Terlipressin for refractory hypotension following angiotensin-II receptor antagonist overdose

Intoxication with massive doses of amlodipine and candesartan requiring venoarterial extracorporeal membrane oxygenation

Background

Calcium channel blockers and angiotensin II receptor blockers are commonly prescribed to treat hypertension. Massive overdoses can cause both distributive and cardiogenic shock because of their effects on vascular smooth muscles and severe myocardial depression.

Case Presentation

We present the case of a 46-year-old man who was brought to our emergency department after ingesting 1210 mg amlodipine and 936 mg candesartan. The patient's hemodynamic status deteriorated despite treatment with vasopressors, calcium gluconate, and hyperinsulinemia-euglycemia therapy with mechanical ventilation. Venoarterial extracorporeal membrane oxygenation was initiated for refractory shock. The patient was weaned off extracorporeal membrane oxygenation on day 5 and discharged on day 18 of hospitalization.

Conclusion

When medical therapies are ineffective, aggressive venoarterial extracorporeal membrane oxygenation should be considered for the management of refractory shock in the setting of calcium channel blocker with angiotensin II receptor blocker overdose.

Vasopressin for persistent hypotension due to amlodipine and olmesartan overdose: A case report

Background

While there are consensus recommendations for managing calcium channel blocker (CCB) toxicity, reports on angiotensin II receptor blocker (ARB) toxicity and management are limited. Herein, we report a case of catecholamine-refractory hypotension due to CCB and ARB overdose.

Case presentation

A 54-year-old woman with underlying hypertension was brought to the emergency department after she attempted suicide by ingesting 345 mg of amlodipine, a CCB, and 340 mg of olmesartan, an ARB. She was hypotensive, which was considered vasodilatory because of high cardiac and low systemic vascular resistance indices. Hypotension persisted despite the administration of norepinephrine and epinephrine. Intravenous calcium gluconate, glucagon, and high-dose insulin euglycemia therapy, which were initiated because CCB toxicity was suspected, failed to raise her blood pressure. The presence of normal anion-gap metabolic acidosis and the fact that the patient remained hypotensive suggested that the hypotension might have been due to the effect of ARB. Vasopressin was finally administered, which improved her hemodynamic status. She was weaned off all vasopressors on day 3.

Discussion

There is no consensus recommendation for ARB toxicity. Since chronic use of ARBs at conventional doses can block the sympathetic nervous and renin–angiotensin systems, catecholamines may not effectively increase blood pressure in cases of hypotension due to ARB overdose, for which vasopressin could be indicated.

Conclusions

Vasopressin could be an option for treating hypotension secondary to ARB and CCB toxicity when catecholamines and treatment for CCB toxicity fail.

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Chronic use of ARBs blocks the sympathetic nervous and renin–angiotensin systems.

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There is no consensus recommendation for angiotensin II receptor blocker (ARB) toxicity.

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Catecholamines may not effectively raise blood pressure in hypotension due to ARB toxicity.

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Vasopressin could be an option for treating hypotension secondary to ARB toxicity.

Radioiodination and biological evaluation of irbesartan as a tracer for cardiac imaging

Irbesartan was labeled using 125I or 131I with N-bromosuccinimide (NBS) as an oxidizing agent. A lot of operators such as, quantity of substrate, the quantity of oxidizing agent, reaction temperature, reaction time, and pH of reaction medium were studied to optimize high radiochemical yield of [125I]IodoIrbesartan ([125I]Irb.). The preclinical evaluation of IodoIrbesartan in experimental mice indicated high accumulation in target organ of heart with a high heart/blood ratio of 12.85 at 30 min post-injection. This study indicates the suitability of [125I]IodoIrbesartan ([125I]Irb.) for cardiac imaging.

Toxicologic issues during cardiopulmonary resuscitation

PURPOSE OF REVIEW

The following review intends to outline the unique aspects of providing cardiopulmonary resuscitation for the poisoned patient and highlights both current practice and new therapies that apply to toxicologic cases.

RECENT FINDINGS

Although there are few prospective randomized studies to further evidence-based care of the poisoned patient, there have been several reports of novel uses of both established medications and new medications in toxicologic patients. These case reports highlight treatment possibilities and potential avenues for further research.

SUMMARY

It is important for providers to recognize the limitations of standard advanced cardiac life support algorithms when caring for poisoned patients. Toxicologic causes of cardiopulmonary compromise should be considered along with administration of appropriate antidotes and adjunctive therapies.