Pharmaceutical poisoning remains a common yet complex challenge in intensive care medicine, accounting for a substantial proportion of intensive care unit (ICU) admissions worldwide. In this comprehensive state-of-the-art narrative review, Hüser and colleagues provide a pragmatic, evidence-based framework for the management of critically ill patients with drug intoxication, bridging clinical toxicology and modern intensive care practice.
The review emphasizes that early stabilization of vital functions is the cornerstone of successful management. Using the ABCDE approach as a structured backbone, the authors highlight poisoning-specific considerations for airway protection, respiratory support, circulatory stabilization, neurological assessment, and temperature and exposure control. Importantly, they challenge traditional dogma where appropriate, such as the routine use of endotracheal intubation in patients with isolated depressed consciousness, advocating for a more individualized and evidence-informed strategy.
Beyond supportive care, the article offers detailed guidance on the timely escalation to toxicant-specific interventions. These include the judicious use of antidotes, gastrointestinal decontamination, strategies to reduce toxicant burden, and enhanced elimination techniques. The role of sodium bicarbonate in sodium channel blocker toxicity, high-dose insulin euglycemia therapy in calcium channel blocker and beta-blocker poisoning, and naloxone titration in opioid overdose are discussed with practical dosing recommendations and clinical caveats. For refractory cases, advanced rescue strategies such as extracorporeal membrane oxygenation are presented as potentially life-saving options when applied early and in appropriate patients.
A structured diagnostic approach is another major strength of this review. The authors underscore the importance of toxidrome recognition, systematic electrocardiographic assessment, and targeted laboratory testing, while clearly outlining the limitations of routine toxicology screens. The discussion of extracorporeal treatments is particularly valuable, incorporating recommendations from the EXTRIP workgroup and offering a rational framework for selecting patients who may benefit from dialysis or other extracorporeal modalities.
Overall, this review stands out for its clinical relevance and practical focus. By combining clear algorithms, illustrative figures, and concise summaries of available antidotes, it equips intensivists with the tools needed to make timely, informed decisions in a dynamic and high-risk clinical setting. It reinforces the message that optimal outcomes in pharmaceutical poisoning depend on systematic assessment, early supportive care, and close collaboration with toxicology expertise.
Reference
Hüser C, Bethlehem C, Dünser MW, et al. Critical care management of the patient with pharmaceutical poisoning. Intensive Care Medicine, 2025.
