Correspondence

Survival of Ethylene Glycol Poisoning with Profound Acidemia

N Engl J Med 1993; 328:515-516February 18, 1993

Article

To the Editor:

We recently encountered a patient who survived ethylene glycol poisoning with an arterial-blood pH of 6.46.

A 44-year-old woman drank approximately 720 ml of ethylene glycol in the form of antifreeze. She had previously attempted suicide by injecting the same substance into her buttocks. When admitted to the hospital, the patient was unresponsive and incontinent and was receiving ventilation. Her temperature was 37.1 °C (98.7 °F), her pulse 110 per minute, and her blood pressure 130/70 mm Hg. Her pupils were fixed and dilated, and she had no corneal, gag, or deep-tendon reflexes. The serum sodium level was 140 mmol per liter, the potassium level 6.6 mmol per liter, the chloride level 110 mmol per liter, and the bicarbonate level 1 mmol per liter (anion gap, 29 mmol per liter). The serum creatinine concentration was 2.8 mg per deciliter (248 μmol per liter), and the lactate concentration 10.1 mmol per liter. The osmolar gap (the difference between the measured value and the predicted value) was 84 mOsm per kilogram. Urinalysis revealed calcium oxalate crystals. The serum concentration of ethylene glycol was 2600 mg per liter; no other toxins were detected. Serial arterial-blood gas values are shown in Table 1Table 1Serial Arterial-Blood Gas, pH, and Bicarbonate Values in a Patient with Severe Ethylene Glycol Poisoning..

Two hours after admission, hemodialysis was begun and continued intermittently for 48 hours. To reduce the conversion of ethylene glycol to its acid metabolites, ethanol was added to the dialysate1 and then given by gavage in a dose of 600 mg per kilogram of body weight, followed by intragastric infusion at a rate of 200 mg per kilogram per hour for 37 hours. Renal failure did not develop, and the patient recovered completely.

Although the arterial-blood pH of normal subjects may fall to 6.80 after extreme exertion,2 in a clinical setting such a level is usually fatal. Arterial-blood pH values of 6.78, 6.57, and 6.49 have been reported in patients who survived poisoning with ammonium chloride3 and strychnine4 and isoniazid overdose,5 respectively.

The pH measurement of 6.46 in the patient described here appeared to be accurate, since the pH values increased in stepwise fashion during treatment and the measured serum bicarbonate concentrations corresponded on several occasions to those predicted from the arterial-blood pH and the partial pressure of carbon dioxide. In ethylene glycol poisoning, glycolic acid is responsible for the acidosis5. Its degradation to lactic acid, glycine, and carbon dioxide consumes bicarbonate. Generally, the severity of the metabolic acidosis and the degree of elevation of serum glycolate concentrations correspond to the amount of ethylene glycol ingested. This patient's course was not complicated by respiratory depression and hypercarbia, indicating that the predominant cause of acidosis was the acid products of ethylene glycol.

Katherine R. Blakeley, M.D.
Steven E. Rinner, M.D.
James P. Knochel, M.D.
Presbyterian Hospital of Dallas, Dallas, TX 75231

5 References

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Citing Articles (10)

Citing Articles

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   R. Müller, J. Planck, T. Heveling. (2009) Äthylenglykolintoxikation. Der Anaesthesist 58:1, 35-38
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2. 2

   Diego Castanares-Zapatero, Catherine Fillée, Marianne Philippe, Philippe Hantson. (2008) Survival with extreme lactic acidosis following ethylene glycol poisoning?. Canadian Journal of Anesthesia/Journal canadien d'anesthésie 55:5, 318-319
   CrossRef

3. 3

   John C.M. Brust. 2007. Éthanol. , 385-516.
   CrossRef

4. 4

   Timothy B Gardner, Harold L Manning, Andrew P Beelen, Robert J Cimis, Justin M.M Cates, Lionel D Lewis. (2004) Ethylene Glycol Toxicity Associated With Ischemia, Perforation, and Colonic Oxalate Crystal Deposition. Journal of Clinical Gastroenterology 38:5, 435-439
   CrossRef

5. 5

   S BORKAN. (2002) Extracorporeal therapies for acute intoxications. Critical Care Clinics 18:2, 393-420
   CrossRef

6. 6

   Brent Wisse, Smiley Thakur, Dana Baran. (1999) Recovery from prolonged metabolic acidosis due to accidental ethylene glycol poisoning. American Journal of Kidney Diseases 33:2, E4
   CrossRef

7. 7

   Joseph F. Buell, Robert Sterling, Srinivas Mandava, Adam C. Berger, Louis M. Paulilio, Yaron Bar-Lavie, Craig A. Trimbach, David R. Gens. (1998) Ethylene Glycol Intoxication Presenting as a Metabolic Acidosis Associated with a Motor Vehicle Crash. The Journal of Trauma: Injury, Infection, and Critical Care 45:4, 811-813
   CrossRef

8. 8

   B. Hylander, C. M. Kjellstrand. (1996) Prognostic factors and treatment of severe ethylene glycol intoxication. Intensive Care Medicine 22:6, 546-552
   CrossRef

9. 9

   K. G. HICKLING, C. JOYCE. (1995) Permissive hypercapnia in ARDS and its effect on tissue oxygenation. Acta Anaesthesiologica Scandinavica 39, 201-208
   CrossRef

10. 10

    Howard Wine, Daniel Savitt, J. Gary Abuelo. (1994) Poisonings & Intoxications. Seminars in Dialysis 7:5, 338-345
    CrossRef