Transforming Toxicology Outcomes: The Game-changing Power of Combined Extracorporeal Therapies

Introduction:As per the 2022 Annual Report of the National Poison Data System, of the 266 cardiovascular drugs, 105 were of amlodipine overdose.Extracorporeal membrane oxygenation (ECMO), venoarterial modality to be precise, used as a bridge to recovery has transformed the recovery of patients with calcium channel blocker toxicity, and when combined with other modalities of extracorporeal support like therapeutic plasma exchange (TPE), will hasten the process of recovery, facilitating early weaning of ECMO.We present three cases of amlodipine overdose with three different doses of the drug and observe that combining extracorporeal therapies results in early recovery.Case 1: A 28-year-old male ingested 100 tablets of 10 mg amlodipine.He was treated at a nursing home within 4 hours of consumption.He was intubated and started on vasopressors and inotropes.He had tachycardia, hypotension, and hypoxemia on arrival.His SVRI was 544 dynes-sec/cm 2 .Started on glucagon, high-dose insulin euglycemia therapy (HIET), and lipid emulsion, but his hemodynamics worsened with VIP score > 100.Initiated on femoral vein to femoral artery -venoarterial (Vf -Af) ECMO.Started TPE.Over the next 6 hours, hemodynamics stabilized.Weaned and successfully decannulated from ECMO on day 6.However, had a floating thrombus in the femoral artery requiring long-term anticoagulation.Case 2: A 65-year-old male ingested about 25 tablets of 5 mg amlodipine.Was referred to us from the primary care facility on the third day after consumption.He was in severe shock and on triple vasopressors.Was intubated in an emergency in view of severe hypotension and metabolic acidosis.Immediately started on invasive cardiac output monitoring, which showed a systemic vascular resistance index (SVRI) of 750 dynessec/cm 2 .Started on glucagon infusion, HIET, lipid emulsion along with IV fluids and vasopressors, with which SVRI improved to 1200 dynes-sec/ cm 2 and the pressor response sustained with an increase in SVRI to 1560 dynes-sec/cm 2 in the next 2 hours.Plan of extracorporeal therapies like TPE or extracorporeal membranous oxygenation was laid back.Vasopressors and other supportive medicines are gradually withdrawn.The patient was off vasopressors in the next 24 hours, extubated 48 hours later, and was discharged on day 7. Case 3: A 32-year-old female ingested 36 tablets of 10 mg amlodipine.Initiated with gastric lavage, glucagon, HIET, and ILE, vasopressors.Pulse indexed continuous cardiac output monitoring (PICCO) revealed SVRI-1500 dynes-sec/cm 2 , CPO 0.44W.It was initiated on started on TPE as hemodynamics were worsening.Achieved nonsustained improvement.Intubated in view of dyspnea and extravascular lung water index (EVLWI) > 10.Underwent the second session of TPE 12 hours later, but hemodynamics continued to worsen with SVRI 560 dynes-sec/cm 2 with VIP score > 100.Initiated on Vf -Af ECMO.Over the next 12 hours, hemodynamics stabilized.Weaned and successfully decannulated from ECMO on day 5.However, had ischemia reperfusion injury and compartment syndrome of the leg.Discussion: Wienberg et al. were able to wean the patient from ECMO on day 8, which could be due to the persistence of the drug in the system.A significant amount of the drug can be removed from the body by one plasma volume exchange, which probably resulted in rapid weaning of the ECMO even after consumption of 1000 mg in one of our cases. Conclusion:We report these cases to bring to light about combining extracorporeal therapies for successful outcome, along with most important learning point that "Intervention marks a milestone, not end to therapy, " as one of our patients required long-term anticoagulation and other had to be limping for long with foot drop splint with aggressive physiotherapy and reconstructive surgery to get back to normalcy.