Extracorporeal membrane oxygenation in aluminum phosphide poisoning in Nepal: a case report

Abstract

BackgroundAluminum phosphide is a very common suicide agent in developing countries like Nepal. Due to the unavailability of a specific antidote, mortality is very high because the phosphine molecule that is formed leads to inhibition of the cytochrome oxidase enzyme system in mitochondria. Extracorporeal membrane oxygenation provides life-saving support to the cardiovascular and respiratory systems until the deadly poison is eliminated from the body.Case presentationWe encountered one case of 67-year-old Asian woman, a known case of major depressive disorder, who presented to our center with suicidal ingestion of aluminum phosphide with cardiovascular and respiratory dysfunction. On presentation in our emergency room, she had an ejection fraction of 20% and had to be immediately intubated for respiratory failure. Based on the evidence of almost 100% mortality with aluminum phosphide poisoning, extracorporeal membrane oxygenation was initiated in our intensive care unit. Her general condition and hemodynamics gradually improved over the course of 2 days and she was weaned from extracorporeal membrane oxygenation and ventilator by post-extracorporeal membrane oxygenation days 3 and 4, respectively. After psychiatric evaluation and establishment of normal vital parameters, she was moved out of intensive care unit on post-extracorporeal membrane oxygenation day 6 and discharged to home on post-extracorporeal membrane oxygenation day 10.ConclusionsAlthough this seems to be a small step in terms of global perspective, it is a giant stride for a developing country. The management of reversible but severe cardiac and respiratory failure certainly opens up newer scopes where we can ensure a quality health care service being made accessible even to the most underprivileged people.

Unexpected survival after deliberate phosphine gas poisoning: An Australian experience of extracorporeal membrane oxygenation rescue in this setting

“…[26][27][28] The past decade has seen a parallel increase in the use of ECMO support in phosphine toxicity, and although individual cases have been reported from Israel, USA and Germany, most case series have been published from developing countries. 8,[29][30][31][32][33] The largest series was an Indian retrospective observational study which identified 83 patients during this decade with severe AlP toxicity, and reported a mortality of 87% in those who did not receive ECMO, compared with only 33% mortality in those who did receive ECMO, despite the latter having worse baseline left ventricular EF and pH <7. The ECMO support period in all these series was typically less than seven days, and most people had normal recovery.…”

Survival after Aluminum Phosphide Poisoning in Pregnancy

“…Other authors suggested the use of intralipid emulsion to neutralize the dissolved circulating phosphine [ 14 ]. Moreover, in cases of severe hemodynamic collapse not responding to usual or novel approaches, recourse to extracorporeal membrane oxygenation (ECMO) or intra-aortic balloon pump is increasingly reported [ 15 , 16 ].…”

Extracorporeal life support in cardiotoxicant poisoning—A narrative review

“…57 ECLS was successfully used to manage AlP-poisoned patients with shock non-responding to inotropes/ vasopressors (Table 5). [56][57][58][59] Lactate concentrations ranged from 8.8 to 47 mmol/L, and all patients survived. All reported single cases presented severely depressed cardiac function with 20%-30% LVEF.…”