Single-Pass Albumin Dialysis as Rescue Therapy for Pediatric Calcium Channel Blocker Overdose

Abstract

Calcium channel blocker ingestions remain one of the leading causes of death related to cardiovascular medication ingestion in both adults and pediatric patients. We report a case of a 17-year-old, 103 kg female presenting after an intentional polypharmacy ingestion, including 500 to 550 mg of amlodipine. She presented with profound vasoplegia and cardiovascular collapse requiring high-dose inotropes and eventual life support with extracorporeal membrane oxygenation (ECMO). Current available treatments, designed for adults, including lipid emulsion and methylene blue, provided no sustained clinical improvement. This resulted in the initiation of single-pass albumin dialysis (SPAD). We aim to describe the clinical implications, amlodipine toxic dose effects, and clinical challenges associated with large pediatric patients and high-dose medications. We also discuss several challenges encountered related to dosing and concentration of medications, which led to fluid overload. Given the ongoing obesity epidemic, we routinely see pediatric patients of adult size. This will continue to challenge pediatric use of adult dosing and concentrations to avoid excessive fluid administration for high-dose medications, such as insulin and vasoactive agents. To our knowledge, this is the first successful case of using SPAD in conjunction with ECMO for salvage therapy after refractory life-threatening calcium channel blocker toxicity.

Treatment Modalities in Calcium Channel Blocker Overdose: A Systematic Review

“…The use of the same was reported in 16 cases. All except two cases reported improvement in both the blood pressure and heart rate, while in two cases, hyperglycemia and vomiting were reported post-glucagon therapy [4][5][6][7][8][9][10][12][13][14][15][16][20][21][22].…”

“…Methylene blue: The use of methylene blue at a dose of 1 mg/kg/hour was reported in three cases to improve blood pressure. All three patients survived and reported improvements in hemodynamic parameters [13,15,16].…”

“…However, inconsistent effects were reported. Improvements in blood pressure and heart rate were reported [4][5][6][7][12][13][14][15][16][19][20][21][22]. Two patients expired despite the use of calcium gluconate [8,9].…”

“…All these patients received high-dose insulin therapy, out of which 36.3% of patients were reported to develop hypokalemia and 25.7% developed hypoglycemia [11]. The majority of the studies reported improvement in hemodynamic parameters in the form of blood pressure, heart rate, mean arterial pressure, and urine output with HIET [4][5][6][7]9,[11][12][13][14][15][16][17][18][19][20].…”

“…The most common vasopressor used in calcium channel blocker-induced cardiogenic shock was norepinephrine [4][5][6][7][8][9][10][12][13][14][15][16][17][18][19][20]22]. In one study, phenylephrine was utilized, and terlipressin was used in another [19].…”