Hemoadsorption in acute pediatric carbamazepine intoxication: a case report and systematic review of extracorporeal therapies.

backgroundSevere carbamazepine intoxication in children may cause coma, seizures, respiratory failure, and hemodynamic instability. When gastrointestinal decontamination and supportive care are insufficient, extracorporeal blood purification may be considered to enhance drug elimination. Hemoadsorption has recently emerged as a potential option, but pediatric evidence remains very limited.

objectivesTo report the first pediatric case successfully managed with hemoadsorption and to systematically review extracorporeal removal strategies in pediatric carbamazepine intoxication. DATA SOURCES: CINAHL, Cochrane Library, Embase, MEDLINE via PubMed, Scopus, Web of Science, ClinicalTrials.gov, and reference lists of eligible articles were searched through April 6, 2025. STUDY ELIGIBILITY CRITERIA: Articles reporting pediatric patients (≤ 18 years) with acute carbamazepine intoxication who were treated with extracorporeal blood purification techniques were included. Eligible studies were randomized controlled trials, observational studies, case series, and case reports. Reports without extractable individual patient data were excluded. PARTICIPANTS AND

interventionsTwenty studies provided individual data for 27 children (16 months-18 years) treated with charcoal hemoperfusion, hemodialysis, continuous kidney replacement therapy, therapeutic plasma exchange, or sequential/combined approaches. We additionally report one index case of acute carbamazepine overdose managed with isolated hemoadsorption using a CytoSorb cartridge. STUDY APPRAISAL AND SYNTHESIS

methodsRecords were screened, full texts were reviewed for eligibility, and individual patient data were extracted. Methodological quality was assessed using Joanna Briggs Institute critical appraisal checklists. Because of substantial heterogeneity, findings were summarized descriptively only, without meta-analysis, formal comparison, or ranking of extracorporeal modalities.

resultsCase report A 7-year-old girl was admitted to our hospital after ingestion of carbamazepine at a dose of 182 mg/kg, with an initial serum carbamazepine concentration of 144 µmol/L. She was unresponsive and hypotensive, with respiratory acidosis requiring endotracheal intubation. Isolated hemoadsorption using a CytoSorb cartridge on a multiFiltrate monitor was initiated 6.5 h after ingestion, and serum carbamazepine concentration decreased to the therapeutic range (17-51 µmol/L) within 18 h post-ingestion. The patient was extubated on day 2 and discharged on day 5 without neurological sequelae. SYSTEMATIC REVIEW: Twenty studies met the inclusion criteria and provided extractable individual data for 27 patients (16 months-18 years). Ingested doses ranged from 47 to 1077 mg/kg, with peak serum carbamazepine concentrations between 85 and 584 µmol/L. Manifestations included coma (85%), respiratory failure (56%), seizures (52%), and hypotension (26%). Management required mechanical ventilation (48%) and inotropic-vasopressor support (22%). Hemodialysis (56%), continuous veno-venous hemodiafiltration (26%), charcoal hemoperfusion (22%), therapeutic plasma exchange (19%), continuous veno-venous hemodialysis (7%), and continuous veno-venous hemofiltration (4%) were used. Documented time to normalization ranged from 4.5 to 84 h. Serum carbamazepine concentrations decreased across the included reports, and no deaths were reported. Pediatric intensive care unit and hospital lengths of stay ranged from 2 to 9 and from 2 to 26 days, respectively. LIMITATIONS: The evidence consisted of heterogeneous case reports and small case series, precluding causal inference or formal comparisons across extracorporeal modalities. CONCLUSIONS AND IMPLICATIONS OF KEY

findingsExtracorporeal techniques may play an important role in severe pediatric carbamazepine intoxication when supportive measures are insufficient. Hemoadsorption may be feasible in carefully selected children. However, current pediatric evidence remains too limited to determine whether it offers any advantage over other extracorporeal modalities. Prospective registries, pharmacokinetic studies, and comparative evaluations are warranted to define indications, timing, and modality selection. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD420251236374.