CORRESPONDENCE
stration is also not without risk. This may be of particular concern with the proliferation of ready-mix charcoal/sorbitol combination products. While many clinicians are aware of the risks of diarrhea and hypermagnesemiaassociated with the administration of magnesium-containingcathartics, serbitol enjoys a more innocuous reputation. The use of multiple-dose charcoal/catharticand the inherent risk of excesscathartic administration have been of concern in the medical literature since premixed charcoal/sorbitol products became available. There have been a number of case reports in the literature describing dehydration,hypernatremia, and other electrolyte abnormalitiesassociatedwith the overzealoususe of cathartics. While reports by Farley) McCord,2 Caldwell,3 and Gazda-Smith4 clearly describe the clinical sequelae of activated charcoal/cathartic administration, it is not uncommon for hospital pharmaciesto stock only premixedactivated charceal/serbitol slurries as their sole charcoal antidote product. The labeling of these products generally includes a caution for use in multiple-dose regimens. However, these precautionsare not always highlighted and may be easily missed. In addition, availability of only one product preventsthe clinician from optimizingthe use of multiple-dosecharcoaland appropriatelytitrating doses of cathartic. Finally,similar bottle sizes and labels may cause products containing sorbitol to appear identical to aqueouscharcoal slurries, increasingthe risk for inadvertentadministration of multiple doses of cathartic. At our institution, we currently recommendthe administration of cathartic with the first dose of charcoal only. Subsequentdoses of cathartic may be indicated if catharsis does not occur in four to eight hours, and doses should be titrated on a patient-specific basis. Fluid and electrolyte status should be monitoredthroughout the course
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of therapy when any dose of charcoal/cathartic is administered. As Dr Tenenbeinclearly states, the role of multiple-dose charcoal must be reassessed.The efficacy of cathartic in the treatment of the poisoned patient is even less well establishedand is associatedwith a potential for significant risk. Cliniciansare encouragedto use cathartics judiciously, with careful monitoring of patient responseand fluid and electrolyte status. Pharmacy departmentsare encouraged to either stock separate charcoal and cathartic products or to assure that both aqueousand sorbitol slurries are available. Finally;the manufacturers of activated charcoal/ sorbitol products should be encouragedto strengthen their label precautionson the use of the combination product in multipledose regimens.
Lois M Jessen, MS, PharmD Joseph A Barone, PharmD Departmentof PharmacyPractice and Administration Rutgers University Collegeof Pharmacy New Brunswick, New Jersey 1. Farley TA: Severe hypernatremic dehydration after use of an activated charcoal-sorbitol suspension. J Pediatr 1986;109:719- 721. 2. MeCord MM, Okun AL: Toxicity of sorbitol-charcoal suspension. J Pediatr 1987;111:307-308. 3. Caldwell JW, Nava AJ, DeHaas DD: Hypernatremia associated with cathartics in overdose management. West J Med 1987;147:593-595. 4. Gazda-Smith E, Synhavsky A: Hypernatremia following treatment of theophylline toxicity with activated charcoal and sorbitol. Arch Intern Med 1990;150:689, 692.
In Reply. I thank Drs Jessen and Baronefor taking the time to write their letter. I fully concur with all of their statements, and we have recently written a similar opinion.1 Sometime age I encountered another problemassociatedwith the use of premixedcharcoal in sorbitol slurries. A physician ordered multiple doses of charcoal plus a magnesiumcathartic. A charcoal-insorbitol slurry rather than a charcoalin-water product was given with the
magnesiumcathartic. The trade names of many of these charcoal/ sorbitol-containingproducts do not clearly indicate the presenceof this cathartic. Fortunately,this patient did well. A similar incident has been describedelsewhere in which the patient died as a direct consequenceof this unfortunate error.2 Cathartics have been shown to be of no benefit whatsoever, and adverse effects due to their use are well documented,t Thus, my opinion regardingtheir use is more polarized--I see no reasonto use them at all. •
Milton Tenenbein,MD, FRCPC, FAAP,FAACT Health Sciences Center Winnipeg, Manitoba, Canada 1. Palataick If~, Tenenbein M: Activated charcoal, an update. Drug Safety (in press). 2. Brent J, Julig KK, Rumack BH: latrogenic death from sorbitol and magnesium sulfate duration treatment for salicylism. Vet Human Toxicol 1989;31:334.
Outpatient Management of Pyelonephritis To the Editor. It may be true that patients with acute pyelonephritiscan be managedsafely as outpatients, but two articles purporting to show this have left me unconvinced. Israel et al, in "Management of Acute Pyelonephritisin an EmergencyDepartmentObservation Unit" [March 1991;20:253-257], showed that the cost of sending home 63 patients was that five had to return to be hospitalizedand eight had diagnosesmissed that might well have been detected and treated had they been admitted. Of these missed diagnoses,certainly the four with pelvic inflammatory disease and the one with a ruptured appendix may have suffered longterm sequelaeas a result of outpatient management.The failure rate of outpatient triage was thus 13 of 63, or 20%. Is that good?
The study by Ward et al, "Treatment of Pyelonephritis in an ObservationUnit" [March 1991;20:258-261],contains a major methodologicalflaw. Although the study is termed a prospectiveone, nine of 61 patients were retrospectivelyexcludedfrom the analysis becausethey had sterile urine cultures. This information was not available to the clinicians managingthe patients. These patients were not discussedfurther. Did any of them rupture an appendix?We do not know. This study was really a retrospective study of a subset of patients who had both bacteriuria and follow-up, both of which could predict a benign course. That seven of 43 outpatients had no follow-up further detracts from the conclusionsof the authors. These articles demonstratethat the safety of outpatient managementof pyelonephritis remains in question.
Anthony White, MD Departmentof EmergencyServices Massachusetts GeneralHospital Boston In Reply: We thank Dr White for his comments, but take issuewith his choice of denominator.Ninety patients (net 63) went home with a presumptivediagnosis of pyelonephritis. Of these, five returned for persistent fever or flank pain requiring admission,and seven had other significant diagnoses uncoveredduring follow-up. Only one (the missed appendicitis) required admission.The clinicians did not identify those patients who would ultimately require admission in six of 90 (7%) cases. Eighty-sevenpatients met a retrospectivedefinition of pyelonephritis after the urine cultures were available. 0nly five (6%) returned and required admission. The dilemma for the clinician, however, is that it can be difficult to makea prospectiveclinical diagnosis of pyelonephritis.Our study emphasizesthe need to consider alternative diagnoseswhen patients present with fever, I~
ANNALS OF EMERGENCY MEDICINE 21:1 JANUARY 1992
stration is also not without risk. This may be of particular concern with the proliferation of ready-mix charcoal/sorbitol combination products. While many clinicians are aware of the risks of diarrhea and hypermagnesemiaassociated with the administration of magnesium-containingcathartics, serbitol enjoys a more innocuous reputation. The use of multiple-dose charcoal/catharticand the inherent risk of excesscathartic administration have been of concern in the medical literature since premixed charcoal/sorbitol products became available. There have been a number of case reports in the literature describing dehydration,hypernatremia, and other electrolyte abnormalitiesassociatedwith the overzealoususe of cathartics. While reports by Farley) McCord,2 Caldwell,3 and Gazda-Smith4 clearly describe the clinical sequelae of activated charcoal/cathartic administration, it is not uncommon for hospital pharmaciesto stock only premixedactivated charceal/serbitol slurries as their sole charcoal antidote product. The labeling of these products generally includes a caution for use in multiple-dose regimens. However, these precautionsare not always highlighted and may be easily missed. In addition, availability of only one product preventsthe clinician from optimizingthe use of multiple-dosecharcoaland appropriatelytitrating doses of cathartic. Finally,similar bottle sizes and labels may cause products containing sorbitol to appear identical to aqueouscharcoal slurries, increasingthe risk for inadvertentadministration of multiple doses of cathartic. At our institution, we currently recommendthe administration of cathartic with the first dose of charcoal only. Subsequentdoses of cathartic may be indicated if catharsis does not occur in four to eight hours, and doses should be titrated on a patient-specific basis. Fluid and electrolyte status should be monitoredthroughout the course
150/111
I
of therapy when any dose of charcoal/cathartic is administered. As Dr Tenenbeinclearly states, the role of multiple-dose charcoal must be reassessed.The efficacy of cathartic in the treatment of the poisoned patient is even less well establishedand is associatedwith a potential for significant risk. Cliniciansare encouragedto use cathartics judiciously, with careful monitoring of patient responseand fluid and electrolyte status. Pharmacy departmentsare encouraged to either stock separate charcoal and cathartic products or to assure that both aqueousand sorbitol slurries are available. Finally;the manufacturers of activated charcoal/ sorbitol products should be encouragedto strengthen their label precautionson the use of the combination product in multipledose regimens.
Lois M Jessen, MS, PharmD Joseph A Barone, PharmD Departmentof PharmacyPractice and Administration Rutgers University Collegeof Pharmacy New Brunswick, New Jersey 1. Farley TA: Severe hypernatremic dehydration after use of an activated charcoal-sorbitol suspension. J Pediatr 1986;109:719- 721. 2. MeCord MM, Okun AL: Toxicity of sorbitol-charcoal suspension. J Pediatr 1987;111:307-308. 3. Caldwell JW, Nava AJ, DeHaas DD: Hypernatremia associated with cathartics in overdose management. West J Med 1987;147:593-595. 4. Gazda-Smith E, Synhavsky A: Hypernatremia following treatment of theophylline toxicity with activated charcoal and sorbitol. Arch Intern Med 1990;150:689, 692.
In Reply. I thank Drs Jessen and Baronefor taking the time to write their letter. I fully concur with all of their statements, and we have recently written a similar opinion.1 Sometime age I encountered another problemassociatedwith the use of premixedcharcoal in sorbitol slurries. A physician ordered multiple doses of charcoal plus a magnesiumcathartic. A charcoal-insorbitol slurry rather than a charcoalin-water product was given with the
magnesiumcathartic. The trade names of many of these charcoal/ sorbitol-containingproducts do not clearly indicate the presenceof this cathartic. Fortunately,this patient did well. A similar incident has been describedelsewhere in which the patient died as a direct consequenceof this unfortunate error.2 Cathartics have been shown to be of no benefit whatsoever, and adverse effects due to their use are well documented,t Thus, my opinion regardingtheir use is more polarized--I see no reasonto use them at all. •
Milton Tenenbein,MD, FRCPC, FAAP,FAACT Health Sciences Center Winnipeg, Manitoba, Canada 1. Palataick If~, Tenenbein M: Activated charcoal, an update. Drug Safety (in press). 2. Brent J, Julig KK, Rumack BH: latrogenic death from sorbitol and magnesium sulfate duration treatment for salicylism. Vet Human Toxicol 1989;31:334.
Outpatient Management of Pyelonephritis To the Editor. It may be true that patients with acute pyelonephritiscan be managedsafely as outpatients, but two articles purporting to show this have left me unconvinced. Israel et al, in "Management of Acute Pyelonephritisin an EmergencyDepartmentObservation Unit" [March 1991;20:253-257], showed that the cost of sending home 63 patients was that five had to return to be hospitalizedand eight had diagnosesmissed that might well have been detected and treated had they been admitted. Of these missed diagnoses,certainly the four with pelvic inflammatory disease and the one with a ruptured appendix may have suffered longterm sequelaeas a result of outpatient management.The failure rate of outpatient triage was thus 13 of 63, or 20%. Is that good?
The study by Ward et al, "Treatment of Pyelonephritis in an ObservationUnit" [March 1991;20:258-261],contains a major methodologicalflaw. Although the study is termed a prospectiveone, nine of 61 patients were retrospectivelyexcludedfrom the analysis becausethey had sterile urine cultures. This information was not available to the clinicians managingthe patients. These patients were not discussedfurther. Did any of them rupture an appendix?We do not know. This study was really a retrospective study of a subset of patients who had both bacteriuria and follow-up, both of which could predict a benign course. That seven of 43 outpatients had no follow-up further detracts from the conclusionsof the authors. These articles demonstratethat the safety of outpatient managementof pyelonephritis remains in question.
Anthony White, MD Departmentof EmergencyServices Massachusetts GeneralHospital Boston In Reply: We thank Dr White for his comments, but take issuewith his choice of denominator.Ninety patients (net 63) went home with a presumptivediagnosis of pyelonephritis. Of these, five returned for persistent fever or flank pain requiring admission,and seven had other significant diagnoses uncoveredduring follow-up. Only one (the missed appendicitis) required admission.The clinicians did not identify those patients who would ultimately require admission in six of 90 (7%) cases. Eighty-sevenpatients met a retrospectivedefinition of pyelonephritis after the urine cultures were available. 0nly five (6%) returned and required admission. The dilemma for the clinician, however, is that it can be difficult to makea prospectiveclinical diagnosis of pyelonephritis.Our study emphasizesthe need to consider alternative diagnoseswhen patients present with fever, I~
ANNALS OF EMERGENCY MEDICINE 21:1 JANUARY 1992
