Dire consequence of lipid emulsion therapy and VA-ECMO in a calcium channel blocker overdose: A case report

Calcium channel blocker (CCB) overdose can result in profound and refractory shock and multiorgan failure requiring advanced therapies, including vasopressors, renal replacement therapy, intravenous lipid emulsion (ILE), and venoarterial extracorporeal membrane oxygenation (VA-ECMO). ILE therapy has been used in selected drug overdoses due to its proposed lipid sink effect; however, the safety of combined ILE therapy and extracorporeal support remains incompletely defined. We report the case of a 26-year-old man who presented after a massive amlodipine overdose and developed progressive refractory shock over an eight-day hospitalization despite maximum medical therapy. This included vasopressors, calcium infusions, high-dose insulin protocols, mechanical ventilation, continuous renal replacement therapy (CRRT), and ILE. After ILE use, CRRT filters clotted and laboratory testing was intermittently rejected due to sample interference. Due to persistent hemodynamic collapse, emergent VA-ECMO was attempted. Upon initiation of flow, yellow particulate material rapidly precipitated within the oxygenator and tubing, resulting in complete circuit obstruction, abrupt loss of support, cardiac arrest, and death. This case highlights a potential catastrophic interaction between ILE and VA-ECMO in severe amlodipine overdose. Although causality cannot be definitively established, the temporal association between ILE, hypertriglyceridemia, and VA-ECMO obstruction raises concern for lipid destabilization and agglutination within the circuit. In selected CCB overdoses, earlier consideration of mechanical circulatory support before prolonged or high-dose ILE exposure may be warranted.