Delayed Lithium Reintoxication in a Case of Severe Multidrug Intoxication: A Case Study

Abstract

The authors present a case of severe multidrug intoxication following massive ingestion of lithium, nortriptyline, aripiprazole, lorazepam, and temazepam. After initial treatment, serum lithium levels decreased significantly. However, 28 hours post ingestion, recurrent elevated lithium levels were observed, and serum lithium level increased 0.71 mmol/L in 12 hours. The intensivist consulted a hospital pharmacist about this. After administering clearance-inducing therapy using continuous venovenous hemodialysis, the lithium level was reduced to a long-lasting nontoxic level. The occurrence of secondary elevation in lithium levels exceeding the toxic limit in cases of massive ingestion of lithium tablets, whether in combination with anticholinergic drugs, should be anticipated. Close monitoring and prompt initiation of clearance-inducing therapy can improve clinical outcomes.

FIGURE 1.

Lithium drug level and applied interventions over time. *Initial treatment: hyperhydration with NaCl 0.9%, sodium bicarbonate 8.4% 300mL, gastric lavage and activated charcoal + laxative. A, the first drop of the lithium serum level, and (B) the second drop of the lithium serum level.