44: Case Series on Management of Aluminum Phosphide Poisoning with Veno-Arterial ECMO

Background: Aluminum phosphide is a widely available pesticide in India, with a toxic dose of less than 0.5 grams. Upon exposure to moisture, it releases phosphine gas, which inhibits oxidative phosphorylation, causing severe mitochondrial dysfunction, tissue hypoxia, and multi-organ failure. Cardiotoxicity is the primary cause of death, and no specific antidote exists. Supportive care, including veno-arterial extracorporeal membrane oxygenation (VA-ECMO), may improve survival. We present a retrospective analysis of 26 patients with aluminum phosphide poisoning who received VA-ECMO support between January 2021 and August 2025. Case Description: All patients presented with cardiogenic shock and lactic acidosis. VA-ECMO was initiated promptly; 80% were male, with ingested doses ranging from 1 to 6 tablets. Ventricular arrhythmias occurred in over 80%, and two patients experienced non-pulsatile flow throughout ECMO. Left heart decompression was achieved via percutaneous left atrial drainage in five patients and direct surgical venting through the superior pulmonary vein in six patients. Except for one patient who underwent right axillary artery grafting for return access, all received femoro-femoral VA-ECMO with distal perfusion cannula. The mean ECMO duration was 4 days. Almost all patients required renal replacement therapy for acidosis, and five developed acute kidney injury. Neurological complications included seizures and embolic stroke in four patients. Two patients required femoral artery embolectomy, and one underwent fasciotomy for compartment syndrome. Several patients developed disseminated intravascular coagulation requiring multiple transfusions. Outcome: Fifteen patients (57%) survived to hospital discharge. Conclusion: Although aluminum phosphide poisoning carries high mortality, early initiation of VA-ECMO combined with comprehensive supportive care can improve survival in patients with refractory cardiogenic shock.