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administered because it may enhance postabsorptive elimination of salicylates
(through GI dialysis).
Healthcare providers should be wary of sedating or mechanically ventilating
aspirin-poisoned patients, as depressing the spontaneous ventilation rate may
worsen acidosis and lead to more severe aspirin-induced neurotoxicity. Specific
therapeutic goals in salicylate intoxication include correction of fluid and
electrolyte disturbances and the enhancement of salicylate excretion.
Fluid therapy is aimed at restoring hydration and electrolyte balance,
preventing distribution of salicylate to the brain, and promoting renal salicylate
excretion. Aggressive restoration of intravascular volume is advisable; however,
fluids should be given prudently to prevent precipitation of pulmonary edema,
particularly in patients with severe intoxication. Hypokalemia promotes
absorption of salicylates and impairs alkalinization required to enhance
elimination, so correct hypokalemia aggressively.
For patients with symptomatic salicylate intoxication, urine alkalinization
should be combined with fluid resuscitation. The administration of sodium
bicarbonate, by increasing urinary pH, ionizes filtered aspirin, increasing tubular
secretion and inhibiting its tubular reabsorption (ion trapping). The initial fluid is,
therefore, designed to replace both sodium and bicarbonate losses as well as
promote urine alkalinization. It should contain 5% dextrose with 100 to 150
mEq/L of sodium bicarbonate. The goal should be a blood pH of 7.45 to 7.5 and a
urine pH of 8. Because hypokalemia impairs the ability of the kidney to create
alkaline urine and is exacerbated by administration of sodium bicarbonate,
potassium must be added to IV fluids. Forced diuresis should not be used as it
does not enhance salicylate excretion more than the clearance accomplished by
alkalinization alone. Therefore, fluids are given as needed to restore normal
hydration and to produce 1 to 2 mL/kg/hr of urine. Calcium homeostasis should
also be monitored during therapy with exogenous bicarbonate. Urine
alkalinization should be continued until salicylate concentration falls below 30
mg/dL and symptoms resolve. As long as there are no contraindications, a second
dose of charcoal should be considered if salicylate levels are not downtrending as

anticipated, if the ingestion was massive, or if there is clinical concern for a
pharmacobezoar.
Salicylate elimination can also be enhanced by hemodialysis or hemoperfusion.
Although hemoperfusion results in superior clearance, hemodialysis is usually
preferred because it permits correction of fluid and electrolyte imbalances and it
is more readily available. Hemodialysis should be reserved for seriously ill
patients. Hemodialysis might be considered for patients with serum salicylate