Treatment of Methanol and Ethylene Glycol Poisoning: RESULTS
Of 32 cases of potential methanol or ethylene glycol poisoning that were identified, 5 patients were excluded for the following reasons: 2 patients with confirmed ingestion had received ethanol infusions of less than 6 h duration; for 2 patients there was insufficient documentation of the initiation and discontinuation times of the ethanol infusion, which made it impossible to accurately assess treatment duration; and 1 patient did not meet the laboratory- based entry criteria (serum methanol concentration undetectable, arterial pH 7.34, serum bicarbonate concentration 15.8 mmol/L, and osmolal gap 6 mmol/kg). All of the excluded patients survived, and 4 did not experience any visual disturbances or renal dysfunction. One excluded patient (who had ethylene glycol poisoning) experienced an elevation in serum creatinine concentration, from 109 pmol/L on admission to 571 pmol/L on discharge. This patient presented with severe acidosis (pH 7.08) and serum ethylene glycol concentration of 3 mmol/L, which suggested a substantial delay between ingestion and presentation. One patient had ingested methanol and ethylene glycol simultaneously; this patient’s baseline characteristics were included in the analyses for both groups, but were counted only once in the analysis of the overall group and the ethanol administration data.
Patient Characteristics
The patients’ baseline characteristics are summarized in Table 2. Ten patients had detectable serum ethanol concentrations at the time of initial assessment (mean 25.0 mmol/L). Five of these patients (mean serum ethanol concentration 27.0 mmol/L) had been transferred from other hospitals, and 5 (mean serum ethanol concentration 22.8 mmol/L) presented directly to the authors’ institution.
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Table 2. Baseline Characteristics of Patients with Ethylene Glycol (EG) or Methanol (MeOH) Poisoning
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Nine of the 27 patients presented with pH less than 7.3, and 17 had serum bicarbonate concentrations less than 20 mmol/L. At the time of admission, all 17 of the patients who had ingested methanol had serum methanol concentrations above the threshold of 6.2 mmol/L (mean ± standard deviation [SD]432 ± 33.3 mmol/L). On admission, 8 of the 11 patients with ethylene glycol poisoning had concentrations above the threshold of 3.2 mmol/L (mean ± SD 57.1 ± 48.9 mmol/L). For the other 3 patients, serum ethylene glycol was undetectable on admission, but all had significant metabolic acidosis.
Patient Management
The mean duration of IV ethanol infusion was 25.7 h (range 6.0 to 54.5 h) from the time of the ethanol loading dose or initial infusion until discontinuation. Twenty-six of the 27 patients received concurrent hemodialysis in addition to IV ethanol infusion. The mean duration of dialysis was 9.2 h (range 4.0 to 233 h). In the single patient who did not undergo hemodialysis, the presenting serum methanol concentration was 11 mmol/L, the initial pH was 7.37, and the serum bicarbonate concentration was 25 mmol/L.
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Clinical Outcomes
Two of the 27 patients died; both had ingested methanol. One of these patients had initially presented to another hospital with severe acidosis (pH 7.03, bicarbonate concentration 5.2 mmol/L) and seizures. The seizures had continued and the patient had been transferred to the intensive care unit for intubation. On transfer to the authors’ institution, the patient remained intubated and was treated with IV ethanol and hemodialysis. Magnetic resonance imaging showed cerebral edema and infarction, and active treatment was withdrawn. The patient did not recover consciousness and died 2 days later. The other patient also initially presented to another institution and experienced respiratory arrest before transfer to the authors’ hospital. At the time of transfer, the patient’s pupils were fixed and dilated, and intubation and ventilation were performed. Active treatment was withdrawn on day 4 after admission, and the patient subsequently died.
Of the 17 patients who had ingested methanol, only 4 received formal ophthalmologic consults. Three of these patients had no methanol-induced damage. The fourth patient, who subsequently died, had pre-existing progressive blindness that was difficult to distinguish from any damage that might have been caused by methanol. Among the patients who did not receive formal ophthalmologic evaluation, no visual disturbances were documented in the health record.
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During the course of the hospital stay, 2 of the 11 patients admitted with ethylene glycol poisoning experienced elevation of serum creatinine concentration. One patient, whose serum creatinine concentration was 476 pmol/L at the time of admission, was discharged with dialysis-dependent renal dysfunction (serum creatinine concentration 983 pmol/L). The other patient was admitted with a serum creatinine concentration of 95 pmol/L, which progressed to a peak of 882 pmol/L on day 5 after admission. This patient was discharged about 1 month after admission with a serum creatinine concentration of 80 pmol/L. Although this case might appear to have been a therapeutic failure, the patient had been admitted to the authors’ institution about 18 h after ingestion of ethylene glycol with severe metabolic acidosis (initial serum bicarbonate concentration 8.7 mmol/L), undetectable ethylene glycol in the serum, and oxaluria. It is likely that acute renal toxicity had already occurred by the time of presentation, despite the initially normal serum creatinine concentration.
