Intensive Care of Acute Poisoning - A. V. Hovenko 2010

Methods of detoxification therapy
Methods for stimulating natural detoxification
Forced diuresis

Forced diuresis is one of the primary Methods of Detoxification Therapy used in acute exogenous and endogenous poisonings to eliminate toxic substances from the bloodstream. As a detoxification method, forced diuresis is based on the administration of osmotic Diuretics (such as mannitol) or saluretics (such as furosemide) that provoke a sharp increase in urine output, serving as the main conservative Treatment approach for hospitalized patients with intoxications. Forced diuresis can be expected to be effective when a significant portion of the toxic substance can be excreted from the body unchanged, provided that the substance predominantly distributes within the extracellular fluid, exhibits minimal protein binding, has low lipid solubility, and that the functional capacity of the Kidneys and Cardiovascular system is preserved. Forced diuresis is a rather effective detoxification method for poisonings caused by barbiturates, morphine, quinine, pachycarpine, organophosphates (OPs), salicylates, heavy metal salts, etc.

The Procedure for performing forced diuresis consists of the following phases:

Phase 1 - preliminary Water loading to compensate for hypovolemia: during alkaline forced diuresis, the patient is intravenously administered 1.5 L of fluid over the course of one hour: 500 mL of 5% glucose solution, 100 mL of 4% sodium bicarbonate solution, and an additional 700 mL of 5% glucose solution.

Phase 2 - diuresis stimulation: intravenous bolus administration over 10-15 minutes of a 15-20% mannitol solution at a dose of 1-1.5 g/kg of body weight per day.

A high diuretic effect (500–800 mL/h) is maintained for 3–4 hours. The Use of osmotic diuretics combined with saluretics (furosemide at a dose of 1-2 mg/kg of body weight with 240 mg of euphylline) additionally increases urine output by 1.5 times.

Phase 3 - replacement electrolyte infusion (by administering a polarizing mixture or "Lactasol") at a rate equal to The rate of diuresis.

During forced diuresis, it is necessary to continuously monitor the plasma electrolyte composition, acid-base balance (ABB) values, circulating Blood volume (CBV, indirectly indicated by the central venous pressure level), central and peripheral hemodynamics parameters, as well as the balance of input and output fluids. When necessary, appropriate correction of these indicators must be carried out. To avoid osmotic nephropathy and ACUTE RENAL FAILURE, forced diuresis should not be used for more than 3 days.

Forced diuresis with preliminary water loading is contraindicated in cases of intoxication complicated by acute and chronic Heart Failure, suspected intracerebral Hemorrhage, pulmonary or cerebral edema, acute and chronic renal failure (oliguria, azotemia), water intoxication, and significant fluid and electrolyte imbalances (until they are corrected).

Mannitol is contraindicated in poisonings caused by nephrotoxic agents (Ethylene glycol, chlorinated Hydrocarbons, heavy metal salts).