Multiple drugs

Abstract

Multiple drugsVarious toxicities: case report A 31-year-old man developed digital pedal gangrene and digital necrosis during treatment with epinephrine, phenylephrine and norepinephrine for hypotension. Additionally, he exhibited lack of efficacy with ceftriaxone and azithromycin, which was used as an empirical treatment and also exhibited lack of efficacy following an off-label treatment with chloroquine, thiamine, ascorbic acid and anakinra for coronavirus disease-2019 (COVID-19) [dosages and routes not stated].The man presented to the emergency department with a 2-day history of dry cough and 5-day history of fever. His medical history was significant for obesity and hypertension. On presentation, he was found to be hypoxic, febrile and tachycardic. He was admitted to the general medicine floor and started receiving empirical treatment with azithromycin and ceftriaxone. On admission, a nasal swab test was found to be positive for COVID-19. Therefore, he started receiving an off-label treatment with chloroquine, anakinra, thiamine and ascorbic acid [vitamin-C]. Despite treatment, he continued to have persistent fevers and developed acute hypoxaemia, indicating lack of efficacy following an off-label treatment with chloroquine, thiamine, ascorbic acid and anakinra.The man was then intubated and transferred to the ICU. He found to be hypotensive, and he was treated with infusions of epinephrine injection, phenylephrine and norepinephrine for 30 days. Additionally, he received heparin for deep venous thrombosis prophylaxis with goal activated partial thromboplastin time of 50-70 seconds. Despite high ventilator settings, medical therapy and prone positioning for an average of 15h intervals over 6 days, he remained with severe acute respiratory distress syndrome and respiratory acidosis. Therefore, he was placed on extracorporeal carbon dioxide removal. He was subsequently transitioned to venovenous extracorporeal membrane oxygenation (VV-ECMO) for refractory hypoxaemia and then started receiving an off-label treatment with methylprednisolone. After the initiation of ECMO, the heparin therapy was switched to argatroban. His ICU course was then complicated by new onset atrial fibrillation with emergent successful cardioversion. He was treated with amiodarone with improvement. On day 24 ECMO was successfully decannulated, and he was extubated on day 34. The podiatry team was consulted on day 35 for concern of new-onset digital pedal gangrene. It was noted that his feet were firmly pressed against the footboard of the hospital bed and not properly off-loaded. At this time, Z-flow boots for off-loading of the feet were placed on, and he started receiving treatment with local wound care with povidone iodine [Betadine] paint every other day. An increased digital necrosis was noted to the left plantar forefoot throughout the hospital course. The digital pedal gangrene and digital necrosis were attributed to the epinephrine, phenylephrine and norepinephrine therapy. After 55 days of hospital stay, he was discharged to acu...