1267: SUCCESSFUL UTILIZATION OF ECMO AND ELS IN A PEDIATRIC PATIENT WITH HYDROXYCHLOROQUINE INGESTION

Abstract

Introduction: Hydroxychloroquine ingestion can present with seizures, myocardial depression, vasodilation, QRS and QTc prolongation leading to ventricular arrhythmias and cardiac arrest. Ingestions >5 g and blood concentrations >20 mg/L are associated with mortality. Plasma concentrations peak at 2-6 hours with 800–1400-hour half-life. Therapies including sodium bicarbonate, benzodiazepines, activated charcoal, and lipid infusions offer questionable benefit. Hydroxychloroquine has a large volume of distribution (>50 L/kg) and is 40-70% protein bound, so hemodialysis is not efficient for drug clearance. We describe the first case of extracorporeal liver support (ELS) (albumin dialysis) for hydroxychloroquine clearance, and the use of ECMO and ELS utilized in tandem for hydroxychloroquine ingestion. Description: A 17-year-old female presented after a 20 g intentional ingestion of hydroxychloroquine. She had ventricular tachycardia with a 15-minute cardiac arrest. She received activated charcoal, sodium bicarbonate, benzodiazepines, and lipid infusion. Due to vasodilatory shock refractory to 4 high-dose vasoactive infusions, she was cannulated to femoral-femoral venoarterial (VA) ECMO on hospital day (HD) 2. She weaned from ECMO on HD 5, but developed lower extremity ischemia necessitating a right through-the-knee amputation. To facilitate clearance of protein-bound hydroxychloroquine, ELS was initiated on HD 1. ELS was discontinued on HD 7, but resumed on HD 9 due to recurrence of vasoplegia. Hydroxychloroquine levels peaked at 52 mg/L on HD 1. Her level was 9.7 mg/L prior to discontinuation of ELS, increased to 12 mg/L after discontinuation, and decreased to < 1 mg/L on HD 15 when ELS was discontinued. She had full renal and neurologic recovery and was discharged to inpatient rehabilitation. Discussion: In cases of severe hydroxychloroquine ingestion, VA ECMO can be utilized for refractory circulatory shock and can provide hemodynamic stability to utilize other extracorporeal therapies in tandem. Based on the clinical and pharmacologic evidence in this case, ELS may provide expedited drug clearance in cases of hydroxychloroquine ingestion.