Monique C. Cormier

Availability and cost of extracorporeal treatments for poisonings and other emergency indications: a worldwide survey

Background Extracorporeal treatments (ECTRs) are used for different conditions, including replacement of organ function and poisoning. Current recommendations for ECTRs in various poisonings suggest that intermittent haemodialysis (IHD) is the most efficient technique. However, the practicality of these recommendations is poorly defined in view of limited information on availability and cost worldwide. Methods A survey invitation to an Internet-based questionnaire was emailed between January 2014 and March 2015 to members of international societies to determine the availability, time to initiation and cost of ECTRs (including filters, dialysate, catheter, anticoagulant and nursing/physician salary). The median cost ratio of every ECTR compared with IHD performed in the same institution were presented. Results The view rate was estimated at 28.1% (2532/9000), the participation rate was 40.1% (1015/2532) and the completion rate was 16.0% (162/1015). Respondents originated from 89 countries, and nearly three-fourths practiced in a tertiary care centre. A total of 162 respondents provided sufficient data for in-depth analysis. IHD was the most available acute ECTR (96.9%), followed by therapeutic plasma exchange (TPE; 68.3%), continuous renal replacement therapy (CRRT; 62.9%), peritoneal dialysis (PD; 44.8%), haemoperfusion (HP; 30.9%) and liver support devices (LSDs; 14.7%). IHD, CRRT and HP were the shortest to initiate (median = 60 min). The median cost ratios of each ECTR compared with IHD were 1.7 for CRRT and HP, 2.8 for TPE, 6.5 for LSDs and 1.4 for PD (P < 0.001 for all). The median cost ratio of a 4-h IHD treatment compared with 1 day in the intensive care unit was 0.6 (P =  0.2). Conclusions IHD appears to be the most widely available ECTR worldwide and is at least 30% less expensive than other ECTRs. The superior efficacy of IHD for enhanced elimination, added to its lower cost and wider availability, strengthens its preference as the ECTR of choice in most cases of acute poisoning. Keywords costing, CRRT, EXTRIP, hemodialysis, hemoperfusion.

Toxicokinetics of Metformin During Hemodialysis

To the Editor: Metformin-associated lactic acidosis (MALA) following metformin overdose or reduced metformin clearance in the setting of acute kidney injury is associated with high mortality. For most severe cases, current guidelines recommend hemodialysis (HD) to correct acidosis and associated electrolyte abnormalities, although its effect on metformin removal is considered uncertain. We report a case of severe MALA treated with HD.

The Reception of Abel Boyer's Royal Dictionary in the 18th Century

me 17th century holds a special place in the history of dictionaries. The first monolingual French dictionaries and the first two-way bilingual (French/English) dictionaries were published during that time. Abel Boyer is the second lexicographer, after Guy Miège, to offer a French-English/English-French dictionary for public use. Abel Boyer, a native of Castres, France, left his country when the Edict of Nantes was revoked in 1685. After spending some time in Holland, Boyer immigrated to England in 1689 and soon became proficient in English. In 1694, encouraged by Princess Anne of

Why are we Still Dialyzing Overdoses to Tricyclic Antidepressants? A subanalysis of the NPDS database.

A recent analysis of the American Association of Poison Control Centers database, showed that poisonings from toxins not usually considered amenable to extracorporeal purification (“non‐classic toxins” such as ethanol and tricyclic antidepressants) continue to be reported. This publication investigates factors that may explain these findings. Our results suggest that: 1) the relatively high absolute number of ECTR performed for non‐classic toxins may simply reflect the large number of exposures to these toxins, 2) poisoning from another toxin may have been the reason for ECTR initiation in some exposures to non‐classic toxins, 3) poisoning from non‐classic toxins may receive ECTR for purposes other than toxin removal, and 4) the decisional threshold to initiate ECTR may be lower for non‐classic toxins because of heightened toxicity.

Extracorporeal Treatments In Poisonings From Four Non-Traditionally Dialyzed Toxins (Acetaminophen, Digoxin, Opioids, and Tricyclic Antidepressants): A Combined Single-Centre and National Study

The use of extracorporeal treatments (ECTRs) for poisonings with four non‐traditionally dialysed toxins (NTDTs) is increasing in the United States. This study evaluated whether ECTRs are prescribed for toxin removal or the treatment of other medical illnesses or complications. We performed a 2‐Phase retrospective analysis evaluating the main indication for ECTRs in patients with poisoning from a NTDT (defined for this study as acetaminophen, opioids, tricyclic antidepressants (TCAs) or digoxin) and ECTR. The first phase assessed all cases from a single site (New York City Poison Control Center) between the years 2000 and 2016, and the second phase surveyed all United States Poison Control Centers (PCCs). In Phase 1, demographics, toxin ingested and main indication for ECTR were extracted. In Phase 2, a query to the National Poison Data System using the a pragmatic subset of inclusion criteria from Phase 1 restricted to single toxin ingestions over a narrower time frame (2014‐2016) provided the cases for study. A structured online questionnaire was sent to all United States PCCs to request their database review regarding the indication for ECTR for their cases. In Phase 1, 92 cases met inclusion criteria. In Phase 2, 519 cases were screened and 425 met inclusion criteria. In Phase 1 91/92 (98.9%) and Phase 2 411/425 (96.7%), of extracorporeal treatments were used to treat underlying medical conditions or poisoning‐related complications rather than accelerate toxin removal. The increasing number of ECTRs reported in patients who ingested one of the four NTDTs thus appears to be for medical indications rather than attempts at toxin removal, a distinction that is important.

Extracorporeal treatments in a dapsone overdose: a case report.

Abstract Introduction: Intentional dapsone intoxication can be life-threatening. There is limited data on the clinical effect of extracorporeal treatments (ECTRs) on dapsone elimination. We describe a case of severe dapsone toxicity treated with different ECTRs. Case details: A 23-year-old woman was admitted 2.5 h after ingesting 2.2 g of dapsone. She developed methemoglobinemia (39.9%) and showed signs of toxicity (hemodynamic instability and altered mental status) despite multiple-activated charcoal, methylene blue, vasopressors and endotracheal intubation. Continuous venovenous hemofiltration (CVVH) was then initiated for 5 h, followed by intermittent hemodialysis with hemoperfusion (IHD-HP) for 4 h, and CVVH for another 48 h. The platelet count decreased to 32 × 109/L 3 h after IHD-HP. The elimination half-life of dapsone was 2.0 h during IHD-HP, and 14.2 h during CVVH. Mean dapsone clearance with IHD was 62 mL/min versus 22 mL/min with CVVH. IHD removed 95.3 mg, and CVVH removed 67.8 mg over 3.8 h. No rebound occurred following ECTR cessation. The toxicokinetics of dapsone metabolites were also accelerated during ECTR. The patient was extubated after 3.5 days and discharged without sequelae after 7 days. Discussion: Dapsone clearance was enhanced by ECTR, especially by IHD-HP. However, HP was associated with severe asymptomatic thrombocytopenia.