Phenobarbital overdose management involves therapy designed to enhance elimination of the drug. Haemoperfusion is generally viewed as the most effective means for the removal of the drug [1]. We report a case of severe barbiturate overdose where haemodialysis led to a significant decrease in blood drug levels. We feel that this report illustrates that haemodialysis is an effective measure in the treatment of barbiturate overdose and that charcoal haemoperfusion cannot be considered as the sole indicated extracorporeal therapy.
A 79-year-old man was admitted in our ICU after phenobarbital overdose complicated by aspiration pneumonia. He was unconscious and needed mechanical ventilation. His blood pressure was 104/61 mmHg and heart rate was 120 beats/min. There was no focal neurological defect. Serum phenobarbital level at admission was 180 mg/l (therapeutic level: 1530 mg/l). Haemodialysis was performed on day 1 for 6 h with an internal jugular dual-lumen catheter (Arrow, Reading, PA). A 1.1 m2 polyamide haemodialysis membrane (Polyflux S; Gambro, Hechingen, Germany) was used for the procedure. The blood flow rate was 180 ml/min and the dialysate flow rate was 500 ml/min. A second haemodialysis was performed for 4 h with the same membrane and parameters, except the blood flow value was 200 ml/min. Barbiturate blood levels were determined before and after each procedure and decreased from 53% and 38%, respectively (Figure 1). The patient was discharged from ICU on day 22, the prolonged hospitalization time was due to a Pseudomonas ventilator-associated pneumonia.
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However, Palmer [4] showed that the use of a high-efficiency dialyser with high blood flow rates (400 ml/min) is effective for patients with life-threatening phenobarbital poisoning, leading to a 59% decrease in phenobarbital blood levels in 4 h. Nevertheless, the use of a high blood flow rate is not always possible in the acute setting, but our data show that conventional haemodialysis remains effective, leading to similar phenobarbital blood level reduction, and should be considered as a valuable therapeutic option in patients with severe phenobarbital overdose.
Conflict of interest statement. None declared.
Service de Réanimation Médicale Hôpital Antoine Béclère Clamart, France Email: frederic.jacobs{at}abc.ap-hop-paris.fr
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