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The Availability and Use of Charcoal Hemoperfusion in the Treatment of Poisoned Patients

2006; Elsevier BV; Volume: 48; Issue: 2 Linguagem: Inglês

10.1053/j.ajkd.2006.04.080

1523-6838

Anna S. Shalkham, Barbara M. Kirrane, Robert S. Hoffman, David S. Goldfarb, Lewis S. Nelson,

Plant-based Medicinal Research

Background: Charcoal hemoperfusion (CHP) has been one of the preferred methods to enhance the elimination of certain toxins in selected poisoned patients. However, the availability of CHP may be limited because of the expense of cartridges, their narrow indications, and their limited shelf life. Improvements in hemodialysis (HD) technology may contribute to making CHP obsolete. We investigated the availability of CHP in in-hospital HD units at hospitals receiving ambulances dispatched through New York City’s emergency response system, hereafter referred to as 911-receiving hospitals, and their recent history of CHP use in poisoned patients. Methods: The medical directors or managers of all in-hospital HD units in the 911-receiving hospitals of New York City were contacted by E-mail and/or telephone. Participants were administered a standard survey that included questions regarding the availability of CHP cartridges and the date and indication for last CHP use. Participants at institutions that did not stock CHP cartridges were questioned about their opinions on the utility of CHP. Results: Forty-two in-hospital HD units were surveyed, of which 34 (81%) completed the survey. Ten units (29%) had CHP cartridges available for immediate use. Each of these 10 units stocked between 1 and 4 adult-size CHP cartridges, and 1 unit stocked 2 pediatric-size CHP cartridges. Nine units had in-date CHP cartridges, and 1 unit had only expired CHP cartridges. Only 3 units performed CHP in the past 5 years (2 units, theophylline poisonings; 1 unit, aluminum overload). In the 24 units without CHP cartridges, 21 directors believed that most common toxins could be removed effectively through HD and thus CHP rarely was indicated. Only 1 director cited expense as a factor in not stocking CHP cartridges. Two directors reported no specific reason for not stocking the cartridges. Conclusion: CHP cartridges are available in only approximately one third of 911-receiving hospitals in New York City. CHP is infrequently performed to enhance toxin elimination in poisoned patients. Background: Charcoal hemoperfusion (CHP) has been one of the preferred methods to enhance the elimination of certain toxins in selected poisoned patients. However, the availability of CHP may be limited because of the expense of cartridges, their narrow indications, and their limited shelf life. Improvements in hemodialysis (HD) technology may contribute to making CHP obsolete. We investigated the availability of CHP in in-hospital HD units at hospitals receiving ambulances dispatched through New York City’s emergency response system, hereafter referred to as 911-receiving hospitals, and their recent history of CHP use in poisoned patients. Methods: The medical directors or managers of all in-hospital HD units in the 911-receiving hospitals of New York City were contacted by E-mail and/or telephone. Participants were administered a standard survey that included questions regarding the availability of CHP cartridges and the date and indication for last CHP use. Participants at institutions that did not stock CHP cartridges were questioned about their opinions on the utility of CHP. Results: Forty-two in-hospital HD units were surveyed, of which 34 (81%) completed the survey. Ten units (29%) had CHP cartridges available for immediate use. Each of these 10 units stocked between 1 and 4 adult-size CHP cartridges, and 1 unit stocked 2 pediatric-size CHP cartridges. Nine units had in-date CHP cartridges, and 1 unit had only expired CHP cartridges. Only 3 units performed CHP in the past 5 years (2 units, theophylline poisonings; 1 unit, aluminum overload). In the 24 units without CHP cartridges, 21 directors believed that most common toxins could be removed effectively through HD and thus CHP rarely was indicated. Only 1 director cited expense as a factor in not stocking CHP cartridges. Two directors reported no specific reason for not stocking the cartridges. Conclusion: CHP cartridges are available in only approximately one third of 911-receiving hospitals in New York City. CHP is infrequently performed to enhance toxin elimination in poisoned patients. CHARCOAL HEMOPERFUSION (CHP) is a method of extracorporeal elimination in which blood circulates through an activated charcoal-containing cartridge added to the circuit of a hemodialysis (HD) machine. CHP generally is considered the preferred method of extracorporeal extraction for several toxins that are adsorbed to activated charcoal.1Goldfarb D.S. Principles and techniques applied to enhance the elimination of toxic compounds.in: Goldfrank L.R. Flomenbaum N.E. Lewin N.A. Goldfrank’s Toxicologic Emergencies. (ed 7). McGraw-Hill, New York, NY2002: 58-68Google Scholar Like HD, CHP is most effective for toxins that have a small volume of distribution. Unlike HD, it also can effectively remove toxins that are bound to plasma proteins. CHP has been used frequently in patients with theophylline, aluminum, and phenobarbital poisoning and can be used for patients with aspirin toxicity, as well. Despite its efficacy in the removal of specific toxins, CHP is not performed routinely. According to the American Association of Poison Control Centers data from 2004, only 27 of the almost 2.5 million exposures reported to US poison control centers were managed with CHP.2Watson W.A. Litovitz T.L. Rodgers G.C. et al.2004 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System.Am J Emerg Med. 2005; 23: 589-666Abstract Full Text Full Text PDF PubMed Scopus (485) Google Scholar Additionally, the annual number of exposures for which CHP is performed has decreased steadily during the past 10 years despite an increase in total number of reported exposures2Watson W.A. Litovitz T.L. Rodgers G.C. et al.2004 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System.Am J Emerg Med. 2005; 23: 589-666Abstract Full Text Full Text PDF PubMed Scopus (485) Google Scholar, 3Litovitz T.L. Klein-Schwartz W. Rodgers G.C. et al.2001 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System.Am J Emerg Med. 2001; 20: 391-452Abstract Full Text PDF Scopus (349) Google Scholar, 4Litovitz T.L. Bailey K.M. Schmitz B.F. et al.1990 Annual Report of the American Association of Poison Control Centers National Data Collection System.Am J Emerg Med. 1990; 9: 461-509Abstract Full Text PDF Scopus (195) Google Scholar (Table 1). The exact reason for the decrease in CHP use is unclear, although several possible explanations exist. Currently, the cost of cartridges ranges between $350 and $500. In addition, some cartridges require sterilization, whereas others expire after several years. Furthermore, improvements in HD technology make historical comparisons between clearance rates of HD and CHP obsolete. For certain toxins, newer high-flux synthetic membranes used in HD offer drug clearance rates similar to those achieved with CHP.Table 1Trends in Measures to Enhance Elimination in Cases Reported to the American Association of Poison Control Centers198619901996200120022004HD2975848391,2801,4001,726CHP9911161453029Data from2Watson W.A. Litovitz T.L. Rodgers G.C. et al.2004 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System.Am J Emerg Med. 2005; 23: 589-666Abstract Full Text Full Text PDF PubMed Scopus (485) Google Scholar, 3Litovitz T.L. Klein-Schwartz W. Rodgers G.C. et al.2001 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System.Am J Emerg Med. 2001; 20: 391-452Abstract Full Text PDF Scopus (349) Google Scholar, 4Litovitz T.L. Bailey K.M. Schmitz B.F. et al.1990 Annual Report of the American Association of Poison Control Centers National Data Collection System.Am J Emerg Med. 1990; 9: 461-509Abstract Full Text PDF Scopus (195) Google Scholar, 12Litovitz T.L. Smilkstein M. Felberg L. et al.1996 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System.Am J Emerg Med. 1997; 15: 447-500Abstract Full Text PDF PubMed Scopus (256) Google Scholar, 13Watson W.A. Litovitz T.L. Rodgers G.C. et al.2002 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System.Am J Emerg Med. 2002; 21: 353-421Abstract Full Text Full Text PDF Scopus (380) Google Scholar, 14Litovitz T.L. Martin T.G. Schmitz B. 1986 Annual Report of the American Association of Poison Control Centers National Data Collection System.Am J Emerg Med. 1987; 5: 405-445Abstract Full Text PDF PubMed Scopus (123) Google Scholar. Open table in a new tab Data from2Watson W.A. Litovitz T.L. Rodgers G.C. et al.2004 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System.Am J Emerg Med. 2005; 23: 589-666Abstract Full Text Full Text PDF PubMed Scopus (485) Google Scholar, 3Litovitz T.L. Klein-Schwartz W. Rodgers G.C. et al.2001 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System.Am J Emerg Med. 2001; 20: 391-452Abstract Full Text PDF Scopus (349) Google Scholar, 4Litovitz T.L. Bailey K.M. Schmitz B.F. et al.1990 Annual Report of the American Association of Poison Control Centers National Data Collection System.Am J Emerg Med. 1990; 9: 461-509Abstract Full Text PDF Scopus (195) Google Scholar, 12Litovitz T.L. Smilkstein M. Felberg L. et al.1996 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System.Am J Emerg Med. 1997; 15: 447-500Abstract Full Text PDF PubMed Scopus (256) Google Scholar, 13Watson W.A. Litovitz T.L. Rodgers G.C. et al.2002 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System.Am J Emerg Med. 2002; 21: 353-421Abstract Full Text Full Text PDF Scopus (380) Google Scholar, 14Litovitz T.L. Martin T.G. Schmitz B. 1986 Annual Report of the American Association of Poison Control Centers National Data Collection System.Am J Emerg Med. 1987; 5: 405-445Abstract Full Text PDF PubMed Scopus (123) Google Scholar. Because CHP is performed infrequently in the treatment of poisoned patients, we sought to determine the availability of CHP in in-hospital HD units in all hospitals receiving ambulances dispatched through New York City’s emergency response system, hereafter referred to as 911-receiving hospitals. In addition, we investigated how frequently and for which indications CHP was performed during the last 5 years at each institution surveyed. The medical directors or managers of all in-hospital HD units in the 911-receiving hospitals of New York City were contacted by E-mail and/or telephone. Before beginning the survey, participants were informed of the nature of the study, including the fact that participation was voluntary. Participants who reported the availability or use of CHP completed a standard 5-question survey. Initial questions focused on the availability of cartridges; specifically, the number and size (300 g [adult] or 150 g [pediatric]) of available cartridges and expiration date, if applicable. The survey also included questions regarding the date and indication of last use and number of times CHP had been performed in the last 5 years. Participants at institutions that did not stock CHP cartridges were questioned regarding their opinion on the utility of CHP, why CHP cartridges were not stocked, and their ability to acquire cartridges, if needed. Forty-two in-hospital HD units were identified in 911-receiving hospitals in New York City; the medical directors or managers were surveyed. Of these, 34 (81%) completed the survey. Ten in-hospital HD units (29%) had CHP cartridges available for immediate use. Each of these stocked between 1 and 4 adult-size (300-g) cartridges. One in-hospital HD unit also stocked 2 pediatric-size (150-g) cartridges. Only 3 in-hospital HD units had performed CHP in the last 5 years. Two units had used CHP in cases of theophylline poisoning, and another unit performed CHP in the case of a patient with HD-related aluminum overload (Table 2).Table 2Survey Results: Hospitals Stocking CHP CartridgesHospital No.No./Size (g) of CHP CartridgesLast CHP Use12/300>5 y21/300>5 y34/300, 2/150>5 y42/3003 y51/300>5 y61/3004 y72/300>5 y81/3002 y92/300>5 y103/300>5 y Open table in a new tab Twenty-four (71%) in-hospital HD units did not stock cartridges. The medical directors or managers at 21 of these units believed that most common toxins could be removed effectively through HD and therefore CHP was rarely indicated. Only 1 medical director or manager cited expense as a factor in not stocking the cartridges. Historically, CHP was used commonly as a treatment for chronic aluminum toxicity in patients with end-stage renal disease. The use of aluminum hydroxide and aluminum carbonate gels as phosphate binders frequently resulted in systemic aluminum accumulation and subsequent neurological toxicity and osteomalacia in patients with end-stage renal disease. CHP, when used in conjunction with deferoxamine, effectively removed aluminum from the body.5Chang I.J. Fischbach B.V. Sile S. Golper T.A. Extracorporeal treatment of poisoning.in: Brenner B. Rector F. Brenner and Rector’s The Kidney. (ed 7). Elsevier, Philadelphia, PA2004: 2733-2754Google Scholar More recently, replacement of phosphate binders containing aluminum with less toxic alternatives, such as calcium carbonate and sevelamer,6Slatopolsky E. Weerts C. Stokes T. Windus D. Delmez J. Alternative phosphate binders in dialysis patients Calcium carbonate.Semin Nephrol. 1986; 6: 35-41PubMed Google Scholar has made aluminum accumulation nearly negligible. CHP remains the preferred method to enhance the elimination of certain drugs after acute overdose, such as phenobarbital and theophylline. Both these drugs are well suited for removal through CHP because they are adsorbed readily to activated charcoal and have small distribution volumes. Theophylline and phenobarbital currently have limited roles in medical therapy, and this reduction likely contributes to the significantly decreased use of CHP for acute poisoning.7Lenhardt R. Malone A. Grant E.N. Weiss K.B. Trends in emergency department asthma care in metropolitan Chicago Results from the Chicago Asthma Surveillance Initiative.Chest. 2003; 124: 1774-1780Crossref PubMed Scopus (12) Google Scholar CHP effectively treats intoxication with other drugs, such as valproic acid and carbamazepine; however, recent data suggest that HD is as effective as CHP in these cases. Most early data comparing HD and CHP were based on older HD technology, less permeable dialysis membranes, and lower blood flow rates than commonly used today.8Higgins R.M. Hearing S. Goldsmith D.J. et al.Severe theophylline poisoning Charcoal haemoperfusion or haemodialysis?.Postgrad Med J. 1995; 71: 224-226Crossref PubMed Scopus (20) Google Scholar By using newer synthetic HD membranes at greater blood flow rates, several studies showed drug elimination rates similar to those achieved through CHP.9Kane S.L. Constantiner M. Staubus A.E. Meinecke C.D. Sedor J.R. High-flux hemodialysis without hemoperfusion is effective in acute valproic acid overdose.Ann Pharmacother. 2000; 34: 1146-1151Crossref PubMed Scopus (51) Google Scholar, 10Tapolyai M. Campbell M. Dailey K. Udvari-Dagy S. Hemodialysis is as effective as hemoperfusion for drug removal in carbamazepine poisoning.Nephron. 2002; 90: 213-215Crossref PubMed Scopus (45) Google Scholar In cases in which HD and CHP offer similar toxin clearance, HD is preferable for several reasons. HD is associated with fewer complications than CHP.5Chang I.J. Fischbach B.V. Sile S. Golper T.A. Extracorporeal treatment of poisoning.in: Brenner B. Rector F. Brenner and Rector’s The Kidney. (ed 7). Elsevier, Philadelphia, PA2004: 2733-2754Google Scholar, 11Shannon M.W. Comparative efficacy of hemodialysis and hemoperfusion in severe theophylline intoxication.Acad Emerg Med. 1997; 4: 674-678Crossref PubMed Scopus (67) Google Scholar Thrombocytopenia, leukopenia, and hypocalcemia are all well documented with CHP and are caused primarily by the adsorption of cells and complement to the activated charcoal. Coating with new biocompatible polymer membranes has decreased the frequency of these complications.5Chang I.J. Fischbach B.V. Sile S. Golper T.A. Extracorporeal treatment of poisoning.in: Brenner B. Rector F. Brenner and Rector’s The Kidney. (ed 7). Elsevier, Philadelphia, PA2004: 2733-2754Google Scholar CHP also is more technically difficult to perform than HD. Although the actual apparatus is similar to that of HD, CHP is limited by cartridge saturation; thus, periodic measurement of toxin levels across the cartridge during the procedure is recommended. Finally, unlike CHP, HD offers the ability to improve acid-base parameters and address fluid and electrolyte abnormalities that also might be present. Several limitations exist in this study. These results may be affected by reporting bias because it is possible that the directors of units stocking cartridges may have been more likely to reply to our survey. However, our response rate of 81% suggests that even if this were true, the overall effect would be small. In addition, the possibility of recall bias exists in that those who recently performed CHP are more likely to accurately report their institution’s capabilities for CHP (ie, number of cartridges, expiration dates, and so on). Additionally, our results may be affected by local clinical practice preferences, although it is likely that trends in New York City are reflective of those across the United States. Finally, our study did not examine the specific type and brand of cartridge stocked at each institution. The type and brand of cartridge stocked could considerably impact on the use of CHP as a therapeutic modality because some newer cartridges are associated with lower complication rates.5Chang I.J. Fischbach B.V. Sile S. Golper T.A. Extracorporeal treatment of poisoning.in: Brenner B. Rector F. Brenner and Rector’s The Kidney. (ed 7). Elsevier, Philadelphia, PA2004: 2733-2754Google Scholar CHP currently is neither widely available nor widely used. CHP cartridges are available in only one third of 911-receiving hospitals in New York City, and the procedure has been used infrequently in the last 5 years. Indications for performing CHP are infrequent, and most cases previously addressed by this modality may be adequately treated with HD. CHP as currently practiced does not appear to be an important therapeutic option.