Extracorporeal Elimination Of Poisons

By/ Faculty of medicine page in Facebook

Introduction:-

Poisons are substances that can cause disturbances to organisms, usually by chem
ical reaction or other activity on the molecular scale, when a sufficient quanti
ty is absorbed by an organism.
Initial management for all poisonings includes ensuring adequate cardiopulmonary
function and providing treatment for any symptoms such as seizures, shock, and
pain. If the toxin was recently ingested, absorption of the substance may be abl
e to be decreased through gastric decontamination in addition to that some poiso
ns have specific antidotes.
An extracorporeal medical procedure is a medical procedure which is performed ou
tside the body.
Although intoxication is a common problem in adult and pediatric medicine, serio
us morbidity is unusual. In 2004, only 3% of all toxic exposures reported to the
Toxic Exposure Surveillance System of the American Association of Poison Center
s were treated in an ICU and in only 0.05% extracorporeal treatment was needed.
Indications of extracorporeal elimination:-
The treatment of intoxication with an extracorporeal technique is justified if e
limination of the toxin can be increased by 30% or more using an extracorporeal
technique.
Extracorporeal elimination of poisons is used if there are signs of severe toxic
ity as:
1- Ingested quantity associated with severe toxicity.
2- Ingestion of a toxin with serious delayed effects.
3- Natural removal mechanism impaired.
4- Clinical condition deteriorating.
5- Clinical evidence of severe toxicity: hypotension, coma, metabolic acidosis,
respiratory depression, dysrhythmias or cardiac decompensation.
Techniques:-
1- Hemodialysis:
During hemodialysis, toxins and other substances are cleared from the blood by d
iffusion across a semipermeable membrane down a concentration gradient from bloo
d into dialysate. In order to be removed by hemodialysis, the toxic substance mu
st be water soluble and must have a low molecular weight, low protein binding an
d a low volume of distribution.
The clearance of a toxic substance depends on membrane surface area and type, as
well as on blood and dialysate flow rates. The larger the membrane surface, the
greater the amount of toxin removed. Newer high-flux membranes can also remove
high-molecular weight substances. Increasing blood and dialysate flow rates can
increase the concentration gradient between blood and dialysate, thus optimizing
the rates of diffusion and elimination. The major drawback of hemodialysis is t
he risk of rebound toxicity after cessation of the treatment, due to redistribut
ion of the toxin.

The principle of hemodialysis is the same as other methods of dialysis; it invol

ves diffusion of solutes across a semipermeable membrane. Hemodialysis utilizes
counter current flow, where the dialysate is flowing in the opposite direction t
o blood flow in the extracorporeal circuit. Counter-current flow maintains the c
oncentration gradient across the membrane at a maximum and increases the efficie
ncy of the dialysis.
Fluid removal (ultrafiltration) is achieved by altering the hydrostatic pressure
of the dialysate compartment, causing free water and some dissolved solutes to
move across the membrane along a created pressure gradient.
2- Hemoperfusion:
Hemoperfusion is a medical process used to remove toxic substances from a patien
t's blood. The technique involves passing large volumes of blood over an adsorbe
nt substance. The adsorbent substance most commonly used in hemoperfusion is res
ins and activated carbon.
During hemoperfusion, the blood passes through a cartridge containing a sorbent
material able to adsorb the toxin. There are three types of sorbents: charcoal b
ased sorbents, synthetic resins and anion exchange resins. In order to be remove
d by hemoperfusion, the toxic substance must have binding affinity to the sorben
t in the cartridge and a low volume of distribution. Charcoal efficiently remove
s molecules in the 1000 1500 kDa range, but does not remove protein-bound molecule
s. Resins are more effective in the removal of protein-bound and lipid-soluble m
olecules. Despite their efficacy, the use of hemoperfusion cartridges has declin
ed over the last 20 years, due to limitations of their indications and shelf lif
e. Moreover, hemoperfusion is technically more difficult to perform than hemodia
lysis, and lacks the possibility of correcting acid base, fluid and electrolyte ab
normalities.
3- Hemofiltration:
As in dialysis, in hemofiltration one achieves movement of solutes across a semi
-permeable membrane. However, solute movement with hemofiltration is governed by
convection rather than by diffusion. With hemofiltration, dialysate is not used
. Instead, a positive hydrostatic pressure drives water and solutes across the f
ilter membrane from the blood compartment to the filtrate compartment, from whic
h it is drained. Solutes, both small and large, get dragged through the membrane
at a similar rate by the flow of water that has been engineered by the hydrosta
tic pressure. So convection overcomes the reduced removal rate of larger solutes
(due to their slow speed of diffusion) seen in hemodialysis.
4- Molecular adsorbent recirculating system:
MARS is a blood purification system, aimed at removing albumin-bound toxic molec
ules. It consists of three serial extracorporeal circuits: a blood circuit, an a
lbumin detoxification circuit and a hemodialysis circuit. The patient s blood pass
es the blood compartment of a high-flux dialyzer, where albumin flows through th
e dialysate compartment in a countercurrent fashion. Protein-bound and water sol
uble substances can enter the albumin circuit by means of diffusion. The albumin
circuit contains two filters, an activated charcoal filter which absorbs the to
xins and an anion-exchange resin filter to cleanse the albumin. Finally, the alb
umin passes through the blood compartment of a second dialyzer, where small mole
cules are filtered down a concentration gradient to bicarbonate dialysate. Altho
ugh the efficacy of MARS in the removal of protein-bound drugs such as diltiazem
, phenytoin and theophylline has been demonstrated in case reports, the use of M
ARS is limited by its availability, technical applicability and high costs.
References:-
1- Poison at Dorland's Medical Dictionary.
2-Anne-Corne´ lie J.M. de Pont," Extracorporeal treatment of intoxications".
3-Abel, J. J., Rountree, L. G., and Turner, B. B. The removal of diffusible subs
tances from the circulating blood by means of dialysis. Tn. Assoc. Am. Phys., 28
:51, 1913.
4-Feinfeld DA, Rosenberg JW, Winchester JF. Three controversial issues in extrac
orporeal toxin removal. Semin Dial 2006; 19:358 362.
5-Palmer BF. Effectiveness of hemodialysis in the extracorporeal therapy of phen
obarbital overdose. Am J Kidney Dis 2000; 36:640 643.
6- Tan HK. Molecular adsorbent recirculating system (MARS). Ann Acad Med Singapo
re 2004; 33:329 335.-