Use of a cytokine adsorber for toxin elimination in a case of severe combined quetiapine and impramine intoxication
A. Faltlhauser, S. Grau, F. Kullmann Klinikum Weiden, Medical Clinic, Interdisciplinary Intensive Care Unit, Weiden, Germany
Background: While various intoxications can nowadays be appropriately treated with specific antidotes, combined intoxications with tricyclic antidepressants and atypical antipsychotics require special attention. Next to very important primary toxin elimination, several therapeutic approaches (Lipid-
Rescue, NaHCO3 therapy, physostigmine) are controversial. We report on a 56 year old female patient, who had taken around 3g of quetiapine and 2.2 g of imipramine with suicidal intent approx. 4 hrs. before hospital admission.
Presentation on admission: On arrival to emergency the patient was soporific with preserved protective reflexes. Primary toxin elimination with gastroscopic tablet recovery and 2 x 50 mg charcoal was performed immediately. Generalized seizure was treated with 1g of levetiracetam. After transfer on our intensive care unit and CVC placement, severe hypokalemia (K+ 2.2 mmol/l) was corrected as well as adequate fluid therapy, protective intubation and analgosedation performed. At this time the ECG showed only a discrete prolonged QT time of 448 msec. 11 hrs after admission torsade de pointes occurred after a short period of bradycardia. Only after 90 minutes of CPR stable ROSC was achieved. With the idea of drugs being adsorbed by a cytokine adsorber, we placed a Shaldon’s catheter even during CPR and started a CVVHDCiCa treatment supplemented with a cytokine adsorber (CytoSorbents GmbH, Berlin). Results: After 4 hrs. of cytokine adsorption stable hemodynamics without catecholamine support could be achieved. The patient could be successfully extubated 38 hrs. after the start of CPR without neurological deficits. The serial drugs levels (taken every 6 hrs) showed very good elimination of quetiapine and the active metabolite, norquetiapine. Elimination of imipramine and desipramine was surprisingly only very moderate.
Conclusion: The use of cytokine adsorption as ultima ratio (“off label use”) enabled fast and efficient elimination of quetiapine and norquetiapine from the serum and stabilization of an extremely critical situation.