Extracorporeal treatment for salicylate poisoning: Systematic review and recommendations from the EXTRIP workgroup

David N. Juurlink, Sophie Gosselin, Jan T. Kielstein, Marc Ghannoum, Valéry Lavergne, Thomas D. Nolin, Robert S. Hoffman, Kurt Anseeuw, Ashish Bhalla, Emmanuel A. Burdmann, Diane P. Calello, Paul I. Dargan, Brian Decker, David S. Goldfarb, Tais Galvo, Lotte C. Hoegberg, Martin Laliberté, Yi Li, Kathleen D. Liu, Robert MacLarenRobert MacTier, Bruno Mégarbane, James B. Mowry, Véronique Phan, Darren M. Roberts, Timothy J. Wiegand, James F. Winchester, Christopher Yates

Research output: Contribution to journalArticle

46 Citations (Scopus)

Abstract

Study objective Salicylate poisoning is a challenging clinical entity associated with substantial morbidity and mortality. The indications for extracorporeal treatments such as hemodialysis are poorly defined. We present a systematic review of the literature along with evidence-and consensus-based recommendations on the use of extracorporeal treatment in salicylate poisoning. Methods The Extracorporeal Treatments in Poisoning (EXTRIP) Workgroup is a multidisciplinary group with international representation whose aim is to provide evidence-based recommendations on the use of extracorporeal treatments in poisoning. We conducted a systematic literature review followed by data extraction and summarized findings, following a predetermined format. The entire work group voted by a 2-round modified Delphi method to reach consensus on voting statements, using a RAND/UCLA Appropriateness Method to quantify disagreement. Anonymous votes were compiled, returned, and discussed in person. A second vote determined the final recommendations. Results Eighty-four articles met inclusion criteria, including 1 controlled clinical trial, 3 animal studies, and 80 case reports or case series, yielding an overall very low quality of evidence for all recommendations. Clinical data on 143 patients (130 sets of which could be analyzed for patient-level entry data), including 14 fatalities, were reviewed. Toxicokinetic data on 87 patients were also included. After the second round of voting, the workgroup concluded that salicylates are dialyzable by hemodialysis and hemoperfusion (level of evidence=B) and recommended extracorporeal treatment in patients with severe salicylate poisoning (1D), including any patient with altered mental status (1D), with acute respiratory distress syndrome requiring supplemental oxygen (1D), and for those in whom standard therapy is deemed to be failing (1D) regardless of the salicylate concentration. High salicylate concentrations warrant extracorporeal treatment regardless of signs and symptoms (>7.2 mmol/L [100 mg/dL] [1D]; and >6.5 mmol/L [90 mg/dL] [2D]), with lower thresholds applied for patients with impaired kidney function (>6.5 mmol/L [90 mg/dL] [1D]; >5.8 mmol/L [80 mg/dL] [2D]). Extracorporeal treatment is also suggested for patients with severe acidemia (pH ≤7.20 in the absence of other indications) (2D). Intermittent hemodialysis is the preferred modality (1D), although hemoperfusion (1D) and continuous renal replacement therapies (3D) are acceptable alternatives if hemodialysis is unavailable, as is exchange transfusion in neonates (1D). Conclusion Salicylates are readily removed by extracorporeal treatment, with intermittent hemodialysis being the preferred modality. The signs and symptoms of salicylate toxicity listed warrant extracorporeal treatment, as do high concentrations regardless of clinical status.

Original languageEnglish (US)
Pages (from-to)165-181
Number of pages17
JournalAnnals of Emergency Medicine
Volume66
Issue number2
DOIs
StatePublished - Aug 1 2015
Externally publishedYes

Fingerprint

Salicylates
Poisoning
Renal Dialysis
Therapeutics
Hemoperfusion
Politics
Signs and Symptoms
Renal Replacement Therapy
Adult Respiratory Distress Syndrome
Controlled Clinical Trials
Newborn Infant
Oxygen
Morbidity
Kidney
Mortality

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Juurlink, D. N., Gosselin, S., Kielstein, J. T., Ghannoum, M., Lavergne, V., Nolin, T. D., ... Yates, C. (2015). Extracorporeal treatment for salicylate poisoning: Systematic review and recommendations from the EXTRIP workgroup. Annals of Emergency Medicine, 66(2), 165-181. https://doi.org/10.1016/j.annemergmed.2015.03.031

Extracorporeal treatment for salicylate poisoning : Systematic review and recommendations from the EXTRIP workgroup. / Juurlink, David N.; Gosselin, Sophie; Kielstein, Jan T.; Ghannoum, Marc; Lavergne, Valéry; Nolin, Thomas D.; Hoffman, Robert S.; Anseeuw, Kurt; Bhalla, Ashish; Burdmann, Emmanuel A.; Calello, Diane P.; Dargan, Paul I.; Decker, Brian; Goldfarb, David S.; Galvo, Tais; Hoegberg, Lotte C.; Laliberté, Martin; Li, Yi; Liu, Kathleen D.; MacLaren, Robert; MacTier, Robert; Mégarbane, Bruno; Mowry, James B.; Phan, Véronique; Roberts, Darren M.; Wiegand, Timothy J.; Winchester, James F.; Yates, Christopher.

In: Annals of Emergency Medicine, Vol. 66, No. 2, 01.08.2015, p. 165-181.

Research output: Contribution to journalArticle

Juurlink, DN, Gosselin, S, Kielstein, JT, Ghannoum, M, Lavergne, V, Nolin, TD, Hoffman, RS, Anseeuw, K, Bhalla, A, Burdmann, EA, Calello, DP, Dargan, PI, Decker, B, Goldfarb, DS, Galvo, T, Hoegberg, LC, Laliberté, M, Li, Y, Liu, KD, MacLaren, R, MacTier, R, Mégarbane, B, Mowry, JB, Phan, V, Roberts, DM, Wiegand, TJ, Winchester, JF & Yates, C 2015, 'Extracorporeal treatment for salicylate poisoning: Systematic review and recommendations from the EXTRIP workgroup', Annals of Emergency Medicine, vol. 66, no. 2, pp. 165-181. https://doi.org/10.1016/j.annemergmed.2015.03.031
Juurlink, David N. ; Gosselin, Sophie ; Kielstein, Jan T. ; Ghannoum, Marc ; Lavergne, Valéry ; Nolin, Thomas D. ; Hoffman, Robert S. ; Anseeuw, Kurt ; Bhalla, Ashish ; Burdmann, Emmanuel A. ; Calello, Diane P. ; Dargan, Paul I. ; Decker, Brian ; Goldfarb, David S. ; Galvo, Tais ; Hoegberg, Lotte C. ; Laliberté, Martin ; Li, Yi ; Liu, Kathleen D. ; MacLaren, Robert ; MacTier, Robert ; Mégarbane, Bruno ; Mowry, James B. ; Phan, Véronique ; Roberts, Darren M. ; Wiegand, Timothy J. ; Winchester, James F. ; Yates, Christopher. / Extracorporeal treatment for salicylate poisoning : Systematic review and recommendations from the EXTRIP workgroup. In: Annals of Emergency Medicine. 2015 ; Vol. 66, No. 2. pp. 165-181.
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title = "Extracorporeal treatment for salicylate poisoning: Systematic review and recommendations from the EXTRIP workgroup",
abstract = "Study objective Salicylate poisoning is a challenging clinical entity associated with substantial morbidity and mortality. The indications for extracorporeal treatments such as hemodialysis are poorly defined. We present a systematic review of the literature along with evidence-and consensus-based recommendations on the use of extracorporeal treatment in salicylate poisoning. Methods The Extracorporeal Treatments in Poisoning (EXTRIP) Workgroup is a multidisciplinary group with international representation whose aim is to provide evidence-based recommendations on the use of extracorporeal treatments in poisoning. We conducted a systematic literature review followed by data extraction and summarized findings, following a predetermined format. The entire work group voted by a 2-round modified Delphi method to reach consensus on voting statements, using a RAND/UCLA Appropriateness Method to quantify disagreement. Anonymous votes were compiled, returned, and discussed in person. A second vote determined the final recommendations. Results Eighty-four articles met inclusion criteria, including 1 controlled clinical trial, 3 animal studies, and 80 case reports or case series, yielding an overall very low quality of evidence for all recommendations. Clinical data on 143 patients (130 sets of which could be analyzed for patient-level entry data), including 14 fatalities, were reviewed. Toxicokinetic data on 87 patients were also included. After the second round of voting, the workgroup concluded that salicylates are dialyzable by hemodialysis and hemoperfusion (level of evidence=B) and recommended extracorporeal treatment in patients with severe salicylate poisoning (1D), including any patient with altered mental status (1D), with acute respiratory distress syndrome requiring supplemental oxygen (1D), and for those in whom standard therapy is deemed to be failing (1D) regardless of the salicylate concentration. High salicylate concentrations warrant extracorporeal treatment regardless of signs and symptoms (>7.2 mmol/L [100 mg/dL] [1D]; and >6.5 mmol/L [90 mg/dL] [2D]), with lower thresholds applied for patients with impaired kidney function (>6.5 mmol/L [90 mg/dL] [1D]; >5.8 mmol/L [80 mg/dL] [2D]). Extracorporeal treatment is also suggested for patients with severe acidemia (pH ≤7.20 in the absence of other indications) (2D). Intermittent hemodialysis is the preferred modality (1D), although hemoperfusion (1D) and continuous renal replacement therapies (3D) are acceptable alternatives if hemodialysis is unavailable, as is exchange transfusion in neonates (1D). Conclusion Salicylates are readily removed by extracorporeal treatment, with intermittent hemodialysis being the preferred modality. The signs and symptoms of salicylate toxicity listed warrant extracorporeal treatment, as do high concentrations regardless of clinical status.",
author = "Juurlink, {David N.} and Sophie Gosselin and Kielstein, {Jan T.} and Marc Ghannoum and Val{\'e}ry Lavergne and Nolin, {Thomas D.} and Hoffman, {Robert S.} and Kurt Anseeuw and Ashish Bhalla and Burdmann, {Emmanuel A.} and Calello, {Diane P.} and Dargan, {Paul I.} and Brian Decker and Goldfarb, {David S.} and Tais Galvo and Hoegberg, {Lotte C.} and Martin Lalibert{\'e} and Yi Li and Liu, {Kathleen D.} and Robert MacLaren and Robert MacTier and Bruno M{\'e}garbane and Mowry, {James B.} and V{\'e}ronique Phan and Roberts, {Darren M.} and Wiegand, {Timothy J.} and Winchester, {James F.} and Christopher Yates",
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language = "English (US)",
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pages = "165--181",
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TY - JOUR

T1 - Extracorporeal treatment for salicylate poisoning

T2 - Systematic review and recommendations from the EXTRIP workgroup

AU - Juurlink, David N.

AU - Gosselin, Sophie

AU - Kielstein, Jan T.

AU - Ghannoum, Marc

AU - Lavergne, Valéry

AU - Nolin, Thomas D.

AU - Hoffman, Robert S.

AU - Anseeuw, Kurt

AU - Bhalla, Ashish

AU - Burdmann, Emmanuel A.

AU - Calello, Diane P.

AU - Dargan, Paul I.

AU - Decker, Brian

AU - Goldfarb, David S.

AU - Galvo, Tais

AU - Hoegberg, Lotte C.

AU - Laliberté, Martin

AU - Li, Yi

AU - Liu, Kathleen D.

AU - MacLaren, Robert

AU - MacTier, Robert

AU - Mégarbane, Bruno

AU - Mowry, James B.

AU - Phan, Véronique

AU - Roberts, Darren M.

AU - Wiegand, Timothy J.

AU - Winchester, James F.

AU - Yates, Christopher

PY - 2015/8/1

Y1 - 2015/8/1

N2 - Study objective Salicylate poisoning is a challenging clinical entity associated with substantial morbidity and mortality. The indications for extracorporeal treatments such as hemodialysis are poorly defined. We present a systematic review of the literature along with evidence-and consensus-based recommendations on the use of extracorporeal treatment in salicylate poisoning. Methods The Extracorporeal Treatments in Poisoning (EXTRIP) Workgroup is a multidisciplinary group with international representation whose aim is to provide evidence-based recommendations on the use of extracorporeal treatments in poisoning. We conducted a systematic literature review followed by data extraction and summarized findings, following a predetermined format. The entire work group voted by a 2-round modified Delphi method to reach consensus on voting statements, using a RAND/UCLA Appropriateness Method to quantify disagreement. Anonymous votes were compiled, returned, and discussed in person. A second vote determined the final recommendations. Results Eighty-four articles met inclusion criteria, including 1 controlled clinical trial, 3 animal studies, and 80 case reports or case series, yielding an overall very low quality of evidence for all recommendations. Clinical data on 143 patients (130 sets of which could be analyzed for patient-level entry data), including 14 fatalities, were reviewed. Toxicokinetic data on 87 patients were also included. After the second round of voting, the workgroup concluded that salicylates are dialyzable by hemodialysis and hemoperfusion (level of evidence=B) and recommended extracorporeal treatment in patients with severe salicylate poisoning (1D), including any patient with altered mental status (1D), with acute respiratory distress syndrome requiring supplemental oxygen (1D), and for those in whom standard therapy is deemed to be failing (1D) regardless of the salicylate concentration. High salicylate concentrations warrant extracorporeal treatment regardless of signs and symptoms (>7.2 mmol/L [100 mg/dL] [1D]; and >6.5 mmol/L [90 mg/dL] [2D]), with lower thresholds applied for patients with impaired kidney function (>6.5 mmol/L [90 mg/dL] [1D]; >5.8 mmol/L [80 mg/dL] [2D]). Extracorporeal treatment is also suggested for patients with severe acidemia (pH ≤7.20 in the absence of other indications) (2D). Intermittent hemodialysis is the preferred modality (1D), although hemoperfusion (1D) and continuous renal replacement therapies (3D) are acceptable alternatives if hemodialysis is unavailable, as is exchange transfusion in neonates (1D). Conclusion Salicylates are readily removed by extracorporeal treatment, with intermittent hemodialysis being the preferred modality. The signs and symptoms of salicylate toxicity listed warrant extracorporeal treatment, as do high concentrations regardless of clinical status.

AB - Study objective Salicylate poisoning is a challenging clinical entity associated with substantial morbidity and mortality. The indications for extracorporeal treatments such as hemodialysis are poorly defined. We present a systematic review of the literature along with evidence-and consensus-based recommendations on the use of extracorporeal treatment in salicylate poisoning. Methods The Extracorporeal Treatments in Poisoning (EXTRIP) Workgroup is a multidisciplinary group with international representation whose aim is to provide evidence-based recommendations on the use of extracorporeal treatments in poisoning. We conducted a systematic literature review followed by data extraction and summarized findings, following a predetermined format. The entire work group voted by a 2-round modified Delphi method to reach consensus on voting statements, using a RAND/UCLA Appropriateness Method to quantify disagreement. Anonymous votes were compiled, returned, and discussed in person. A second vote determined the final recommendations. Results Eighty-four articles met inclusion criteria, including 1 controlled clinical trial, 3 animal studies, and 80 case reports or case series, yielding an overall very low quality of evidence for all recommendations. Clinical data on 143 patients (130 sets of which could be analyzed for patient-level entry data), including 14 fatalities, were reviewed. Toxicokinetic data on 87 patients were also included. After the second round of voting, the workgroup concluded that salicylates are dialyzable by hemodialysis and hemoperfusion (level of evidence=B) and recommended extracorporeal treatment in patients with severe salicylate poisoning (1D), including any patient with altered mental status (1D), with acute respiratory distress syndrome requiring supplemental oxygen (1D), and for those in whom standard therapy is deemed to be failing (1D) regardless of the salicylate concentration. High salicylate concentrations warrant extracorporeal treatment regardless of signs and symptoms (>7.2 mmol/L [100 mg/dL] [1D]; and >6.5 mmol/L [90 mg/dL] [2D]), with lower thresholds applied for patients with impaired kidney function (>6.5 mmol/L [90 mg/dL] [1D]; >5.8 mmol/L [80 mg/dL] [2D]). Extracorporeal treatment is also suggested for patients with severe acidemia (pH ≤7.20 in the absence of other indications) (2D). Intermittent hemodialysis is the preferred modality (1D), although hemoperfusion (1D) and continuous renal replacement therapies (3D) are acceptable alternatives if hemodialysis is unavailable, as is exchange transfusion in neonates (1D). Conclusion Salicylates are readily removed by extracorporeal treatment, with intermittent hemodialysis being the preferred modality. The signs and symptoms of salicylate toxicity listed warrant extracorporeal treatment, as do high concentrations regardless of clinical status.

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