Treatment Approach for Drug Toxicity Requiring Dialysis

General Principles of Extracorporeal Treatment Selection

The American College of Critical Care recommends intermittent hemodialysis as the first-line extracorporeal therapy for dialyzable poisons, including salicylates, toxic alcohols, lithium, long-acting barbiturates, and hydrophilic beta-blockers, with a strength of evidence level of high 1, 3, 4.
High-flux dialyzers with the largest available surface area provide superior clearance and should be selected over low-flux membranes, according to the Critical Care society, with a moderate level of evidence 3.
Continuous renal replacement therapy (CRRT) is the preferred alternative when intermittent hemodialysis is unavailable or cannot be initiated quickly enough, as recommended by the Critical Care society, with a high level of evidence 5, 6, 4.
Hemoperfusion can be used as a third-line option for specific toxins, such as barbiturates and highly protein-bound beta-blockers, when hemodialysis and CRRT are unavailable, according to the American Journal of Kidney Diseases, with a low level of evidence 1, 7.

The Critical Care society recommends maximizing blood flow rates to 300-400 mL/min to enhance toxin clearance, with a high level of evidence 3.
Using higher dialysate/effluent flow rates can maintain concentration gradients, as suggested by the Critical Care society, with a moderate level of evidence 1, 3.
Lowering dialysate temperature can minimize hemodynamic compromise in unstable patients, according to the Critical Care society, with a low level of evidence 1, 3.
Priming the extracorporeal circuit and using dialysate with appropriate electrolyte concentrations can reduce dysrhythmia risk, as recommended by the Critical Care society, with a high level of evidence 1, 2.

The Critical Care society strongly recommends intermittent hemodialysis for severe atenolol or sotalol poisoning requiring extracorporeal treatment, with a high level of evidence 1, 2.
Indications for hemodialysis include refractory bradycardia, hypotension despite vasopressors, or need for extracorporeal life support (ECLS), according to the Critical Care society, with a moderate level of evidence 1.
Maintaining serum magnesium >1 mmol/L and potassium 4.5-5 mmol/L during dialysis can prevent torsades de pointes, as recommended by the Critical Care society, with a low level of evidence 1, 2, 3.

The American Journal of Kidney Diseases recommends intermittent hemodialysis for severe long-acting barbiturate poisoning, with a moderate level of evidence 7, 8.
Indications for hemodialysis include prolonged coma, shock after fluid resuscitation, toxicity persisting despite multiple-dose activated charcoal (MDAC), rising serum concentrations despite MDAC, or respiratory depression requiring mechanical ventilation, according to the American Journal of Kidney Diseases, with a low level of evidence 7, 8.

The Critical Care society strongly recommends intermittent hemodialysis when glycolate concentration >12 mmol/L, anion gap >27 mmol/L, or severe clinical features present, with a high level of evidence 5, 6, 4.
CRRT is preferred over hemodialysis if marked brain edema is present or if CRRT can be initiated faster, according to the Critical Care society, with a moderate level of evidence 5, 6.
Increasing fomepizole dosing frequency to every 4 hours during hemodialysis can be effective, as recommended by the Praxis Medical Insights, with a low level of evidence 4.

The Praxis Medical Insights recommends hemodialysis for persistent shock after fluid resuscitation, significant renal dysfunction, or respiratory failure requiring mechanical ventilation, with a low level of evidence 9.
Intermittent hemodialysis is preferred over CRRT due to higher efficacy, according to the Praxis Medical Insights, with a low level of evidence 9.

The Praxis Medical Insights recommends never delaying hemodialysis while attempting less effective modalities in severe poisonings with clear indications, with a high level of evidence 3, 4.
The Praxis Medical Insights suggests not using peritoneal dialysis when hemodialysis is available, as it provides lower clearance, with a moderate level of evidence 3.

The Critical Care society recommends not ceasing dialysis based solely on toxin concentration, but rather on clinical improvement, with a high level of evidence 1, 2, 7, 3.
The Praxis Medical Insights suggests not stopping dialysis for salicylate poisoning based on clinical improvement alone when concentrations remain >7.2 mmol/L, with a low level of evidence 4.

The Praxis Medical Insights recommends adjusting antidote dosing during dialysis for dialyzable antidotes, such as fomepizole, with a low level of evidence 4.
The Critical Care society suggests ensuring appropriate electrolyte concentrations in dialysate to minimize dysrhythmias, particularly for cardiotoxic drugs, with a high level of evidence 1, 2, 3.

The Critical Care society recommends considering lower toxin thresholds for dialysis in children receiving ethanol and pregnant patients, with a low level of evidence 5.