Pediatric emergency medicine trisk 3056 3056
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or metabolic correction include poisoning by valproic acid, phenobarbital,
methotrexate, massive acetaminophen overdose, and metformin-induced lactic
acidosis. Table 102.11 summarizes the generally accepted common drugs and
drug concentrations for which renal replacement therapy should be considered.
Risks include complications associated with central venous access, electrolyte
disturbances, and hemodynamic instability. Of note, while typical dialysis
patients are often hypervolemic, most poisoned dialysis patients are hypovolemic;
it is incumbent upon the ED care provider to strive for euvolemia prior to
hemodialysis. Very young infants in particular require extremely close attention
to volume shifts. In rare neonatal cases, exchange transfusion may in fact be
preferable for this reason. Nonetheless, the use of hemodialysis for other
indications in pediatrics is somewhat commonplace, and in the hands of an
experienced nephrologist can be safely performed. Extracorporeal therapy should
not be withheld even if it means transfer to another institution, as it may be
essential in the critically ill poisoned child.
TABLE 102.11
A PARTIAL LISTING OF DRUGS AND THEIR PLASMA
CONCENTRATIONS FOR WHICH HEMODIALYSIS SHOULD BE
CONSIDERED
Lithium (acute), 4.0 mEq/L
Lithium (chronic), 2.5 mEq/L
Ethylene glycol, 70 mg/dL
Methanol, 70 mg/dL
Salicylates, 60 (chronic) to 80–90 (acute) mg/dL
Phenobarbital, 100 mg/L
Theophylline, 60–100 mg/L
Paraquat, 0.1 mg/dL
Adapted from Winchester JF. Active methods for detoxification. In: Hadded LM, Shannon MW, Winchester
JF, eds. Clinical Management of Poisoning and Drug Overdose . 3rd ed. Philadelphia, PA: WB Saunders,
1998:175–187; Extracorporeal Treatments in Poisoning (EXTRIP) Workgroup recommendations. Available
online at . Accessed May 9, 2019.
Supportive Care
The final step in optimizing treatment for the poisoned child is the direction of
scrupulous attention to supportive care, including continued close monitoring of
ABCs, fluid and electrolyte status, urine output, and level of consciousness. The
value of these efforts usually far outweighs that which may be ascribed to any
specific toxicologic interventions in most cases. Severely symptomatic patients
