Extracorporeal life support for severe cardiogenic shock induced  by diltiazem intoxication

Ilija Srdanovic; Mila Kovacevic; Maja Stefanovic; Milovan Petrovic; Milenko Cankovic; Lazar Velicki

doi:10.2298/VSP170926164S

Ilija Srdanovic University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia; Institute of Cardiovascular Diseases of Vojvodina, Sremska Kamenica, Serbia
Mila Kovacevic University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia; Institute of Cardiovascular Diseases of Vojvodina, Sremska Kamenica, Serbia
Maja Stefanovic University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia
Milovan Petrovic University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia; Institute of Cardiovascular Diseases of Vojvodina, Sremska Kamenica, Serbia
Milenko Cankovic University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia; Institute of Cardiovascular Diseases of Vojvodina, Sremska Kamenica, Serbia
Lazar Velicki University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia; Institute of Cardiovascular Diseases of Vojvodina, Sremska Kamenica, Serbia

DOI: https://doi.org/10.2298/VSP170926164S

Keywords: calcium channel blockers, extracorporeal membrane oxygenation, poisoning, pulmonary edema, shock, cardiogenic, treatment outcome

Abstract

Abstract

Introduction. Management of cardiogenic shock caused by severe drug intoxication is always challenging. In case of multidrug intoxication, a result, despite aggressive medical therapy, is often unpredictable. Utilization of extracorporeal life support devices in these cases has been suggested and reported results are promising. Case report. We presented a case of profound cardiogenic and distributive shock caused by suicidal intoxication with diltiazem and anionic surfactant ingestion in a 36-year-old woman. The patient ingested more than 90 tablets of diltiazem of 90 mg (ingested dose of 8.1 g), and 4 pieces of household toilet refresh agent containing anionic surfactant. During the admission, systemic blood pressure was 65/40 mmHg, heart rate 45 beats per minute, with signs of metabolic acidosis. The patient underwent several repeated gastric lavages. Emergent fluid resuscitation, calcium gluconate, insulin and vasopressive agents (dopamine and noradrenaline) infusions were administered with negligible effect. Due to progressive and refractory cardiogenic shock with signs of multiorgan failure, a decision was made to put the patient on venoarterial extracorporeal membrane oxygenator. Immediately after starting the extracorporeal membrane oxygenation, diuresis was established. During the next 36 h, an adequate end-organ perfusion was achieved with complete reversal of multi-organ failure. After the successful restoration of all major organ functions, the patient was successfully decannulated and discharged from the hospital after 10 days in a good condition. Conclusion. In severe cases of refractory cardiogenic and distributive shock due to diltiazem and other poison intoxication, venoarterial extracorporeal membrane oxygenation could allow additional circulatory support providing the bonus time for endogenous clearance of toxins. Venoarterial extracorporeal membrane oxygenation could be used in conjunction with the optimal medical therapy aiming to the restoration of end-organ perfusion and allowing for intrinsic drug and toxin metabolism and natural elimination.

References

REFERENCES

Bronstein AC, Spyker DA, Cantilena LR, Rumack BH, Dart RC. 2011 Annual report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 29th Annual Report. Clin Toxicol (Phila) 2012; 50(10): 911–1164.

Howarth DM, Dawson AH, Smith AJ, Buckley N, Whyte IM. Cal-cium channel blocking drug overdose: An Australian series. Hum Exp Toxicol 1994; 13(3): 161–6.

DeWitt CR, Waksman JC. Pharmacology, pathophysiology and management of calcium channel blocker and beta-blocker tox-icity. Toxicol Rev 2004; 23(4): 223–38.

Graudins A, Lee HM, Druda D. Calcium channel antagonist and beta-blocker overdose: Antidotes and adjunct therapies. Br J Clin Pharmacol 2016; 81(3): 453–61.

Müller D, Desel H. Common causes of poisoning: Etiology, di-ag¬nosis and treatment. Dtsch Arztebl Int 2013; 110(41): 690–9; quiz 700.

Persson HE, Sjöberg GK, Haines JA, Pronczuk de Garbino J. Poi-son¬ing severity score. Grading of acute poisoning. J Toxi¬col Clin Toxicol 1998; 36(3): 205–13.

St-Onge M, Dubé PA, Gosselin S, Guimont C, Godwin J, Archam-bault PM, et al. Treatment for calcium channel blocker poi-soning: A systematic review. Clin Toxicol (Phila) 2014; 52(9): 926–44.

Masson R, Colas V, Parienti J, Lehoux P, Massetti M, Charbonneau P, et al. A comparison of survival with and without extracor¬poreal life support treatment for severe poisoning due to drug intoxication. Resuscitation 2012; 83(11): 1413–7.

Radovanović MR, Miletić GM, Radovanović MS. Successful treat-ment of polymedicamentous poisoning with metoprolol, dilti-azem and cilazapril. Vojnosanit Pregl 2009; 66(11): 904–8. (Serbian)

Vuković-Ercegović G, Perković-Vukčević N, Đorđević S, Šegrt Z, Potre¬bić O, Janković SR, et al. Successful usage of intravenous li-pid emulsion in treatment of acuteverapamil poisoning: A case report. Vojnosanit Pregl 2017; 74(3): 278–81.

Daubin C, Lehoux P, Ivascau C, Tasle M, Bousta M, Lepage O, et al. Extracorporeal life support in severe drug intoxication: a ret¬rospective cohort study of seventeen cases. Crit Care 2009; 13(4): R138.

Mégarbane B, Leprince P, Deye N, Résière D, Guerrier G, Rettab S, et al. Emergency feasibility in medical intensive care unit of extracorporeal life support for refractory cardiac arrest. Inten-sive Care Med 2007; 33(5): 758–64.

Babatasi G, Massetti M, Verrier V, Lehoux P, Le Page O, Bruno PG, et al. Severe intoxication with cardiotoxic drugs: Value of emergency percutaneous cardiocirculatory assistance. Arch Mal Coeur Vaiss 2001; 94(12): 1386–92.

Lange DW, Sikma MA, Meulenbelt J. Extracorporeal membrane oxygenation in the treatment of poisoned patients. Clin Toxi-col (Phila) 2013; 51(5): 385–93.

Pozzi M, Koffel C, Djaref C, Grinberg D, Fellahi JL, Hugon-Vallet E, et al. High rate of arterial complications in patients sup-ported with extracorporeal life support for drug intoxication-induced refractory cardiogenic shock or cardiac arrest. J Tho-rac Dis 2017; 9(7): 1988–96.

Lee HM, Archer JR, Dargan PI, Wood DM. What are the adverse effects associated with the combined use of intravenous lipid emulsion and extracorporeal membrane oxygenation in the poisoned patient. Clin Toxicol (Phila) 2015; 53(3): 145–50.

Kolcz J, Pietrzyk J, Januszewska K, Procelewska M, Mroczek T, Malec E. Extracorporeal life support in severe propranolol and vera¬pamil intoxication. J Intensive Care Med 2007; 22(6): 381–5.