Theophylline toxicity: Successful management of a patient with distributive shock secondary to drug overdose.

Presenting a case of acute theophylline and salbutamol overdose with distributive shock. Twenty one years old lady presented with history of consumption of 3 gram of theophylline and 40 mg of salbutamol. On admission she had altered sensorium with the systolic blood pressure of 60 mmHg, unrecordable diastolic blood pressure and heart rate of 147/min. Investigations revealed severe metabolic acidosis, hypokalemia, hypocalcemia which was managed by intravenous fluids, vasopressors, infusion of injection calcium gluconate and injection potassium chloride. As her hemodynamic status did not improve, she has been initiated on 1.5 mL/kg of lipid emulsion as bolus and then 0.5 mL/kg/h as infusion. Her hemodynamic status improved gradually and she was discharged in 24 h. Lipid emulsion had been used in local anesthetics and many tablet overdoses. In this patient timely administration of lipid emulsion resulted in early recovery of shock.

Severe theophylline poisoning treated with continuous venovenous hemodialysis in a child.

Theophylline poisoning generally occurs due to acute high dose intake as well as chronic intake of the medication. Toxicity symptoms can be seen with a plasma concentration of theophylline over 20 µg/ml. The consequences of theophylline toxicity include metabolic disturbances (hypokalemia, hyperglycemia, and metabolic acidosis), nausea, vomiting, and in severe cases seizures, cardiac arrhythmias, and death. Theophylline poisoning in children is rarely described in the literature. A 3-year-old girl was referred from another hospital to our pediatric intensive care unit (PICU) due to prolonged refractory status epilepticus and respiratory failure linked with severe theophylline poisoning. The patient was admitted to our PICU 24 hours after the patient took theophylline. The referring center could not measure the serum theophylline level. The patient's first serum theophylline level that was checked at admission was 54 µg/ml. We started continuous venovenous hemodialysis (CVVHD) 3 hours after PICU admission and the patient's theophylline level successfully decreased within 9 hours. The patient was discharged at the 40th day of admission from our hospital with severe neurological disability. In conclusion, severe theophylline poisoning may be seen in children. We must consider CVVHD in critically ill children with severe theophylline poisoning.

Extracorporeal treatment for theophylline poisoning: systematic review and recommendations from the EXTRIP workgroup.

BACKGROUND: The Extracorporeal Treatments in Poisoning workgroup was created to provide evidence-based recommendations on the use of extracorporeal treatments (ECTRs) in poisoning. Here, the workgroup presents its systematic review and recommendations for theophylline. METHODS: After a systematic review of the literature, a subgroup reviewed articles, extracted data, summarized findings, and proposed structured voting statements following a pre-determined format. A two-round modified Delphi method was chosen to reach a consensus on voting statements and the RAND/UCLA Appropriateness Method was used to quantify disagreement. Anonymous votes were compiled, returned, and discussed. A second vote determined the final recommendations. RESULTS: 141 articles were included: 6 in vitro studies, 4 animal studies, 101 case reports/case series, 7 descriptive cohorts, 4 observational studies, and 19 pharmacokinetic studies, yielding a low-to-very-low quality of evidence for all recommendations. Data on 143 patients were reviewed, including 10 deaths. The workgroup concluded that theophylline is dialyzable (level of evidence = A) and made the following recommendations: ECTR is recommended in severe theophylline poisoning (1C). Specific recommendations for ECTR include a theophylline concentration [theophylline] > 100 mg/L (555 µmol/L) in acute exposure (1C), the presence of seizures (1D), life-threatening dysrhythmias (1D) or shock (1D), a rising [theophylline] despite optimal therapy (1D), and clinical deterioration despite optimal care (1D). In chronic poisoning, ECTR is suggested if [theophylline] > 60 mg/L (333 µmol/L) (2D) or if the [theophylline] > 50 mg/L (278 µmol/L) and the patient is either less than 6 months of age or older than 60 years of age (2D). ECTR is also suggested if gastrointestinal decontamination cannot be administered (2D). ECTR should be continued until clinical improvement is apparent or the [theophylline] is < 15 mg/L (83 µmol/L) (1D). Following the cessation of ECTR, patients should be closely monitored. Intermittent hemodialysis is the preferred method of ECTR (1C). If intermittent hemodialysis is unavailable, hemoperfusion (1C) or continuous renal replacement therapies may be considered (3D). Exchange transfusion is an adequate alternative to hemodialysis in neonates (2D). Multi-dose activated charcoal should be continued during ECTR (1D). CONCLUSION: Theophylline poisoning is amenable to ECTRs. The workgroup recommended extracorporeal removal in the case of severe theophylline poisoning.

Accidental overdose of tiotropium in a patient with atrial fibrillation.

OBJECTIVE: To report a case of refractory tachycardia after an excessive dose of inhaled tiotropium. CASE SUMMARY: A 74-year-old male with atrial fibrillation was admitted for increased heart rate and shortness of breath. The patient's heart rate was initially stabilized between 80 and 90 beats/min with metoprolol succinate 50 mg daily. During hospitalization, he accidentally received 5 capsules of tiotropium 18 microg inhaled as a single dose (total 90 microg) and, approximately 15 minutes later, his heart rate increased from 80 to 160 beats/min. Over 5 days of hospitalization, the patient's tachycardia was difficult to control and he required multiple atrioventricular (AV) nodal blocking agents (physostigmine, metoprolol tartrate, diltiazem) for effective stabilization prior to discharge. On outpatient follow-up 11 days after the ingestion the patient's heart rate was in the 40s and the AV nodal blocking agents were proportionately decreased. DISCUSSION: Tiotropium is a long-acting anticholinergic medication used to treat chronic obstructive pulmonary disease. Little has been reported as to the potential systemic toxicities of tiotropium. Tachycardia is listed as a potential adverse effect, but based on a MEDLINE search (1966-July 2009) using tiotropium, tachycardia, and overdose as search terms, there have been no case reports published. Renal impairment may increase plasma concentrations of tiotropium; our patient's creatinine clearance was estimated to be below 50 mL/min. According to the Naranjo probability scale, our patient's development of tachycardia was probably associated with tiotropium inhalation. CONCLUSIONS: Tiotropium can be temporally implicated in a rapid heart rate following excessive ingestion. Health care professionals should be aware of tachycardic effects of tiotropium, particularly in patients with underlying structural heart disease, atrial fibrillation, and renal impairment.

Iatrogenic intravenous medication errors reported to the GIZ-Nord Poisons Center Göttingen.

BACKGROUND: We analyzed the iatrogenic intravenous medication errors (IIME) reported to the GIZ-Nord Poisons Center Göttingen. METHODS: IIME over a ten year period were analyzed retrospectively and categorized into error types, age groups, drugs involved, and severity of IIME at registration and after known outcome. RESULTS: 265 IIME were registered from 1997 to 2006. They rose from 12 in 1997 to 45 in 2006 corresponding to an increase from 0.058 to 0.148% of all calls of the respective year. Children were affected in (21.1%) and adults in 78.9% of all cases. The drug classes (ATC classification) involved most frequently were antipsychotics (7.9%) and antithrombotic agents (6.0%). The main types of IIME were dosing error (37.7%) and wrong route of administration (28.7%). The severity of IIME at registration was none (33.6%), minor (32.5%), moderate (13.6%), severe (13.6%), fatal (1.5%), and unratable (5.2%). In the 46 cases followed to a known outcome, 15 were asymptomatic and 27 were symptomatic with minor (11 cases), moderate (5 cases) and severe features (11 cases). Four cases of IIME were already fatal at registration and one severe case died in the further course. Dosing error of theophylline was often observed in severe outcomes. CONCLUSION: IIME increased from 1997 to 2006. Intravenous use of antipsychotics and theophylline should be restricted to a minimum.

A case of accidental ingestion of a salbutamol sulfate inhalant, Venetlin®.

Pediatricians examine increasing numbers of children with bronchial asthma every year. In Japan, medical institutions can provide standardized therapies according to the Japanese Pediatric Guideline for the Treatment and Management of Asthma 2005. Inhalation therapy is highly beneficial, and a substantial proportion of patients choose to purchase inhalators and practice inhalation therapy at home. Recently, we experienced a case of accidental ingestion of a salbutamol sulfate inhalant by a non-asthmatic child, which reminded us anew of the importance of managing the medicines for asthma. We also recognized the need to educate patients and their families on the knowledge of these medicines. In this report, we analyze the case and discuss measures that pediatricians can implement to avoid accidental inhalant ingestion by children.

[Adverse reaction of pseudoephedrine]. / Reacción adversa por seudoefedrina.

We present a case of a 7 years old girl who developed an episode of myoclonic movements and tremors after being medicated with a not well quantified amount of a pseudoephedrine/antihistamine combination. We want to highlight the potential toxicity of pseudoephedrine, usually administered as part of cold-syrup preparations which are used for symptomatic treatment of upper respiratory tract cough and congestion associated with the common cold and allergic rhinitis. Although these products are generally considered to be safe either by physicians and parents, we can't underestimate the potential adverse events and toxic effects that can occur when administering these medications.

Reacción adversa por seudoefedrina / Adverse reaction of pseudoephedrine

Aportamos el caso de una niña de 7 años de edad que presentó un episodio de mioclonías y temblores de pocas horas de duración tras haber ingerido una cantidad no bien determinada de un preparado que contenía antihistamínico y seudoefedrina. Queremos destacar la potencial toxicidad de la seudoefedrina, comercializada en asociación con antihistamínicos y que se vende como fármaco para aliviar el resfriado común y la obstrucción nasal. Dichos productos se consideran medicamentos para tratar síntomas a menudo banales, por lo que pensamos que la población y, con menos frecuencia, los profesionales, pueden infravalorar la potencial toxicidad de los fármacos que los componen (AU)

We present a case of a 7 years old girl who developed an episode of myoclonic movements and tremors after being medicated with a not well cuantified amount of a pseudoephedrine/antihistamine combination. We want to highlight the potencial toxicity of pseudoephedrine, usually administered as part of cold-syrup preparations which are used for symptomatic treatment of upper respiratory tract cough and congestion associated with the common cold and allergic rhinitis. Although these products are generally considered to be safe either by physicians and parents, we can’t underestimate the potencial adverse events and toxic effects that can occur when administering these medications We present a case of a 7 years old girl who developed an episode of myoclonic movements and tremors after being medicated with a not well cuantified amount of a pseudoephedrine/antihistamine combination. We want to highlight the potencial toxicity of pseudoephedrine, usually administered as part of cold-syrup preparations which are used for symptomatic treatment of upper respiratory tract cough and congestion associated with the common cold and allergic rhinitis. Although these products are generally considered to be safe either by physicians and parents, we can’t underestimate the potencial adverse events and toxic effects that can occur when administering these medications (AU)

Salbutamol intoxication: is salbutamol a drug-inducing fever? A case report and treatment strategy.

A four-year-old female with salbutamol intoxication was referred to our paediatric emergency medicine unit, due to agitation, tremulousness, sinus tachycardia, mild hypokalaemia and hyperglycaemia. On admission the child was agitated and had a noticeable tremor, an axillary temperature of 38 degrees C and a pulse rate of 185 beats/min. She had no identifiable focus of infection on physical examination to explain her fever. Gastric lavage, activated charcoal, intravenous hydration and electrocardiogram (ECG) monitoring were performed. Her plasma potassium level, blood sugar and QT interval were closely monitored during her hospital stay. Her fever, tachycardia and serum potassium and glucose levels returned to normal and she was discharged in good condition 24 h after admission. The difference of this case from prior cases of salbutamol intoxication was the observation of fever in the absence of evidence of infection. Since the cause of fever was not a reaction to the medication used in the treatment or related to environmental factors, it is assumed that salbutamol is a fever-inducing drug.

Metabolic effects of metaproterenol overdose: hypokalemia, hyperglycemia and hyperlactatemia.

This case report of metaproterenol toxicity was associated with hypokalemia, hyperglycemia and hyperlactatemia. A similar triad has been reported in acute theophylline poisoning. Hypokalemia and hyperglycemia have been reported with other beta-agonists, but not metaproterenol. Patients presenting with the metabolic triad of hypokalemia, hyperglycemia, and hyperlactatemia should have theophylline and beta-agonist toxicity included in their differential diagnosis because the prognosis and therapy of these 2 intoxications is markedly different.

Continuous venovenous haemofiltration for the treatment of theophylline toxicity.

In patients with severe theophylline toxicity charcoal haemoperfusion is the recommended method for rapid reduction of serum theophylline levels. However, access to this technique is limited in most hospitals. This case report shows that continuous venovenous haemofiltration, a technique available in most hospitals, is an effective alternative to charcoal haemoperfusion.