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Introduction Cardiovascular failure is the leading cause of death in severe acute drug intoxication. In this setting, we report the feasibility, complications, and outcome of emergency extracorporeal life support (ECLS) in refractory shock or cardiac arrest following a drug overdose.

We aimed to identify factors associated with hospital mortality among patients receiving extracorporeal life support (ECLS). All consecutive patients treated with ECLS for refractory cardiac arrest or shock in the Caen University Hospital in northwestern France during the last decade were included in a retrospective cohort study. Sixty-four patients were included: 29 with refractory cardiac arrest and 35 with refractory shock. The main reasons for ECLS were acute coronary syndrome (n = 23) and severe poisoning caused by drug intoxication (n = 19). At ECLS initiation, the left ventricular ejection fraction was 16% (±11). Initial blood test results were arterial pH = 7.19 (±0.20) and plasma lactate = 8.02 (±5.88) mmol/L. Forty (63%) patients died including 33 under ECLS. In a multivariate analysis, two factors were independently associated with survival: drug intoxication as the reason for ECLS (adjusted odds ratio [AOR], 0.07; 95% confidence intervals [CI], 0.01-0.28; p < 0.001) and arterial pH (an increase of 0.1 point [AOR, 0.013; 95% CI, <0.001-0.27; p < 0.01]). This study supports early ECLS as a last resort therapeutic option in a highly selected group of patients with refractory cardiac arrest or shock, in particular before profound acidosis occurs and when the cause is reversible.

Introduction. Tramadol use is largely considered safe. However, several lethal cases of tramadol intoxication were reported, suggesting an underestimated toxicity. We report for a tramadol overdose case in combination with other central nervous system depressants, leading to refractory shock requiring extracorporeal life support. Case report. A 33-year-old man was admitted in our intensive care unit for drug intoxication with coma, seizures, and hypotension without signs of heart failure. A few hours later, he developed a ventricular tachycardia, followed by a brief cardiac arrest in asystole with refractory shock requiring an extracorporeal life support, vasopressors, and hemofiltration. With this aggressive support, his overall status gradually improved. Repeated echocardiography showed an improvement in the cardiac function. The patient was weaned off extracorporeal life support on day eight and discharged on day 12. On admission, a urine analysis, using gas chromatography-mass spectrometry, showed high peaks of tramadol and desmethyltramadol with the presence of hydroxyzine, gabapentine, and clonazepam. The tramadol blood concentration measured by the high-performance liquid chromatography method-diode array detector was 23.9 mg/L, much higher than many previously reported fatal overdoses. No other drugs with potential cardiac toxicity, such as beta-blockers, calcium antagonists, antiarrythmic, antidepressants, meprobamate, or other xenobiotics were detected. Conclusion. This case illustrates that tramadol overdose may cause refractory shock and asystole when taken in combination with CNS depressants, and reminds all physicians to be vigilant with regard to the potential toxic effects of tramadol.

The use of these scores in helping physicians to determine the patients with ARDS most likely to benefit from ECMO should be limited in clinical practice because of their relatively poor performance in predicting death in subjects with severe ARDS receiving ECMO support. Before widespread use is initiated, these scoring systems should be tested in large prospective studies of subjects with severe ARDS undergoing ECMO treatment.

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