Sir, We report a patient who had a severe respiratory and renal failure due to the massive ingestion of morphine, bromazepam, mianserine, and codeine and who was successfully treated continuos veno-venous hemodiafiltration (CVVHDF).The patient was admitted in our Unit in a critical condition. She was in coma (Coma Glasgow Score 5), respiratory rate 5 breaths per min. Arterial blood pressure was 70/40 mmHg; heart rate was 152 beats per min, and arterial blood gases (fractional concentration of inspired gases 0.21) showed a partial arterial pressure of oxygen of 42 mmHg, and a carbon dioxide 95mmHg. pH was 7.20 and arterial oxygen saturation 78%. An accurate anamnesis revealed the massive ingestion of morphine, bromazepam, mianserine, and codeine for suicidal aim. The patients was intubated and ventilated with intermittent positive pressure mechanical ventilation (Tidal Volume 7 ml/kg, respiratory rate 12 breaths per min, fractional concentration of inspired gases 0.5). Naloxone, Flamazenil were given up to standard doses. Dopamine was started at 8 ? kg-1 min-1. The patient partially improved. One day later a severe renal failure with diuresis kept (creatinine 4.6 mg/ml, K+ 5.7 mmoles/ml) complicated the Intensive Care stay. Immediately a CVVHDF was started (blood flow 120 ml/h, ultrafiltrate rate 500 ml/h, dialysate 30 ml/h) and performed for 30 hours using a D-30NR polysulfone Diafilter (Minntech, Minneapolis, MN). At the end of treatment the patient improved and sensory was correct. Arterial blood pressure was 120/75 mmHg; heart rate was 98 beats per min; arterial blood gases (fractional concentration of inspired gases 0.5) were partial arterial pressure of oxygen of 94 mmHg, and a carbon dioxide 37 mmHg; pH was 7.35 and arterial oxygen saturation 95%. Respiratory weaning was started and successfully completed in 24 hours.The patient was then transferred to the Medical Unit, then discharged home and alive after 14 days.This report suggests that CVVHDF can be effective in the treatment of renal failure due to drugs intoxication. This modality offers the advantage of slow sustained removal of drugs without hemodynamic instability. Only a few papers reported the use of CVVHDF for treating drugs intoxication (1, 2). Moreover many Authors suggest that continuous renal replacement therapy have to be considered the choice therapy in Intensive Care Unit patients affected by acute renal failure (3, 4) respect to the conventional dialysis.Concerns regarding the hazards of transporting critically ill patients to the Dialysis Unit and the absolute haemodynamic stability have demonstrated continuous renal replacement therapy to be safer (5), but this concept has not been widely accepted. Future research should be done into the efficacy of continuos renal replacement therapy in the treatment of massive ingestion of drugs.;Correspondence to Francesco Imperatore MDConsultant Anaesthetist and IntesivistAnaesthesia and Intensive Care Unit, Department of Emergency “A. Cardarelli” HospitalVia Michele Tenore 1480137, Naples, ItalyFax 0039 081 7472921e-mail: francesco.imperatore@fastwebnet.it
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机译：主席先生，我们报告了由于大量摄入吗啡，溴马西m，米安色林和可待因而患有严重的呼吸和肾脏衰竭的患者，并成功治疗了连续性静脉-静脉血液透析滤过（CVVHDF）。危急情况。她处于昏迷状态（Coma Glasgow得分5），呼吸频率每分钟5次。动脉血压为70/40 mmHg;心率是每分钟152次跳动，动脉血气（吸入气体的分形浓度为0.21）显示出氧分压为42 mmHg，二氧化碳为95mmHg。 pH为7.20，动脉血氧饱和度为78％。准确的回忆记录显示，出于自杀目的，大量摄入了吗啡，溴马西m，勉强碱和可待因。为患者插管并通气，进行间歇性正压机械通气（潮气量7 ml / kg，呼吸频率每分钟12次呼吸，吸入气体的分数浓度为0.5）。给予纳洛酮，Flamazenil达标准剂量。多巴胺从8点开始？ kg-1分-1。患者部分改善。一天后，严重的肾功能衰竭伴利尿（肌酐4.6 mg / ml，K + 5.7 mmoles / ml）使重症监护病情复杂化。立即开始CVVHDF（血流量120 ml / h，超滤液速率500 ml / h，透析液30 ml / h），并使用D-30NR聚砜渗滤器（明尼苏达州明尼阿波利斯）进行30小时。在治疗结束时，患者病情好转，感觉正确。动脉血压为120/75 mmHg;心率每分钟98次;动脉血气（吸入气体的分数浓度为0.5）是氧气的分压为94 mmHg，二氧化碳的分压为37 mmHg; pH为7.35，动脉血氧饱和度为95％。呼吸断奶开始并在24小时内成功完成，然后将患者转移到医疗部门，然后在14天后出院并活着，该报告表明CVVHDF可有效治疗药物中毒引起的肾衰竭。这种方式的优点是缓慢持续清除药物而没有血液动力学不稳定。只有几篇论文报道了使用CVVHDF治疗药物中毒（1、2）。此外，许多作者建议，在常规透析方面，对于受急性肾衰竭影响的重症监护病房患者（3，4），必须考虑采用连续性肾脏替代治疗。对于将重症患者运送到透析室的危害，存在担忧并且绝对血液动力学稳定性已证明连续肾脏替代治疗更为安全（5），但这一概念尚未被广泛接受。应继续研究连续性肾脏替代疗法在大量摄入药物治疗中的功效。;对应于Francesco Imperatore MD顾问麻醉师和Intesivist麻醉及重症监护室，急诊科。卡达雷利”医院通过意大利那不勒斯米歇尔·特诺尔市1480137传真0039 081 7472921电子邮件：francesco.imperatore@fastwebnet.it
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