Clinical review: Aggressive management and extracorporeal support for drug-induced cardiotoxicity

Abstract

Poisoning may induce failure in multiple organs, leading to death. Supportive treatments and supplementation of failing organs are usually efficient. In contrast, the usefulness of cardiopulmonary bypass in drug-induced shock remains a matter of debate. The majority of deaths results from poisoning with membrane stabilising agents and calcium channel blockers. There is a need for more aggressive treatment in patients not responding to conventional treatments. The development of new antidotes is limited. In contrast, experimental studies support the hypothesis that cardiopulmonary bypass is life-saving. A review of the literature shows that cardiopulmonary bypass of the poisoned heart is feasible. The largest experience has resulted from the use of peripheral cardiopulmonary bypass. However, a literature review does not allow any conclusions regarding the efficiency and indications for this invasive method. Indeed, the majority of reports are single cases, with only one series of seven patients. Appealing results suggest that further studies are needed. Determination of prognostic factors predictive of refractoriness to conventional treatment for cardiotoxic poisonings is mandatory. These prognostic factors are specific for a toxicant or a class of toxicants. Knowledge of them will result in clarification of the indications for cardiopulmonary bypass in poisonings. IntroductionFailure of various organs may result in the death of acutely poisoned patients. In the 1960s, sedative-induced respiratory failure was the leading cause of death in Western countries. In these cases, endotracheal intubation and mechanical ventilation dramatically improved the prognosis. Similarly, renal replacement therapy with dialysis prevents deaths related to toxicant-induced acute renal failure. Even druginduced fulminant liver failure is successfully treated in selected cases by liver transplantation. In contrast, the usefulness of temporary mechanical assistance in druginduced cardiac failure still remains a matter of debate [1,2].However, promising results have been obtained using a combination of percutaneous cardiopulmonary support and cardiac resuscitation [3,4]. Furthermore, a recent report of the first series of acute poisonings treated with extracorporeal life support (ECLS) [5], together with an increasing number of case reports [6-10], suggests it is necessary to define the place of this aggressive treatment for drug-induced cardiotropic toxicity. Drug-induced cardiovascular shock: a leading cause of deathOver the past 30 years, improvements in the treatment of drug-induced cardiovascular shock have been due mainly to a better understanding of the different mechanisms of shock. Routine bedside haemodynamic examinations have provided evidence of the different mechanisms of drug-induced cardiovascular shock, which has enabled the selection of drugs to address the different components of shock. Within the same period of time, indications for mechanical ventilation were extended to conscious poisoned patients presenting ...

Nouveautés dans les indications de l’ECMO veino-artérielle périphérique

“…Quatre malades ont dû être transplantés en raison d'une absence de récupération et sont sortis vivants de l'hôpital. Les facteurs prédictifs indépendants en analyse multivariée de mortalité en réanimation étaient un SAPS II ≥ 56 (OR : 10,23 ; IC95 % : 1,75-59,69) et une troponine à l'admission ≥ 12 µg/L (OR : 7,49 ; IC95 % : 1, [25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44]82).…”

“…Le bénéfice de l'ECMO-VAP dans cette indication a été rapporté à de nombreuses reprises [31,32]. Une étude observationnelle a comparé le pronostic de deux groupes de patients présentant un choc cardiocirculatoire réfractaire dans les suites d'une intoxication aux cardiotropes et implantés ou non d'une ECMO-VAP [33]. La survie hospitalière était fortement augmentée dans le groupe ECMO-VAP par rapport au groupe sans ECMO-VAP (86 % contre 48 % p=0,02).…”

High rate of arterial complications in patients supported with extracorporeal life support for drug intoxication-induced refractory cardiogenic shock or cardiac arrest

“…Drug intoxication still represents a potentially lethal condition despite a better knowledge of the pathophysiologic mechanisms and a significant improvement of its management over the past 40 years (1). The clinical spectrum of poisoning from cardiotoxic drugs is broad encompassing life-threatening cardiac arrhythmias, hypotension or even cardiogenic shock and cardiac failure remains a leading cause of death (2).…”

Successful Treatment of Metoprolol-Induced Cardiac Arrest With High-Dose Insulin, Lipid Emulsion, and ECMO

“…This illustrates the need for medical interventions that reduce mortality in this population [7]. In massive overdose, traditional therapies such as glucagon, atropine, and vasopressors are insufficient; and circulatory device support, as well as high-dose insulin and intralipid therapies, may be indicated [8][9][10][11][12][13][14][15][16]. Venoarterial extracorporeal membrane oxygenation (VA-ECMO)…”