Time to Burn? Characteristics of Hydroxocobalamin Administration in an Academic Medical Center

Background/Objective: Hydroxocobalamin is indicated for cyanide poisoning and its package insert states it should be given "without delay". We sought to evaluate time to administration and clinical characteristics when hydroxocobalamin was administered in a quaternary care academic medical center. Methods: All hydroxocobalamin administrations from January 1, 2007 to December 31, 2018 were analyzed. Data points recorded were: carboxyhemoglobin, cyanide and methemoglobin levels, hospital time and course, time and dose of hydroxocobalamin administration, lactate and bicarbonate levels, initial and nadir pH, initial heart rate, and initial and lowest systolic blood pressure. Results: Fifty-six cases were identified. One case was excluded as hydroxocobalamin was administered for nitroprusside toxicity. Among 55 cases analyzed, 93% (n = 51) were adults. Median hospital length of stay was 4.3 days (IQR 2.5 to 12). Burn, inhalation injury, and smoke inhalation were 80% of admitting diagnoses. Median time to hydroxocobalamin administration was 208 minutes (IQR 62.5 to 330). Eleven of 55 cases died. Hydroxocobalamin was given within 60 minutes of arrival in 12 cases, of which 3 died. All adults received 5 g of hydroxocobalamin. Time to hydroxocobalamin administration was longer in death cases [median: 221 minutes (IQR 119 to 594)] vs survivors [median: 184.5 minutes (IQR 62.8 to 315)]. Seventeen cases had cyanide levels drawn, with 9 being measurable, but none were toxic. Conclusions: Significant delay in hydroxocobalamin administration was seen in this study. Cases that resulted in death had significantly longer times to hydroxocobalamin administration. Further studies are warranted to identify reasons for delays in hydroxocobalamin administration.