Department of Nephrology, Verdun Hospital, University of Montreal , Verdun, QC , Canada.
Clin Toxicol (Phila). 2015 Jun;53(5):454-65. doi: 10.3109/15563650.2015.1035441.
The EXtracorporeal TReatments In Poisoning (EXTRIP) workgroup presents its systematic review and clinical recommendations on the use of extracorporeal treatment (ECTR) in valproic acid (VPA) poisoning.
The lead authors reviewed all of the articles from a systematic literature search, extracted the data, summarized the key findings, and proposed structured voting statements following a predetermined 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 in person. A second vote was conducted to determine the final workgroup recommendations.
The latest literature search conducted in November 2014 retrieved a total of 79 articles for final qualitative analysis, including one observational study, one uncontrolled cohort study with aggregate analysis, 70 case reports and case series, and 7 pharmacokinetic studies, yielding a very low quality of evidence for all recommendations. Clinical data were reported for 82 overdose patients while pharmaco/toxicokinetic grading was performed in 55 patients. The workgroup concluded that VPA is moderately dialyzable (level of evidence = B) and made the following recommendations: ECTR is recommended in severe VPA poisoning (1D); recommendations for ECTR include a VPA concentration > 1300 mg/L (9000 μmol/L)(1D), the presence of cerebral edema (1D) or shock (1D); suggestions for ECTR include a VPA concentration > 900 mg/L (6250 μmol/L)(2D), coma or respiratory depression requiring mechanical ventilation (2D), acute hyperammonemia (2D), or pH ≤ 7.10 (2D). Cessation of ECTR is indicated when clinical improvement is apparent (1D) or the serum VPA concentration is between 50 and 100 mg/L (350-700 μmol/L)(2D). Intermittent hemodialysis is the preferred ECTR in VPA poisoning (1D). If hemodialysis is not available, then intermittent hemoperfusion (1D) or continuous renal replacement therapy (2D) is an acceptable alternative.
VPA is moderately dialyzable in the setting of overdose. ECTR is indicated for VPA poisoning if at least one of the above criteria is present. Intermittent hemodialysis is the preferred ECTR modality in VPA poisoning.
EXtracorporeal TReatments In Poisoning (EXTRIP) 工作组就体外治疗 (ECTR) 在丙戊酸 (VPA) 中毒中的应用进行了系统评价和临床推荐。
主要作者对系统文献检索中的所有文章进行了回顾，提取数据，总结关键发现，并按照预定格式提出了结构化投票声明。选择两轮改良 Delphi 法就投票声明达成共识，并使用 RAND/UCLA 适宜性方法量化分歧。匿名投票被汇编、返回并当面讨论。进行第二次投票以确定最终工作组建议。
2014 年 11 月进行的最新文献检索共检索到 79 篇文章进行最终定性分析，包括 1 项观察性研究、1 项汇总分析的非对照队列研究、70 例病例报告和病例系列，以及 7 项药代动力学研究，所有建议的证据质量均非常低。临床数据报告了 82 例过量患者，55 例患者进行了药物/毒代动力学分级。工作组得出结论，VPA 可适度透析（证据水平 = B），并提出以下建议：ECTR 推荐用于严重 VPA 中毒（1D）；ECTR 建议包括 VPA 浓度>1300mg/L（9000μmol/L）（1D）、脑水肿（1D）或休克（1D）；ECTR 建议包括 VPA 浓度>900mg/L（6250μmol/L）（2D）、昏迷或需要机械通气的呼吸抑制（2D）、急性高血氨症（2D）或 pH 值≤7.10（2D）。当临床改善明显（1D）或血清 VPA 浓度在 50 至 100mg/L（350-700μmol/L）（2D）之间时，应停止 ECTR。在 VPA 中毒中，间歇性血液透析是首选的 ECTR（1D）。如果没有血液透析，那么间歇性血液灌流（1D）或连续肾脏替代治疗（2D）是可接受的替代方法。
在过量服用的情况下，VPA 可适度透析。如果存在上述至少一项标准，则应进行 VPA 中毒的 ECTR。在 VPA 中毒中，间歇性血液透析是首选的 ECTR 方式。
