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Use of CytoSorb in chloroquine intoxication and prolonged reanimation
Dr. Melanie Suda, Dr. Philipp Kunz | Department of Anesthesiology and Intensive Care Medicine, Clinic Association Southwest, Sindelfingen-Böblingen Hospital, Böblingen Clinic, Germany
09/19/2018
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Summary
CoW 37/2018 – This case study reports on a 25-year-old patient (no significant pre-existing conditions, questionable psychiatric history), who was found drunk by the emergency physician somnolent, tachycardic, with reduced reflexes and acrocyanotic after an announced suicide attempt where the alarm was raised by the partner 15 minutes after ingestion of at least 50 tablets of chloroquine 250 mg followed by direct admission to the hospital via emergency transport.
Case presentation
After establishing basic monitoring, peripheral venous access and oxygen delivery by the ambulance service on-site, a sinus tachycardia developed which quickly converted into a bradycardiac ventricular escape rhythm accompanied by a barely palpable carotid pulse. Resuscitation was started, i.e. compression massage with administration of 6 mg epinephrine as well as uneventful intubation and manual ventilation. Return of spontaneous circulation was achieved after 15 minutes
After arrival at the hospital he was directly transferred to the intensive care unit
Contact with the Poison Emergency Center Freiburg revealed the following: seizures and cardiac arrhythmias are major side effects of chloroquine overdose. Recommendation: sustained continuous administration of diazepam 1-2 mg/kg body weight. Therefore, given his estimated body weight of 80 kg, 160 mg diazepam was administered as a bolus and continued i.v. at 40 mg/h
Immediately after admission, again necessity for cardiopulmonary resuscitation for a total period of 45 minutes and start of continuous norepinephrine administration as well as epinephrine infusion via perfusor
Initial blood gas analysis after immediate arterial cannulation showed severe lactic acidosis (7.6 mmol/l, pH 6.96), a hemoglobin level of 17 g/dl, and mild hypokalemia (3.4 mmol/l) consequently he was given fluid administration, potassium substitution and a buffering solution of 3x100ml 8.4% sodium bicarbonate resulting in a slow stabilization of his pH
After 45 minutes of intermittent external cardiac massage, the team decided to discontinue all resuscitation efforts, after which the patient spontaneously converted back from bradycardiac ventricular escape rhythm to a tachycardic sinus rhythm over the next 30 minutes
Under the established treatment regimen with diazepam, norepinephrine, fluid administration and balancing of the acid-base metabolism, the level of ventilation invasiveness could be significantly reduced
Due to radiologically confirmed infiltrates, presumably as a result of silent aspiration during his initially reduced vigilance, antibiotic therapy with ampicillin/sulbactam was started and regular inhalations were prescribed
Administration of 30 g charcoal
Subsequently, the patient was connected to a Coolguard system for 24 hours to prevent hypoxic brain damage
The following day forced lavage was initiated and an electroencephalography (EEG) was carried out to evaluate his seizures
The patient’s renal function was initially reduced with a GFR of 52 ml/min and a creatinine of 1.8 mg/dl, while lactic acidosis regressed after intermittent peaks up to 12.2 mmol/l and normalized over time
Low dose norepinephrine therapy at 0.2 µg/kg/min in the context of sedation with propofol and diazepam
Determination of chloroquine plasma levels showed 789 µg/l one day after admission, while the concentration on the day of admission could not be determined retrospectively, but was certainly much higher (chloroquine toxic >1000 µg/l)
Given the potential elimination of chloroquine by CytoSorb based on the molecular size and hydrophobicity of the substance as well as to support kidney function, continuous renal replacement therapy was started together with CytoSorb 30 hours after initial admission
Treatment
One treatment with CytoSorb for a total treatment time of 24 hours
CytoSorb was used in combination with a CRRT (Multifiltrate, Fresenius Medical Care) run in CVVHD mode
Blood flow rate: 100-150 ml/min
Anticoagulation: Citrate
CytoSorb adsorber position: pre hemofilter
Measurements
Need for catecholamines
Renal function
Chloroquine plasma concentrations
Results
Reduction of norepinephrine dosages within hours, the patient was free from catecholamines two days after the end of CytoSorb, however he had significantly decreasing requirements for noradrenaline already before CytoSorb initiation
Improvement in renal function as part of the combined treatment (creatinine 1.0 mg/dl, GFR to 90 ml/min)
Chloroquine plasma concentrations could be reduced from 789 to 474 µg/l during the course of the 24 hour treatment
Patient Follow-Up
Recurrent seizures treated with Trapanal
Over the following days, a one-off oxygen desaturation occurred accompanied by an increase in the FiO2 to 85%. Subsequent bronchoscopy revealed congestion in the right lower and middle lobes, therefore adaptation of antibiotic therapy was done
An MRI under general anesthesia to examine the presence of potential hypoxic brain damage did not provide any indication, EEG was normal without epilepsy-typical potentials
Development of a delirium with marked restlessness and initiation of quetiapine and melneurin therapy
Following consultation with psychiatric colleagues, the patient was discharged in an improved general condition, oriented and well-managable to a psychiatric hospital close to his own home
Conclusions
In this patient with severe chloroquine intoxication, the combination of renal replacement therapy and CytoSorb resulted in a marked reduction in chloroquine plasma levels and improved renal function
According to the medical team, early additional use of CytoSorb therapy should be considered in patients with intoxication, but generally also in patients with septic shock or after prolonged reanimation
The application of CytoSorb was safe and easy
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