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5. All of the above
Our patient’s severe high anion gap metabolic acidosis and obtundation without another apparent cause suggest toxic alcohol ingestion (4). Unfortunately, a suppositional diagnosis needs to be made before confirmation since it normally takes several days before serum levels return. In addition to ethanol the toxic alcohols include ethylene glycol (EG), methanol, and isopropanol. These alcohols exert most of their toxicity by conversion to metabolites through alcohol dehydrogenase. Fomepizole is an inhibitor of alcohol dehydrogenase that should be started when toxic alcohol ingestion is suspected (4). Fomepizole is advantageous because it does not depress the patient's mental status or airway and needs to be administered only every 12 hours. The main drawback of fomepizole is the cost, which can total thousands of dollars. Because this agent is so expensive, clinicians should check its availability at their institution and discuss the plan for use of this antidote, especially for empiric treatment of cases in which the cause of acidosis is unknown.
This patient eventually proved to have ethylene glycol ingestion. Ethylene glycol is the major ingredient of almost all radiator fluid products in the United States. Fluorescein dye is often added to radiator fluid to help mechanics identify the source of a radiator leak. It can be detected in a patient’s urine under ultraviolet light several hours after ingestion. In addition, ethylene glycol is metabolized to oxalate and the crystals may be detected in the urine as well as deposited in multiple tissues (4). It is the oxalate that is deposited in the kidney that results in the renal failure that can be caused by ethylene glycol.
Our patient his renal function continued to decline, with a creatinine as high as 6 and he was started on hemodialysis. However, his blood pressure and mental status improved and he was quickly weaned from the nicardipine drip. Four days after transfer he was successfully extubated. Unfortunately, shortly after he was extubated though he his blood pressure rose with systolic readings 200’s. He became more somnolent and severely encephalopathic, ultimately requiring re-intubation.
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