Extracorporeal Circulatory Support in Near-Fatal Flecainide Overdose

Abstract

Flecainide, a class 1c antiarrhythmic, has a high mortality associated with significant overdose. We report the case of a 20-year-old female who took approximately 4 grams of flecainide and a small amount of paracetamol as an impulsive gesture. Circulatory failure unresponsive to pacing, inotropes and sodium bicarbonate was successfully treated with cardiopulmonary bypass (CPB). Resolution of her myocardial failure occurred over 24 hours and she was weaned from CPB 30 hours after its initiation. Coagulopathy and intravascular haemolysis were apparent during bypass and necessitated substantial use of blood products. Ischaemic renal dysfunction manifested early in her admission and required haemodiafiltration. Despite a prolonged period of unresponsiveness and pupillary dilatation during resuscitation and CPB she made a full recovery. We believe this is the first reported case of flecainide overdose, requiring extracorporeal circulatory support, not resulting in neurological deficit.

Successful treatment of flecainide overdose with sustained mechanical circulatory support

“…In the second successful report, also from Australia, VA-ECMO was used for 26 hours for a 6-g ingestion, and the authors argue that VA-ECMO time >36 hours is unlikely to be required 12 . The use of VA-ECMO in these reports was complicated by bleeding and hematoma formation requiring blood products,12, 13, 15 similar to our experience.…”

“…These rhythms may be refractory to electrical cardioversion 8, 10, 11. Treatment options include atropine or a pacemaker for bradyarrhythmias, although capture may be difficult 10, 12, 13. For tachyarrhythmias, there have been reports of success with lidocaine for sustained VT, although the theoretical risk of interaction between class IB and IC agents remains high 14 .…”

“…The report argued for the use of VA-ECMO in shock to maintain perfusion to the liver, which sustains flecainide clearance. The first successful report using VA-ECMO was in 1999 from Australia, where VA-ECMO was used for 30 hours for a 4-g ingestion 13 . The patient survived to discharge with normal neurologic function.…”

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

“…Limb ischemia, vena cava thrombus, severe bleeding, nerve palsy, and deep venous thrombus have all been reported [14,24]. In this patient, the risk of these complications was greatly outweighed by the benefits of VA-ECMO; and he did not develop any complication.…”

Treatment of poisoning induced cardiac impairment using cardiopulmonary bypass: a review

“…Somewhat surprisingly only two patients 4 6 had ingested a cocktail of medication, which included a non-steroidal antiinflammatory drug and b-blockers 6 and an unknown quantity of alcohol and paracetamol. 4 Prolonged cardiovascular instability (including arrhythmias varying from heart block to fast atrial fibrillation) combined with lack of response to conventional resuscitative measures prompted use of CPB. Four patients had experienced cardiac arrest prior to CPB and the remainder had arrhythmias (both first and second degree heart block).…”