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Intravenous Lipid Emulsion Therapy for Sustained Release Diltiazem Poisoning: a Case Report

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Intravenous Lipid Emulsion Therapy for Sustained Release Diltiazem Poisoning: a Case Report INTRAVENOUS LIPID EMULSION THERAPY FOR SUSTAINED RELEASE DILTIAZEM POISONING: A CASE REPORT Ben J Wilson1, Jack S Cruikshank1, Kim L Wiebe2, Valerian C Dias3, Mark C Yarema4 1Department of Medicine, University of Calgary, Calgary, Alberta; 2Departments of Critical Care Medicine, Psychiatry, and Family Medicine, University of Manitoba, Winnipeg, Manitoba; 3Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta; 4Poison and Drug Information Service, Alberta Health Services, Calgary, Alberta, Departments of Physiology and Pharmacology, Critical Care Medicine, and Division of Emergency Medicine, University of Calgary, Calgary, Alberta Corresponding Author: [email protected] _____________________________________________________________________________________ ABSTRACT We present a case of refractory cardiogenic shock secondary to sustained release diltiazem poisoning. Intravenous lipid emulsion therapy was initiated approximately 13 hours after ingestion. Vasopressors were weaned off hours after initiation of intravenous lipid emulsion therapy and the patient went on to make a full recovery. This report adds to the paucity of data on intravenous lipid emulsion rescue therapy in sustained release diltiazem poisoning. We hypothesize that the intravenous lipid emulsion may have mediated its favorable hemodynamic effects via increases in myocardial calcium concentration with resultant increased inotropy. Key Words: Diltiazem, poisoning, calcium channel blockers, fat emulsion, overdose _____________________________________________________________________________________ ntravenous lipid emulsion (ILE) therapy has Case Report Ibeen used as a rescue agent in a number of A 57-year-old female with a past medical history medication overdoses. Calcium channel blocker of hypertension, peripheral vascular disease, (CCB) overdose is one such scenario in which smoking, ethanol abuse and depression with prior ILE therapy has been used successfully. ILE may suicide attempts, with normal baseline kidney increase blood pressure through increased function, was brought to the emergency myocyte calcium concentration, disinhibition of department (ED) by ambulance after her transmembrane fatty acid transport, and via ‘lipid roommate found her with deep lacerations to her sink’ mechanisms. The effectiveness of ILE in the wrists. She admitted to ingesting an unknown setting of sustained release (SR) diltiazem is amount of sustained release (SR) diltiazem 360 unknown. Traditionally, therapy for CCB mg, bisoprolol 5 mg, overdose has consisted of gastric decontamination candesartan/hydrochlorothiazide 16/12.5 mg, and hemodynamic support. These supportive acetaminophen/caffeine/codeine, dimenhydrinate, measures have resulted in variable hemodynamic and ethanol. responses and outcomes. Recently, the first On arrival to the ED, her vital signs were: reports of ILE therapy for SR diltiazem overdose temperature 37.3 C, blood pressure 65/40 mmHg, were published. In these cases, ILE therapy heart rate of 55/min, respiratory rate 22/min, and produced disparate hemodynamic effects. We oxygen saturation 97% on 5L/min nasal cannula. present a case in which ILE rescue therapy She was alert and oriented with a Glasgow coma contributed to hemodynamic improvement and scale score of 15. The remainder of the physical eventual recovery in a patient with a SR diltiazem examination was unremarkable. Initial laboratory overdose. investigations were remarkable for a hemoglobin of 115 g/L, creatinine of 170 umol/L, sodium of 139 mmol/L, potassium of 3.4 mmol/L, chloride J Popul Ther Clin Pharmcol Vol 19(2):e218-e222; June 3, 2012 e218 © 2012 Canadian Society of Pharmacology and Therapeutics. All rights reserved. Intravenous lipid emulsion therapy for sustained release diltiazem poisoining: a case report of 110 mmol/L, and a blood glucose of 6.4 and was discharged after a 16-day hospital stay. A mmol/L. A venous blood gas demonstrated a pH 4-hour post-ingestion serum diltiazem level (9 of 7.33, pC02 35, p02 60, and HC03 19. Serum hours prior to ILE therapy) was 1891 ng/ml salicylate, acetaminophen, methanol, ethylene (reference range 50-200 ng/ml), and a repeat glycol, isopropyl alcohol, and acetone were concentration at 19 hours postingestion was 1944 negative. Initial EKG showed sinus bradycardia ng/ml (6 hours after ILE therapy). with no evidence of atrioventricular block, wide QRS, or prolonged QT. Troponin T was elevated DISCUSSION at 0.14 mcg/L. Comprehensive urine drug screen by gas chromatography-mass spectrometry was We present a case of ILE therapy in a case of positive for codeine, norcodeine, hydrocodone, intentional SR diltiazem overdose. There have morphine, diltiazem, and dimenhydrinate. been two reports of ILE therapy for diltiazem In the ED, the patient was given 4 liters of overdose; one in which the ingestion was with normal saline, 3 g of calcium chloride, and two 5 diltiazem alone and the formulation was clearly mg doses of glucagon. The poison centre was SR1 and a second in which diltiazem was part of a consulted and gastrointestinal decontamination polydrug overdose and the formulation was with whole bowel irrigation was discussed but not unknown.2 Aside from these two recent reports, performed at the discretion of the attending previous descriptions of ILE therapy in CCB emergency physician. To continue treatment for overdose have been restricted to verapamil.3-5 suspected bisoprolol toxicity, additional glucagon Prior to recent initiatives with ILE, was administered in the form of an infusion at 5 management of patients with SR diltiazem has mg/hr. The patient was admitted to the intensive consisted of hemodynamic support and expediting care unit. gastric decontamination during hepatic Infusions of norepinephrine, vasopressin, and elimination of diltiazem to subtoxic levels.1,6-12 dopamine were administered for ongoing Whole bowel irrigation with polyethylene glycol hypotension. These agents were titrated up to 0.6 solution has also been employed. A review of the mcg/kg/min, 0.04 U/min, and 20 mcg/kg/min, literature has demonstrated a wide range of respectively. After nine hours of vasopressor reported therapies, including aggressive therapy, the patient experienced chest pain with crystalloid infusions, calcium, glucagon, ischemic EKG changes. Her repeat blood gas extracorporeal membrane oxygenation10, to, most showed a pH of 7.22, pC02 of 46 mmHg, p02 of recently, extracorporeal albumin dialysis.13 As 43 mmHg, and HC03 of 18 meq/L. Her mean was also the case in the present report, arterial pressure (MAP) was 60 mmHg and her vasopressin, dopamine, and norepinephrine have urine output was 10-20 ml/hr. She was been used as adjuncts to overcome profound subsequently intubated and the decision was made hypotension, and not for any CCB-specific to initiate ILE therapy. Hyperinsulinemia- antagonism. The reported effectiveness of euglycemia therapy (HIE) was considered at this individual agents within this supportive regimen point; however, given the patient’s hemodynamic has varied widely. instability and failure to respond to other There is also emerging evidence for HIE as therapies, ILE was preferentially selected because an adjunct in the management of CCB toxicity.14 of its potential for rapid effect. Further, the use of HIE is thought to improve hemodynamics by HIE could be re-evaluated after ILE was minimizing CCB-induced insulin insufficiency, completed. 20% ILE was administered with a which increases myocardial glucose influx, loading dose of 1.5 ml/kg then an infusion of 0.25 ultimately improving cardiac output. ml/kg/min for a total of 8 ml/kg. After completion Hypoinsulinemia and peripheral insulin resistance of ILE therapy her MAP was 68 mm Hg. are mediated by inhibition of L-type calcium Dopamine was discontinued 4 hours post ILE, channels in pancreatic beta cells and peripheral glucagon at 5 hours, vasopressin at 20 hours, and tissues, respectively.14 As a result, glucose influx norepinephrine at 45 hours. The patient was into cardiomyocytes is limited, precluding optimal extubated six days post-admission and was anaerobic myocardial metabolism, exacerbating transferred to psychiatry. She made a full recovery CCB-mediated decreases in inotropy and e219 J Popul Ther Clin Pharmcol Vol 19(2):e218-e222; June 3, 2012 © 2012 Canadian Society of Pharmacology and Therapeutics. All rights reserved. Intravenous lipid emulsion therapy for sustained release diltiazem poisoining: a case report chronotropy. Insulin infusion, with rates ranging reports1,6,7, the combination of ingested from 0.5 to 1.0 U/kg/hr, have yielded variable medications, close proximity to the initiation of hemodynamic improvements, with reported HIE, and the patient’s HOCM make it difficult to effects ranging from equivocal1,2, to rapid and attribute the hypotension or its recovery to the marked.14 Part of this variability may result from diltiazem and the ILE, respectively. disparate times to administration, with earlier Our case of ILE therapy in SR diltiazem administration times being associated with greater overdose is unique in that it describes a hemodynamic improvement.14 hemodynamic response. Although not resulting in Case reports of SR diltiazem toxicity have an immediate or dramatic response, ILE included patients with ingestions ranging from administration, 12-hours post ingestion, led to 0.78 to 1210 g. Elimination half-lives have ranged improvement in MAP. Dopamine and glucagon from 13.37 to 4010 hours, far longer than
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