Refractory vasodilatory shock secondary to metformin overdose supported with VA ECMO

Tallman, Crystal Ives; Zhang, Yu; Black, Nicholas; Lynch, Kara L.; Fayed, Muhammad E.; Armenian, Patil

doi:10.1016/j.toxrep.2021.12.010

Cited by 10 publications

(9 citation statements)

References 28 publications

(26 reference statements)

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“…One case report of severe MALA progressing to cardiac arrest despite ongoing CVVHD has been described but that patient was resuscitated per advanced life-support protocol for 25 min until the patient had return of spontaneous circulation 16. A man in his 30s and a woman in her 70s with severe MALA were unable to receive CVVHD due to unstable circulation but had VA-ECMO, received CVVHD and both survived severe MALA without any sequelae 17 18. To our knowledge, this case is the first to describe good outcome in a patient with MALA that progressed into refractory cardiac arrest and was treated with VA-ECMO, double CVVHD, mechanical ventilation and vasopressors.…”

Section: Discussionmentioning

confidence: 87%

Surviving cardiac arrest from severe metformin-associated lactic acidosis using extracorporeal membrane oxygenation and double continuous venovenous haemodialysis

Akkaoui,

Andersen,

Nørgaard

et al. 2023

BMJ Case Rep

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Metformin-associated lactic acidosis (MALA) is a serious condition with high mortality. This case describes a man in the mid-60s with diabetes mellitus type 2 treated with metformin developing MALA 4 days after coronary stenting for non-ST-elevation myocardial infarction. He presented acutely with severe abdominal pain, a lactate of 19 mmol/L and pH 6.74. Despite treatment for MALA, he went into refractory cardiac arrest and was connected to venoarterial extracorporeal membrane oxygenation (VA-ECMO). He suffered a massive haemothorax due to perforation of the right atrial appendage. It was repaired through a sternotomy while being given massive blood transfusions. The following days, he was on VA-ECMO and double continuous venovenous haemodialysis (CVVHD). He survived with only mild paresis of the left hand. VA-ECMO should be considered a rescue therapy alongside treatment with CVVHD in case of cardiac arrest due to severe MALA.

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Section: Discussionmentioning

confidence: 87%

Surviving cardiac arrest from severe metformin-associated lactic acidosis using extracorporeal membrane oxygenation and double continuous venovenous haemodialysis

Akkaoui,

Andersen,

Nørgaard

et al. 2023

BMJ Case Rep

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show abstract

“…Survival is reported in patients with levels as high as 678 μg/mL. [ 25 ] Not surprisingly, an observational study of 105 patients with MALA reported that a lower APACHE II score and time to dialysis (<6 h) are associated with lower 30-day mortality. [ 26 ]…”

Section: Discussionmentioning

confidence: 99%

“…[ 39 ] The administration of methylene blue, an inhibitor of nitric oxide synthase, has been shown to provide transient improvements in hypotension. [ 25 27 ] In cases of refractory shock, venoarterial extracorporeal membrane oxygenation (ECMO) may be considered. [ 25 ] Indications for ECMO from the Extracorporeal Treatments in Poisoning Workgroup include lactate levels >20 mmol/L, pH ≤7.0, shock, failure of supportive care, and decreased level of consciousness.…”

Section: Discussionmentioning

confidence: 99%

“…[ 25 27 ] In cases of refractory shock, venoarterial extracorporeal membrane oxygenation (ECMO) may be considered. [ 25 ] Indications for ECMO from the Extracorporeal Treatments in Poisoning Workgroup include lactate levels >20 mmol/L, pH ≤7.0, shock, failure of supportive care, and decreased level of consciousness. [ 39 ]…”

Section: Discussionmentioning

confidence: 99%

“…[ 36 37 38 39 41 ] ECMO may provide the necessary hemodynamic support if dialysis and supportive care are insufficient. [ 25 ]…”

Section: Discussionmentioning

confidence: 99%

See 2 more Smart Citations

Metformin toxicity in the intensive care unit: A case series and review of the literature

Peake,

Tessier,

Longo

et al. 2024

International Journal of Critical Illness and Injury Science

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Metformin toxicity is a life-threatening condition with high morbidity and mortality. Toxicity predominantly occurs in the setting of acute renal dysfunction, as the drug is solely eliminated by the kidneys. While this risk is widely known to clinicians, diagnosing metformin toxicity is challenging because commercially available serum metformin levels require days to weeks to result. Therefore, the intensivist must rely on medical history, clinical presentation, and routine laboratory findings to make the preliminary diagnosis. Treatment of metformin toxicity includes supportive fluid hydration, vasopressors, and emergent hemodialysis (HD). We report three critically ill patients who had near-fatal severe metformin-induced lactic acidosis. Their metformin levels were markedly higher than the toxicity threshold reported by the Federal Drug Agency. These patients made a prompt and complete recovery after the initiation of HD. We also review the pathophysiology, clinical presentation, diagnosis, and treatment of metformin toxicity.

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Successful use of methylene blue for catecholamine‐refractory vasoplegic shock due to metformin intoxication: A case report and literature review

Takahashi,

Nakano,

Motoki

et al. 2024

Acute Medicine & Surgery

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BackgroundSevere metformin intoxication can lead to lactic acidosis and vasoplegic shock, for which the optimal management strategy remains uncertain, especially in cases of severe circulatory collapse.Case PresentationA 45‐year‐old diabetic woman on metformin therapy presented with impaired consciousness and seizures. She had experienced a cardiac arrest and undergone extracorporeal cardiopulmonary resuscitation. Blood gas analysis showed severe lactic acidosis. A 71‐g metformin packet was found at the patient's home, suggesting an overdose. Despite extracorporeal support and blood purification, severe lactic acidosis and hypotension persisted. Methylene blue was administered 32 h from the onset, which improved her metabolic and circulatory status. We examined her blood sample throughout the case to check the transition of metformin blood concentration.ConclusionMethylene blue may be beneficial for severe metformin toxicity, regardless of the blood concentration of metformin and the time since intoxication. However, further research is needed to establish its optimal use and effectiveness.

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Refractory vasodilatory shock secondary to metformin overdose supported with VA ECMO

Abstract: Graphical abstract

Cited by 10 publications

References 28 publications

Surviving cardiac arrest from severe metformin-associated lactic acidosis using extracorporeal membrane oxygenation and double continuous venovenous haemodialysis

Surviving cardiac arrest from severe metformin-associated lactic acidosis using extracorporeal membrane oxygenation and double continuous venovenous haemodialysis

Metformin toxicity in the intensive care unit: A case series and review of the literature

Successful use of methylene blue for catecholamine‐refractory vasoplegic shock due to metformin intoxication: A case report and literature review

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