Extra-corporeal life support for near-fatal multi-drug intoxication: a case report

Abstract

IntroductionSevere mixed β-blocker and calcium channel blocker intoxication presents a significant risk for patient mortality. Although treatment is well-established, it sporadically fails to support the patient through massive overdoses, thus requiring non-conventional treatments. We report the use of extra-corporeal life support in a patient with refractory hemodynamic impairment due to multi-drug intoxication. Although sometimes used in clinical practice, extra-corporeal membrane oxygenation for intoxications has rarely been reported.Case presentationA 36-year-old Caucasian man presented to our hospital with refractory hypotension, severe cardiac insufficiency and multi-organ failure due to mixed intoxication with atenolol, nifedipine, Lacidipine and sertraline. Together with standard treatment, we performed extra-corporeal membrane oxygenation to overcome refractory cardiogenic shock and lead the patient to achieve a full recovery.ConclusionStandard of care for β-blocker and calcium channel blocker intoxication is well-defined and condensed into protocols of treatment. Although aimed at clearing the noxious agents from the patient's system, standard measures may fail to provide adequate hemodynamic support to allow recovery. In selected cases, extra-corporeal membrane oxygenation could be considered a bridge to drug clearance while preventing multi-organ failure due to profound shock.

Extracorporeal Membrane Oxygenation For Multi-drug Intoxication

“…VA-ECMO can be used as a bridge to recovery for these patients who are not responding to conventional therapy 3 . Only a few reports have been published about the use VA-ECMO in drug overdose patients presenting with refractory cardiogenic shock 1,2 . ß-blocker and Calcium Channel Blocker toxicity results in poor myocardial contractility, hemodynamic deterioration due to cardiogenic shock and Arrhythmias 1 .…”

General Approach to Poisoned Patient

“…Extracorporeal membrane oxygenation (ECMO) ECMO: extracorporeal technique used when the patients are critically ill and they cannot provide an adequate amount of gas exchange or perfusion to sustain. This technique may be used in the case of severe and massive overdose especially cardiotoxic drugs (beta blockers, calcium channel blocker) [18].…”

Extracorporeal life support: The final ‘antidote’ for massive propranolol overdose

“…From other case reports, we note that ECLS is often initiated later in the patient's time course in hospital, usually in the ICU instead of the ED. 5,16 These patients may suffer from repeated arrests prior to ECLS. The reluctance to initiate ECLS may be related to the high complication rate or the huge resources needed.…”

“…19 In a retrospective French study of 17 patients with cardiac arrest from drug overdose, 59% had significant vascular complications. 9 In a patient with multidrug overdose including betablockers who had collapsed, 5 ECLS had been initiated only much later in the ICU when all other treatment options had been exhausted. Although the patient survived to discharge, he was significantly neurologically impaired.…”