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ECMO for Shock Due to Drug Overdose: Timely Transfer to ECMO Capable Center Can Save Lives FREE TO VIEW

Ameer Khan, MBBS; Jai Raman, MD; Omar Lateef, MD
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Rush University Medical Center, Chicago, IL

Chest. 2015;148(4_MeetingAbstracts):197A. doi:10.1378/chest.2270082
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SESSION TITLE: Critical Care Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Drug overdose and intoxication caused 2937 deaths in 2012. 9.84% of these deaths were due to cardiovascular medications. We present a case of a patient in refractory shock of unknown etiology who required ECMO for salvage, which later turned out to be due to drug overdose

CASE PRESENTATION: Our patient was a 31 y/o medical assistant who had initially presented to an outside hospital with headaches. She was found to be in severe shock and required multiple vasopressors. She was referred to a tertiary hospital for further management She arrived at Rush MICU on 5 vasopressors with MAPs around 50mmHg. Echocardiography showed mild RV dysfunction and normal LV function. CT chest, abdomen and pelvis did not reveal significant abnormalities. She was given 9 L of crystalloid over 8 hours, started on inhaled NO to decrease RV afterload, given stress dose steroids and broad spectrum antibiotics. For possible drug overdose, she received lipid emulsion, insulin and D10. CVVH was started. Unfortunately, her MAP declined to 40mmHg. Given refractory shock, VA-ECMO was started for hemodynamic support with cannulae placed in the left femoral artery and vein. Vasopressors were weaned in 12 hours and CVVH stopped on day 3. Weaning of ECMO with successful decannulation occurred on day 5. She was extubated on day 7. After extubation, she admitted to intentionally taking multiple combination pills containing Amlodipine and Losartan. She was discharged from our hospital on day 12, with no sequelae of severe shock and no evidence of organ dysfunction

DISCUSSION: ECMO has been successfully employed for refractory shock due to drug overdose with 2 case series demonstrating neurologically intact survival rate of 76% and 66%. Interestingly, in both case series, all the patients were started on ECMO within 24 hours of admission. Given that most drug overdoses cause transient hemodynamic issues, ECMO seems a reasonable choice of support. In our patient, rapid institution of ECMO was performed for refractory shock due to drug overdose - which was only confirmed later

CONCLUSIONS: For patients with severe shock suspected to be due to drug overdose, ECMO has a role and should be strongly considered. Early transfer to an ECMO capable center can potentially save lives

Reference #1: Crit Care 2009;13(4) Extracorporeal life support in severe drug intoxication: a retrospective cohort study of seventeen cases. Daubin C et al

Reference #2: J Med Toxicol 2013 Mar;9(1):54-60 A review of emergency cardiopulmonary bypass for severe poisoning by cardiotoxic drugs. Johnson et al

DISCLOSURE: The following authors have nothing to disclose: Ameer Khan, Jai Raman, Omar Lateef

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