Publications by authors named "Alexander M Sidlak"

8 Publications

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Don't Throw the Sodium Bicarbonate Out with the Correlation.

J Med Toxicol 2021 Apr 14. Epub 2021 Apr 14.

Division of Medical Toxicology, Department of Emergency Medicine, University Hospitals, Cleveland, OH, USA.

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http://dx.doi.org/10.1007/s13181-021-00838-3DOI Listing
April 2021

Alcoholic Ketoacidosis: Review of Current Practice and Association of Treatments to Improvement.

Am J Ther 2020 Feb 1. Epub 2020 Feb 1.

Division of Toxicology Department of Emergency Medicine University Hospitals Cleveland, Ohio Department of Emergency Medicine, Inova Fairfax Medical Center, Fall Church, VA Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA Pittsburgh Poison Center, Pittsburgh, PA.

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http://dx.doi.org/10.1097/MJT.0000000000001323DOI Listing
February 2020

Highest reported clearance of valproate by hemodialysis in massive overdose.

Am J Emerg Med 2021 01 16;39:255.e5-255.e6. Epub 2020 Jul 16.

Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh School of Medicine, United States of America.

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http://dx.doi.org/10.1016/j.ajem.2020.06.073DOI Listing
January 2021

Intrathecal bupivacaine and morphine toxicity leading to transient hypotension and delayed status epilepticus.

Am J Emerg Med 2020 08 6;38(8):1683. Epub 2020 Apr 6.

Pittsburgh Poison Center, Pittsburgh, PA, USA.

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http://dx.doi.org/10.1016/j.ajem.2020.03.064DOI Listing
August 2020

Single versus continued dosing of fomepizole during hemodialysis in ethylene glycol toxicity.

Clin Toxicol (Phila) 2021 Feb 26;59(2):106-110. Epub 2020 May 26.

Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.

Background: In cases of ethylene glycol (EG) toxicity requiring hemodialysis (HD), fomepizole is dosed every four hours. HD efficiently clears EG and its toxic metabolites, and it's unclear if multiple doses (MD) of fomepizole improve patient outcomes or whether a single dose (SD) prior to initiation of HD is sufficient.

Methods: We reviewed cases of EG toxicity at a toxicology referral center from 2008 to 2018. Patients treated with HD with EG levels greater than 20 mg/dL were included. Duration of dialysis, creatinine at discharge, hospital length of stay (LOS), and complications were analyzed. We compared patients who received a single dose of fomepizole prior to HD to those who received continued dosing during and after HD.

Results: Twenty-five patient encounters were identified (MD: 20; SD: 5). Initial bicarbonate (11 [SD] vs. 9 mg/dL [MD]) and pH (7.1 vs. 7.1) were similar between the groups; however, there was a trend toward a greater proportion of patients with renal dysfunction in the MD group: 11 (55%) vs. 1 (20%). HD was initiated a median interval of 5.2 h [SD] vs. 5.7 h [MD] after a dose of fomepizole. There was one death in the MD group and none in the SD group. Median creatinine on the day of discharge was 0.7 mg/dL (IQR: 0.57-3.8) in the SD group and 2.0 mg/dL (0.90-7.0) in the MD group. LOS was similar (5.8 days [95% CI 3.6-8.0] vs. 7.6 days [5.3-9.9]) ( = .61).

Conclusion: Patients with moderately severe EG toxicity (acidosis and no initial renal dysfunction) treated with a single dose of fomepizole prior to HD had similar outcomes to those receiving continued dosing of fomepizole during or after HD. This raises the possibility that a single dose of fomepizole may be sufficient if HD is initiated quickly.
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http://dx.doi.org/10.1080/15563650.2020.1770780DOI Listing
February 2021

Feasibility of Intermittent Hemodialysis in Metformin Toxicity With Shock.

J Emerg Med 2020 May 21;58(5):749-755. Epub 2020 Apr 21.

Division of Medical Toxicology, Department of Emergency Medicine, University Hospitals, Cleveland Medical Center, Cleveland, Ohio.

Background: Metformin toxicity can lead to profound shock and has a high mortality rate. Supportive care and enhanced elimination are the mainstays of therapy. Intermittent hemodialysis (HD) produces a higher clearance of metformin than continuous veno-venous hemofiltration or hemodiafiltration (CVVH/HDF). Nevertheless, CVVH/HDF has been proposed as an alternative in critically ill patients with the suggestion that hypotension may limit the use of HD.

Objective: This study sought to analyze the feasibility of performing hemodialysis in patients with persistent shock from metformin toxicity.

Methods: We performed a 6-year (2012-2017) retrospective chart review of patients with metformin toxicity managed at a large academic institution with a toxicology service. We included patients with persistent shock on vasopressor support who were treated with HD. Baseline characteristics, complications from treatment, timing of dialysis, and differences between mean arterial pressures before, during, and at the end of dialysis were recorded and analyzed.

Results: Despite critical mean peak lactate (23.9 mMol/L [range 17.6-27.9]), pH (6.91 [range 6.78-7.01]), and metformin levels (range 25-58 μg/mL], 6 of 7 patients recovered. All patients required prolonged HD (mean 19 h). Upon completion of HD, hemodynamics had improved (45 mm Hg [95% confidence interval 35-55 mm Hg] vs. 80 mm Hg [95% confidence interval 74-86 mm Hg]) and vasopressor support decreased. Mortality in this patient cohort was 14.3% (1/7).

Conclusion: Intermittent HD is feasible in metformin toxicity despite persistent shock and high-dose vasopressor support. Mean arterial pressures improved during the course of HD and high blood flow rates were tolerated.
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http://dx.doi.org/10.1016/j.jemermed.2020.02.018DOI Listing
May 2020

Serotonin toxicity from isolated bupropion overdoses.

Clin Toxicol (Phila) 2020 Dec 14;58(12):1347-1349. Epub 2020 Apr 14.

Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.

Bupropion is a synthetic cathinone, which acts therapeutically through norepinephrine and dopamine reuptake inhibition. Recent evidence suggests that serotonin receptor activation occurs with high doses of bupropion and severe serotonin toxicity can occur after isolated bupropion overdoses. Prior observational studies may therefore underestimate the incidence of serotonin toxicity. A retrospective study of patients with bupropion toxicity at a toxicology referral center from 2015-2017 was performed. Patients who overdosed on other serotonergic medications were excluded. Serotonin toxicity was diagnosed retrospectively using Hunter Criteria. Overall, 96 patients were identified with bupropion toxicity. Of these, 18 patients ingested bupropion in the absence of other serotonergic drugs. The incidence of serotonin toxicity was 33% in this population. Serotonin toxicity was more likely after a suicide attempt than those with an accidental ingestion or after recreational drug use. The median dose of bupropion ingested was 2,250 mg in the cohort diagnosed with serotonin syndrome. The incidence of bupropion induced serotonin toxicity is higher than reported. Clinicians should monitor for serotonergic toxicity when evaluating patients after bupropion overdose.
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http://dx.doi.org/10.1080/15563650.2020.1742920DOI Listing
December 2020

Intrathecal bupivacaine and morphine toxicity leading to transient hypotension and delayed status epilepticus.

Am J Emerg Med 2020 05 8;38(5):1046.e5-1046.e7. Epub 2020 Jan 8.

Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh School of Medicine, USA; Pittsburgh Poison Center, Pittsburgh, PA, USA.

Background: Local anesthetic systemic toxicity characteristically occurs after inadvertent intravascular injection of local anesthetics; however, it is unclear if similar symptoms arise after intrathecal adminstration. Intrathecal use of local anesthetics for chronic pain is increasing and carries a potential risk of toxicity. Experience with the presenting symptoms and appropriate treatment for intrathecal local anesthetic toxicity is limited.

Case Study: A 74-year-old woman with an intrathecal bupivacaine/morphine pump developed lower extremity sensory neuropathy followed by obtundation, hypotension, and lower extremity flaccidity after an intrathecal pump refill. Her condition evolved to status epilepticus (SE) refractory to standard treatment. Intravenous fat emulsion (IFE) was administered, but was not immediately effective thus necessitating phenobarbital loading and propofol infusion. Despite significant bupivacaine neurotoxicity, no cardiotoxicity developed.

Discussion: The patient developed intrathecal local anesthetic and opioid toxicity after a malfunction of her intrathecal pump during a refill. We hypothesize that no cardiotoxicity developed secondary to sequestration of bupivacaine within the central nervous system. Likewise, poor CNS penetration of intravenous lipid emulsion may have negated or delayed any antidotal effect.

Conclusion: We present a case of intrathecal toxicity leading to prolonged spinal anesthesia, progressive encephalopathy, and SE refractory to intravenous lipid emulsion. Management of SE with benzodiazepines and barbiturates may be more effective than lipids in cases of toxicity from intrathecal administration of bupivacaine.
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http://dx.doi.org/10.1016/j.ajem.2019.12.055DOI Listing
May 2020