povidone-iodine and Renal-Insufficiency

A critical elevation of povidone-iodine absorption which occurred in a burn patient who was topically treated with 10% povidone-iodine (PI) gel is herein reported. A 65-year-old man was admitted to our hospital for deep second- and third-degree burns covering 26% of his total body surface area. The intravenous administration with lactated Ringer's solution and topical treatment with silver sulfadiazine were applied in addition to such treatments as debridement and skin grafting. However, wound infection occurred due to Pseudomonas aeruginosa. Topical treatment with PI gel was effective for this condition. Persistent nodal bradycardia with hypotension, metabolic acidosis, and renal failure occurred 16 days after the start of PI gel treatment. Iodine toxicosis caused by PI gel was suspected with a serum iodine level of 20600 microg/dl (normal range 2-9 microg/dl). The PI gel treatment was therefore discontinued immediately, and hemodialysis was scheduled. However, the patient's family refused hemodialysis and he died 44 days after admission. To our knowledge, only eight patients with iodine toxicosis have been reported in burn patients treated with PI gel.

Topics: Absorption; Acidosis; Aged; Anti-Infective Agents, Local; Bradycardia; Burns; Debridement; Fatal Outcome; Gels; Humans; Hypotension; Iodine; Male; Povidone-Iodine; Pseudomonas Infections; Renal Insufficiency; Silver Sulfadiazine; Skin Transplantation; Wound Infection

We present a case study of a severe episode of iodine toxicity following povidone-iodine wash with clinical manifestations of cardiovascular collapse, metabolic acidosis, renal failure and seizures. Povidone-iodine has been used as a medical antiseptic and disinfectant since 1952 Iodine toxicity secondary to povidone-iodine use is rare. Iodine toxicity is difficult to diagnose and the diagnosis is made by a high index of suspicion. Toxicity due to iodine correlates with serum and urine iodine levels. Treatment of iodine toxicity is supportive. A review of literature relating to the components of povidone-iodine, iodine metabolism, its manifestations and management of iodine toxicity secondary to povidone-iodine is also presented. An Ovid-Medline search from 1950 to 2009 revealed 1236 articles on the clinical manifestations of povidone-iodine usage but no article on iodine toxicity relating to povidone-iodine based on the following search criteria: povidone-iodine and/or iodine toxicity secondary to povidone-iodine (limited to English language, review articles, full text and human patients).

Topics: Acidosis; Aged; Anti-Infective Agents, Local; Anticonvulsants; Diuretics; Fluid Therapy; Follow-Up Studies; Furosemide; Heart Arrest; Hemodiafiltration; Humans; Iodine; Male; Povidone-Iodine; Renal Insufficiency; Seizures; Therapeutic Irrigation

Continuous mediastinal irrigation with povidone-iodine is used commonly for treating severe postoperative mediastinitis. However, concurrent iodine toxicity has been reported, particularly in patients with renal dysfunction (likely because absorbed iodine is renally excreted). The authors were consulted on a 45-year-old patient with mediastinitis who had renal and hepatic dysfunction while being treated with mediastinal irrigation of povidone-iodine. The povidone-iodine irrigation was discontinued because he had toxic plasma iodine levels. Despite this, his condition worsened, and the iodine levels remained elevated. Thus, hemodialysis (HD) was initiated using high-flux membranes followed by continuous venovenous hemodiafiltration (CVVHDF; 2 L/h of hemofiltration and 2 L/h of HD). Plasma and effluent iodine levels were measured repeatedly to determine iodine clearance by these 2 modalities (HD, 120 mL/min; CVVHDF, 37 mL and 44 mL/min on days 1 and 2, respectively). Hepatic and renal functions improved with decreasing plasma iodine levels. Based on this experience and after reviewing the literature the authors conclude that: (1) iodine irrigation can increase blood iodine levels significantly, especially in the setting of renal failure, and lead to increased morbidity and mortality; (2) plasma iodine levels should be monitored in patients with renal insufficiency; and (3) HD and CVVHDF are effective at clearing iodine. The authors suggest that patients that are at high risk or already developing signs of iodine toxicity should have the iodine irrigation discontinued and may benefit from renal replacement therapy (RRT). Alternatively, concomitant RRT during iodine irrigation may be attempted to maintain the systemic iodine levels at nontoxic levels.

Topics: Hemodiafiltration; Humans; Iodine; Liver Failure; Male; Mediastinitis; Mediastinum; Middle Aged; Poisoning; Povidone-Iodine; Referral and Consultation; Renal Dialysis; Renal Insufficiency; Therapeutic Irrigation