P4: Successful VA-Extracorporeal Membrane Oxygenation course in a patient with intentional Calcium Channel Blocker overdose without the need for mechanical ventilation

Abstract

Background: Cardiovascular medication overdose constitutes about 3.5% of all drug overdoses, and carries a mortality of 16%. Calcium channel blockers (CCBs) and beta blockers account for more than 65% of these deaths. Overdose of cardiovascular medications cause impaired cardiac contractility, vasoplegia, and/or rhythm disturbances. We review the current literature and case reports of VA ECMO being utilized to support patients with cardiovascular medication overdose. Methods: We present a case of a 20-year-old female with no medical history presenting with bradycardia and hypotension after ingesting ninety ezetimibe 10mg, seventy-five nebivolol 10mg, and one hundred and eighty amlodipine 5mg, from her mother’s medication, with the intent of self harm. Patient received glucagon, calcium, lipid emulsion, and was being supported on vasopressin, norepinephrine, epienephrine, phenylephrine and dopamine. The patients HR 78 and SBP 68mmHg. Laboratory significant for leukocytosis and elevated lactic acid. On exam, patient was lethargic, without respiratory distress. Echocardiogram revealed EF 55-65% and a large right ventricular mass suspicious for atrial myxoma. Patient was initiated on peripheral Veno-Arterial ECMO using Femoral-Femoral configuration to provide circulatory support as a bridge to allow drug metabolism and clearance. Results: Following 72 hours of VA-ECMO, vasopressors were weaned, with ECMO successfully being discontinued. Throughout the ECMO course, the patient had no respiratory compromise and did not require intubation or mechanical ventilation. Following decannulation, the patient was discharged to follow for an elective resection of the atrial myxoma. Conclusion: ECMO has been reported as a rescue therapy in CCB and Beta blocker overdose when refractory to medical therapy. Conventional medical therapy includes limiting absorption, increasing elimination and hemodynamic support using vasopressor agents, intravenous (IV) calcium infusion, hyperinsulinemia therapy, glucagon infusion, and IV lipid emulsion. This unique case demonstrates the successful utilization of VA ECMO to support patients with cardiovascular medication overdose and illustrates the potential for hemodynamic support without the need for ventilator support. This is the only known report of VA ECMO being utilized for calcium channel overdose while the patient is awake and unventilated throughout their ECMO course.