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Extracorporeal membrane oxygenation (ECMO) overview. (A) venovenous (VV) ECMO, and (B) venoarterial (VA) ECMO.
Source publication
Context
Poisoning may lead to respiratory failure, shock, cardiac arrest, or death. Extracorporeal membrane oxygenation (ECMO) may be used to provide circulatory support, termed venoarterial (VA) ECMO; or respiratory support termed venovenous (VV) ECMO. The clinical utility of ECMO in poisoned patients remains unclear and guidelines on its use in t...
Context in source publication
Context 1
... is a technique of draining venous blood by means of an extracorporeal blood pump and passing it through a membrane lung where oxygen is added and carbon dioxide is removed. The oxygenated blood is then returned to the venous system (venovenous [VV] ECMO) for respiratory support or to the arterial system (venoarterial [VA] ECMO) for circulatory support (Figure 1). ...
Citations
... 30 Extracorporeal life support (commonly extracorporeal membrane oxygenation, ECMO) is increasingly employed to support poisoned patients as they metabolize and eliminate xenobiotics responsible for shock and cardiovascular instability. 31,32 Few reports describe the use of ECMO to support patients following bupropion overdose 33 ; fewer still describe support of pediatric bupropion poisonings. 28 This study describes the clinical characteristics of pediatric bupropion overdoses treated with ECMO and reported to a regional poison control (PC) center over several decades. ...
Objective Our objective was to describe clinical characteristics and course of pediatric bupropion ingestions requiring extracorporeal membrane oxygenation (ECMO) life support.
Desgin The study included a retrospective cohort of patients ≤18 years of age reported to a regional poison control (PC) system covering three states in the upper Midwest United States. All bupropion exposures ≤18 years of age, coded as receiving ECMO to treat toxicity, were included. Clinical presentation and management including ECMO are presented as descriptive statistics.
Results During the study period, 4,951 bupropion exposures were reported; 1,145 (23.1%) were children. Nine patients were coded as undergoing ECMO; four (44.4%) were ≤18 years of age (median 16, range 14–17). All were treated with venoarterial ECMO. The median time from ingestion to presentation was 2.25 hours (range: 1–3.5). Median first systolic blood pressure and pulse were 100 mm Hg (range: 70–124) and 119.5 (range: 70–175). The median time from ingestion to ECMO was 17.63 hours (range: 7.25–33.75); median number of vasopressors was 2.5 (range: 2–3). All experienced multiple seizures, ventricular dysrhythmias, and hypotension. Three of four sustained cardiac arrest. All but one required transfer to an ECMO-capable facility for definitive care. Three patients survived with full neurologic recovery; one died.
Conclusion Pediatric bupropion cases requiring ECMO were rare in this study. Time to initiation and duration of EMCO suggest that the variable onset of hemodynamic instability may delay ECMO initiation. It is incumbent on PCs and medical toxicologists to educate prescribers and pediatricians about bupropion's potential lethality and to consider early transfer to an ECMO center.
... As many such cases involve reversible impairment, the possibility of saving lives increases with prompt initiation of V-A ECMO. 54 In cardiopulmonary arrest due to accidental hypothermia, restoration of temperature with V-A ECMO has been effective. 55 Although the indication for V-A ECMO in septic shock has not yet been fully established, 56 its use is reported to improve survival in cardiogenic shock due to sepsis-induced myocardial damage. ...
... It is commonly used in patients with refractory cardiogenic shock and for patients with refractory cardiac arrest from ventricular tachycardia as extracorporeal cardiopulmonary resuscitation (ECPR) [8,9]. Data for extracorporeal membrane oxygenation (ECMO) as a bridge to recovery in poisoned patients are encouraging; poisoned patients have better outcomes than those cannulated for other indications, presumably due to the implied reversibility of their underlying pathophysiology [10]. Poison center data reveal thousands of bupropion exposures annually [2], of which only a small percentage develop severe cardiotoxicity. ...
Bupropion is a substituted cathinone (β-keto amphetamine) norepinephrine/dopamine reuptake inhibitor andnoncompetitive nicotinic acetylcholine receptor antagonist that is frequently used to treat major depressive disorder. Bupropion overdose can cause neurotoxicity and cardiotoxicity, the latter of which is thought to be secondary to gap junction inhibition and ion channel blockade. We report a patient with a confirmed bupropion ingestion causing severe cardiotoxicity, for whom prophylactic veno-arterial extracorporeal membrane oxygenation (ECMO) was successfully implemented. The patient was placed on the ECMO circuit several hours before he experienced multiple episodes of hemodynamically unstable ventricular tachycardia, which were treated with multiple rounds of electrical defibrillation and terminated after administration of lidocaine. Despite a neurological examination notable for fixed and dilated pupils after ECMO cannulation, the patient completely recovered without neurological deficits. Multiple bupropion and hydroxybupropion concentrations were obtained and appear to correlate with electrocardiogram interval widening and toxicity.
... However, as in this case, if the patient develops refractory shock, VA-ECMO has the potential to improve the patient's hemodynamic and metabolic status. In 2021, Upchurch et al. 9 recommended the consideration of VA-ECMO in the absence of contraindications for all patients with acute poisoning and refractory cardiogenic shock. In fact, the use of VA-ECMO for treating drug intoxication, including several cases of amlodipine intoxication, has increased in recent years. ...
... In fact, the use of VA-ECMO for treating drug intoxication, including several cases of amlodipine intoxication, has increased in recent years. 9 Similar to drug-induced refractory shock, septic shock causes a condition that can result in simultaneous cardiogenic and distributive shock. In recent years, VA-ECMO has been found to be effective for distributive shock. ...
Background:
Calcium channel blockers and angiotensin II receptor blockers are commonly prescribed to treat hypertension. Massive overdoses can cause both distributive and cardiogenic shock because of their effects on vascular smooth muscles and severe myocardial depression.
Case presentation:
We present the case of a 46-year-old man who was brought to our emergency department after ingesting 1210 mg amlodipine and 936 mg candesartan. The patient's hemodynamic status deteriorated despite treatment with vasopressors, calcium gluconate, and hyperinsulinemia-euglycemia therapy with mechanical ventilation. Venoarterial extracorporeal membrane oxygenation was initiated for refractory shock. The patient was weaned off extracorporeal membrane oxygenation on day 5 and discharged on day 18 of hospitalization.
Conclusion:
When medical therapies are ineffective, aggressive venoarterial extracorporeal membrane oxygenation should be considered for the management of refractory shock in the setting of calcium channel blocker with angiotensin II receptor blocker overdose.
... Neurologically intact survival and cardiac recovery are more likely in poisoned patients requiring VA-ECMO. [42][43][44] If administration of ILE is being considered to treat severe cardiotoxic poisoning unresponsive to maximal toxin-specific cardiovascular support measures, the patient will be a candidate for VA-ECMO. Unfortunately, clinical equipoise has been lost with this therapy, as evidenced by reports of ILE use in non-life-threatening poisoning prior to accepted therapies, including the treatment of serotonin syndrome, low-dose cyclic antidepressant overdoses without risk of CVS toxicity and various sedative intoxications. ...
Intravenous lipid emulsion (ILE) has been suggested as a potential universal antidote for cardiovascular and central nervous system toxicity resulting from a multitude of pharmaceutical and nonpharmaceutical poisonings. While there is some evidence to suggest that ILE may have a positive effect in cardiovascular system toxicity after accidental intravenous lipophilic local anaesthetic overdose, this cannot be extrapolated to cases of severe poisoning resulting from oral drug overdose. Treatment recommendations are based upon variable outcome animal studies and low‐level clinical evidence with a significant degree of positive reporting bias. Currently, there is a paucity of controlled clinical data to support ILE use to treat severe drug poisoning after oral overdose. ILE use should be limited to well‐designed, ethically approved, controlled clinical trials aimed at determining the true effectiveness of this therapy. This should replace the current scattergun clinical use in a multiplicity of poisoning scenarios and subsequent anecdotal reporting approach.
... Although reported ECPR survival rates vary widely, a significant number of studies have described instances of functional and neurologically-intact recovery with ECPR. This suggests that optimal patient selection is key and ECPR still shows much promise in the correct carefully selected patient subgroup 94 . ...
Background:
Extracorporeal cardiopulmonary resuscitation (ECPR) represents last-line salvage therapy for poisoning-induced cardiac arrest but no review has focused on this specific area.
Objective:
This scoping review sought to evaluate the survival outcomes and characteristics of published cases of ECPR for toxicological arrest, with the aim of highlighting the potential and limitations of ECPR in toxicology.Eligibility Criteria.We searched PubMed and Cochrane for eligible papers from database inception to October 1, 2022 using the keywords "toxicology", "ECLS" and "CPR". References of included publications were searched to identify additional relevant articles. Qualitative synthesis was used to summarize the evidence.
Results:
85 articles were chosen: 15 case series, 58 individual cases and 12 other publications that were analyzed separately due to ambiguity. ECPR may improve survival outcomes in selected poisoned patients, although the extent of benefit is unclear. As ECPR for poisoning-induced arrest may have better prognosis compared to from other aetiologies, it is likely reasonable to apply ELSO ECPR consensus guideline recommendations to toxicological arrest.Out-of-hospital cardiac arrest alone may not be sufficient grounds to deny ECPR if effective resuscitation had been promptly instituted. Poisonings involving membrane-stabilizing agents and cardio-depressive drugs, and cardiac arrests with shockable rhythms appear to have better outcomes. ECPR may permit excellent neurologically-intact recovery despite prolonged low-flow time of up to four hours. Early ECLS activation and pre-emptive catheter placement can significantly shorten time-to-ECPR and possibly improve survival.
Conclusion:
As effects of poisoning may be reversible, ECPR can potentially support poisoned patients through the critical peri-arrest state.
... ECMO is an attractive choice as a bridge to spontaneous recovery of CLS in patients with refractory shock or hypoxemia [9]. The use of V-V ECMO and veno-arterial ECMO (V-A ECMO) is dependent on the hemodynamic profile, with patients with fluid overload or intact perfusion needing V-V ECMO and patients with fulminant hypovolemic shock requiring V-A ECMO. ...
Capillary leak syndrome (CLS) is a rare clinical syndrome associated with significant morbidity and mortality. Intensive care and supportive therapy constitute the mainstay of the treatment, along with judicious use of crystalloids and colloids such as dextran and starch during the leak phase. The advantages of proning, steroids, and intravenous immunoglobins are worth contemplating in patients with such a presentation. Extracorporeal membrane oxygenation appears to be an excellent strategy to surmount the impediments of the leak and post leak phase of CLS, especially in patients with severe or refractory hypoxemia.
... Several cases concerning the treatment of patients with glyphosate surfactant intoxication using ECMO and CRRT have been reported. [5][6][7] Garlich et al [8] reported the clinical improvements and a hemodialysis clearance of 97.5 mL/min of a patient with glyphosate surfactant herbicide poisoning and the subsequent hemodialysis treatment. They considered that the molecular weight and volume distribution of POEA would be large. ...
... Overall, evidence for the use of VA ECMO for hemodynamic support in acutely poisoned patients is growing and is associated with relatively short ECMO runs and good outcomes. The most frequently encountered complications are bleeding and limb ischemia [31]. ...
Metformin overdose may result in vasodilatory shock, lactic acidosis and death. Hemodialysis is an effective means of extracorporeal elimination, but may be insufficient in the shock setting. We present a case of a 39 yo male who presented with hypotension, coma, hypoglycemia, and lactate of 6.5 mmol/L after ingesting an unknown medication. Metformin overdose was suspected, and he was started on hemodialysis. He developed profound vasoplegia refractory to high doses of norepinephrine, vasopressin, epinephrine and phenylephrine. Venoarterial extracorporeal membrane oxygenation (VA ECMO) was initiated and he had full recovery. Serum analysis with high resolution liquid chromatography mass spectrometry revealed a metformin level of 678 μg/mL and trazodone level of 2.1 μg/mL. This case is one of only a handful of reported cases of metformin overdose requiring ECMO support, and we report the highest serum metformin levels in the literature to date. We recommend early aggressive hemodialysis and vasopressor support in all suspected cases of metformin toxicity as well as VA ECMO if refractory to these therapies.
Objective:
We present a case of vasodilatory shock secondary to metformin overdose requiring venoarterial extracorporeal membrane oxygenation (VA ECMO) support. This case is one of only a handful of reported cases of metformin overdose requiring ECMO support, and we report the highest serum metformin levels in the literature to date.
Data sources:
University of San Francisco, Fresno.
Study design:
Case report.
Data extraction:
Clinical records and high resolution liquid chromatography mass spectroscopy analysis.
Data synthesis:
None.
Conclusions:
Venoarterial ECMO provided an effective means of hemodynamic support for a patient with severe metformin toxicity.
