Calcium Channel Blocker Overdose and ECMO: Profound Effect of Multidisciplinary Approach in Patient Outcomes

Document Type

Conference Proceeding

Publication Date

10-2024

Publication Title

Chest

Abstract

INTRODUCTION: Calcium channel blockers (CCBs) are commonly used medications, and when used in excess, can result in life threatening side effects such as vasoplegia, hypoglycemia, and shock. We present a case of a male who overdosed on a CCB, and required extra corporeal membrane oxygenation (ECMO) support following an unsuccessful intense medical therapy. CASE PRESENTATION: A 59-year-old male with a history of hypertension, and schizophrenia, presented for severe hemodynamic instability secondary to accidental amlodipine overdose. On arrival, he had blood pressure of 60/34 mmHg, heart rate of 43 bpm, and oxygen saturation of 94% on room air. CXR was unremarkable, and EKG showed sinus bradycardia. His hemodynamics did not improve despite initial fluid resuscitation, multiple ampules of calcium chloride, and 2 doses of atropine. He was started on high dose insulin therapy with glucagon as per the recommendations of the poison control. Cordis was placed in an anticipation of transvenous pacemaker placement but his HR improved with the initial medical therapy. Subsequently, he was started on vasopressors including norepinephrine, epinephrine, and vasopressin due to worsening shock. Notably, insulin drip rate was increased from 1u/kg/hr to 6 u/kg/hr at a rate of 660 units/hour along with glucagon, and D5 drip. With the help of inpatient pharmacists, IV bolus of 250 ml of lipid emulsion was prepared and provided over one minute. Patient had worsening hypoxic respiratory failure due to volume overload requiring ventilator support, and renal replacement treatment was initiated. Following that, the patient was centrally cannulated for venoarterial(VA) ECMO for refractory shock with the help of the ECMO team. Patient's hemodynamic status improved significantly on the circuit, and was successfully decannulated on day 4. Two weeks later, the patient was discharged with good neurological function, and preserved cardiac contractility. DISCUSSION: Dihydropyridines like amlodipine, at very high doses, can lead to severe vasoplegia, cardiac suppression resulting in shock, bradycardia, and multiorgan failure. The first line of treatment includes atropine, IV calcium therapy, high dose insulin therapy, glucagon, vasopressors, and inotropes. Lipid emulsification therapy and plasmapheresis are considered second line medical interventions. For patients with shock refractory to these treatments, ECMO has shown to improve survival with meaningful recovery of functional status. While the medical ICU team provided and orchestrated the care, participation of a variety of disciplines was instrumental in this case. The surgical ICU/ECMO team helped with prompt ECMO cannulation, and the nephrology service helped with emergent renal replacement therapy. The pharmacy team assisted in preparing and delivering medications, including lipid emulsification therapy. The excellent nursing staff managed titration of multiple medications at very high doses, like an insulin drip at 660 units/hour. The collaboration of multiple specialties was crucial in the successful survival of our critically ill patient. CONCLUSIONS: Medical management remains the mainstay of treatment in patients with CCB overdose. Early consideration of ECMO in patients with refractory shock may improve meaningful survival. In such critically ill patients, early and effective involvement of a multidisciplinary team should be highly encouraged to improve mortality.

Volume

166

Issue

4 Suppl

First Page

A2992

Last Page

A2993

Comments

Chest 2024 Annual Meeting, October 6-9, 2024, Boston, MA

DOI

10.1016/j.chest.2024.06.1803

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