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

Abstract

Massive propranolol overdose may result in severe cardiotoxicity. A 48-year-old female had consumed more than 5000 mg of propranolol. Despite high-dose insulin, intravenous sodium bicarbonate, glucagon and inotropic support, she became hypotensive and subsequently arrested. Following cardiopulmonary resuscitation, she had a return of spontaneous circulation but continued to experience refractory hypotension. Resuscitation continued with venoarterial extracorporeal life support. Therapeutic plasma exchange was initiated to shorten time on extracorporeal life support. Extracorporeal life support was weaned off within 67 h, and she survived without neurological deficits. This records the largest propranolol overdose in recent years. When traditional antidotes are insufficient to prevent collapse, extracorporeal life support is a salvage therapy to maintain perfusion and reduce vasopressor requirements. As drug clearance is significantly prolonged, therapeutic plasma exchange can enhance removal of propranolol and reduce the time to extracorporeal life support removal. With increasing expertise and availability, extracorporeal life support should be considered early in patients who have overdosed with significant cardiotoxicity.

Extracorporeal treatment for poisoning to beta-adrenergic antagonists: systematic review and recommendations from the EXTRIP workgroup

“…In the final analysis, 76 studies were included for qualitative analysis, including 4 in vitro experiments [ 58 – 61 ], 2 animal experiments [ 62 , 63 ], 1 pharmacokinetic simulation study [ 64 ], 37 pharmacokinetic studies [ 65 – 101 ], and 32 case reports/series [ 13 , 15 , 35 , 102 – 130 ]. No comparative studies or randomized controlled trials were identified.…”

“…Dysrhythmias recurred in two patients, within two hours of ECTR cessation, requiring another session [ 13 , 15 ]. Although nine patients were reported for propranolol, the clinical impact of ECTR could only be analyzed in two patients: one improved slowly after hemoperfusion [ 125 ] while the other improved after TPE but had recurrence of hypotension shortly after [ 130 ]. For acebutolol, four patients were described, three of which improved during ECTR [ 109 , 113 , 117 ], while this was uncertain in one patient who received hemoperfusion [ 112 ].…”

The Utility of Ecmo and Intraaortic Balloon Pumps in Lipophilic Beta Blocker and Bupropion Overdose

“…Often extracorporeal life support (ECLS) such as ECMO and IABPs are initiated later in the patient's time course in hospital, oftentimes patients suffer multiple cardiac arrest prior to ECLS [23]. Delayed initiation of ECLS has direct implications of neurological outcomes of these patients [23]. We were able to get our patient out of the emergency room and into the ICU where cannulation for ECMO was immediately initiated.…”

“…Therefore, it should be noted that ECMO should be reserved for the most severely ill poisoned patients. Often extracorporeal life support (ECLS) such as ECMO and IABPs are initiated later in the patient's time course in hospital, oftentimes patients suffer multiple cardiac arrest prior to ECLS [23]. Delayed initiation of ECLS has direct implications of neurological outcomes of these patients [23].…”