Cleansing the blood. Hemodialysis, peritoneal dialysis, exchange transfusion, charcoal hemoperfusion, forced diuresis

ECDR can be a valuable adjunct to the therapy of pediatric poisonings. Careful consultation with a medical toxicologist and a nephrologist will be useful in reaching the decision as to which poisonings lend themselves to ECDR and which method is most appropriate for the specific case. Avoid advice that amounts to, "if you are not certain, dialyze." While the risks of many ECDR techniques are acceptable in major medical centers, it may not be good medicine to superimpose any morbidity from ECDR upon the poisoned patient when there can be little expectation of drug removal. It is wise to phrase your questions to consultants carefully. The question: "can this substance be dialyzed (hemoperfused, plasmaphoresed, etc.)?" is loaded and the answer frequently will be "yes!" The more proper questions are: "how much drug can be removed by ECDR, how long will the method take, how will this affect the present condition of the patient?" Clearly, a risk: benefit ratio must always be considered. There are lists of substances that "can" be removed by ECDR. It is more difficult to judge how much of the body burden is removed by such methods. Digoxin "can" be dialyzed, but it is not quantitatively removed from the body and there is no accepted benefit from ECDR in this instance. The volume of distribution is a useful guide to determine which substances may be removed quantitatively by ECDR. The exaggerated claims to increased plasma clearance of a hemoperfusion device may not be meaningful if the distribution space is large and plasma levels are correspondingly low. Finally, many of the advantages and disadvantages of ECDR are not likely to change markedly as a result of technology. We currently have very efficient machines for ECDR. It is the chemical characteristics of some toxic substances that limit the more global role of ECDR in poisoning. Serologic therapy, such as specific Fab antibody fragments for use in digoxin poisonings or the exciting work by Russell and colleagues using affinity chromatography to purify specific antibody fragments from horse serum, may be applicable to numerous intoxications. This approach, used in combination with ECDR or alone, will undoubtedly influence the future growth of clinical toxicology.