This protocol applies when ethanol antidote therapy was initiated for ethylene glycol poisoning but the required clinical endpoints were not reached — or when fomepizole is unavailable or contraindicated — and the patient meets confirmed or strongly suspected poisoning criteria.
This protocol is indicated when the patient has a documented plasma ethylene glycol concentration >20 mg/dL; or a documented recent history of toxic ethylene glycol ingestion with a serum osmol gap >10 mosm/L; or a strong clinical suspicion of poisoning with at least two of the following: arterial pH <7.3, serum bicarbonate <20 mEq/L, osmol gap >10 mosm/L, or urinary oxalate crystals present — and fomepizole is unavailable or the patient has a documented hypersensitivity to it.
Ethanol antidote therapy was the initial line of management. The targets it aimed to achieve — an undetectable or <20 mg/dL serum ethylene glycol level, a normal arterial pH, and clinical resolution — were not reached. This failure to meet those endpoints is the trigger for escalation to this protocol.
Success is defined as an undetectable or <20 mg/dL serum ethylene glycol concentration, normalisation of arterial pH, correction of the metabolic acidosis (anion gap) and osmol gap, and resolution of systemic signs of toxicity.
DOI: 10.1081/clt-100102445
Documented plasma ethylene glycol concentration >20 mg/dL.
Documented recent (hours) history of ingesting toxic amounts of ethylene glycol and osmol gap >10 mosm/L.
History or strong clinical suspicion of ethylene glycol poisoning and at least two of the following criteria: A. Arterial pH <7.3. B. Serum bicarbonate <20 mEq/L. C. Osmol gap >10 mosm/L. D. Urinary oxalate crystals present.
Fomepizole unavailable.
Hypersensitivity to fomepizole.
Hemodialysis should be considered for the following conditions: deteriorating vital signs despite intensive supportive care, significant metabolic acidosis (<7.25–7.30), and renal failure or electrolyte imbalances unresponsive to conventional therapy.
Hemodialysis effectively removes both ethylene glycol and its toxic metabolites.
Increased administration of ethanol (e.g., addition of 95% ethanol to dialysate or increased infusion rates) or of fomepizole is necessary to replace the drug lost during the dialysis procedure.
The traditional endpoint for dialysis is an undetectable serum ethylene glycol concentration or an EG <20 mg/dL and the disappearance of acid-base abnormalities and signs of systemic toxicity.
Correction of the metabolic acidosis (anion gap) and the osmol gap are adequate endpoints for dialysis, particularly when the patient is receiving fomepizole or ethanol and the serum ethylene glycol and/or glycolate concentrations are unavailable.
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