Venoarterial extracorporeal membrane oxygenation for the management of massive amlodipine overdose

Abstract

A 50-year-old man was admitted to the intensive care unit with respiratory failure and shock after suffering a massive overdose of amlodipine, lisinopril and hydrochlorothiazide. Despite mechanical ventilation, vasopressors, calcium gluconate, hyperinsulinemia-euglycemia therapy, methylene blue and intravenous fat emulsion, the patient's respiratory and hemodynamic status deteriorated. Venoarterial extracorporeal membrane oxygenation (ECMO) was initiated to provide cardiopulmonary support in the setting of profound respiratory failure and refractory shock. The patient was placed on ECMO 19 hours after arrival to the hospital, after which vasopressor and ventilatory requirements decreased significantly. The patient was decannulated from ECMO after 8 days and was discharged home after a 56-day hospitalization. Early institution of ECMO should be considered for the management of respiratory failure and refractory shock in the setting of calcium channel blocker overdose when medical therapies are insufficient.

Acute Respiratory Distress Syndrome Associated with Intravenous Lipid Emulsion Therapy for Verapamil Toxicity, Successfully Treated with Veno-Venous ECMO

“…Veno-venous ECMO requires less heparin than veno-arterial ECMO, thus reducing mortality from bleeding. ECMO was reported in several cases of CCBs poisoning [8][9][10], in all of them veno-arterial ECMO was used because of cardiovascular collapse. This is unlike our case where veno-venous ECMO was used due to ARDS.…”

“…Few case reports described the successful use of extracorporeal membrane oxygenation (ECMO) for CCBs poisoning [8][9][10]. Only one case report of ECMO used for ILE-induced ARDS was published [11], the procedure was veno-arterial ECMO, not veno-venous.…”

Pilot Trial of Intravenous Lipid Emulsion Treatment for Severe Nifedipine-Induced Shock

“…Nifedipine was cited in two publications in which both patients survived [7,24]. There are three published toxic cases of another dihydropyridine, amlodipine, where ILE was included in therapy; two survived [7,16]. Of course, all of these reports are subject to confounders including publication bias, effects of co-ingested xenobiotics, and multiple treatments in addition to ILE.…”

“…It has also been used to treat calcium channel antagonist toxicity in at least 20 published human cases, primarily involving verapamil and diltiazem [7][8][9][10][11][12][13][14][15][16]. However, there is limited pre-clinical and clinical experience with ILE use for dihydropyridine toxicity [7,[16][17][18][19]. Swine have been used in numerous toxin and shock models and are one of the dominant animal species used in evaluating calcium channel antagonists and betablockers in the toxicology literature [20][21][22][23].…”

Therapeutic Approach to the Critically Poisoned Patient

“…Extracorporeal membrane oxygenation is indicated in poisoned patients in refractory shock that are failing conventional treatment [144] (Level III recommendation). There are multiple reports of poisoned patients successfully resuscitated with ECMO [145,146]. In a retrospective review of poisoned patients in arrest or shock, mortality was improved in those that received ECMO (12/14) compared to those that did not (23/48) (86 % vs. 48 %, p < 0.02) [147].…”