Extracorporeal Treatment for Barbiturate Poisoning

Recommendations From the EXTRIP Work Group

Robert Mactier, MD; Martin Laliberté, MD, MSc; Joelle Mardini, MD; Marc Ghannoum, MD; Valery Lavergne, MD, MSc; Sophie Gosselin, MD; Robert S. Hoffman, MD; Thomas D. Nolin, PharmD, PhD


Am J Kidney Dis. 2014;64(3):347-358. 

In This Article

Abstract and Introduction


The EXTRIP (Extracorporeal Treatments in Poisoning) Workgroup conducted a systematic review of barbiturate poisoning using a standardized evidence-based process to provide recommendations on the use of extracorporeal treatment (ECTR) in patients with barbiturate poisoning. The authors reviewed all articles, extracted data, summarized key findings, and proposed structured voting statements following a predetermined format. A 2-round modified Delphi method was used to reach a consensus on voting statements, and the RAND/UCLA Appropriateness Method was used to quantify disagreement. 617 articles met the search inclusion criteria. Data for 538 patients were abstracted and evaluated. Only case reports, case series, and nonrandomized observational studies were identified, yielding a low quality of evidence for all recommendations. Using established criteria, the workgroup deemed that long-acting barbiturates are dialyzable and short-acting barbiturates are moderately dialyzable. Four key recommendations were made. (1) The use of ECTR should be restricted to cases of severe long-acting barbiturate poisoning. (2) The indications for ECTR in this setting are the presence of prolonged coma, respiratory depression necessitating mechanical ventilation, shock, persistent toxicity, or increasing or persistently elevated serum barbiturate concentrations despite treatment with multiple-dose activated charcoal. (3) Intermittent hemodialysis is the preferred mode of ECTR, and multiple-dose activated charcoal treatment should be continued during ECTR. (4) Cessation of ECTR is indicated when clinical improvement is apparent. This report provides detailed descriptions of the rationale for all recommendations. In summary, patients with long-acting barbiturate poisoning should be treated with ECTR provided at least one of the specific criteria in the first recommendation is present.


Barbiturates frequently are implicated in poisoning. In 2008, they were the 15th most common class of drugs associated with fatal poisoning in the United States,[1] and barbiturate intoxication remains an important cause of morbidity and mortality today.[2] Recognition of the low therapeutic index of barbiturates and the high historical incidence of fatal and nonfatal barbiturate poisoning has led to strict guidelines dictating barbiturate prescription, and these guidelines have contributed to the decreased availability of barbiturates worldwide. The barbiturate most frequently associated with self-poisoning is phenobarbital, although cases of severe poisoning and death from other barbiturates continue to be reported worldwide.[2–21]

The EXTRIP (Extracorporeal Treatments in Poisoning) Workgroup (www.extrip-workgroup.org), comprising international experts representing diverse specialties and professional societies, was assembled to provide recommendations on the use of extracorporeal treatment (ECTR) in poisoning. The rationale, background, objectives, and methods of the Workgroup have been reported previously.[22] We present recommendations on the use of ECTR in patients with barbiturate poisoning based on a systematic review of relevant literature using a standardized evidence-based process.