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Plotting of Ethylene Glycol Blood Concentrations Using Linear Regression before and during Hemodialysis in a Case of Intoxication and Pharmacokinetic Review.

Kim Y - Case Rep Nephrol (2015)

Bottom Line: Discussion.Plotting of natural logarithm of EG concentrations over time showed that EG elimination follows first-order kinetics and predicts the change of its concentration well.Consideration and application of pharmacokinetics could assist in management of EG intoxication including HD planning.

View Article: PubMed Central - PubMed

Affiliation: Division of Nephrology, Department of Internal Medicine, University of New Mexico, 901 University Boulevard SE, Suite 150, MSC 04-2785, Albuquerque, NM 87106, USA.

ABSTRACT
Introduction. As blood concentration measurement of commonly abused alcohol is readily available, the equation was proposed in previous publication to predict the change of their concentration. The change of ethylene glycol (EG) concentrations was studied in a case of intoxication to estimate required time for hemodialysis (HD) using linear regression. Case Report. A 55-year-old female with past medical history of seizure disorder, bipolar disorder, and chronic pain was admitted due to severe agitation. The patient was noted to have metabolic acidosis with elevated anion gap and acute kidney injury, which prompted blood concentration measurement of commonly abused alcohol. Her initial EG concentration was 26.45 mmol/L. Fomepizole therapy was initiated, soon followed by HD to enhance clearance. Discussion. Plotting of natural logarithm of EG concentrations over time showed that EG elimination follows first-order kinetics and predicts the change of its concentration well. Pharmacokinetic review revealed minimal elimination of EG by alcohol dehydrogenase (ADH) which could be related to genetic predisposition for ADH activity and home medications as well as presence of propylene glycol. Pharmacokinetics of EG is relatively well studied with published parameters. Consideration and application of pharmacokinetics could assist in management of EG intoxication including HD planning.

No MeSH data available.


Related in: MedlinePlus

Gray bar represents hemodialysis.
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fig1: Gray bar represents hemodialysis.

Mentions: A 55-year-old female with past medical history of seizure disorder, bipolar disorder, and chronic pain was admitted to ICU due to severe agitation. The patient complained of dizziness along with nausea shortly before hospitalization which was first reported to home physical therapist. There was no neurological deficit besides becoming agitated progressively over time for which she was given several doses of benzodiazepines. Her initial vital signs were blood pressure 119/75 mmHg, pulse rate 58/min, tympanic temperature 98.5, and body weight 99 kg. The second set of laboratory data after ICU admission revealed following: sodium 148 mEq/L, potassium 5.6 mEq/L, chloride 108 mEq/L, carbon dioxide 6 mEq/L, urea nitrogen 24 mg/dL, creatinine 1.85 mg/dL, calcium 8.7 mg/dL, and albumin 4.0 mg/dL. The serum anion gap was elevated at 34. Serum osmolality was not obtained. The patient was intubated for airway protection using lorazepam and rocuronium. Arterial blood gas revealed pH 7.22 and PCO2 17 mmHg. Her baseline creatinine before admission was noted as 1.1 mg/dL. Blood concentrations of commonly abused alcohols were sought given anion gap metabolic acidosis and additional history of psychosocial issues from family. Urinalysis was negative for crystals. Ethylene glycol level became available 169 mg/dL (26.45 mmol/L) 19 hours after admission and other alcohols were negative. Glycolic acid or glyoxylic acid blood concentration was not obtained. Quantification of consumed ethylene glycol was not possible due to the lack of reliable consumption history. Plotting of blood concentrations of ethylene glycol and urea and their corresponding natural logarithm with trend lines using linear regression function is shown in Figure 1. Fomepizole therapy was initiated and, within 2 hours, hemodialysis followed. The patient was treated using Polyflux Revaclear MAX dialyzer (Gambro, 1.8 m2 membrane surface area) via right internal jugular vascular catheter. Blood flow and dialysate flow were set 300–400 mL/min and 1.5 times blood flow, respectively. Total volume treated was 138.6 L for 8 hours with average blood flow 290 mL/min. The patient was maintained on continuous IV drip of lorazepam for sedation along with several doses of IV phenytoin for subtherapeutic drug level noted upon admission.


Plotting of Ethylene Glycol Blood Concentrations Using Linear Regression before and during Hemodialysis in a Case of Intoxication and Pharmacokinetic Review.

Kim Y - Case Rep Nephrol (2015)

Gray bar represents hemodialysis.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4543587&req=5

fig1: Gray bar represents hemodialysis.
Mentions: A 55-year-old female with past medical history of seizure disorder, bipolar disorder, and chronic pain was admitted to ICU due to severe agitation. The patient complained of dizziness along with nausea shortly before hospitalization which was first reported to home physical therapist. There was no neurological deficit besides becoming agitated progressively over time for which she was given several doses of benzodiazepines. Her initial vital signs were blood pressure 119/75 mmHg, pulse rate 58/min, tympanic temperature 98.5, and body weight 99 kg. The second set of laboratory data after ICU admission revealed following: sodium 148 mEq/L, potassium 5.6 mEq/L, chloride 108 mEq/L, carbon dioxide 6 mEq/L, urea nitrogen 24 mg/dL, creatinine 1.85 mg/dL, calcium 8.7 mg/dL, and albumin 4.0 mg/dL. The serum anion gap was elevated at 34. Serum osmolality was not obtained. The patient was intubated for airway protection using lorazepam and rocuronium. Arterial blood gas revealed pH 7.22 and PCO2 17 mmHg. Her baseline creatinine before admission was noted as 1.1 mg/dL. Blood concentrations of commonly abused alcohols were sought given anion gap metabolic acidosis and additional history of psychosocial issues from family. Urinalysis was negative for crystals. Ethylene glycol level became available 169 mg/dL (26.45 mmol/L) 19 hours after admission and other alcohols were negative. Glycolic acid or glyoxylic acid blood concentration was not obtained. Quantification of consumed ethylene glycol was not possible due to the lack of reliable consumption history. Plotting of blood concentrations of ethylene glycol and urea and their corresponding natural logarithm with trend lines using linear regression function is shown in Figure 1. Fomepizole therapy was initiated and, within 2 hours, hemodialysis followed. The patient was treated using Polyflux Revaclear MAX dialyzer (Gambro, 1.8 m2 membrane surface area) via right internal jugular vascular catheter. Blood flow and dialysate flow were set 300–400 mL/min and 1.5 times blood flow, respectively. Total volume treated was 138.6 L for 8 hours with average blood flow 290 mL/min. The patient was maintained on continuous IV drip of lorazepam for sedation along with several doses of IV phenytoin for subtherapeutic drug level noted upon admission.

Bottom Line: Discussion.Plotting of natural logarithm of EG concentrations over time showed that EG elimination follows first-order kinetics and predicts the change of its concentration well.Consideration and application of pharmacokinetics could assist in management of EG intoxication including HD planning.

View Article: PubMed Central - PubMed

Affiliation: Division of Nephrology, Department of Internal Medicine, University of New Mexico, 901 University Boulevard SE, Suite 150, MSC 04-2785, Albuquerque, NM 87106, USA.

ABSTRACT
Introduction. As blood concentration measurement of commonly abused alcohol is readily available, the equation was proposed in previous publication to predict the change of their concentration. The change of ethylene glycol (EG) concentrations was studied in a case of intoxication to estimate required time for hemodialysis (HD) using linear regression. Case Report. A 55-year-old female with past medical history of seizure disorder, bipolar disorder, and chronic pain was admitted due to severe agitation. The patient was noted to have metabolic acidosis with elevated anion gap and acute kidney injury, which prompted blood concentration measurement of commonly abused alcohol. Her initial EG concentration was 26.45 mmol/L. Fomepizole therapy was initiated, soon followed by HD to enhance clearance. Discussion. Plotting of natural logarithm of EG concentrations over time showed that EG elimination follows first-order kinetics and predicts the change of its concentration well. Pharmacokinetic review revealed minimal elimination of EG by alcohol dehydrogenase (ADH) which could be related to genetic predisposition for ADH activity and home medications as well as presence of propylene glycol. Pharmacokinetics of EG is relatively well studied with published parameters. Consideration and application of pharmacokinetics could assist in management of EG intoxication including HD planning.

No MeSH data available.


Related in: MedlinePlus