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Lithium toxicity

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of lithium toxicity are prepared by our editorial team based on guidelines from the Royal Australian and New Zealand College of Psychiatrists (RANZCP 2017), the British Association for Psychopharmacology (BAP 2016), the Extracorporeal Treatments in Poisoning Workgroup (EXTRIP 2015), and the National Institute for Health and Care Excellence (NICE 2014). ...
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Screening and diagnosis

Clinical monitoring of patients taking lithium: as per NICE 2014 guidelines, monitor patients taking lithium at every appointment for symptoms of neurotoxicity, including paresthesia, ataxia, tremor and cognitive impairment. Recognize that these complications can occur at therapeutic levels of lithium.
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  • Laboratory monitoring of patients taking lithium

Therapeutic procedures

ECTR, indications for initiation
As per EXTRIP 2015 guidelines:
Initiate ECTR in patients with severe lithium poisoning, as defined by any of the following:
impaired kidney function and serum lithium level of > 4.0 mEq/L
decreased level of consciousness, seizures or life-threatening dysrhythmias, irrespective of the serum lithium level
B
Consider initiating ECTR in patients with:
serum lithium level of > 5.0 mEq/L
significant confusion
an expected time to reduce serum lithium level to < 1.0 mEq/L with optimal management of > 36 hours
C

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  • ECTR (choice of technique)

  • ECTR (indications for discontinuation)

Patient education

Counseling of patients taking lithium: as per NICE 2014 guidelines, educate patients taking lithium to report new developed diarrhea or vomiting or if they become acutely ill for any reason.
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Follow-up and surveillance

Post-treatment lithium monitoring: as per EXTRIP 2015 guidelines, obtain serial serum lithium measurements over 12 hours after interruption of ECTR to determine the need for subsequent ECTR sessions.
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