Is glutathione recommended for a patient with a blast abdominal injury, coagulopathy (high Prothrombin Time (PT) International Normalized Ratio (INR)), and acute kidney injury (AKI)?

Glutathione Use in Blast Abdominal Injury with Coagulopathy and AKI

Glutathione should NOT be administered in this clinical scenario, as high-dose parenteral glutamine (a related compound) is contraindicated in critically ill patients with acute kidney injury, and there is no established evidence supporting glutathione use for blast trauma, coagulopathy, or AKI management. 1

Primary Contraindication in AKI

• High-dose parenteral glutamine shall not be administered to critically ill patients with AKI or kidney failure (Grade A recommendation, 100% consensus). 1

• The landmark REDOX study demonstrated that high doses of alanyl-glutamine (intravenously or enterally) appear harmful in critically ill patients with kidney failure. 1

• The MetaPlus trial confirmed similar harmful results in critically ill patient populations. 1

• While glutathione and glutamine are distinct compounds, the strong evidence against glutamine supplementation in this exact clinical context (critically ill with AKI) raises significant safety concerns about related antioxidant therapies. 1

Lack of Evidence for Blast Trauma

• No guideline or high-quality evidence supports glutathione use specifically for blast abdominal injuries or trauma-related coagulopathy. 1

• The only relevant research showing potential benefit is a 2023 study on glutathione sodium salt for contrast-associated AKI in STEMI patients undergoing PCI—a completely different clinical scenario from blast trauma. 2

• This STEMI study showed reduced CA-AKI rates (10% vs 38%, p<0.001) but involved elective contrast exposure, not polytrauma with established AKI and coagulopathy. 2

Management Priorities for This Patient

Immediate Hemodynamic Stabilization

• Maintain systolic blood pressure >110 mmHg using vasopressors (norepinephrine preferred over dopamine) and isotonic crystalloid resuscitation. 3, 4

• Provide plasma volume expansion with isotonic crystalloids in patients with suspected hypovolemia. 3

Coagulopathy Management

• The elevated PT/INR in stable trauma patients often overestimates true coagulopathy and should not automatically trigger fresh frozen plasma (FFP) transfusion. 5

• Consider thromboelastography (TEG) if available to assess actual coagulation status, as INR was developed for Coumadin monitoring, not trauma coagulopathy assessment. 5

• Transfuse blood products based on clinical bleeding and hemodynamic instability, not INR values alone in stable patients. 5

AKI-Specific Management

• Remove all nephrotoxic medications immediately, including NSAIDs and unnecessary antibiotics. 3

• Monitor kidney function closely and stage AKI according to KDIGO criteria to guide management decisions. 3

• Provide appropriate nutritional support with 20-30 kcal/kg/day total energy intake and 1.0-1.5 g/kg/day protein if renal replacement therapy is initiated. 3

• Maintain glycemic control with target blood glucose of 110-149 mg/dL. 3

Abdominal Injury Assessment

• Perform immediate contrast-enhanced abdominal CT to evaluate for solid organ injuries, hollow viscus perforation, and active bleeding. 1, 4

• Consider non-operative management for solid organ injuries (liver, spleen, kidney) even if high-grade, provided hemodynamic stability is maintained. 4, 6

• Consider therapeutic angioembolization for documented active bleeding (contrast extravasation) on CT. 4, 6

Critical Pitfalls to Avoid

• Do not use glutathione or glutamine supplementation in critically ill patients with AKI—this carries potential harm based on high-quality evidence. 1

• Do not transfuse FFP based solely on elevated INR in hemodynamically stable trauma patients—INR overestimates coagulopathy in this population. 5

• Do not delay imaging or definitive management while pursuing unproven antioxidant therapies. 1, 4

• Do not use N-acetylcysteine for prevention of AKI in critically ill patients with hypotension or for prevention of postsurgical AKI. 3

Alternative Evidence-Based Approaches

• Focus on optimizing hemodynamics, removing nephrotoxic agents, and providing appropriate supportive care—these are the only proven interventions for AKI management. 3

• If contrast imaging is required, consider pre-procedural isotonic crystalloid hydration, though the patient likely already has established AKI. 1

• Initiate renal replacement therapy emergently only if life-threatening electrolyte, acid-base, or fluid balance abnormalities develop. 1