This week, we are putting up an entry into #NephMadness 2024, a beautiful educational initiative from the nephro folks. They pit various topics in nephrology against each other in a competition of learning. Our topic is Extracorporeal Therapies (Renal Replacement Therapies) for the poisoned patient.
I am joined by a panel of 3 brilliant nephrologists to discuss the topic:
- Elena Cervantes, MD
- Marc Ghannoum, MD
- Jorge Gaytán, MD
What We Discuss
- Consult Conversations
- Sharing the same mental model on the state of the evidence
- Rapid access for HD
- Modality choices in the tox patient
- Maintaining Hemodynamic Stability
- Charcoal Hemoperfusion
- Plasma Exchange
- Poisons not covered by ExTRIP
Jorge's Write-up for the Toxicology Region of NephMadness
Shownotes
Consult Conversations
Sharing the same mental model on the state of the evidence
Here are the ExTRIP Executive Summaries for all of the Poisons they have done so far
Rapid access for HD
ED and ICU docs must have ready access to HD caths and be able to place them, hopefully universally with ultrasound
Modality choices in the tox patient
IHD vs.
SLEDD vs.
CRRT
Maintaining Hemodynamic Stability
beyond vasopressors/inotropes…
Colder Dialysate leads to greater hemo stability
35 vs 37 [PMID 19587499]
From increased TPR, venous tone, and increased LV function
Albumin
Not great evidence either way! So if you proceed, remember it is costly in most places
Here is an RCT in hypoalbuminemic patients [10.1186/s13054-020-03441-0], a trial using high-conc albumin as the prime [PMID 7116885], SAFER-SLED trial showed better stability with albumin but baseline mismatching made this hard to be sure about. [10.1186/s13613-021-00962-x]
Review Paper [10.2215/CJN.09670620]
This is another trial using mannitol [10.1159/000341273]
Charcoal Hemoperfusion
you need either hemoperfusion or plasma exchange to deal with large, protein bound poisons.
Really rare to need hemoperfusion anymore except for rare poisons with a low Vd and are >90% protein bound, like quinine
Plasma Exchange
Only poison our panel can think of that would be removed by plasma exchange but not hemoperfusion was monoclonal antibodies
Poisons not covered by ExTRIP
Resus Leadership Academy
Become the most versed member of your department on all things resuscitation and acute critical care at the:
Additional New Information
More on EMCrit
- What the hell is SLED?
- EMCrit 351 – Severe Acetaminophen (Tylenol) Toxicity
- EMCrit 27 – Calcium Channel Blocker Overdose
Additional Resources
Now on to the Podcast
Professor
Nassau University Medical Center
No conflicts of interest (coi).
- EMCrit Wee (392.5) – Naughty or Nice? Bad Behavior in Healthcare with Liz Crowe, PhD - January 15, 2025
- EMCrit 392 – All Things Defibrillation with Sheldon Cheskes - January 10, 2025
- EMCrit 391 – Pericardiocentesis and Tamponade Temporization - December 27, 2024
Great episode, bummed that the role of the pharmacist was completely overlooked.
happy to be educated, what do you think the role of a pharmacist is in what we spoke about
A practical and interesting topic to discuss. Pharmacists have an important role in the research and development of extracorporeal therapies for toxic patients.
@geometry dash subzero