Refractory Hypotension and Delayed Respiratory Failure in Amlodipine Toxicity: A Multimodal Management Approach

Pulmonary oedema is a rare but possible paradoxical complication following the withdrawal of high-dose insulin euglycemic therapy (HIET). In the context of calcium channel blocker (CCB) toxicity, other potential confounding factors that could account for delayed pulmonary oedema include inadvertent fluid overload from management of hypotension caused by CCB toxicity, delayed toxicodynamic effects on the pulmonary vasculature and the heart, or a previously unknown underlying cardiac dysfunction. We report a case involving a woman in her early 50s who developed a symptomatic pulmonary oedema following the discontinuation of HIET used in the management of refractory hypotension complicating a massive amlodipine intoxication. This unexpected deterioration occurred despite improved haemodynamics following HIET used in the management of amlodipine toxicity. We have reviewed this case in relation to the existing literature on delayed or paradoxical pulmonary oedema complicating CCB toxicity, to the benefit of clinical personnel managing future similar cases.