Extracorporeal Membrane Oxygenation in Drug Overdose: A Clinical Case Series

Case Report IntroductIonCardiovascular medication overdose constitutes about 3.5% of all drug overdoses, and it carries a mortality of about 16%.[1] Calcium channel blockers (CCBs) and beta blockers alone account for more than 65% of these deaths.[2] The cardiovascular collapse associated with these drugs is due to impaired cardiac contractility, profound vasodilation, and/or rhythm disturbances.Treatment with volume resuscitation, vasopressors, hyperinsulinemia-euglycemia therapy, glucagon, and temporary pacing has been successful when the overdose is mild to moderate.[3] In severe overdose, with shock refractory to maximal medical therapy, circulatory assist device has been used successfully.[4] This case series describes the use of venoarterial extracorporeal membrane oxygenation (VA ECMO) circulatory support as a salvage therapy in patients resistant to maximal medical management. case reports Case 1A 29-year-old female was admitted to the emergency department with severe hypotension and vomiting, 8 h following ingestion of 40 tablets of amlodipine (10 mg each; total 400 mg).She was conscious, oriented with blood pressure (BP) of 70/40 mmHg; heart rate (HR) of 55/min; respiratory rate (RR) of 30/min; oxygen saturation (SpO 2 ) of 92% and warm peripheries.Gut decontamination with activated charcoal and resuscitation with boluses of intravenous (IV) crystalloids, calcium gluconate, and norepinephrine infusion was done.On arrival to Intensive Care Unit (ICU), her BP was 80/40 mmHg.Arterial blood gas (ABG) analysis revealed metabolic acidosis with pH of 7.25 and serum lactate of 5.2 mmol/dL.Her echocardiography showed normal left ventricular (LV) function.She was electively intubated and ventilated and resuscitated with a total volume of 5.94 L of IV crystalloids.She was also initiated on standard doses of IV 10% calcium gluconate; IV 20% intralipid IV insulin, and IV glucagon [Table 1].Despite 9 h of aggressive resuscitation, her metabolic acidosis and hemodynamics worsened requiring Overdose of cardiovascular medications such as beta blockers and calcium channel blockers cause impaired cardiac contractility, vasoplegia, and/or rhythm disturbances.In addition to conventional management of limiting absorption, increasing elimination and hemodynamic support intravenous (IV) calcium infusion, hyperinsulinemia-euglycemia therapy, glucagon infusion, and IV lipid emulsion have been tried.Extracorporeal circulatory assist device support has been reported as a rescue therapy in overdose refractory to maximal medical therapy.We report three patients with cardiovascular medication overdose presenting with profound cardiovascular instability refractory to medical therapy.Venoarterial extracorporeal membrane oxygenation support (VA ECMO) was initiated to provide hemodynamic support.Despite the occurrence of device-associated complications, the outcome was good and all patients survived.VA ECMO may be considered in patients with severe refractory shock due to cardiotoxic medication overdose.