Massive Atenolol, Lisinopril, and Chlorthalidone Overdose Treated with Endoscopic Decontamination, Hemodialysis, Impella Percutaneous Left Ventricular Assist Device, and ECMO

Heise, C. William; Beutler, David S.; Bosák, Adam; Orme, Geoffrey; Loli, Akil; Graeme, Kimberlie A.

doi:10.1007/s13181-014-0419-y

Cited by 10 publications

(3 citation statements)

References 24 publications

(34 reference statements)

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“…Data for continuous kidney replacement therapy (CKRT) are sparse: in 3 cases of atenolol overdose, CKRT removed between 8 and 25% of total body burden adjusted for a 6-h period [ 120 , 123 , 128 ], with atenolol clearance ranging from 20 to 48 mL/min. In one sotalol overdose, CKRT clearance was estimated as 53 mL/min [ 122 ].…”

Section: Resultsmentioning

confidence: 99%

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

et al. 2021

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Background β-adrenergic antagonists (BAAs) are used to treat cardiovascular disease such as ischemic heart disease, congestive heart failure, dysrhythmias, and hypertension. Poisoning from BAAs can lead to severe morbidity and mortality. We aimed to determine the utility of extracorporeal treatments (ECTRs) in BAAs poisoning. Methods We conducted systematic reviews of the literature, screened studies, extracted data, and summarized findings following published EXTRIP methods. Results A total of 76 studies (4 in vitro and 2 animal experiments, 1 pharmacokinetic simulation study, 37 pharmacokinetic studies on patients with end-stage kidney disease, and 32 case reports or case series) met inclusion criteria. Toxicokinetic or pharmacokinetic data were available on 334 patients (including 73 for atenolol, 54 for propranolol, and 17 for sotalol). For intermittent hemodialysis, atenolol, nadolol, practolol, and sotalol were assessed as dialyzable; acebutolol, bisoprolol, and metipranolol were assessed as moderately dialyzable; metoprolol and talinolol were considered slightly dialyzable; and betaxolol, carvedilol, labetalol, mepindolol, propranolol, and timolol were considered not dialyzable. Data were available for clinical analysis on 37 BAA poisoned patients (including 9 patients for atenolol, 9 for propranolol, and 9 for sotalol), and no reliable comparison between the ECTR cohort and historical controls treated with standard care alone could be performed. The EXTRIP workgroup recommends against using ECTR for patients severely poisoned with propranolol (strong recommendation, very low quality evidence). The workgroup offered no recommendation for ECTR in patients severely poisoned with atenolol or sotalol because of apparent balance of risks and benefits, except for impaired kidney function in which ECTR is suggested (weak recommendation, very low quality of evidence). Indications for ECTR in patients with impaired kidney function include refractory bradycardia and hypotension for atenolol or sotalol poisoning, and recurrent torsade de pointes for sotalol. Although other BAAs were considered dialyzable, clinical data were too limited to develop recommendations. Conclusions BAAs have different properties affecting their removal by ECTR. The EXTRIP workgroup assessed propranolol as non-dialyzable. Atenolol and sotalol were assessed as dialyzable in patients with kidney impairment, and the workgroup suggests ECTR in patients severely poisoned with these drugs when aforementioned indications are present.

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Section: Resultsmentioning

confidence: 99%

“…For atenolol (n = 9), when hemodialysis was used, an increase in blood pressure was noted after the first treatment, with one exception [ 129 ]. Again, apparent improvement was slower with CKRT [ 120 , 127 , 128 ]. Dysrhythmias recurred in two patients, within two hours of ECTR cessation, requiring another session [ 13 , 15 ].…”

Section: Resultsmentioning

confidence: 99%

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

et al. 2021

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“…Cardiac pacing may be effective in increasing the rate of myocardial contraction however, electrical capture is not always successful and adequate blood pressure may not be restored [5]. It is not known how nodal agent toxicity will behave in the setting of an LVAD, though a handful of case reports described successful resuscitation of patients using percutaneous left ventricular assist (Impella) heart pump devices [6][7][8]. This is an interesting area of future research as one study has shown increased rates of suicide in patients with LVADs [9].…”

Section: Discussionmentioning

confidence: 99%

Complex Management of AV Nodal Agent Toxicity in Patients with Cardiac Devices: Massive Calcium Channel Antagonist Overdose in a Patient with a Permanent Pacemaker

Gibbons¹,

Chai²,

Erickson³

2022

J Cardio Case Rep

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We present a unique case of a massive calcium channel antagonist overdose in a patient with a permanent pacemaker. Upon presentation after the acute overdose, the patient's cardiac device was found to be pacing to an adequate rate (75 beats per minute) and she was admitted to the cardiac intensive care unit. Approximately 24 hours after her ingestion, she acutely decompensated and became hypotensive. The patient was started on infusions of norepinephrine, epinephrine, phenylephrine, and vasopressin. Her mean arterial pressure was unresponsive to multi-vasopressor therapy. She was then given a bolus of methylene blue and high-dose insulin euglycemic therapy. Despite these treatments, the patient remained hypotensive Therefore, intralipid emulsion therapy and IV epinephrine pushes were also administered. As a result of her shock and hemodynamic instability, her course was further complicated by hypoxemic respiratory failure for which she required ventilatory support and developed oliguric renal failure for which she was initiated on continuous veno-venous hemofiltration. This case emphasizes the challenges in managing complex physiology associated with nodal agent toxicity and is the first, to our knowledge, to describe management in a patient who already had a pacemaker, though it was ultimately ineffective in avoiding the patient's profound decompensation.

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Extracorporeal Membrane Oxygenation and Cardiopulmonary Bypass in the Poisoned Patient

Kerns¹,

Heffner²

2017

Critical Care Toxicology

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Massive Atenolol, Lisinopril, and Chlorthalidone Overdose Treated with Endoscopic Decontamination, Hemodialysis, Impella Percutaneous Left Ventricular Assist Device, and ECMO

Cited by 10 publications

References 24 publications

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

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

Complex Management of AV Nodal Agent Toxicity in Patients with Cardiac Devices: Massive Calcium Channel Antagonist Overdose in a Patient with a Permanent Pacemaker

Extracorporeal Membrane Oxygenation and Cardiopulmonary Bypass in the Poisoned Patient

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