or “sludge,” as long as there is no evidence of peritonitis or perforation In patients with considerable initial radiographic findings, particularly pill concretions, a follow-up radiograph should be obtained to assess the adequacy of bowel cleansing Further options of gastroscopy or even gastrotomy are reserved as last resorts to effect iron pill removal For example, large clumps of coalesced iron tablets in the stomach or duodenum have led to severe hemorrhagic infarction of these viscera with subsequent perforation, peritonitis, and death As previously noted, even in such patients who survive the acute phase, there is considerable risk of subsequent pyloric or bowel stenosis with obstruction, usually to weeks after ingestion In this regard, we also urge early pediatric surgical consultation for patients in the first few days after ingestion who show any evidence of peritoneal irritation Chelation therapy with parenteral deferoxamine enhances the excretion of iron as the ferrioxamine complex, which turns urine an orange or vin rose tint The most efficacious route is a continuous IV infusion, and the maximum recommended dose is 15 mg/kg/hr (maximum daily dose 360 mg/kg, up to g total) A higher infusion rate has been associated with hypotension but may be necessary (in conjunction with blood pressure support) for severe ingestions Chelation is continued until the serum iron level returns to normal, metabolic acidosis has resolved, the patient is clinically improved, and the urine color returns to normal The dose of deferoxamine may be titrated down in concert with the patient’s clinical response and fall in iron levels Of note, deferoxamine is considered to be a siderophore that promotes the growth of certain bacteria such as Yersinia enterocolitica; therefore, monitoring for Yersinia sepsis is important Once the patient has been stabilized initially, further problems may include hypotension, profound metabolic acidosis, hypoglycemia or hyperglycemia, anemia, and colloid loss caused by GI hemorrhage (after equilibration), renal shutdown resulting from shock, and hepatic failure with an associated bleeding diathesis The maintenance of an adequate urine output is critical to prevent renal failure and to foster excretion of the ferrioxamine complex If renal failure supervenes, chelation may be continued with concurrent dialysis because the complex is dialyzable Psychotropic Medications Antidepressants Tricyclic Antidepressants