J Extra Corpor Technol 2023 , 55 , 206 – 208 Ó The Author ( s ), published by EDP Sciences , 2023 https :// doi . org / 10.1051 / ject / 2023037
Available online at : ject . edpsciences . org
CASE REPORT
Central ECMO cannulation for severe dihydropyridine calcium channel blocker overdose
Jose M . Cardenas ( MD ) 1 ,* , Santiago Borasino ( MD ) 1 , Joseph Timpa ( CCP ) 2 , Jeremy Hawkins ( CCP ) 2 , Martha McBride ( CRNP ) 3 , William Rushton ( MD ) 4 , Jordan Newman ( MD ) 5 , Erika Mendoza ( MD ) 1 , Robert Sorabella ( MD ) 1 , and Jonathan Byrnes ( MD ) 1
1 Division of Pediatric Cardiology Section of Cardiac Critical Care . University of Alabama at Birmingham School of Medicine , Birmingham , AL , USA 2 Department of Cardiovascular Perfusion Children ’ s of Alabama , Birmingham , AL , USA 3 ECMO Clinical Coordinator Children ’ s of Alabama , Birmingham , AL , USA 4 Department of Pediatric Emergency Medicine . University of Alabama at Birmingham School of Medicine , Birmingham , AL , USA 5 Department of Pediatric Critical Care . University of Alabama at Birmingham School of Medicine , Birmingham , AL , USA
Received 14 August 2023 , Accepted 5 October 2023
Abstract – Calcium channel blocker ( CCB ) toxicity carries a high mortality and is the sixth most fatal drug class reported to US poison centers . Amlodipine overdose is characterized by a life-threatening arterial vasodilation that compromises organ perfusion . The management of CCB intoxication is focused on maintaining adequate organ perfusion . In cases refractory to medical therapies , hemodynamic support with extracorporeal membrane oxygenation ( ECMO ) is warranted necessitating higher flows than usual to compensate for the vasodilation and requiring central cannulation . We present a case of a 12-year-old with severe dihydropyridine CCB ingestion , refractory to medical management and successfully treated with central ECMO cannulation . The patient was discharged home with no significant disability . Central ECMO cannulation may be helpful to facilitate adequate flows in vasodilatory shock such as CCB overdose .
Key words : ECMO ( extracorporeal membrane oxygenation ), Shock , Peripheral vascular disease , Pediatric , Pharmacology , cardiovascular .
Overview
Calcium channel blockers ( CCB ) are commonly used for the management of hypertension and dysrhythmias . They are generally classified as :
Non-dihydropyridines such as diltiazem and verapamil preferentially inhibit the L-type calcium channels in the myocardium precipitating negative inotropism and chronotropism . At toxic concentrations , these drugs can induce a vasodilatory shock and bradycardia with poor myocardial contractility .
Dihydropyridines such as amlodipine , nifedipine , and nicardipine block the L-type calcium channels in peripheral vascular smooth muscle , reducing peripheral vascular resistance . Supratherapeutic ingestion induces a lifethreatening vasodilatory shock with reflex tachycardia [ 1 ].
* Corresponding author : jcardenasfimbres @ yahoo . com
However , in massive ingestion , each drug class can lose specificity and precipitate both vasodilatory and cardiogenic shock .
Calcium channel blocker ( CCB ) toxicity carries a high mortality ; recent data published by the American Association of Poison Control Centers reports CCB as the sixth most fatal xenobiotic class making CCBs more lethal than any other antihypertensive agent [ 2 ]. Dihydropyridine CCB toxicity management emphasizes re-establishing appropriate organ perfusion with aggressive fluid resuscitation and vasoactive infusions . In addition , drug effects can be ameliorated by administratio of intravenous calcium , high-dose insulin and glucose therapy , and lipid emulsion . In cases refractory to medical therapies , hemodynamic support with extracorporeal membrane oxygenation ( ECMO ) is indicated and due to the distributive shock higher flows than usual may be warranted necessitating central cannulation [ 3 ].
Here we report a case of severe dihydropyridine overdose presenting with refractory vasodilatory shock managed with central ECMO cannulation .
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