or metabolic correction include poisoning by valproic acid, phenobarbital, methotrexate, massive acetaminophen overdose, and metformin-induced lactic acidosis Table 102.11 summarizes the generally accepted common drugs and drug concentrations for which renal replacement therapy should be considered Risks include complications associated with central venous access, electrolyte disturbances, and hemodynamic instability Of note, while typical dialysis patients are often hypervolemic, most poisoned dialysis patients are hypovolemic; it is incumbent upon the ED care provider to strive for euvolemia prior to hemodialysis Very young infants in particular require extremely close attention to volume shifts In rare neonatal cases, exchange transfusion may in fact be preferable for this reason Nonetheless, the use of hemodialysis for other indications in pediatrics is somewhat commonplace, and in the hands of an experienced nephrologist can be safely performed Extracorporeal therapy should not be withheld even if it means transfer to another institution, as it may be essential in the critically ill poisoned child TABLE 102.11 A PARTIAL LISTING OF DRUGS AND THEIR PLASMA CONCENTRATIONS FOR WHICH HEMODIALYSIS SHOULD BE CONSIDERED Lithium (acute), 4.0 mEq/L Lithium (chronic), 2.5 mEq/L Ethylene glycol, 70 mg/dL Methanol, 70 mg/dL Salicylates, 60 (chronic) to 80–90 (acute) mg/dL Phenobarbital, 100 mg/L Theophylline, 60–100 mg/L Paraquat, 0.1 mg/dL Adapted from Winchester JF Active methods for detoxification In: Hadded LM, Shannon MW, Winchester JF, eds Clinical Management of Poisoning and Drug Overdose 3rd ed Philadelphia, PA: WB Saunders, 1998:175–187; Extracorporeal Treatments in Poisoning (EXTRIP) Workgroup recommendations Available online at https://www.extrip-workgroup.org/recommendations Accessed May 9, 2019 Supportive Care The final step in optimizing treatment for the poisoned child is the direction of scrupulous attention to supportive care, including continued close monitoring of ABCs, fluid and electrolyte status, urine output, and level of consciousness The value of these efforts usually far outweighs that which may be ascribed to any specific toxicologic interventions in most cases Severely symptomatic patients