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To the Editor: In his discussion of pralidoxime as an antidote to sarin, Dr Lee¹ emphasized the need for slow intravenous infusion to minimize adverse effects. Although Lee described many adverse effects related to rapid infusion, the primary reason for slow administration is to prevent the muscle weakness and subsequent respiratory arrest that result from transient inhibition of cholinesterases when pralidoxime binds to the enzymes.²

The optimal dosing regimen for intravenous pralidoxime is controversial. Animal research suggests that a minimal plasma level of 4 µg/mL is effective in reversing nicotinic symptoms of poisoning; however, more recent research proposes that even higher levels may be necessary.^3-4 In either case, achieving and maintaining therapeutic plasma oxime levels varies depending on weight. In a randomized crossover study, healthy volunteers receiving pralidoxime as an initial bolus (4 mg/kg) followed up with a continuous infusion (3.2 mg/kg per hour) for 3.75 hours maintained mean therapeutic . . . [Full Text of this Article]

Joshua G. Schier, MD
National Center for Environmental Health
Centers for Disease Control and Prevention
Atlanta, Ga

Robert S. Hoffman, MD
New York City Poison Control Center
New York, NY

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