Critical care management of the patient with pharmaceutical poisoning

Clinical Snapshot

Key Findings

• Effect Size: Not applicable - narrative review

• Primary Outcome: Structured evidence-based approach to pharmaceutical poisoning management in ICU settings

• Nnt Or Sensitivity: Clinical decision algorithms provided for diagnostic evaluation, ABCDE stabilization, gastrointestinal decontamination, and extracorporeal elimination

• Confidence Interval: Not provided

Clinical Application

High feasibility with structured algorithms and decision pathways designed for real-world ICU application Highly relevant to Australian ICUs; antidote availability through hospital pharmacy services; ECMO capabilities align with major Australian tertiary centers; guidance compatible with ANZICS guidelines ICU patients with pharmaceutical poisoning, representing up to 10% of ICU admissions

Abstract

Poisonings account for up to 10% of admissions to intensive care units and represent a common yet complex challenge in critical care. While most patients recover with supportive care alone, a significant proportion require targeted interventions and advanced organ support. This state-of-the-art review provides a practical, evidence-based guide to manage pharmaceutical poisoning in the intensive care unit, with emphasis on real-world applicability for intensivists. It highlights toxicant-specific considerations for early resuscitation, structured by the ABCDE approach. Essential principles of the diagnostic workup are also summarized. In addition, the review offers actionable guidance on when and how to escalate care, moving from supportive measures to specific interventions including gastrointestinal decontamination, extracorporeal toxicant elimination, antidote therapy, and rescue strategies such as intravenous lipid emulsion and extracorporeal membrane oxygenation. Key algorithms and decision pathways-such as the diagnostic evaluation, ABCDE-based stabilization, gastrointestinal decontamination, and extracorporeal elimination approaches-are presented with visually structured figures. A comprehensive table provides an overview of the most relevant antidotes used in critical care, including indications and dosing.

References

1. 1.Hüser, C., Bethlehem, C., Dünser, M. W., Genbrugge, C., Ghannoum, M., Hoegberg, L. C. G., Van der Linden, L., Roedl, K., Sabbe, M., Sikma, M. A., Vodovar, D., & Mégarbane, B. (2025). Critical care management of the patient with pharmaceutical poisoning. Intensive Care Medicine. https://doi.org/10.1001/jamanetworkopen.2023.27739