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Successful use of extracorporeal life support and hemadsorption in the context of venlafaxine intoxication requiring cardiopulmonary resuscitation: a case report
Matthias Hoffmann1, Samira Akbas1, Rahel Kindler2, Dominique Bettex1 | 1 Institute of Anesthesiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland | 2 Institute of Intensive Care Medicine, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland | J Artif Organs 2023; epub
07/05/2023
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Summary
CoM 07/2023 – This case reports on a 17-year-old female patient who was admitted to a regional hospital for mixed intoxication with a presumed intake of 24 g of venlafaxine (both immediate and extended-release preparations) and unknown amounts of oxycodone, zolmitriptan and itinerol B6.
Case presentation
The patient had been treated with venlafaxine by her outpatient psychiatrist for severe depression with suicidal ideation for two weeks prior to the event. An inpatient psychiatric stay had already been planned
Approximately five hours after taking the medication, the patient was found somnolent and brought to the hospital by ambulance
Due to the severity of the intoxication with the risk of developing hemodynamic instability, the patient was immediately transferred to the intensive care unit
Shortly after that, the patient went into status epilepticus
Because of this the patient was then analgosedated and intubated
After tracheal intubation, progressive hemodynamic deterioration occurred with sinus tachycardia up to 140 bpm, hypotension with systolic blood pressure of 70 mmHg and vasoconstriction (prolonged capillary refill time > 3 s)
ECG on the day of admission showed sinus tachycardia and a prolongation of cQT-time
Furthermore, echocardiography revealed severely impaired left ventricular function (Ejection Fraction – EF 10–15%) with hypokinetic left ventricle, apical and midventricular akinesia with normal right ventricular function. Pericardial effusion was excluded
Arterial blood gas analysis showed metabolic acidosis (pH 7.28) and a serum lactate of 7.8 mmol/l
Despite extended catecholamine therapy with high-dose norepinephrine, dobutamine and epinephrine, the patient could not be stabilized and cardiopulmonary resuscitation due to cardiac arrest had to be initiated
After 2.5 h (150 min) of mechanical resuscitation, extracorporeal life support (ECLS) system was established on-site with subsequent air-ambulance transfer to a tertiary hospital
Shortly after arrival at the tertiary hospital, a large volume of tablets (filling one-third of the stomach) was removed during primary decontamination via gastroscopy. The gastric mucosa was slightly hemorrhagic
A total of 55 g of activated charcoal was applied for additional adsorption. Because of her distended abdomen with subileus, repeated administration was withheld
Laboratory chemistry revealed disseminated intravascular coagulation (DIC) and acute liver failure with transaminase elevation, drop in coagulation factor V (Factor V: < 10%), INR elevation (max. INR 5.9) and lactic acidosis (lactate max. 9.8 mmol/l, pH min. 7.27), leading to the administration of N-acetylcysteine following Prescott schema for four days despite negative paracetamol serum levels
Sonographically, the liver was well perfused without obstructive intra- or extrahepatic cholestasis
Balanced hemodynamic management using volume and low-dose epinephrine (0.1 µg/kg/min) to promote inotropy, as well as high ECLS blood flow (maximum 5 l/min), were used to maintain sufficient
mean arterial pressure
Toxicological screening in urine and blood detected the metabolites of oxycodone, tramadol, nicotine and lidocaine, venlafaxine, metoprolol, metoclopramide, naloxone, and caffeine. In addition, iatrogenic amoxicillin, midazolam and levetiracetam metabolites were found
The initial compound venlafaxine plasma concentration was markedly elevated (maximum 52.53 µmol/l, therapeutic range of 0.7–1.44 µmol/l)
Therefore, a CytoSorb adsorber was initiated 6 h after admission to support drug removal
Treatment
Hemoadsorption treatment with CytoSorb was run for a total of 72 h with three adsorber changes during that time
The adsorber was integrated into a bypass within the running ECLS circuit
Blood flow rate: 300 ml/min
Measurements
Venlafaxine systemic plasma concentration
Left ventricular ejection fraction (LV-EF)
Results
Venlafaxine plasma concentrations were reduced significantly from a maximum of 52.53 µmol/l to 9.60 µmol/l within the first 12 hours. On day 2, it was 7.17 µmol/l and decreased further to 3.74 µmol/l
LV-EF increased steadily reaching ~22% at discontinuation of CytoSorb and ~36% on day 7
Patient Follow-Up
A 900 ml serous left pleural effusion was drained following the correction of coagulation on day four
The patient was anuric with acute kidney injury (AKIN stage 3, max. creatinine 331 µmol/l) and required continuous hemodiafiltration from day five
Already on admission, microbiological sampling was performed after documented aspiration and the established antimicrobial therapy with amoxicillin/clavulanic acid was continued
Despite negative bacterial detection, antimicrobial therapy was escalated to piperacillin/tazobactam on day eight due to respiratory deterioration and increasing inflammatory parameters (C-reactive protein peak level 154 mg/l)
The patient’s health condition progressively improved over the next few days
In addition to an increased blood pressure amplitude over 20 mmHg, serial transthoracic echocardiograms documented improved cardiac function and sufficient ejection fraction
Electrocardiographically, cQT peaked at 507 ms with no arrhythmias
Three days post-admission, levosimendan (0.1mcg/kg/min) intravenously (25 mg) facilitated weaning and removal of the ECLS system
Hepatic function recovered and after 7 days of high-volume hemodiafiltration, acid–base and fluid hemostasis were restored
The patient was transferred back to the peripheral hospital on day 11 post symptom onset and completely recovered neurologically and cardiopulmonarily
The discharge to inpatient psychiatric treatment was organized 31 days after the initial intoxication due to persistent suicidality
Conclusions
The combination of hemadsorption with CytoSorb with ECLS, along with traditional decontamination strategies, resulted in the intact neurological survival of the highest venlafaxine intoxication reported in the literature to date
The authors state this case supports the evidence that hemadsorption with CytoSorb might help to reduce blood serum levels of venlafaxine, and that swift clearance of toxic blood levels may support cardiovascular recovery after life-threatening intoxications.
