1207: Therapeutic Plasma Exchange in an Adolescent With Massive Ibuprofen Overdose

Introduction: Massive ibuprofen overdose with doses more than 400 mg/kg can lead to multi-organ failure and death. Treatment of ibuprofen overdose is complicated by its highly protein-bound pharmacokinetics, and the standard of care remains largely supportive. We present a case of a patient with ibuprofen overdose who underwent therapeutic plasma exchange (TPE) in our ICU. Description: A 17-year-old male with a history of depression and anxiety presented after intentional overdose of 500 tablets of 200 mg ibuprofen, approximately 1400 mg/kg ideal body weight. He was initially hemodynamically stable with normal neurologic exam but developed altered mental status requiring intubation for airway protection. Despite a bicarbonate infusion and aggressive resuscitative measures, he developed a persistent lactic acidemia (pH 7.08, bicarbonate 7, lactate > 17), acute kidney injury (creatinine 1.78), and hypotension refractory to norepinephrine, epinephrine, vasopressin, and stress-dose steroids. We started continuous renal replacement therapy (CRRT) for intractable metabolic acidosis. One session of TPE was performed with a 45% reduction in serum ibuprofen level from 860 mcg/ml to 470 mcg/ml. Within 12 hours of completing this single TPE session, he was fully weaned off vasopressors and no longer required CRRT. His course was further complicated by a significant upper gastrointestinal bleed, which improved after embolization of the left gastric artery and right gastroepiploic artery. He made a full recovery and was extubated after 5 days. Discussion: With ibuprofen being largely protein-bound and having a low volume of distribution, TPE was effective in reducing ibuprofen levels, leading to significant clinical improvement. This is consistent with 3 previous pediatric cases of massive ibuprofen overdose that were refractory to maximum medical therapy prior to the implementation of TPE, which reduced ibuprofen levels by 30-35% and allowed for rapid improvement. TPE may be considered in ibuprofen overdose when clinical deterioration is refractory to usual supportive care measures.