PART 3 / CH 55
Lithium Toxicity
Amy Gagliardi and George Papakostas
A. Risk factors
1. sodium depletion
(dehydration, dietary restrictions, sodium wasting diuretics)
2. decreased renal blood flow
(CHF, cirrhosis, ACE-inhibitors, NSAIDs)
3. intrinsic renal disease
B. Management of suspected Li toxicity
1. Hold the next dose until a level can be checked
2. Send a lithium level immediately
3. Toxicity correlates poorly with lithium level:
- Any level above 2.0 requires treatment,
even if the patient appears well.
- Any patient with signs/symptoms of toxicity
requires treatment, regardless of level.
4. Consult renal service for possible hemodialysis
5. Consult medicine
5. Treat immediately
(damage caused by high level and duration of high level)
C. Lithium level and treatment
| lithium level | clinical picture | treatment |
|---|---|---|
| below 3.0 | with mild symptoms: lethargy, fatigue, weakness, coarse tremor, mild nausea | 1) NS at 150-200 cc/hr and IV lasix until level normalizes 2) correct electrolyte abnormalities, especially K+ 3) avoid charcoal (does not bind Li) 4) hold lithium, work up cause of toxicity - if unknown, check renal function (BUN/Cr, U/A, creatinine clearance): ?NSAID use, laxatives/diuretics, dehydration, … |
| 3.0 to 4.0 | with no symptoms, mild symptoms, or moderate symptoms: nausea, vomiting, mild ataxia, dysarthria, incoordination, hyperreflexia, poor concentration, fasciculations | In patients with normal cardiac and renal function (able to tolerate volume load): 1) call renal consult for possible hemodialysis and treat as above while awaiting consult. 2) check Li levels q2hrs to be sure they are decreasing. 3) consider ICU transfer. |
| 3.0 to 4.0 | with severe symptoms: delirium, ataxia, seizures, renal failure, hallucinations, coma | 1) dialysis required (hemodialysis best but peritoneal can be used) 2) move patient to the ICU for hemodynamic monitoring 3) re-equilibration occurs; retest levels several times after dialysis 4) end-point is level of 1.0 or less 6 hours after dialysis 5) work up cause of toxicity |
| above 4.0 | with no symptoms, mild symptoms, or moderate symptoms | 1) IV NS at 250 cc/hr, recheck level every hour 2) if level does not begin to decrease in 2-3 hours, institute dialysis regardless of patient's clinical appearance 3) work up cause of toxicity |
| above 4.0 | with severe symptoms | as above |
Source: Hyman S and Tesar GE (1994) Manual of Psychiatric Emergencies.