Rescue extracorporeal membrane oxygenation therapy in methamphetamine toxicity

Substance-Use Disorders in Critically Ill Patients: A Narrative Review

Substance-use disorders (SUDs) represent a major public health concern. The increased prevalence of SUDs within the general population has led to more patients with SUD being admitted to intensive care units (ICUs) for an SUD-related condition or with SUD as a relevant comorbidity. Multiprofessional providers of critical care should be familiar with these disorders and their impact on critical illness. Management of critically ill patients with SUDs is complicated by both acute exposures leading to intoxication, the associated withdrawal syndrome(s), and the physiologic changes associated with chronic use that can cause, predispose patients to, and worsen the severity of other medical conditions. This article reviews the epidemiology of substance use in critically ill patients, discusses the identification and treatment of common intoxication and withdrawal syndromes, and provides evidence-based recommendations for the management of patients exposed to chronic use.

2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.

Extracorporeal membrane oxygenation use in poisoning: a narrative review with clinical recommendations

CONTEXT

Poisoning may lead to respiratory failure, shock, cardiac arrest, or death. Extracorporeal membrane oxygenation (ECMO) may be used to provide circulatory support, termed venoarterial (VA) ECMO; or respiratory support termed venovenous (VV) ECMO. The clinical utility of ECMO in poisoned patients remains unclear and guidelines on its use in this setting are lacking.

OBJECTIVES

To perform a literature search and narrative review on the use of ECMO in poisonings. Additionally, to provide recommendations on the use of ECMO in poisonings from physicians with expertise in ECMO, medical toxicology, critical care, and emergency medicine.

METHODS

A literature search in Ovid MEDLINE from 1946 to October 14, 2020, was performed to identify relevant articles with a strategy utilizing both MeSH terms and adjacency searching that encompassed both extracorporeal life support/ECMO/Membrane Oxygenation concepts and chemically-induced disorders/toxicity/poisoning concepts, which identified 318 unique records. Twelve additional manuscripts were identified by the authors for a total of 330 articles for screening, of which 156 were included for this report.

NARRATIVE LITERATURE REVIEW

The use of ECMO in poisoned patients is significantly increasing over time. Available retrospective data suggest that patients receiving VA ECMO for refractory shock or cardiac arrest due to poisoning have lower mortality as compared to those who receive VA ECMO for non-poisoning-related indications. Poisoned patients treated with ECMO have reduced mortality as compared to those treated without ECMO with similar severity of illness and after adjusted analyses, regardless of the type of ingestion. This is especially evident for poisoned patients with refractory cardiac arrest placed on VA ECMO (termed extracorporeal cardiopulmonary resuscitation [ECPR]).

INDICATIONS

We suggest VA ECMO be considered for poisoned patients with refractory cardiogenic shock (continued shock with myocardial dysfunction despite fluid resuscitation, vasoactive support, and indicated toxicologic therapies such as glucagon, intravenous lipid emulsion, hyperinsulinemia euglycemia therapy, or others), and strongly considered for patients with cardiac arrest in institutions which are structured to deliver effective ECPR. VV ECMO should be considered in poisoned patients with ARDS or severe respiratory failure according to traditional indications for ECMO in this setting.

CONTRAINDICATIONS

Patients with pre-existing comorbidities with low expected survival or recovery. Relative contraindications vary based on each center's experience but often include: severe brain injury; advanced age; unrepaired aortic dissection or severe aortic regurgitation in VA ECMO; irreversible organ injury; contraindication to systemic anticoagulation, such as severe hemorrhage.

CONCLUSIONS

ECMO may provide hemodynamic or respiratory support to poisoned patients while they recover from the toxic exposure and metabolize or eliminate the toxic agent. Available literature suggests a potential benefit for ECMO use in selected poisoned patients with refractory shock, cardiac arrest, or respiratory failure. Future studies may help to further our understanding of the use and complications of ECMO in poisoned patients.

Clinical Characteristics and Management of Methamphetamine-Associated Cardiomyopathy: State-of-the-Art Review

Methamphetamine‐associated cardiomyopathy (MACM) is an increasingly recognized disease entity in the context of a rapidly spreading methamphetamine epidemic. MACM may afflict individuals with a wide range of ages and socioeconomic backgrounds. Presentations can vary greatly and may involve several complications unique to the disease. Given the public health significance of this disease, there is a relative dearth of consensus material to guide clinicians in understanding, diagnosing, and managing MACM. This review therefore aims to: (1) describe pathologic mechanisms of methamphetamine as they pertain to the development, progression, and prognosis of MACM, and the potential to recover cardiac function; (2) summarize existing data from epidemiologic studies and case series in an effort to improve recognition and diagnosis of the disease; (3) guide short‐ and long‐term management of MACM with special attention to expected or potential sequelae of the disease; and (4) highlight pivotal unanswered questions in need of urgent investigation from a public health perspective.

Delayed cardiomyopathy and cardiogenic shock due to intravenous methamphetamine use requiring hemodynamic support with veno-arterial extracorporeal membrane oxygenation

Cardiovascular disease is the leading cause of mortality in chronic methamphetamine users. We present the case of a 29-year-old man, a prior heroin user, who presented following first-time use of intravenous methamphetamine, with delayed development of cardiomyopathy and severe cardiogenic shock, treated with veno-arterial extracorporeal membrane oxygenation (VA ECMO), and subsequent recovery. His initial chief complaint was shortness of breath, a common presentation to the emergency department. However, this case presentation is unique in three aspects: (1) a delayed presentation, (2) methamphetamine was administered intravenously as opposed to the common methods of being snorted or smoked, (3) and the effects were seen after first-time usage as compared to in a chronic user. This unique presentation can bring awareness to an uncommon etiology of shortness of breath due to intravenous methamphetamine usage.