Can charcoal hemoperfusion treatment be an option for pediatric MIS-C patients? A single-center experience in a tertiary pediatric intensive care unit.

INTRODUCTION: Multisystem inflammatory syndrome in children (MIS-C) is a hyper-inflammatory disorder that develops following SARS-CoV-2 infection and has clinical signs that overlap with Kawasaki disease. Immunomodulatory treatments can be used in these patients. One of the alternative treatments reported in the literature is hemoperfusion therapy. In this study, we aim to evaluate our experience of charcoal hemoperfusion therapy in children admitted and followed up with a diagnosis of MIS-C at our Pediatric Intensive Care Unit (PICU). MATERIAL AND METHODS: We performed a retrospective evaluation of children diagnosed with MIS-C and children treated with charcoal hemoperfusion who are admitted to our PICU. RESULTS: Among 49 MIS-C patients, hemoperfusion therapy was performed on 14 patients. Duration of hospitalization, duration of invasive/non-invasive ventilation, VIS, OFI, PRISM 3 scores, and mortality rates were significantly higher in the charcoal hemoperfusion group before treatment. In patients who did not respond to conventional therapies, we observed a statistically significant decrease in the need for inotrope and invasive mechanical ventilation support and statistically significant improvements in clinical indicators after hemoperfusion therapy. DISCUSSION: In our study, we observed a significant clinical and laboratory improvement by charcoal hemoperfusion in our MIS-C patients who had a severe clinical course and multiple organ failure. CONCLUSION: In our opinion, this study is the first report regarding the use of charcoal hemoperfusion therapy in MIS-C patients, and the choice of charcoal hemoperfusion as an initial or rescue therapy is needed to be investigated in large patient groups both in children and adults who are diagnosed with COVID-19 and MIS-C.

Severe caffeine poisoning successfully treated with high flow continuous hemodialysis.

In recent years, severe or lethal cases of caffeine poisoning after large or massive ingestion of caffeinated tablets have increased in Japan. Here we report the case of a 23-year-old male who ingested high-dose caffeine tablets (total: 32.4 g caffeine) in a suicide attempt. He was transferred to our hospital about 2 h after ingesting the tablets and presented with repeated vomiting and tremor in the trunk and extremities. His respiratory rate was 40 breaths/min, heart rate 240 beats/min, blood pressure 109/77 mmHg, and Glasgow Coma Scale E3V2M5. Blood tests revealed metabolic acidosis compensated with respiratory alkalosis, hyperlactatemia, hypokalemia, hyperglycemia, and leukocytosis. After tracheal intubation, gastric lavage was performed and activated charcoal was administered. The patient gradually became hypotensive (systolic blood pressure < 90 mmHg) with a heart rate > 250 beats/min, and non-sustained ventricular tachycardia frequently occurred. Given the lack of response to intravenous noradrenaline and landiolol, high flow continuous hemodialysis (CHD) was initiated 4 h after tablet ingestion with a blood flow rate of 150 mL/min and dialysate flow rate of 2000 mL/h. This dramatically improved his clinical signs and symptoms, especially during the first 3 h. His serum caffeine concentration was 240.9 µg/mL on admission and 344.0 µg/mL at the initiation of high flow CHD, but rapidly decreased to 153.8 µg/mL 3 h after initiating high flow CHD. Our findings suggest that high flow CHD may be effective in treating cases of severe caffeine poisoning with hemodynamics too unstable for intermittent hemodialysis.

Successful treatment of a severe cannabinoid toxicity using extracorporeal therapy in a dog.

OBJECTIVE: To describe the use of extracorporeal therapy (ECT) to treat severe cannabinoid intoxication in a dog with severe hyperlipidemia. CASE SUMMARY: A 7-month-old female intact Labrador Retriever presented with seizures and severe hyperesthesia that were refractory to multiple anticonvulsant medications and required induction of general anesthesia with propofol and mechanical ventilation. The dog's urine yielded a strong positive signal for delta-9-tetrahydrocannabinol (THC) on urine drug test and exposure to THC oil was confirmed by the owner. Bloodwork revealed severe hyperlipidemia such that IV lipid emulsion was considered contraindicated. The dog was treated with a 3-hour ECT session, using charcoal hemoperfusion and hemodialysis in series. Neurologic signs improved during the session and mechanical ventilation was discontinued. Immediately after the session, the dog's mentation was significantly improved and seizures and hyperesthesia had ceased, although the dog remained moderately ataxic. The dog was hospitalized for 36 hours following the ECT session for continued monitoring. The dog fully recovered and was successfully discharged. NEW OR UNIQUE INFORMATION PROVIDED: To the authors' knowledge, this is the first published report to document ECT to treat THC intoxication in veterinary medicine. ECT may be considered as a treatment option for severe THC intoxication that is refractory to standard therapy or where severe hyperlipidemia precludes use of IV lipid emulsions.

Review of a Case of Paraquat Poisoning in a Tertiary Care Rural-based ICU.

Paraquat (1,1'-dimethyl-4, 4'-dipyridylium) is a broad-spectrum liquid herbicide associated with both accidental and intentional ingestion leading to severe and often fatal toxicity.1 Paraquat is actively taken up against a concentration gradient into lung tissue leading to pneumonitis and lung fibrosis. Paraquat also causes renal and liver injury.2 There are few case publications of paraquat poisoning and only few of them have reported that renal failure has ensued before acute respiratory distress syndrome (ARDS). Our patient presented with above lethal dose intake of paraquat containing substance and we did gastric lavage followed by charcoal hemoperfusion and hemodialysis but patient could not be saved despite optimum efforts suggesting the high fatality of this kind of poisoning. HOW TO CITE THIS ARTICLE: Sharma DS, Prajapati AM, Shah DM. Review of a Case of Paraquat Poisoning in a Tertiary Care Rural-based ICU. Indian J Crit Care Med 2019;23(6):284-286. KEY MESSAGES: Acute renal injury with hypoperfusion state due to toxicity at cellular level, redox cycling and intracellular reactive oxidative stress generation may also cause death in early stages in paraquat poisoning despite optimal management.

Amitriptyline accumulation in tissues after coated activated charcoal hemoperfusion-a randomized controlled animal poisoning model.

Amitriptyline poisoning (AT) is a common poisoning, and AT possess the ability to promote life-threatening complications by its main action on the central nervous and cardiovascular systems. The pharmacokinetic properties might be altered at toxic levels compared to therapeutic levels. The effect of coated activated charcoal hemoperfusion (CAC-HP) on the accumulation of AT and its active metabolite nortriptyline (NT) in various tissues was studied in a non-blinded randomized controlled animal trial including 14 female Danish Land Race piglets. All piglets were poisoned with amitriptyline 7.5 mg/kg infused in 20 min, followed by orally instilled activated charcoal at 30 min after infusion cessation. The intervention group received 4 h of CAC-HP followed by a 1-h redistribution phase. At study cessation, the piglets were euthanized, and within 20 min, vitreous fluid, liver tissue, ventricle and septum of the heart, diaphragm and lipoic and brain tissues were collected. AT and NT tissue concentrations were quantified by UHPLC-MS/MS. A 4-h treatment with CAC-HP did not affect the tissue accumulation of AT in the selected organs when tested by Mann-Whitney U test (p values between 0.44 and 0.73). For NT concentrations, p values were between 0.13 and 1.00. Although not significant, an interesting finding was that data showed a tendency of increased tissue accumulation of AT and NT in the CAC-HP group compared with the control group. Coated activated charcoal hemoperfusion does not significantly alter the tissue concentration of AT and NT in the AT-poisoned piglet.

Initial Management of Poisoned Patient.

How to cite this article: Chandran J, Krishna B. Initial Management of Poisoned Patient. Indian J Crit Care Med 2019;23(Suppl 4):S234-S240.

Novel Extracorporeal Hemoperfusion System for Hepatic Arterial Infusion of Cisplatin.

BACKGROUND/AIM: Hepatic venous isolation and extracorporeal charcoal hemoperfusion (HVI-CHP) can reduce systemic exposure to hepatic arterial infusion (HAI) chemotherapy. The pre-existing HVI-CHP system has limited effectiveness against high-dose cisplatin; therefore, we designed a new system and evaluated its efficacy in a canine model. MATERIALS AND METHODS: Cisplatin was administered via HAI under HVI-CHP. HVI-CHP was performed using one charcoal column in group I and two charcoal columns in group II; it was not performed in group III. The plasma cisplatin levels in the systemic circulation and at the column inlet and outlet, and the column extraction rate of were analyzed. RESULTS: The column extraction rates of free and total cisplatin in group II were significantly higher than those in group I. The systemic concentration of free cisplatin was significantly lower in group II than in groups I and III after HAI. No significant differences were observed in cisplatin concentrations in the liver tissue among all groups. CONCLUSION: A novel HVI-CHP system for HAI of cisplatin was successfully developed.

Effect of activated charcoal hemoperfusion on renal function in patients with paraquat poisoning.

The present study retrospectively analyzed 19 patients diagnosed with paraquat (PQ) poisoning with the aim to investigate the effect of activated charcoal hemoperfusion on renal function and PQ elimination. The results indicated that 7 patients died and 12 survived. Non-oliguric renal failure occurred in all of the 7 patients who died. Among the 12 surviving patients, 10 had normal renal function and 2 developed non-oliguric renal failure. There was a linear correlation between plasma and urine paraquat concentration prior to and during activated charcoal hemoperfusion. The equation parameters together with the correlation coefficient on admission were as follows: Y=0.5820+1.7348X (R2=0.678; F=35.768; P<0.0001). The equation parameters together with the correlation coefficient were as follows during activated charcoal hemoperfusion: Y=0.6827+1.2649X (R2=0.626; F=50.308; P<0.0001). Therefore, it was concluded that in patients with normal renal function, the elimination kinetics of PQ by the kidneys were only associated with the plasma PQ concentration. Activated charcoal hemoperfusion had little effect on avoiding acute kidney injury in patients with severe PQ poisoning.

Charcoal hemoperfusion in the treatment of medically refractory pruritus in cholestatic liver disease.

BACKGROUND: Pruritus is a distressing symptom in a considerable proportion of cholestatic patients and a few of them do not respond to conventional treatment. Charcoal hemoperfusion (CH) is an extracorporeal technique that is effective in eliminating protein-bound substances which may have accumulated during cholestasis. Several case reports have shown significant reduction of bilirubin in mechanical jaundice and neonatal hemolytic jaundice. However, the published data of CH for the treatment of refractory pruritus in cholestatic patients are scarce. METHODS: Procedure code "Charcoal hemoperfusion" (90997) was used to identify patients who received CH at Mayo Clinic, Rochester, from 1 January 2000 to 5 January 2015. Patients who received CH for refractory cholestatic pruritus were retrospectively reviewed. RESULTS: Thirteen patients were identified. A median of 5 (range 1-18) sessions for a total of 20 (1-72) h were performed. CH resulted in a significant decrease of pruritus in nine patients (69%). Two patients did not have significant relief and two patients did not pursue further treatments after having adverse reactions during the first session. Median pruritus numerical rating scale significantly decreased from 9/10 (9-10) to 4/10 (0-9) post-treatment (p = 0.004). Duration of symptom-free periods ranged from 8 to 90 days (median 18 days) in six patients who returned for follow-up. Most common adverse reactions were pain, bleeding from the catheter site and fever. CONCLUSION: CH temporarily improves the severity of medically refractory cholestatic pruritus in some patients. However, the improvement is not sustained and the short duration of benefit should be balanced with the invasive nature of the therapy and the relatively common adverse reactions.

Extracorporeal treatment with high-volume continuous venovenous hemodiafiltration and charcoal-based sorbent hemoperfusion for severe metformin-associated lactic acidosis.

We present a case of a 49-year-old female with an alleged history of ingestion of approximately 100 tablets of metformin (850 mg each). Investigations revealed severe lactic acidosis with lactate levels of 13.5 mmol/L and pH of 7.17. This indicates severe toxicity and is associated with a high mortality. Charcoal-based sorbent hemoperfusion was done as a desperate effort, as patient continued to deteriorate despite supportive care and high-volume continuous venovenous hemodiafiltration. The patient survived despite metformin-associated lactic acidosis related to severe metformin toxicity.

Should we do early and frequent charcoal hemoperfusion in phenytoin toxicity?

Phenytoin toxicity or adverse drug reaction is common due to its narrow therapeutic window. Mild and moderate toxicity require supportive care and enteral activated charcoal. In severe toxicity, charcoal hemoperfusion (CHP) have been shown to decrease serum phenytoin half-life and early recovery. Here, we report two cases with phenytoin toxicity who showed marked clinical improvement after early and frequent CHP treatment.

Management of life-threatening calcium channel blocker overdose with continuous veno-venous hemodiafiltration with charcoal hemoperfusion.

Cases of calcium channel blocker overdose reported from India are few, and although rare, they are associated with high mortality. Management includes fluids, vasopressors, calcium gluconate or chloride, glucagon infusion, and hyperinsulinemia-euglycemia therapy along with some rescue therapies tried in anecdotal reports. We report here a case of life-threatening overdose of amlodipine with shock, refractory to conventional therapies. Salvage therapy with continuous veno-venous hemodiafiltration using charcoal hemoperfusion with prior infusion of intravenous lipid emulsion resulted in a successful outcome.