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Resumen El dicloruro de 1,1'-dimetil-4,4'-bipiridilo (Paraquat®) es un compuesto químico de la familia de las piridinas, utilizado como herbicida no selectivo y desecante. Este compuesto puede causar intoxicación aguda por todas las vías de exposición. En el momento, no hay un antídoto conocido y los tratamientos disponibles, incluidos los pediátricos, se basan en contrarrestar su absorción y propiciar su remoción oportuna. Se describe una serie de casos de 14 pacientes pediátricos, procedentes en su mayoría del departamento del Cauca, con intoxicación aguda por ingestión de paraquat. Los pacientes fueron remitidos y atendidos en un hospital de mediana a alta complejidad en el suroccidente colombiano, con un protocolo institucional para el manejo de la intoxicación aguda por el herbicida. La intoxicación aguda con paraquat por vía oral se asocia con una alta tasa de mortalidad, aún con atención médica oportuna, pues fácilmente se alcanzan concentraciones sistémicas para ser fulminante. Basado en la literatura disponible, el Hospital Universitario San José ha propuesto un protocolo clínico -adecuado para la intoxicación aguda por paraquat en población pediátrica- que incluye manejo estándar temprano, tratamiento inmunosupresor y antioxidante, y técnicas para su remoción sistémica

Abstract Paraquat®, or N,N'-dimethyl-4,4'-bipyridinium dichloride, is a bipyridyl compound used as a non-selective herbicide and desiccant that can cause acute poisoning through all routes of exposure. There is no known antidote, and the available treatments are based on avoiding its absorption and timely removing it, in adults and children. We describe a case series of 14 pediatric patients from the department of Cauca, Colombia, with acute intoxication after oral intake of paraquat. Patients were referred to a medium-high complexity hospital in southwestern Colombia and treated according to an institutional protocol for acute paraquat poisoning. Acute paraquat poisoning after oral ingestion is associated with a high mortality rate, even with timely medical attention, as the compound has no known antidote and quickly reaches systemic concentrations for fulminant poisoning. Based on the available literature, our center has proposed a clinical protocol including early standard management, immunosuppressive and antioxidant treatments, and systemic removal techniques. This protocol suggests an adequate approach to acute paraquat poisoning in the pediatric population.

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OBJECTIVE: To examine the efficiency of hemoperfusion in removing South American rattlesnake (Crotalus durissus terrificus) venom from rats compared with neutralization by antivenom. DESIGN: An exploratory experimental investigation in rats involving the injection of snake venom with or without subsequent hemoperfusion or antivenom administration. SETTING: Basic animal research laboratory in a private university. ANIMALS: Normal, healthy male Wistar rats (0.29-0.40 kg, 3-6 months old) from a commercial breeder. INTERVENTIONS: Four experimental groups of randomly allocated rats (n = 3/group) were studied: Group 1: rats were injected with a single dose of venom (5 mg/kg, IM, in the right thigh) with no other treatment; blood samples were collected minutes before death to determine leukocyte, platelet, and erythrocyte counts; Group 2 (Control): rats underwent hemoperfusion alone for 60 min using a hemoperfusion cartridge designed for protein adsorption (by granulated charcoal) and protein precipitation (by tannic acid); Group 3 (Venom + antivenom): rats were injected with venom (5 mg/kg, IM) and, 10 min later, were treated with antivenom at the venom:antivenom ratio recommended by the manufacturer; Group 4 (Venom + hemoperfusion): Rats were injected with venom (5 mg/kg, IM) and, 10 min later, were hemoperfused for 60 min. In groups 2-4, blood samples were collected for leukocyte, platelet, and erythrocyte counts 24 h after venom. MEASUREMENTS AND MAIN RESULTS: Rats injected with venom alone (Group 1) developed signs of neurotoxicity and ataxia and died in 9.0 ± 0.43 h but showed no changes in leukocyte or erythrocyte counts. In contrast, there were no deaths in groups 2-4. The lack of deaths in Groups 3 and 4 indicated that antivenom and hemoperfusion, respectively, protected against the lethal effects of the venom. CONCLUSIONS: Hemoperfusion with a double-action hemoperfusion cartridge capable of protein adsorption and precipitation protected rats against C. d. terrificus venom.

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OBJECTIVE: To examine the efficiency of hemoperfusion in removing South American rattlesnake (Crotalus durissus terrificus) venom from rats compared with neutralization by antivenom. DESIGN: An exploratory experimental investigation in rats involving the injection of snake venom with or without subsequent hemoperfusion or antivenom administration. SETTING: Basic animal research laboratory in a private university. ANIMALS: Normal, healthy male Wistar rats (0.29-0.40 kg, 3-6 months old) from a commercial breeder. INTERVENTIONS: Four experimental groups of randomly allocated rats (n = 3/group) were studied: Group 1: rats were injected with a single dose of venom (5 mg/kg, IM, in the right thigh) with no other treatment; blood samples were collected minutes before death to determine leukocyte, platelet, and erythrocyte counts; Group 2 (Control): rats underwent hemoperfusion alone for 60 min using a hemoperfusion cartridge designed for protein adsorption (by granulated charcoal) and protein precipitation (by tannic acid); Group 3 (Venom + antivenom): rats were injected with venom (5 mg/kg, IM) and, 10 min later, were treated with antivenom at the venom:antivenom ratio recommended by the manufacturer; Group 4 (Venom + hemoperfusion): Rats were injected with venom (5 mg/kg, IM) and, 10 min later, were hemoperfused for 60 min. In groups 2-4, blood samples were collected for leukocyte, platelet, and erythrocyte counts 24 h after venom. MEASUREMENTS AND MAIN RESULTS: Rats injected with venom alone (Group 1) developed signs of neurotoxicity and ataxia and died in 9.0 ± 0.43 h but showed no changes in leukocyte or erythrocyte counts. In contrast, there were no deaths in groups 2-4. The lack of deaths in Groups 3 and 4 indicated that antivenom and hemoperfusion, respectively, protected against the lethal effects of the venom. ONCLUSIONS: Hemoperfusion with a double-action hemoperfusion cartridge capable of protein adsorption and precipitation protected rats against C. d. terrificus venom. (AU)

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If Septic shock (SS) evolves to refractory SS, mortality could reach 90%, despite giving an optimal treatment. Nowadays, extracorporeal devices which adsorb inflammatory cytokines are available, reducing the systemic inflammatory response syndrome. These devices can be used with continuous renal replacement therapy or conventional hemodialysis. We report two diabetic females aged 50 and 58 years, who underwent a total colectomy and amputation of diabetic foot and who developed a SS with high requirements of vasoactive drugs (norepinephrine and adrenaline) to maintain a mean arterial pressure about 60 mmHg. Both were subjected to hemodialysis, connected to a cytokine hemadsorption device. The most important finding was the progressive reduction of vasopressor doses, effect that was observed nine hours after the beginning of the hemadsorption and lasted until its removal at 26 hours. Both patients survived.

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If Septic shock (SS) evolves to refractory SS, mortality could reach 90%, despite giving an optimal treatment. Nowadays, extracorporeal devices which adsorb inflammatory cytokines are available, reducing the systemic inflammatory response syndrome. These devices can be used with continuous renal replacement therapy or conventional hemodialysis. We report two diabetic females aged 50 and 58 years, who underwent a total colectomy and amputation of diabetic foot and who developed a SS with high requirements of vasoactive drugs (norepinephrine and adrenaline) to maintain a mean arterial pressure about 60 mmHg. Both were subjected to hemodialysis, connected to a cytokine hemadsorption device. The most important finding was the progressive reduction of vasopressor doses, effect that was observed nine hours after the beginning of the hemadsorption and lasted until its removal at 26 hours. Both patients survived.

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O paraquat e o diquat são herbicidas de contacto do grupo dos bipiridilos, utilizados largamente para controlo de ervas daninhas. A importância deste grupo de herbicidas reside na sua utilização frequente para fins suicidas e pela inexistência de antídoto ou tratamento médico específico. O envenenamento com diquat é muito menos comum que com o paraquat e por isso existem poucos casos descritos na literatura. A dose letal de ambos é sobreponível, contudo o diquat é considerado menos tóxico devido ao menor dano pulmonar. Por outro lado, o diquat tem efeitos tóxicos graves sobre o sistema nervoso central. Por este motivo os sinais de neurotoxicidade pelo diquat são os mais relevantes e incluem sinais de parkinsonismo. O rim é a principal via excretora do diquat e a necrose tubular aguda é a lesão tipicamente identificada. A sobrevida depende de dois fatores: a concentração da substância no plasma e o tempo após a ingestão. O tratamento centra-se em três pontos essenciais: prevenção da absorção, rápida excreção e modificação dos efeitos tecidulares. A hemoperfusão é mais eficaz na clearance do diquat do que a hemodiálise e a sua utilização nas primeiras 12 horas de intoxicação pode reduzir a mortalidade.

Paraquat and diquat are contact herbicides from bipyridyl group, commonly used in weed control. The importance of this herbicide group is due to its frequent use with suicidal purpose and because there is neither an antidote nor a specific treatment. Poisoning with diquat is much less common that with paraquat, so there are few cases published in literature. The lethal dose of both is similar, however diquat is considered less toxic because it causes less lung damage. On the other side, diquat has severe toxic effects on central nervous system and neurotoxic signs are the more relevant, and include Parkinsonism. The kidney is the main excretory pathway of diquat and acute tubular necrosis is typical. Survival depends on two factors: plasma concentration and time of ingestion. Treatment focus in three key points: preventing absorption, rapid excretion and tissue effects. Hemoperfusion is more effective in diquat clearance than haemodialysis and its use in first 12 hours can reduce mortality.

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This study aimed to observe the clinical curative effect of penehyclidine hydrochloride (PHC) combined with hemoperfusion in treating acute severe organophosphorus pesticide poisoning. We randomly divided 61 patients with severe organophosphorus pesticide poisoning into an experimental group (N = 31) and a control group (N = 30), and we compared the coma-recovery time, mechanical ventilation time, healing time, hospital expenses, and mortality between the two groups. The coma-recovery time, mechanical ventilation time, and healing time were lower in the experimental group than in the control group (P < 0.05), while the hospitalization expenses were higher in the experimental group than in the control group (P < 0.01); moreover, no significant difference was observed in the mortality rate between the two groups. Thus, PHC combined with hemoperfusion exerts a better therapeutic effect in acute severe organophosphorus pesticide poisoning than PHC alone.

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El paraquat es un plaguicida agricola bipiridilo, cuyos efectos tóxicos más severos son año hepato-renal y fibrosis pulmonar irreversible. Se reportan dos casos de intoxicación en niños, por ingestión accidental de paraquat; ellos desarrollaron sialorrea, vómitos azul verdoso, lesión digestiva cáustica. dificultad respiratoria, daño hepato-renal, alteraciones radiológicas y presencia de paraquat en orina y sangre. Ambos pacientes recibieron el tratamiento disponible entre 24-48 horas despues de la ingestion y tuvieron una evolución satisfactoria. El tratamiento consistió basicamente en diálisis gastrointestinal, diuresis forzada ácida, N-acetilcisteína y dexametasona.

Paraquat is a bipyridyl agricultural pesticide, whose more severe effects are hepatic-renal damage and irreversible pulmonary fibrosis. Two children with paraquat accidental poisoning are reported; they developed syalorrhea, blue greenish vomiting, caustic digestive injury, breathing difficulty, liver and kidney damage, radiographic changes and presence of paraquat in blood and urine. Both patients received the available treatment 24-48 hours after ingetion and had a satisfactory autcome. The consisted basically of gatrointestinal dialysis, acidic forced diuresis, N-acetylcysteine and dexamethasone.

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BACKGROUND: Levothyroxine (l-thyroxine) intoxication may arise from intentional or accidental ingestion of excessive doses of the hormone and may cause symptoms equivalent to thyroid storm. We report a case of massive accidental l-thyroxine intoxication resulting from an error in the preparation of capsules to treat goiter. SUMMARY: A 61-year-old woman was admitted showing high levels of thyroid hormones, with serum-free l-thyroxine level of 955.90 nmol/L (74.1 ng/mL) (normal values: 11.61-27.09 nmol/L or 0.9-2.1 ng/mL). It was discovered that she had ingested 50 mg instead of 50 microg/day of l-thyroxine during 9 days. Following charcoal hemoperfusion, the levels of total thyroxine, serum-free l-thyroxine, and triiodothyronine declined dramatically, with a reproducible pattern of reduction in hormone levels observed after each of the three sessions. The patient recovered from her stuporous mental state, atrial fibrillation, and acute respiratory failure. CONCLUSION: The use of hemoperfusion with a charcoal filter appears to be a very important therapeutic tool for the treatment of acute and severe forms of thyrotoxicosis due to l-thyroxine intoxication.

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Técnicas dialíticas são estudadas a fim de se verificar suas reais contribuições no tratamento das mais diversas formas deintoxicações. Esta pesquisa foi realizada com o objetivo de avaliar o comportamento clínico e o perfil hematológico de cãesintoxicados com cabamato (Aldicarb) e submetidos a duas diferentes técnicas dialíticas: hemodiálise e hemoperfusão. Quinzecães adultos, sem raça definida foram intoxicados experimentalmente com 4,97mg/kg de peso vivo de Aldicarb, por via oral.Todos os animais, para controle dos efeitos clínicos provocados pela droga, foram medicados 30 minutos e uma hora após aingestão, com sulfato de atropina e benzodiazepínico (Diazepam), ambos na dose de 1mg/kg. Esses cães foram divididos emtrês grupos experimentais, compostos de cinco animais cada, denominados grupos I, II e III. Os animais do grupo II e do grupoIII, três horas após administração do Aldicarb foram submetidos a sessões de duas horas de hemodiálise e de hemoperfusão,respectivamente. Os animais do grupo I serviram de controle, não tendo sido submetidos a nenhum tratamento dialítico. Aintoxicação provocada pelo aldicarb foi capaz de causar alterações clínicas manifestadas por vômito, sialorréia, diarréia,incontinência urinária, fasciculações e alterações no perfil hematológico relacionadas principalmente a hemoconcentração.Houve leucocitose e aumento no número absoluto de neutrófilos em todos os animais 30 minutos após administração docarbamato. Não foram observadas diferenças clínicas entre os animais do grupo controle e os animais tratados por hemodiáliseou hemoperfusão. Após a sessão de hemoperfusão ocorreu discreta redução no número dos leucócitos, com diminuição dosvalores absolutos de eosinófilos, basófilos, monócitos e linfócitos. Nenhuma das técnicas foi efetiva em retirar o Aldicab doorganismo.

The aim of this work was to study the contribution of dialysis techniques, hemodialysis and hemoperfusion, after poisoning byAldicarb (carbamate), an anticholinesterasic compound, in dogs. Fifteen adult mongrel dogs were experimentally intoxicated by4.97mg/kg of Aldicarb orally. All animals, to prevent and treatment of clinical signs received a standard treatment with atropinesulfate (1mg/kg) and benzodiazepine (1mg/kg), administered endovenously 30 minutes and one hour after poisoning. Thedogs were separated in three groups: group I (control), group II (hemodialysis) and group III (hemoperfusion) with five animalsin each. Hemodialysis and hemoperfusion were performed three hours after poisoning, through a double lumen catheterimplanted in the jugular vein. Symptoms like vomiting, diarrhea, urinary incontinence and muscle fasciculation were observedafter poisoning in all groups. It was observed increase of leucocytes and neutrophils, 30 minutes after carbamate administration.Any clinical difference was observed after therapy with hemodialysis and hemoperfusion. After hemoperfusion occurred decreaseof total leukocyte, eosinophil, basophile, monocyte and lymphocyte. None of the techniques were effective to withdraw theAldicarb compound from the organism.

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Intoxicación Aguda por Carbamazepina: Tratamiento por hemoperfusión y hemofiltración. Las intoxicaciones accidentales o intencionales por fármacos son una consulta habitual en Emergencia y origen de frecuentes ingresos en Unidades de Cuidados Intensivos. El manejo del paciente intoxicado involucra un equipo multidisciplinario donde el nefrólogo puede formar parte por las repercusiones de la intoxicación en sí y/o en la recuperación del tóxico de la sangre. El uso de las técnicas de depuración extracorpóreas en intoxicaciones ha sido muy limitado y depende de la severidad y farmacocinética del tóxico involucrado. La hemoperfusión con carbón activado ha sido de las técnicas más utilizadas en estos casos, así como la hemodiálisis convencional, pero hay escasos datos del uso de técnicas continuas como la hemofiltración en el tratamiento de intoxicaciones exógenas. En esta comunicación se analiza un paciente que presenta dos severos episodios de intoxicación intencional con Carbamazepina, en uno de los cuales se intentó la recuperación del fármaco con hemoperfusión con carbón activado con buenos resultados y en el segundo episodio se realizó hemofiltración. Se discute la farmacocinética del fármaco involucrado y las características de las técnicas utilizadas así como posibles indicaciones de cada una de ellas en este tipo de intoxicaciones(AU)

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Intoxicación Aguda por Carbamazepina: Tratamiento por hemoperfusión y hemofiltración. Las intoxicaciones accidentales o intencionales por fármacos son una consulta habitual en Emergencia y origen de frecuentes ingresos en Unidades de Cuidados Intensivos. El manejo del paciente intoxicado involucra un equipo multidisciplinario donde el nefrólogo puede formar parte por las repercusiones de la intoxicación en sí y/o en la recuperación del tóxico de la sangre. El uso de las técnicas de depuración extracorpóreas en intoxicaciones ha sido muy limitado y depende de la severidad y farmacocinética del tóxico involucrado. La hemoperfusión con carbón activado ha sido de las técnicas más utilizadas en estos casos, así como la hemodiálisis convencional, pero hay escasos datos del uso de técnicas continuas como la hemofiltración en el tratamiento de intoxicaciones exógenas. En esta comunicación se analiza un paciente que presenta dos severos episodios de intoxicación intencional con Carbamazepina, en uno de los cuales se intentó la recuperación del fármaco con hemoperfusión con carbón activado con buenos resultados y en el segundo episodio se realizó hemofiltración. Se discute la farmacocinética del fármaco involucrado y las características de las técnicas utilizadas así como posibles indicaciones de cada una de ellas en este tipo de intoxicaciones

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Os autores apresentam um caso de intoxicação aguda por paraquat, em paciente com dosagens urinárias precoces positivas para o agente, com evolução inicial favorável, desenvolvendo fibrose pulmonar e falência de múltiplos órgãos mais tardiamente. A evolução pode parecer benigna de início mas após alguns dias pode evoluir com fibrose pulmonar irreversível e morte. Esta situação torna-se relevante na medida em que mesmo doses muito baixas de paraquat, um produto amplamente difundido no meio agrícola, podem causar acidentes fatais. São revisados aspectos clínicos e farmacológicos da intoxicação, bem como manejo preconizado para esses casos, enfatizando a necessidade de uso precoce de hemoperfusão com filtro de carvão ativado

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Se presenta el caso de una paciente de 19 años sin antecedentes patológicos. Ingresa a la Unidad de Cuidados Intensivos debido a una intoxicación barbitúrica aguda, grave, secundaria a la ingesta de 4 gramos de pentobarbital. Se realizó tratamiento en base a rescate del tóxico, asistencia respiratoria mecánica, apoyo inotrópico, diuresis forzada alcalina y reposición hidro-electrólitica. Asimismo se realizó depuración extrarrenal mediante hemodiálisis convencional, la cual por ser inefectiva fue sustituida al cabo de 6 horas por una hemoperfusión sobre cartucho de carbón activado, con lo que se objetivó una franca mejoría clínica. La distinta eficacia depuradora de ambos métodos fue asimismo corroborada por la dosificación del tóxico en orina y sangre(AU)

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