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Severe quetiapine voluntary overdose successfully treated with a new hemoperfusion sorbent
Lorenzo Giuntoli1, Vittorio Dalmastri2, Nicola Cilloni1, Claudio Orsi2, Lucia Stalteri2, Valentina Demelas2, Giovanni Giuliani2, Giovanni Gordini1, Fabrizio De Ponti3 and Gaetano La Manna2 1 Department of Emergency-Urgency Medicine, Intensive Care Unit, Maggiore Hospital, Bologna, Italy 2 Nephrology, Dialysis and Transplantation Unit, Azienda Ospedaliera-Universitaria di Bologna, Bologna, Italy 3 Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
05/22/2019
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Summary
CoW 21/2019 – This report describes the case of a previously healthy 27-year-old woman without preexistent chronic pharmacologic therapies, who was admitted to the Emergency Department of a peripheral hospital with worsening mental status and seizures after a voluntary intake of 15 g of quetiapine (50 extended-release 300 mg tablets) in a suicide attempt.
Case presentation
She was sedated, intubated, mechanically ventilated, and transferred directly to the ICU of the Maggiore Hospital (Bologna)
On admission, she showed moderate sinus tachycardia and lactic acidosis (lactate levels 3.5 mmol/l), with neither renal or liver impairment, nor thrombocytopenia
After contacting the Poison Control Centre, she underwent crystalloid hydration, gastrolusis, charcoal, and laxative administration as well as diuretic therapy
A sedative lightening attempt after 12 h showed no neurologic impairment apart from severe agitation
Because of the extremely high plasma quetiapine concentration (1850 µg/l about 24 h after consumption, therapeutic reference range of 70–170 µg/l) associated with the persistence of tachycardia (QTc interval still in normal range) and the lactate acidosis, the decision was made to restart sedatives and to perform CytoSorb hemoperfusion in order to rapidly reduce plasma quetiapine concentrations in combination with a hemodiafiltration (CVVHDF) treatment
Treatment
Two consecutive treatments with CytoSorb for a total treatment period of 48 hours (24 hours per treatment)
Cytosorb was used in combination with CRRT (Prismaflex, Baxter) run in CVVHDF mode
Blood flow rate: 200 ml/min
Anticoagulation: citrate
CytoSorb adsorber position: post-hemofilter
Measurements
Plasma quetiapine levels
Results
After 12 hours of treatment, quetiapine levels reduced from 1850 to 648 µg/l (removal rate 65%), after which an increase in blood concentration was observed followed by initiation of a second CytoSorb treatment session. Quetiapine had totally disappeared from the blood the day after completion of the second treatment
Patient Follow-Up
The patient was extubated 96 h after the start of CytoSorb
She was no longer agitated (however still confused) and hemodynamically stable, with mild tachycardia, which disappeared in the following hours
She was discharged to the Step Down Unit after 7 days in a clinically stable condition and was later referred to the psychiatric service
Conclusion
This is one of the first published experiences of the application of hemoadsorption therapy following quetiapine overdose
The use of CytoSorb resulted in the fast and efficient elimination of quetiapine from the blood and the stabilization of a critical situation
More in vivo experiences are required in order to understand the behavior in the light of the extensive volume of distribution of this substance
