Diagnostik und Therapie von Glykolintoxikationen im Kindesalter

Zusammenfassung

Glykolintoxikationen stellen ein seltenes, akut lebensbedrohliches Krankheitsbild dar. Klinisch stehen neben den neurologischen Symptomen eine ausgeprägte metabolische Azidose mit großer Anionenlücke sowie eine große osmotische Lücke im Vordergrund. Beweisend ist der Nachweis von Glykol bzw. seiner Metabolite im Blut, jedoch verfügen nur wenige Zentren über die Möglichkeit, Glykol qualitativ bzw. quantitativ im Serum zu bestimmen. Die Diagnose muss deshalb zunächst klinisch gestellt werden. Allein der Verdacht erfordert die sofortige Einleitung einer adäquaten Therapie mit einem Antidot (Fomepizol oder Ethanol). Dieser Artikel soll dazu dienen, die typischen klinischen und paraklinischen Befunde sowie die Therapie von Glykolintoxikationen ausführlich darzustellen.

Summary

Severe poisoning with the antifreezer ethylene glycol is a rare, life-threatening event: Neurological symptoms are accompanied by metabolic acidosis with elevated anion gap and osmotic gap. The poisoning is verified by quantitative glycol analysis in serum, but only few laboratories are able to perform this investigation in emergency cases. Therefore, in the beginning diagnosis has to be based on patient’s history, clinical signs and symptoms. Every substantial suspicion of ethylene glycol poisoning has to be treated with an antidote (fomepizole or ethanol) rapidly. The aim of this article is to give an overview about the typical clinical and laboratory findings and the therapeutic options of severe glycol intoxication in children.

Schlüsselwörter

Glykol - Frostschutzmittel - Intoxikation - Hämodialyse

Keywords

Ethylene glycol - antifreezer - poisoning - hemodialysis

• Literatur

• 1 Barceloux DG. et al. American Academy of Clinical Toxicology practice guidelines on the treatment of ethylene glycol poisoning. Journal of Toxicology-Clinical Toxicology 1999; 37: 537-60.
• 2 Baum CR, Langman CB, Oker EE. et al. Fomepizole treatment of ethylene glycol poisoning in an infant. Pediatrics 2000; 106: 1489-91.
• 3 Berman LB, Schreiner GE, Feys J. The nephrotoxic lesion of ethylene glycol. Annals of Internal Medicine 1957; 46: 611-5.
• 4 Bobbit WH, Williams RM, Freed CR. Severe ethylene glycol intoxikation with multisystemic failure. Western Journal of Medicine 1986; 144: 225-8.
• 5 Boyer EW, Mejla M, Woolf A, Shannon M. Severe ethylene glycol ingestion treated without hemodialysis. Pediatrics 2001; 107: 172-3.
• 6 Brent J. Current management of ethylene glycol poisoning. Drugs 2001; 7: 979-88.
• 7 Brent J, McMartin K, Phillips S. et al. Fomepizole for treatment of ethylene glycol poisoning. Fomepizole for treatment of ethylene glycol poisoning. New England Journal of Medicine 1999; 340: 832-8.
• 8 Caravati EM. et al. Treatment of severe pediatric ethylene glycol intoxication without hemodialysis. J. of Clinical Toxicology 2004; 42: 255-9.
• 9 Casavant MJ, Shah MN, Battels R. Does fluorescent urine indicate antifreeze ingestion by children?. Pediatrics 2001; 107: 113-4.
• 10 Church AS, Witting MD. Laboratory testing in ethanol, methanol, ethylene glycol, and isopropanol toxicities. Journal of Emergency Medicine 1997; 15: 687-92.
• 11 Davis DP. et al. Ethylene glycol poisoning: case report of a record high level and a review. Journal of Emergency Medicine 1997; 15: 653-67.
• 12 Desel H, Neurath H. Bestimmung von Glykolethern mittels GC/FID. In: Pragst F. (ed) GTFCh-Symposium Toxikologische Analytik, Mosbach 04/1999, Symposiumsband. Berlin: 1999: 120-31.
• 13 Detaille T. et al. Fomepizole alone for severe infant ethylene glycol poisoning. Pediatric Critical Care Medicine 2004; 5: 490-1.
• 14 Eder AF. et al. Ethylene glycol poisoning: toxicokinetic and analytical factors affecting laboratory diagnosis. Clinical Chemistry 1998; 44: 168-77.
• 15 Fraser AD. Clinical toxicologic implications of ethylene glycol and glycolic acid poisoning. Therapeutic Drug Monitoring 2002; 24: 232-8.
• 16 Fraser AD, Coffin L. Optimal screening and monitoring of methanol and ethylene glycol poisoning by formic acid and glycolic acid. Therapeutic Drug Monitoring 2001; 23: 486.
• 17 Fraser AD. et al. Drug and chemical metabolites in clinical toxicology investigations. Clin. Biochem. 2002; 35: 501-11.
• 18 Frommer JP, Ayus JC. Acute ethylene glycol intoxikation. American J. of Nephrology 1982; 2: 1-5.
• 19 Harry P, Jobard E, Briand M. et al. Ethylene glycol poisoning in a child treated with 4-methylpyrazole. Pediatrics 1998; 102: 1-3.
• 20 Introna Jr F, Smialek JE. Antifreeze (ethylene glycol) intoxications in Baltimore: report of six cases. Acta Morphol Hung 1989; 37 (3–4): 245-63.
• 21 Jackson MH, Payne HA. Bittering agents: their potential application in reducing ingestionjs of engine coolants and windshields wash. Veterninary and Human Toxicology 1995; 37: 323-6.
• 22 Jacobsen D, McMartin KE. Antidotes for methanol and ethylene glycol poisoning. Journal of Toxicology-Clinical Toxicology 1997; 35: 127-43.
• 23 Kawamoto T. et al. The effect of ethylene glycol monomethyl ether and diethylene glycol monomethyl ether on hepatic gamma-glutamyl transpeptidase. Toxicology 1992; 76: 49-57.
• 24 Luft FC. Störungen des Säure-Basen-Haushalts. In: Kuhlmann U. et al. (Hrsg) Nephrologie. 3. Aufl.. Stuttgart: Thieme; 1998: 177-202.
• 25 Scalley RD. et al. Treatment of ethylene glycol poisoning. Am. Family Physician 2002; 66: 807-12.
• 26 Spillane L. et al. Multiple cranial nerve deficits after ethylene glycol poisoning. Annals of Emergency Medicine 1991; 20: 208-10.
• 27 Walder AD, Tyler CK. Ethylene glycol antifreeze poisoning: three cases case reports and a review of treatment. Anaesthesia 1994; 49: 964-7.
• 28 Watson WA, Litovitz TL, Rodgers Jr GC. et al. 2004 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 2005; 23: 589-666.
• 29 Yao HH, Porter WH. Simultaneous determination of ethylene glycol and its toxic metabolite, glycolic acid, in serum by gas chromatography. Clinical Chemistry 1996; 42: 292-7.