Comparison of Charcoal Hemoperfusion and Hemodialysis in Treatment of Severe Carbamazepine Intoxications

• Published in: Clinical toxicology (Philadelphia, Pa.) Vol. 45; no. 4; p. 346
• Main Authors: Sentsov, V G, Brusin, K M, Meledin, VY, Novikova, O V, Urazaev, TH
• Format: Journal Article
• Language: English
• Published: 01.05.2007
• ISSN: 1556-3650

Objective: Effective drug elimination in severe carbamazepine toxicity is expected to decrease morbidity and mortality. Management of carbamazepine overdoses utilizes gut clearance techniques and multiple doses of activated charcoal. Unfortunately, its efficacy is reduced when given more than 1 hour after ingestion. Because of absorption capacity of activated charcoal for carbamazepine, many authors recommend charcoal hemoperfusion (HP) for enhanced clearance, but its clinical benefit is often insufficient because of a moderately large volume of distribution, reequilibration after detoxification and rebound of drug level in plasma. Furthermore, it is uncertain if the highly protein bound carbamazepine is effectively removed by hemodialysis (HD). Recently there have been reports of successful treatment with both conventional, albumin enhanced and high-flux HD. Therefore we decided to examine the clinical and toxicometric efficacy in severe carbamazepine intoxication. Methods: Eight patients with severe carbamazepine intoxication underwent HP on charcoal hemosor-bent (350 ml) with blood flow 100 ml/min for 1 hour. Four patients were treated by HD (Gambro, S 1.4 m2, dialysis fluid flow rate 500 ml/min 6-12 hours). Two patients after HP underwent HD. Additionally, we performed experimental plasmadialysis on plasma, obtained from plasmapheresis. Previously carbamazepine 1 mg/ml was added to the plasma. The serum concentration carbamazepine was measured by fluorescent polarizing immunoassay (TDx-FLx, Abbott Laboratories). Results: Carbamazepine clearance in experimental plasmadialysis was 93.9+14.0 ml/min. The plasma level of carbamazepine 1 hour after the procedure decreased to 28%. A similar clearance (96.9+1.0 ml/min) was obtained for charcoal HP. Carbamazepine concentration before HP was 20.4+4.5 mcg/ml and decreased to 16% after HP. In five of eight patients there was clinical improvement, but three remained comatose. These latter three patients underwent HD. Two of them were successfully weaned from ventilator support and fully recovered. One patient died, despite a dramatically decreased level of carbamazepine from 40 to 9 mcg/ml. Two patients, initially treated only by HD, recovered consciousness. Their carbamazepine level before HD was very high -- 36.7 and 31.5 mcg/ml and decreased to 43.0 and 32.5%, respectively. Carbamazepine clearance obtained in HD was 50.4 ml/min. Conclusion: HD may be an effective component of decontaminating measures in severe carbamazepine intoxications. It seems to be promising to investigate albumin enhanced and high-flux versus conventional HD.