Lithium toxicity - NYSORA

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Lithium toxicity

Lithium toxicity

Learning objectives

  • Diagnose and treat lithium toxicity

Definition and mechanisms

  • Lithium is a very powerful, antimanic medication with a narrow therapeutic index
  • Excessive intake or impaired excretion can result in lithium accumulation
  • Decreased excretion may occur as a result of dehydration such as from vomiting or diarrhea, a low sodium diet, or from kidney problems
  • Co-ingestants can increase the risk of lithium toxicity
    • NSAIDs
    • Indomethacin
    • Selective COX-2inhiitors
    • Acetaminophen
    • Metronidazole
    • Calcium channel blockers 
    • ACE inhibitors
    • Diuretics 
  • Acute toxicity: lithium overdose in a patient who does not regularly take lithium
  • Acute-on-chronic toxicity: acute overdose in a patient who takes lithium daily, a sudden decline in renal function in a patient taking lithium can also lead to acute-on-chronic toxicity
  • Chronic toxicity: the history generally involves a patient on chronic lithium therapy who, due to toxic drug effects, physical disability, or concurrent illness, becomes hypovolemic, leading to reduced renal excretion of lithium alternatively and toxicity can develop solely from the effects of medications that reduce kidney function

Signs and symptoms

  • Mild symptoms occur at a level of 1.5-2.5 mEq/L
    • Nausea and fatigue
  • Moderate symptoms occur at a level of 2.5-3.5 mEq/L
    • Confusion, increased heart rate, and low muscle tone
  • Severe symptoms occur at a level > 3.5 mEq/L
Neurological effects
Tremor
Hyperreflexia
Nystagmus
Ataxia
Confusion
Delirium
Renal effects
Renal toxicity
Impaired urinary concentrating ability
Nephrogenic diabetes insipidus
Sodium-losing nephritis
Nephrotic syndrome
Cardiovascular effects
T wave flattening
Sinus node dysfunction
QT prolongation
Intraventricular conduction defects
U waves
Gastrointestinal effectsNausea
Vomiting
Diarrhea
Abdominal pain
Endocrine effectsHypothyroidism

Complications

  • Cerebellar dysfunction
  • Extrapyramidal symptoms
  • Brainstem dysfunction
  • Memory deficits
  • Cognitive deficits
  • Sub-cortical dementia

Diagnosis

  • Lithium levels > 1.2 mEq/L
  • ECG
  • Fingerstick glucose
  • Renal function
  • Serum acetaminophen and salicylate concentrations

Management

Lithium toxicity, activated charcoal, gastric lavage, whole-bowel irritation, hemodialysis, peritoneal dialysis

Anesthetic implications

  • Lithium prolongs both depolarizing and non-depolarizing neuromuscular block
  • Perform neuromuscular monitoring in patients on lithium undergoing general anesthesia with the use of neuromuscular blocking agents 
  • Consider conduction defects and ST changes on ECG in patients on lithium undergoing GA

Suggested reading

  • Gitlin, M., 2016. Lithium side effects and toxicity: prevalence and management strategies. International Journal of Bipolar Disorders 4.
  • Flood S, Bodenham A. 2010. Lithium: mimicry, mania, and muscle relaxants. Continuing Education in Anaesthesia Critical Care & Pain. 10;3:77–80.

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