53: Enhancing Toxicology Outcomes with Combined Extracorporeal Therapies: A Path to Success

Introduction: Based on the 2022 Annual Report of the National Poison Data System, Of the 266 cardiovascular drugs,105 were of amlodipine overdose. Two such cases are discussed here. Case Presentation: Case 1: A 28-year-old male ingested 100 tablets of 10 mg Amlodipine. He was treated at nursing home within 4hrs consumption. He was intubated and started on vasopressors and inotropes. He had tachycardia, hypotension, hypoxemia on arrival. His SVRI was 544 dynes-sec/cm2. Started on Glucagon, High dose insulin euglycemia therapy, and lipid emulsion but his hemodynamics worsened with VIP score>100.Intiated on Vf-Af ECMO Started therapeutic plasma exchange. Over next 6 hours hemodynamics stabilized. Weaned and successfully decannulated ECMO on day 6. However, had floating thrombus in femoral artery requiring long term anticoagulation. Case 2: 32-year-old female ingested 36 tablets of 10mg Amlodipine, Initiated with Gastric lavage, Glucagon, HIET and ILE, Vasopressors. PICCO monitoring revealed SVRI - 1500 dynes-sec/cm2, CPO-0.44W. Was initiated on Started on TPE as hemodynamics were worsening. Achieved non sustained improvement. Intubated in view of dyspnea and EVLWI>10. Underwent second session of TPE 12 hours later, but hemodynamics continued to worsen with SVRI 560 dynes-sec/cm2with VIP score>100. Initiated on Vf-Af ECMO. Over next 12 hours, hemodynamics stabilized. Weaned and successfully decannulated ECMO on day 5. However, had ischemia reperfusion injury and compartment syndrome of leg. Conclusions: We report our cases to bring to light about combining extracorporeal therapies for successful outcome. Another important learning point is “Intervention marks a milestone, not end to therapy”. Similar outcomes were reported in literature, where patient was successfully weaned off ECMO on day8, which could be due to the persistence of the drug in the system. A significant amount of drug can be removed from the body by one plasma volume exchange, which probably resulted for rapid weaning of the ECMO even after consumption of 1000mg in one of our cases.