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Title: The use of sustained low efficiency dialysis (SLED) in massive paracetamol overdose.
Austin Authors: Wong, Anselm ;Tong, Roger L K;Ryan, Liam;Crozier, Tim;Graudins, Andis 
Affiliation: Monash Toxicology Service, Program of Emergency Medicine, Monash Health, Melbourne, Australia
Monash Emergency Research Collaboration, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
Intensive Care Department, Monash Health, Clayton, Australia
Issue Date: Mar-2019
Date: 2017-08-16
Publication information: Clinical Toxicology 2018; 56(3): 229-231
Abstract: Massive paracetamol ingestion causing mitochondrial dysfunction is uncommon. Use of sustained low-efficiency dialysis (SLED) to improve acidaemia and enhance paracetamol elimination has not been previously described. A 44-year-old male presented to the emergency department 2.5 hours post overdose of 200 g (2.5 g/kg) of paracetamol. Examination revealed a BP 85/60 mmHg, pulse 112 bpm, temperature 33.9 °C and blood glucose of 13.9 mmol/l. Venous blood gas 5.5-hours post-ingestion showed a pH 6.9, pCO2 58 mmHg, HCO3 13 mmol/l and lactate 14 mmol/l. Fifty-grams of nasogastric activated charcoal and double-strength intravenous acetylcysteine were administered. Paracetamol concentration peaked at 4207 µmol/l six hours post-ingestion. SLED was commenced nine-hours post ingestion and acetylcysteine dose was doubled again during dialysis. Paracetamol extraction ratio was 47-52%. Plasma paracetamol clearance was steady throughout SLED (53-58 ml/min). Hepatotoxicity did not develop and the patient recovered. Intermittent hemodialysis (IHD) is more efficient than SLED or continuous renal replacement therapy for enhancing paracetamol elimination and clearance. IHD plasma clearance is reported to range from 36 to 215 ml/min compared with endogenous clearance of 224 ml/70 kg/min. SLED improved acidaemia with only moderate overall increase in paracetamol plasma clearance. Lack of development of hepatotoxicity was likely the result of early administration of acetylcysteine rather than any effect of SLED on paracetamol elimination.
DOI: 10.1080/15563650.2017.1358366
ORCID: 0000-0002-6817-7289
Journal: Clinical Toxicology (Philadelphia, Pa.)
PubMed URL: 28812394
Type: Journal Article
Subjects: Paracetamol
Appears in Collections:Journal articles

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