Thursday, November 21, 2013

Quick caveat: Salicylate poisoning

The American College of Medical Toxicology, in their positional statement on Salicylate Toxicity, mentions that:

Clinical deterioration, even in the setting of a falling serum concentration, is ominous, and suggestive of increasing central nervous system (CNS) salicylate concentration. As blood pH falls, there is an increased proportion of nonionized salicylate that more readily distributes into the cerebrospinal fluid (CSF) and other tissues.
Download the pdf version of the statement here.
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Other caveats from that positional statement:

  1. Acidemia should be avoided.  Continuous intravenous infusion of sodium bicarbonate is also indicated even in the presence of mild alkalemia. 
  2. Alkalemia can be expected to occur as is a function of salicylate-induced respiratory alkalosis and is almost universally associated with a bicarbonate deficit and paradoxical aciduria, limiting salicylate excretion. 
  3. Therefore, urine alkalinization to a pH of 7.5 - 8.0 increases urinary excretion of salicylates more than 10-fold and should be considered for significant salicylate toxicity in patients with intact renal function, alone or in combination with hemodialysis. 
  4. Intravenous (not oral) administration of sodium bicarbonate as a crystalloid preparation should be used. One commonly utilized intravenous solution consists of one liter of D5W to which three 50 ml-ampules of 8.4% sodium bicarbonate (for a total of 132-150 mmol) and 30-40 mmol of potassium chloride per liter are added. The rate of infusion should be sufficient to induce a urine output of 2-3 mL/kg/hr. Urine pH should be checked frequently.

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