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ABSTRACT
In the 19th century, barbiturates were first-line treatment as hypnotic and anticonvulsants, then gradually replaced by agents with a safer clinical profile. However, its ongoing use in Australian veterinary medicine and steadfast prescriptions in developing countries/our migrant population, still contributes to overdoses.
We present a case of a middle-aged man with a life-threatening phenobarbital overdose. Haemofiltration was trialled, causing a rapid fall in phenobarbital levels and a speedy recovery. Through a review of the literature, treatment options of barbiturate overdose presentations will be discussed. It is imperative clinicians are aware of barbiturate's mechanism and its enhanced elimination through extracorporeal treatment.
Key Words
Phenobarbital overdose, haemofiltration, extracorporeal treatment
Implications for Practice:
1.What is known about this subject?
Barbiturates were once a very common cause of drug dependence and overdoses. Extracorporeal elimination has been trialled in low-quality evidence only, with positive conclusions.
2. What new information is offered in this case study?
Phenobarbital overdose of this prolonged period has rarely been reported in the literature. The trial of haemofiltration successfully eliminated the drug, facilitating early recovery.
3. What are the implications for research, policy, or practice?
In the absence of adequate phenobarbital elimination with forced alkaline diuresis, clinicians should consider extracorporeal treatment; so as to prevent prolonged hospital stay and complications.
Background
Barbiturates were commonly prescribed as an anti-epileptic and sedative in the 1930s and 1940s, peaking to 24.7 million American barbiturate prescriptions in 1968.1 Its major drawbacks of dependence and overdose-related deaths subsequently led to heavy restriction laws.2 Prescription rates have also declined with the development of safer anti-epileptics like levetiracetam and anxiolytics like benzodiazepine.3 Despite these two factors, acute barbiturate poisoning is still common due to its affordability in developing countries and ongoing prescription in human/animal epilepsy disorders such as partial and tonic-clonic generalized seizures.4
Clinicians need to recognise the symptoms and physiology of barbiturate overdose. In a minor toxicity scenario, supportive care and forced alkaline diuresis may be sufficient therapeutic options. However, in severe overdoses, early recognition of when conservative management is no longer justified and consideration of extracorporeal treatment is critical; this will enhance drug elimination. Speedier neurological and clinical recovery will decrease hospital stay and complication risks such as ventilator-associated pneumonia and pressure ulcers.3,4
Case details
A 45-year-old man with...