Submit Manuscript | http://medcraveonline.com Abbreviations: ECG, electrocardiography; CVVHDF, conti- nuous veno-venous hemo dia fltration; ARDS, acute respiratory dis- tress syndrome Introduction Glyphosate-surfactant herbicide is one of the most frequently used herbicides. Glyphosate kills plants by suppressing the shikimic metabolic pathway. 1 The mechanism of toxicity of glyphosate in mammals has been proposed to be the uncoupling of oxidative phosphorylation. 2 Surfactants are inert ingredients that are added to herbicides to precisely increase the absorption of the active component. Surfactants may contribute to the toxicity of the active substance. 1 An experiment in dogs found that hypotension is primarily caused by myocardial depression with surfactant. 3 The ingestion of small amounts of glyphosate-surfactant herbicide usually causes only mild symptoms. However, when large volumes of concentrates are ingested intentionally, it can generate potentially fatal symptoms that are refractory to the treatment. 4 The treatment for glyphosate- surfactant herbicide poisoning is primarily of a supportive nature. 5 Early continuous veno-venous hemodiafltration (CVVHDF) contributes to the survival. 4,6 Case report At noon, a 45-year-old man deliberately drank a ½-liter of glyphosate-surfactant herbicide (trade name Cidokor). Cidokor is formulated as a liquid concentrate for solution and contains 480g/ L±24g/L (41.5% approx. weight) monoizopropylamine glyphosate salt (monoizopropylamine salt of N-phosphonomethyl-glycine). Other ingredients include ethoxylated fatty amines (mixture of n-alkyl (C 14 +C 16 +C 18 )-N, N, -bis (poliethoxylated) fatty amines 176g/L±11g/L (15.5% approx. weight). Cidokor is manufactured by Monsanto Europe SA, Brussels, Belgium. Immediately after drinking the poison, his wife gave him a few deciliters of milk to drink. For many years, the patient had suffered from psychosis, which was recently in a deterioration (paroxetine and risperidone were not taken regularly). He consumed alcohol. After poisoning he was transported by boat from the island to the hospital. He was admitted into the Gastroenterology Department at 3 p.m. Upon admission, he was conscious, complained of pain in the throat and epigastric area. Treatment was started, and diuresis was stimulated by furosemide. Hyperkalemia was corrected with an infusion of glucose and insulin, sodium bicarbonate and calcium gluconate. The patient received pantoprazole, amiodarone and oxygenation through a facemask with a bag. Despite treatment, his consciousness deteriorated into a coma (Glasgow coma score 3), and the patient demonstrated dilated pupils and no reaction to light. Chest X-rays showed confuent opacities and the development of ARDS. Cardiovascular collapse developed (blood pressure 80/50mmHg). Anuric acute renal failure, hyperkalemia and metabolic acidosis also developed. ECG showed progressive hyperkalemia. Nasogastric retention of bloody content was large. Rhabdomyolysis developed. For further treatment, he was admitted to the intensive care unit. Orotracheal intubation was performed, and mechanical ventilation was started. A central venous catheter and arterial line were placed for invasive hemodynamic monitoring. Saline infusion, infusions of dopamine (15μg/kg/min) and norepinephrine (0.25µg/kg/min) were started as inotropic and vasoactive support. Hydrocortisone (1.5g), vitamin B 1 (250mg), continuous infusion of bicarbonates (250mmol) and antibiotic ceftrixone were administered. CVVHDF was started at 11 p.m. Laboratory fndings before and three days after the start of CVVHDF are presented in Table 1. In our case, for vascular access, a double lumen catheter was inserted percutaneously into the right subclavian vein. A prisma M 100 preset was used. The manufacturer of the device was Gambro Industries, MOJ Addict Med Ther. 2017;4(1):202‒204 202 © 2017 Nincevic et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and build upon your work non-commercially. Severe glyphosate - surfactant herbicide poisoning; successful treatment - case report Volume 4 Issue 1 - 2017 Zeljko Nincevic, 1 Jasna Nincevic, 2 Maja Gabelica, 3 Zeljko Sundov, 4 Zeljko Puljiz, 4 Mirko Gabelica 5 1 Department of Anaesthesiology and Intensive Care Medicine, University Hospital Split, Croatia 2 Department of Epidemiology, Public Health Institute of Split and Dalmatian County, Croatia 3 Department of Emergency Medicine of Split and Dalmatian County, Croatia 4 Department of Internal Medicine, University Hospital Split, Croatia 5 Department of Ear, nose and throat, University Hospital Split, Croatia Correspondence: Zeljko Nincevic, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Split, Spinciceva 121000 Split, Croatia, Tel 0038521556184, Email zeljko.nincevic@gmail.com Received: August 23, 2017 | Published: September 11, 2017 Abstract Glyphosate-surfactant herbicide is one of the most frequently used herbicides. When large volumes of concentrates are ingested intentionally, it can generate fatal symptoms that are refractory to treatment. We present a case of a 45-year-old male who suffered from psychosis and deliberately drank a ½-liter of glyphosate-surfactant herbicide. His consciousness deteriorated into a coma, and he developed ARDS. Cardiovascular collapse developed. Acute renal failure, hyperkalemia and metabolic acidosis also developed. He was admitted to the intensive care unit. Orotracheal intubation was performed and mechanical ventilation was initiated. Infusions of dopamine and norepinephrine were also started. Continuous veno-venous hemodiafiltration was started 11 hours after ingestion and was performed for 5 days. Intermittent daily two-hour dialysis was performed for further 18 days. His renal function had fully recovered. He was mechanically ventilated for 9 days. After treatment, he was discharged to go home fully recovered with no neurological deficits. This is a case of severe glyphosate-surfactant herbicide poisoning which was successfully cured by supportive treatment and CVVHDF. According to the literature this is among the largest ingestion that patient survived. Keywords: cardiovascular collapse, anuric acute renal failure, altered consciousness, severe poisoning, supportive treatment MOJ Addiction Medicine & Terapy Case Report Open Access