Management of Isopropanol Ingestion in Critically Ill Patients
The best practice for treatment of isopropanol ingestion in critically ill patients focuses on supportive care with emphasis on respiratory and cardiovascular support, with hemodialysis reserved for severe, life-threatening poisoning. 1
Clinical Presentation and Assessment
- Isopropanol toxicity manifests primarily as CNS depression, respiratory depression, and cardiovascular collapse 1
- Key diagnostic findings include an increased osmolar gap, ketonemia, and ketonuria without metabolic acidosis, along with a fruity or sweet odor on the breath 1
- Unlike methanol or ethylene glycol poisoning, isopropanol toxicity does not typically cause severe metabolic acidosis 1
- Isopropanol is rapidly absorbed following ingestion with peak plasma concentrations occurring within 30 minutes 1
Treatment Algorithm
Immediate Management
- Prioritize airway management and respiratory support for patients with CNS depression 1
- Provide cardiovascular support with IV fluids for hypotension; vasopressors may be required in severe cases 1
- Correct hypoglycemia if present with glucose-containing fluids 2
- Address hypothermia with external warming measures 2
Specific Interventions
- Unlike methanol poisoning, antidotes such as fomepizole or ethanol are not indicated as isopropanol itself (rather than its metabolites) is the primary toxin 1, 3
- Monitor serum osmolality and calculate osmolar gap to track severity and response to treatment 1
- Implement protocol-based pain and sedation assessment and management if needed, using an analgesia-first approach 4
Hemodialysis Considerations
- Hemodialysis significantly enhances elimination of isopropanol and its metabolite acetone 1
- Consider hemodialysis for patients with:
- Pharmacokinetic analysis shows isopropanol has a half-life of approximately 2.5-8.0 hours, while acetone elimination is slower (7.7-27 hours) 1, 6
- Decisions regarding hemodialysis should be made within 1-2 hours of patient presentation due to the pharmacokinetic profile of isopropanol 6
Special Considerations for ICU Management
- Avoid benzodiazepines if possible in patients with or at risk for delirium, unless treating alcohol withdrawal 4
- If sedation is required, use the lowest effective dose of opioids for pain management 4
- Consider stress ulcer prophylaxis with either PPIs or H2RAs for critically ill patients with risk factors for GI bleeding 4
- Provide appropriate nutritional support, preferring enteral nutrition when the gastrointestinal tract is functional 7
- Be cautious with IV lorazepam if needed for sedation, as the propylene glycol diluent can cause renal toxicity, especially at doses as low as 1 mg/kg/day 8
Monitoring and Follow-up
- Monitor vital signs, mental status, and cardiovascular function closely 1
- Follow serum isopropanol and acetone levels if available 1
- Track osmolar gap as a surrogate marker when direct measurement of isopropanol levels is not readily available 1
- Monitor for improvement in CNS depression as isopropanol is eliminated 1
Common Pitfalls to Avoid
- Failing to recognize that isopropanol can be absorbed through dermal application, not just ingestion 2
- Mistaking isopropanol toxicity for ethanol intoxication due to similar clinical presentation 1
- Delaying hemodialysis decisions in severe cases 6
- Overlooking the possibility of co-ingestions that may complicate management 1
- Underestimating the potential for toxicity in patients with renal failure, as elimination may be delayed 2