A Severe Degreaser Poisoning Treated Successfully with Extracorporeal Therapies in an Adolescent. When Should Charcoal Hemoperfusion Take Priority

Introduction

Poisoning by household cleaners is the second most frequent cause of poisoning in the pediatric-age group after drug intake (Gummin DD, et al., Clin Toxicol (Phila) 2020; 58: 1360–1541). Degreasing agents are caustic substances whose components differ from each other (Hoffman RS, et al., N Engl J Med 2020; 382: 1739–1748)

Serious, life-threatening poisonings should be treated in pediatric intensive care units (PICU), and sometimes rapid administration of extracorporeal treatments to remove toxins is required (Roberts DM, et al., Crit Care Med 2015; 43: 461–472). There is insufficient data in the literature on severe poisoning with degreasers. This report involves the successful treatment of an adolescent, who ingested large amounts of a degreaser to commit suicide. Ethical approval was obtained from the hospital and the patient's parents

Case Report

A previously healthy 15-year-old girl was admitted to the emergency department (ED) with complaints of nausea and vomiting. On arrival, the patient had paroxysmal limb movements, vertical nystagmus, and a metallic odor in her mouth. Blood gas values revealed pH:7.00, PCO₂:69.3 mmHg, HCO₃:16.9 mmol/L, and lactate:15 mmol/L. It was determined that she had taken approximately 350 ml [5% non-ionic active substance, cationic active substance, sodium salt of methylglycine-diacetic acid (MGDA)] from a household degreaser called Asperox 8 hours before the application. She was intubated due to respiratory arrest. Her airway was seen as edematous and hemorrhagic during intubation. Then she was transferred to PICU. Her Glasgow coma scale (GCS) was 5, with slow light reflexes, and paroxysmal limb tics lasting approximately 5 minutes each. Her blood pressure was 63/41 mmHg; on blood gas analysis: pH 6.86, PCO₂ 27 mmHg, PO₂ 94 mmHg, lactate 26.1 mmol/L, BE – 27.80, HCO₃ 4.9 mmol/ L. A central venous catheter was placed, and epinephrine and norepinephrine infusions were administered. Low FiO2 (below 40%) was given when mechanically ventilated because there was endothelial damage due to the degreaser. The patient's ethanol level was normal, body fluids were tested for narcotics, and no harmful substances were detected. It was reported that she was healthy before ingesting degreaser and hadn't used high-protein binding meds, especially antidepressants. On the second day of admission, she developed multiple organ failure. Continuous venovenous hemodiafiltration (CVVHDF) was applied for fluid overload and to remove the toxins with a 4000 ml/1.73 m²/hr effluent dose. Plasma exchange (PE) was performed due to the development of thrombocytopenia-associated multi-organ failure. The initial dose of PE utilized plasma, with albumin being used in the following two sessions, each at 1.5 times the total plasma volume per session. Despite the decrease in creatinine after three days of PE and CVVHDF, she was still oliguric, her cardiac dysfunction persisted (high troponin level, ejection fraction 50% on echocardiography, high need for inotropic agents), and there was no neurological improvement without any sedation. Then we contacted the manufacturer's chemist again and learned that the active substance can be tightly bound to the plasma proteins. Therefore, we decided to apply hemoperfusion (HP). The hemoperfusion cartridge consisted of cellulose-coated activated carbon with a surface area of 150 milliliters, and the blood flow rate was started with a lower blood flow rate (150 ml/min) for the first half hour due to hypotension, then gradually increased to 200 ml/min. Subsequently, she underwent charcoal HP for approximately 4 hours in a single session. After HP, her hypotension resolved, inotropic infusions were reduced, and vasoactive inotrope score (VIS) decreased from 92 to 40 ([Table 1]). The patient's laboratory values are shown in [Table 2]. Eighteen hours after charcoal HP, she was extubated. Total parenteral nutrition was started on the fifth day due to esophageal injury. She was transferred out of the PICU three days later. During her discharge, she had clear consciousness, was able to answer questions accurately, and had a GCS of 15.

Table 1 Vital findings and clinical conditions of the patient before, during, and after administration of charcoal hemoperfusion.

	Duration of Hemoperfusion
	Before	2nd hour	4th hour	After 8hours	After 18hours
BP (mmHg)	87/52	102/58	110/62	115/70	120/82
HR (bpm)	65	80	88	84	84
RR	24 (with MV)	22 (with MV)	20 (with MV)	16 (with MV)	16 (extubated)
VIS *	92	50	20	0	0

(BP: Blood pressure, HR: heart rate, MV: mechanical ventilator, RR: respiratory rate, VIS: vasoactive inotrope score); [^*VIS is calculated as the following formula: VIS=dopamine dosage (µg/kg/min)+dobutamine dosage (µg/kg/min)+100 x epinephrine dosage (µg/kg/min) + 10 x milrinone dosage (µg/kg/min)+10,000 x vasopressin dosage (µg/kg/min)+100 x norepinephrine dosage (µg/kg/min)].

Table 2 Laboratory values of the patient during follow-up.

Days	PICU admission	First day in PICU	Before CRRT and PE	After CRRT and PE	Before Hemoperfusion	After Hemoperfusion 2nd hour
pH	6.86	7.15	7.15	7.18	7.26	7.42
PCO2 (mmHG)	27.4	30.7	47	36	38.4.2	38.8
BE	− 27	− 15	− 12.4	− 14.5	− 14.6	0.7
HCO3 (mmol/L)	4.9	11.8	12.6	18.5	15.1	25.1
Lactate (mmol/L)	26.2	18.7	14.6	9.4	10.2	2.9
HCT (%)	40.1	31.9	27.8	43.2	32.5	25.8
HGB (g/dL)	12.8	11.7	9.6	14.5	11.3	10.6
Plt (10 3/ uL)	256	74	42	46	47	77
Creatinine (mg/dL)	1.49	2.02	4.06	1.56	1.56	1.1
AST (U/L)	43	86	107	76	24	44
ALT (U/L)	20	136	284	250	225	42
Troponin (ng/L)	24.1	22609	2910	1943	1891	182
INR	1.74	1.75	2.75	1.29	1.37	1.3

(PICU: pediatric intensive care unit, CRRT: continuous renal replacement therapy, PE: plasma exchange, BE: base excess, HCO3: bicarbonate, HCT: hematocrit, HGB: hemoglobin, Plt: platelet, AST: aspartate transaminase, ALT: alanine transaminase).

Publication History

Article published online:
11 January 2024