SUCCESSFUL MANAGEMENT OF SOTALOL OVERDOSE IN THE ICU: UTILIZATION OF EARLY TEMPORARY IV PACING AND HEMODYALISIS

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Sotalol is a non-selective beta blocker with class III antiarrhythmic properties, a bioavailability of 90-100%, negligible protein binding, low lipid solubility, and 80-90% renal excretion. Sotalol toxicity is a medical emergency associated with hemodynamic instability and fatal arrhythmias. There are no standardized management guidelines with literature suggesting the use of IV glucagon, calcium, bicarbonate, high dose insulin infusion, lipid emulsion therapy and hemodialysis (HD). We report a case of Sotalol toxicity with significant cardiac instability successfully managed with conventional therapy in conjunction with early utilization of temporary pacing and HD. CASE PRESENTATION: 29-year-old female with history of thyroidectomy and drug abuse presented to the emergency department at 15:00 after ingesting 60 tablets of Sotalol 80mg in a suicide attempt. IV Glucagon and calcium were administered on scene. On arrival, she was bradycardic, hypotensive, with a QTc of 495 and serum sotalol concentration (SCC) of 11374ng/ml. Dextrose 10% and insulin infusion at 25units/hr were started for stabilization, up-titration was limited due to glucose disturbance. At 17:00 she required an Epinephrine infusion at 0.04mcg/hr for hemodynamic support, bicarbonate infusion, IV Mg, calcium gluconate and atropine. At 18:34 QTc increased to 683, patient was taken for prompt placement of temporary pacer with a set rate of 45bpm. Nephrology was consulted for emergent HD despite a normal kidney function to help with drug clearance. HD was initiated at 00:30 but was stopped after 2.5 hours due to hypotension and Torsades de Pointes (TdP). Insulin and Epinephrine drips were increased to 45units/hr and 0.24mcg/hr, pacing was increased to 50bpm, 2g of IV Mg were given with subsequent resolution of TdP. At 5:30, she had another episode of NSVT for which she received IV Mg. She required up to 0.5mcg/hr of Epinephrine for stabilization. On day 2 SSC was reduced to 6916ng/mL. At 1600, recurrent NSVT was noted, over-ride pacing was set at 90bpm, she underwent an additional 4 hours of HD. On day 3 she had a 3rd session 4-hour-HD with a post SCC of 401ng/mL. Temporary Pacer was removed on day 4. She had no recurrent arrhythmias and was successfully weaned off insulin and epinephrine drips. Repeat Sotalol levels remained <120ng/mL. DISCUSSION: Large dose Sotalol overdose is rarely encountered and carries significant risk to patients due to its QT prolonging effect associated with TdP, ventricular arrhythmias, and cases reporting asystole requiring cardiopulmonary resuscitation. Our patient was successfully managed without major complications or end-organ damage with early utilization of a temporary pacemaker and HD in addition to conventional therapy. CONCLUSIONS: It is plausible that early external pacing and HD played a role in avoiding adverse outcomes and should be considered in future cases of sotalol toxicity. REFERENCE #1: Anderson JL, Askins JC, Gilbert EM, et al. Multicenter trial of sotalol for suppression of frequent, complex ventricular arrhythmias: a double-blind, randomized, placebo-controlled evaluation of two doses. J Am Coll Cardiol. 1986;8(4):752-762. doi:10.1016/s0735-1097(86)80414-4 DISCLOSURES: No relevant relationships by Anil Kumar Ananthaneni, source=Web Response No relevant relationships by Cory Markham, source=Web Response No relevant relationships by Malak Modi, source=Web Response No relevant relationships by Nasim Motayar, source=Web Response No relevant relationships by Axel Rodriguez Rosa, source=Web Response