Critical care management of the patient with pharmaceutical poisoning

Christoph Hüser^{1

2}, Carina Bethlehem³, Martin W Dünser⁴, Cornelia Genbrugge^{5

6}, Marc Ghannoum⁷, Lotte C G Hoegberg^{8

9}, Lorenz Van der Linden^{10

11}, Kevin Roedl¹², Marc Sabbe^{5

6}, Maaike A Sikma¹³, Dominique Vodovar^{14

15

16}, Bruno Mégarbane^{17

18}; ESICM Trauma, Emergency Medicine Section

Affiliations

¹ Emergency Department, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
² Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
³ Department of Clinical Pharmacy and Pharmacology, Frisius Medical Centre, Leeuwarden, The Netherlands.
⁴ Department of Anesthesiology and Critical Care Medicine, Kepler University Hospital, Linz, Austria.
⁵ Emergency Department, University Hospitals Leuven, Leuven, Belgium.
⁶ Emergency Medicine, Department of Public Health and Primary Care, Catholic University Leuven, Leuven, Belgium.
⁷ Dutch Poisons Information Center, Utrecht University Medical Center, University Utrecht, Utrecht, The Netherlands.
⁸ Division of Chemical Operations, Danish Emergency Management Agency, Copenhagen, Denmark.
⁹ Department of Clinical Pharmacology and the Danish Poisons Information Centre, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark.
¹⁰ Hospital Pharmacy Department, UZ Leuven, Leuven, Belgium.
¹¹ Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
¹² Department of Intensive Care Medicine, University Medical Center Hamburg, Hamburg, Germany.
¹³ Intensive Care and Dutch Poisons Information Center, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands.
¹⁴ Service de Médecine Intensive Réanimation, Hôpital Charles Nicolle, Rouen, France.
¹⁵ UFR de Santé, Université Rouen Normandie, Rouen, France.
¹⁶ Laboratoire ENVI, INSERM UMR1096, Université Rouen Normandie, Rouen, France.
¹⁷ Department of Medical and Toxicological Critical Care, Lariboisière Hospital, Paris Cité University, Paris, France. bruno.megarbane@aphp.fr.
¹⁸ Université Paris Cité, INSERM UMRS-1144, Paris, France. bruno.megarbane@aphp.fr.

PMID: 41222651
DOI: 10.1007/s00134-025-08176-6

Review

Critical care management of the patient with pharmaceutical poisoning

Christoph Hüser et al. Intensive Care Med. 2025.

. 2025 Nov 12.

doi: 10.1007/s00134-025-08176-6. Online ahead of print.

Authors

Affiliations

¹ Emergency Department, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
² Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
³ Department of Clinical Pharmacy and Pharmacology, Frisius Medical Centre, Leeuwarden, The Netherlands.
⁴ Department of Anesthesiology and Critical Care Medicine, Kepler University Hospital, Linz, Austria.
⁵ Emergency Department, University Hospitals Leuven, Leuven, Belgium.
⁶ Emergency Medicine, Department of Public Health and Primary Care, Catholic University Leuven, Leuven, Belgium.
⁷ Dutch Poisons Information Center, Utrecht University Medical Center, University Utrecht, Utrecht, The Netherlands.
⁸ Division of Chemical Operations, Danish Emergency Management Agency, Copenhagen, Denmark.
⁹ Department of Clinical Pharmacology and the Danish Poisons Information Centre, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark.
¹⁰ Hospital Pharmacy Department, UZ Leuven, Leuven, Belgium.
¹¹ Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
¹² Department of Intensive Care Medicine, University Medical Center Hamburg, Hamburg, Germany.
¹³ Intensive Care and Dutch Poisons Information Center, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands.
¹⁴ Service de Médecine Intensive Réanimation, Hôpital Charles Nicolle, Rouen, France.
¹⁵ UFR de Santé, Université Rouen Normandie, Rouen, France.
¹⁶ Laboratoire ENVI, INSERM UMR1096, Université Rouen Normandie, Rouen, France.
¹⁷ Department of Medical and Toxicological Critical Care, Lariboisière Hospital, Paris Cité University, Paris, France. bruno.megarbane@aphp.fr.
¹⁸ Université Paris Cité, INSERM UMRS-1144, Paris, France. bruno.megarbane@aphp.fr.

PMID: 41222651
DOI: 10.1007/s00134-025-08176-6

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.

Keywords: Antidote; Intensive care; Pharmaceutical overdose; Poisoning; Toxicology; Toxidrome.

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Conflict of interest statement

Declarations. Conflicts of interest: Christoph Hüser: none to declare. Carina Bethlehem: none to declare. Martin Dünser: none to declare. Cornelia Genbrugge: Payment or honoraria for lectures, presentations, speaker’s bureaus, manuscript writing or educational events: Royal Higher Institute for Defence, Belgium; Support for attending meetings and/or travel: ESICM 2024, 2023; Leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid: Belgian Society of Disaster and Emergency Medicine, Pre-hospital section, European Society of Emergency Medicine. Marc Ghannoum: I am regularly asked to be an expert witness in medicolegal cases in Canada with a written expertise. Lotte Hoegberg: none to declare. Lorenz Van der Linden: none to declare. Kevin Roedl: none to declare. Marc Sabbe: none to declare. Maaike Sikma: Participation on a Data Safety Monitoring Board or Advisory Board: Bullseye study, EU_CT 2024-512950-13-00; Leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid: IATDMCT anti-infectives committee; ESICM pharmacology committee; ESICM AKI committee. Dominique Vodovar: none to declare. Bruno Mégarbane: none to declare.

References

1. Bremen K, Wirtz TH, Brozat JF et al (2023) Intensivmedizinische Versorgung von Patienten mit akuter Intoxikation in Deutschland – ein Rückblick über 20 Jahre. Med Klin Intensivmed Notfmed 118:283–292. https://doi.org/10.1007/s00063-022-00937-1 - DOI - PubMed
1. Reisinger AC, Schneider N, Schreiber N et al (2024) Critical care management of acute intoxications, dynamics and changes over time: a cohort study. Intern Emerg Med 19:2015–2024. https://doi.org/10.1007/s11739-024-03570-2 - DOI - PubMed - PMC
1. Siedler S, Trageser HB, Grensemann J et al (2022) Akute Intoxikationen auf der Intensivstation: Eine 10-Jahres-Analyse. Med Klin Intensivmed Notfmed 117:129–136. https://doi.org/10.1007/s00063-021-00839-8 - DOI - PubMed
1. Zwaag SM, van den Hengel-Koot IS, Baker S et al (2024) The INTOXICATE study: methodology and preliminary results of a prospective observational study. Crit Care 28:316. https://doi.org/10.1186/s13054-024-05096-7 - DOI - PubMed - PMC
1. Kraaijvanger N, Raven W, van Dijken T, Gresnigt F (2024) The PIRATE mnemonic: providing a structured approach in the care for intoxicated patients at the emergency department. Int J Emerg Med 17:30. https://doi.org/10.1186/s12245-024-00606-4 - DOI - PubMed - PMC

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Critical care management of the patient with pharmaceutical poisoning

Affiliations

Critical care management of the patient with pharmaceutical poisoning

Authors

Affiliations

Abstract

Conflict of interest statement

References

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