SESSION TITLE: Critical Care Cases - Student/Resident
SESSION TYPE: Student/Resident Case Report Slide
PRESENTED ON: Sunday, October 25, 2015 at 10:45 AM - 11:45 AM
INTRODUCTION: Despite its widespread use, significant overdose of ibuprofen is an uncommon occurrence. However, massive ingestions have been associated with critical illness and death. We report here a case of severe overdose and a novel therapeutic approach.
CASE PRESENTATION: An 18 year old female, presented after intentional overdose of up to 600 pills of 200mg ibuprofen, roughly 120g. On presentation she was afebrile, BP 106/50 mm Hg, and HR of 119 bpm. She was minimally responsive, and was intubated. While initially hemodynamically stable, she soon became hypotensive requiring aggressive fluid hydration and combined norepinephrine, vasopressin, and phenylephrine. AKI and severe acidosis refractory to bicarbonate infusion were noted, and CVVH was started. GI hemorrhage was appreciated. Within 24h of admission her APACHE score was 30, with a predicted mortality of 70%. One plasma volume was exchanged during a session of TPE. Serum ibuprofen level decreased from 420 to 270 mcg/mL, a 35.7% reduction. After TPE there was marked improvement in hemodynamics. Vasopressors were weaned off within 24 hours, CVVH was discontinued after 48 hours, and patient was weaned from the ventilator after 72 hours.
DISCUSSION: We report here the first use of TPE to treat ibuprofen overdose. At normal doses, ibuprofen is an inhibitor of the COX enzymes, is 90-99% bound to protein, with renal and gastrointestinal side effects that are generally mild. However, massive ingestions of ibuprofen have been associated with encephalopathy, shock, renal failure, acidosis, dysrhythmia, and death (1). The optimal treatment of these severe cases is unclear. Therapeutic plasma exchange has been shown to be effective in reducing plasma levels of medications, including the NSAID diclofenac (2). Others have reviewed medications successfully cleared with TPE, identifying pharmacologic properties which may predict successful removal (3). With severe illness despite maximal support, extracorporeal removal appeared necessary for a chance of survival. Based on available information, ibuprofen had characteristics amenable to successful removal with TPE, including high protein binding, low volume of distribution, and chemical similarities to other medications successfully cleared by TPE. There were significantly reductions in plasma levels, and rapid subsequent clinical improvement.
CONCLUSIONS: While we would caution against the use of this therapy in minor overdoses, it appears to be an effective management for the massive overdose of ibuprofen with severe clinical consequences.
Reference #1: Holubek, et al. A report of two deaths from massive ibuprofen ingestion. Journal of Medical Toxicology. Volume 3, No. 2. 2007. 52-55.
Reference #2: Fauvelle, et al. Diclofenac, paracetamol, and vidarabine removal during plasma exchange in polyarteritis nodosa patients. Biopharmaceutics & drug disposition. Vol. 12. 1991. 411-424.
Reference #3: Ibrahim, et al. Drug removal by plasmapharesis: an evidence-based review. Pharmacotherapy. 27(11). 2007. 1529-1549.
DISCLOSURE: The following authors have nothing to disclose: Patrick Manning, Russel Roberts, Nitender Goyal
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