related septic central venous thrombosis (CR-SCVT) is an uncommon but serious complication related to central venous catheter use. Prolonged sepsis, late detection of the right diagnosis, difficult, long and costly treatment (and its own complications) threaten patients with further, potentially lethal complications. By the patients with an evidence of catheter sepsis, which persists despite targeted antibiotic therapy, it is important to think of this possible complication. Diagnosis can be determined by a combination of clinical, laboratory, microbiological and imaging techniques, from which is transesophageal echocardiography the most useful diagnostic test. Treatment of CR-SCVT consists of long-term targeted antibiotic therapy, the role of anticoagulation is not clearly solved. The article presents case studies of four patients diagnosed and treated in our clinic for infected thrombus in the superior vena cava and right atrium in relation with a central venous catheter. It also compares our diagnostic and therapeutic strategies with the similar cases described in literature.

Intermittent hemodialysis is superior to continuous veno-venous hemodialysis/hemodiafiltration to eliminate methanol and formate during treatment for methanol poisoning.

During an outbreak of methanol poisonings in the Czech Republic in 2012, we were able to study methanol and formate elimination half-lives during intermittent hemodialysis (IHD) and continuous veno-venous hemodialysis/hemodiafiltration (CVVHD/HDF) and the relative impact of dialysate and blood flow rates on elimination. Data were obtained from 11 IHD and 13 CVVHD/HDF patients. Serum methanol and formate concentrations were measured by gas chromatography and an enzymatic method. The groups were relatively comparable, but the CVVHD/HDF group was significantly more acidotic (mean pH 6.9 vs. 7.1 IHD). The mean elimination half-life of methanol was 3.7 and formate 1.6 h with IHD, versus 8.1 and 3.6 h, respectively, with CVVHD/HDF (both significant). The 54% greater reduction in methanol and 56% reduction in formate elimination half-life during IHD resulted from the higher blood and dialysate flow rates. Increased blood and dialysate flow on the CVVHD/HDF also increased elimination significantly. Thus, IHD is superior to CVVHD/HDF for more rapid methanol and formate elimination, and if CVVHD/HDF is the only treatment available then elimination is greater with greater blood and dialysate flow rates.