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A Farrar R, B Justus A, A Masurkar V, M Garrett P. Unexpected survival after deliberate phosphine gas poisoning: An Australian experience of extracorporeal membrane oxygenation rescue in this setting. Anaesth Intensive Care 2021; 50:250-254. [PMID: 34871510 DOI: 10.1177/0310057x211047603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Phosphine poisoning is responsible for hundreds of thousands of deaths per year in countries where access to this pesticide is unrestricted. Metal phosphides release phosphine gas on contact with moisture, and ingestion of these tablets most often results in death despite intensive support. A 36-year-old woman presented to a regional hospital after ingesting multiple aluminium phosphide pesticide tablets and rapidly developed severe cardiogenic shock. In this case, serendipitous access to an untested Extracorporeal Membrane Oxygenation (ECMO) service of a regional hospital effected a successful rescue and prevented the predicted death. We discuss the toxicology, management and the evidence for and against using ECMO in this acute poisoning.
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Affiliation(s)
- Ross A Farrar
- Intensive Care Unit, 523457Sunshine Coast University Hospital, Sunshine Coast University Hospital, Queensland, Australia
| | - Angelo B Justus
- Intensive Care Unit, 523457Sunshine Coast University Hospital, Sunshine Coast University Hospital, Queensland, Australia
| | - Vikram A Masurkar
- Intensive Care Unit, 523457Sunshine Coast University Hospital, Sunshine Coast University Hospital, Queensland, Australia.,Griffith University, Sunshine Coast, Queensland, Australia
| | - Peter M Garrett
- Intensive Care Unit, 523457Sunshine Coast University Hospital, Sunshine Coast University Hospital, Queensland, Australia.,Griffith University, Sunshine Coast, Queensland, Australia
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Lewis J, Zarate M, Tran S, Albertson T. The Recommendation and Use of Extracorporeal Membrane Oxygenation (ECMO) in Cases Reported to the California Poison Control System. J Med Toxicol 2019; 15:169-177. [PMID: 30895517 DOI: 10.1007/s13181-019-00704-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 02/28/2019] [Accepted: 03/04/2019] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Antidotes are available to treat some specific poisonings; however, the mainstay of treatment for the poisoned patient remains supportive care. Extracorporeal membrane oxygenation (ECMO) is one of the most aggressive supportive measures available to manage poisoned patients. OBJECTIVE To characterize the recommendation and use of ECMO in cases reported to the California Poison Control System (CPCS). METHODS This retrospective chart review queried the CPCS database from 1997 to 2016 for cases containing the American Association of Poison Control Centers (AAPCC) code for ECMO, and "ECMO" and "ECLS" free-text searches. The collected data included year, age, gender, substances involved, route of exposure, clinical effects, treatments, and medical outcome. RESULTS A total of 94 cases discussed ECMO as a supportive option with 16 cases utilizing ECMO. Cases where ECMO was discussed rose from one case in 1997 to 13 cases in 2016. Of the 94 cases where ECMO was discussed, 38 cases (40%) involved toxicity from a cardiovascular agent(s) and 33 cases (35%) involved exposure to hydrocarbons. Of the 16 cases where ECMO was performed, 13 (81%) involved males. The median age was 17 years (range 1 month-54 years). Ten cases (63%) involve patients under the age of 18. In this series, 13 of 16 ECMO-supported patients survived (81%). CONCLUSIONS ECMO is being recommended more often for treatment of acute poisoning cases by the CPCS. All caregivers involved in the treatment of poisoning should gain a working knowledge of the potentially lifesaving technology of ECMO, its indications for use, adverse effects, and drug or poison interactions.
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Affiliation(s)
- Justin Lewis
- California Poison Control System (CPCS), Sacramento Division, 2450 48th St. ASB 1260, Sacramento, CA, 95817, USA.
- School of Pharmacy, University of California San Francisco, San Francisco, CA, USA.
- School of Medicine, University of California Davis, Sacramento, CA, USA.
| | - M Zarate
- California Poison Control System (CPCS), Sacramento Division, 2450 48th St. ASB 1260, Sacramento, CA, 95817, USA
- School of Pharmacy, University of California San Francisco, San Francisco, CA, USA
| | - S Tran
- California Poison Control System (CPCS), Sacramento Division, 2450 48th St. ASB 1260, Sacramento, CA, 95817, USA
- School of Pharmacy, University of California San Francisco, San Francisco, CA, USA
| | - T Albertson
- California Poison Control System (CPCS), Sacramento Division, 2450 48th St. ASB 1260, Sacramento, CA, 95817, USA
- School of Pharmacy, University of California San Francisco, San Francisco, CA, USA
- School of Medicine, University of California Davis, Sacramento, CA, USA
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Hughes A, Johnson NJ, Mazor SS. Extracorporeal Life Support: Indications and Use in Severely Poisoned Patients. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2017. [DOI: 10.1016/j.cpem.2017.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Makrygianni EA, Palamidou F, Kaditis AG. Respiratory complications following hydrocarbon aspiration in children. Pediatr Pulmonol 2016; 51:560-9. [PMID: 26910771 DOI: 10.1002/ppul.23392] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 01/08/2016] [Accepted: 01/13/2016] [Indexed: 11/12/2022]
Abstract
Accidental hydrocarbon ingestion may lead to aspiration and chemical pneumonitis in children. In this review article, the clinical course of hydrocarbon pneumonitis, chest radiographic abnormalities, complications, and treatment interventions are summarized. Most children remain asymptomatic and without complications following ingestion of a hydrocarbon. In approximately 15% of ingestions, aspiration pneumonitis occurs and evolves over the first 6-8 hr presenting with fever, tachypnea, hypoxemia, and tachycardia. A symptom zenith is reached within 48 hr followed by progressive improvement. Up to 5% of pneumonitis cases progress rapidly to acute respiratory failure. Chest radiographic abnormalities develop by 4-8 hr after ingestion, but they are not always predictive of clinical pneumonitis. Patients with history of hydrocarbon ingestion should be monitored for 6-8 hr in the emergency department and a chest radiogram should be obtained at the end of the observation period. Spontaneous or induced emesis and gastric lavage have been related to aspiration pneumonitis. Children who are symptomatic are admitted to the hospital for cardiorespiratory status monitoring and supportive care. Approximately 90% of hospitalized patients have a benign clinical course. Increased work of breathing with or without altered sensorium and seizures are indications for admission to the intensive care unit. Hypoxemia unresponsive to supplemental oxygen and/or severe central nervous system involvement require mechanical ventilation. Corticosteroids do not seem to offer any benefit and antibiotics are administered in cases of bacterial superinfection. Pneumatoceles may become evident after the first 6-10 days of symptoms on follow-up chest radiograms and they resolve up to 6 months later. Pediatr Pulmonol. 2016;51:560-569. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Evanthia A Makrygianni
- Pediatric Pulmonology Unit, First Department of Pediatrics, University of Athens School of Medicine and Aghia Sophia Children's Hospital, Athens, Greece
| | - Fani Palamidou
- Pediatric Pulmonology Unit, First Department of Pediatrics, University of Athens School of Medicine and Aghia Sophia Children's Hospital, Athens, Greece
| | - Athanasios G Kaditis
- Pediatric Pulmonology Unit, First Department of Pediatrics, University of Athens School of Medicine and Aghia Sophia Children's Hospital, Athens, Greece
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Ouellet G, Bouchard J, Ghannoum M, Decker BS. Available extracorporeal treatments for poisoning: overview and limitations. Semin Dial 2014; 27:342-9. [PMID: 24697909 DOI: 10.1111/sdi.12238] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Poisoning is a significant public health problem. In severe cases, extracorporeal treatments (ECTRs) may be required to prevent or reverse major toxicity. Available ECTRs include intermittent hemodialysis, sustained low-efficiency dialysis, intermittent hemofiltration and hemodiafiltration, continuous renal replacement therapy, hemoperfusion, therapeutic plasma exchange, exchange transfusion, peritoneal dialysis, albumin dialysis, cerebrospinal fluid exchange, and extracorporeal life support. The aim of this article was to provide an overview of the technical aspects, as well as the potential indications and limitations of the different ECTRs used for poisoned patients.
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Affiliation(s)
- Georges Ouellet
- Division of Nephrology, Hôpital Maisonneuve-Rosemont, University of Montreal, Montreal, Quebec, Canada
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Baud FJ, Megarbane B, Deye N, Leprince P. Clinical review: aggressive management and extracorporeal support for drug-induced cardiotoxicity. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:207. [PMID: 17367544 PMCID: PMC2206443 DOI: 10.1186/cc5700] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Poisoning may induce failure in multiple organs, leading to death. Supportive treatments and supplementation of failing organs are usually efficient. In contrast, the usefulness of cardiopulmonary bypass in drug-induced shock remains a matter of debate. The majority of deaths results from poisoning with membrane stabilising agents and calcium channel blockers. There is a need for more aggressive treatment in patients not responding to conventional treatments. The development of new antidotes is limited. In contrast, experimental studies support the hypothesis that cardiopulmonary bypass is life-saving. A review of the literature shows that cardiopulmonary bypass of the poisoned heart is feasible. The largest experience has resulted from the use of peripheral cardiopulmonary bypass. However, a literature review does not allow any conclusions regarding the efficiency and indications for this invasive method. Indeed, the majority of reports are single cases, with only one series of seven patients. Appealing results suggest that further studies are needed. Determination of prognostic factors predictive of refractoriness to conventional treatment for cardiotoxic poisonings is mandatory. These prognostic factors are specific for a toxicant or a class of toxicants. Knowledge of them will result in clarification of the indications for cardiopulmonary bypass in poisonings.
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Affiliation(s)
- Frédéric J Baud
- Medical and Toxicological Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, University Paris 7, Hôpital Lariboisière, 75010 Paris, France.
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Mégarbane B, Leprince P, Deye N, Résière D, Guerrier G, Rettab S, Théodore J, Karyo S, Gandjbakhch I, Baud FJ. Emergency feasibility in medical intensive care unit of extracorporeal life support for refractory cardiac arrest. Intensive Care Med 2007; 33:758-764. [PMID: 17342517 DOI: 10.1007/s00134-007-0568-4] [Citation(s) in RCA: 163] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2006] [Accepted: 01/29/2007] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To report the feasibility, complications, and outcomes of emergency extracorporeal life support (ECLS) in refractory cardiac arrests in medical intensive care unit (ICU). DESIGN AND SETTING Prospective cohort study in the medical ICU in a university hospital in collaboration with the cardiosurgical team of a neighboring hospital. PATIENTS Seventeen patients (poisonings: 12/17) admitted over a 2-year period for cardiac arrest unresponsive to cardiopulmonary resuscitation (CPR) and advanced cardiac life support, without return of spontaneous circulation. INTERVENTIONS ECLS femoral implantation under continuous cardiac massage, using a centrifugal pump connected to a hollow-fiber membrane oxygenator. MEASUREMENTS AND RESULTS Stable ECLS was achieved in 14 of 17 patients. Early complications included massive transfusions (n=8) and the need for surgical revision at the cannulation site for bleeding (n=1). Four patients (24%) survived at medical ICU discharge. Deaths resulted from multiorgan failure (n=8), thoracic bleeding(n=2), severe sepsis (n=2), and brain death (n=1). Massive hemorrhagic pulmonary edema during CPR (n=5) and major capillary leak syndrome (n=6) were observed. Three cardiotoxic-poisoned patients (18%, CPR duration: 30, 100, and 180 min) were alive at 1-year follow-up without sequelae. Two of these patients survived despite elevated plasma lactate concentrations before cannulation (39.0 and 20.0 mmol/l). ECLS was associated with a significantly lower ICU mortality rate than that expected from the Simplified Acute Physiology Score II (91.9%) and lower than the maximum Sequential Organ Failure Assessment score (>90%). CONCLUSIONS Emergency ECLS is feasible in medical ICU and should be considered as a resuscitative tool for selected patients suffering from refractory cardiac arrest.
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Affiliation(s)
- Bruno Mégarbane
- Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Medical and Toxicological Critical Care Department, University of Paris 7, 2 rue Ambroise Paré, 75010, Paris, France
| | - Pascal Leprince
- Pitié Salpétrière Hospital, Assistance Publique-Hôpitaux de Paris, Department of Cardiothoracic Surgery, University of Paris 6, 75013, Paris, France
| | - Nicolas Deye
- Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Medical and Toxicological Critical Care Department, University of Paris 7, 2 rue Ambroise Paré, 75010, Paris, France
| | - Dabor Résière
- Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Medical and Toxicological Critical Care Department, University of Paris 7, 2 rue Ambroise Paré, 75010, Paris, France
| | - Gilles Guerrier
- Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Medical and Toxicological Critical Care Department, University of Paris 7, 2 rue Ambroise Paré, 75010, Paris, France
| | - Samia Rettab
- Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Medical and Toxicological Critical Care Department, University of Paris 7, 2 rue Ambroise Paré, 75010, Paris, France
| | - Jonathan Théodore
- Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Medical and Toxicological Critical Care Department, University of Paris 7, 2 rue Ambroise Paré, 75010, Paris, France
| | - Souheil Karyo
- Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Medical and Toxicological Critical Care Department, University of Paris 7, 2 rue Ambroise Paré, 75010, Paris, France
| | - Iradj Gandjbakhch
- Pitié Salpétrière Hospital, Assistance Publique-Hôpitaux de Paris, Department of Cardiothoracic Surgery, University of Paris 6, 75013, Paris, France
| | - Frédéric J Baud
- Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Medical and Toxicological Critical Care Department, University of Paris 7, 2 rue Ambroise Paré, 75010, Paris, France.
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Marciniak KE, Thomas IH, Brogan TV, Roberts JS, Czaja A, Mazor SS. Massive ibuprofen overdose requiring extracorporeal membrane oxygenation for cardiovascular support. Pediatr Crit Care Med 2007; 8:180-2. [PMID: 17273120 DOI: 10.1097/01.pcc.0000257036.26436.42] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Ibuprofen is rarely associated with severe toxicity. We report a massive ibuprofen overdose that resulted in refractory hypotension requiring extracorporeal membrane oxygenation (ECMO) for cardiovascular support. DESIGN Individual case report. SETTING Pediatric intensive care unit of a tertiary care hospital. PATIENT A 14-yr-old male presented with apnea and cardiovascular collapse after a nonaccidental ingestion of approximately 50 g of ibuprofen. His laboratory evaluation demonstrated an anion gap metabolic acidosis and elevated lactate levels. INTERVENTIONS The patient required pressor support with norepinephrine, phenylephrine, and vasopressin infusions. Due to refractory hypotension, he was placed on ECMO. His serum ibuprofen level at an estimated 5-10 hrs postingestion was 776 microg/mL (therapeutic 20-30 microg/mL). Urine toxicological screen for drugs of abuse, serum acetaminophen, salicylate, and carboxyhemoglobin levels showed that these levels were not elevated. The patient developed high-output renal failure, pulmonary hemorrhage, and gastric bleeding, all of which resolved by hospital day 3. MEASUREMENTS AND MAIN RESULTS ECMO was discontinued on hospital day 4, inotropic support was discontinued, and the patient was extubated on hospital day 5. He was transferred to an inpatient psychiatric unit on hospital day 9 with no identifiable medical sequelae. CONCLUSIONS Although ibuprofen overdose typically has few consequences, severe hypotension, renal failure, and gastrointestinal bleeding can occur. We report the first known case of successful ECMO therapy for ibuprofen overdose.
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Mégarbane B, Leprince P, Deye N, Guerrier G, Résière D, Bloch V, Baud FJ. Extracorporeal life support in a case of acute carbamazepine poisoning with life-threatening refractory myocardial failure. Intensive Care Med 2006; 32:1409-13. [PMID: 16835785 DOI: 10.1007/s00134-006-0257-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2005] [Accepted: 05/30/2006] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To report the efficacy of extracorporeal life support (ECLS) in acute carbamazepine poisoning with sustained refractory myocardial failure and a high degree of conductance disturbances. DESIGN AND SETTING Case report from the toxicological and medical intensive care unit in a university hospital. PATIENT A 26-year-old man with severe myocardial failure unresponsive to 1.7 microg kg(-1) min(-1) epinephrine and 1.9 microg kg(-1) min(-1) norepinephrine (SvO2, 17.8% and cardiac index, 0.8 l min(-1) m(-2)) following a suicidal ingestion of 32 g slow-release carbamazepine. INTERVENTIONS ECLS (Jostra-Maquet centrifugal pump (Rotaflow) connected to a hollow-fiber membrane oxygenator). MEASUREMENTS AND RESULTS ECLS device allowed inotropic drug weaning while maintaining end-organ function and supported the patient until myocardial recovery. The plasma carbamazepine level was 224 micromol/l on admission and peaked at 338 micromol/l 101 h after admission with a prolonged gastrointestinal absorption phase despite multiple doses of activated charcoal. The patient survived and was successfully explanted on day 6. An extensive and regressive thrombosis of the inferior vena cava was noted. Cardiac function totally recovered and at 2-year follow-up. There were no significant sequelae. CONCLUSIONS We report a case of life-threatening myocardial failure with conductance disturbances secondary to an acute carbamazepine poisoning, demonstrating the efficacy of ECLS to assist recovery.
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Affiliation(s)
- Bruno Mégarbane
- AP-HP, Hôpital Lariboisière, Réanimation Médicale et Toxicologique, INSERM U705, CNRS, UMR 7157, Université Paris VII, 2 Rue Ambroise Paré, 75010 Paris, France
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Massetti M, Tasle M, Le Page O, Deredec R, Babatasi G, Buklas D, Thuaudet S, Charbonneau P, Hamon M, Grollier G, Gerard JL, Khayat A. Back from Irreversibility: Extracorporeal Life Support for Prolonged Cardiac Arrest. Ann Thorac Surg 2005; 79:178-83; discussion 183-4. [PMID: 15620939 DOI: 10.1016/j.athoracsur.2004.06.095] [Citation(s) in RCA: 226] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2004] [Indexed: 11/30/2022]
Abstract
BACKGROUND The survival of patients after prolonged cardiac arrest is still inadequate. Extracorporeal life support (ECLS) represents an alternative therapeutic method for patients who do not respond to conventional cardiopulmonary cerebral resuscitation. This technology is used to support the circulation of a patient with severe cardiac failure. METHODS Between June 1997 and January 2003, 40 ECLS procedures were performed in patients who presented with refractory cardiac arrest. During external cardiac massage, the patient was connected to an extracorporeal circuit by the insertion of an arterial and venous cannula through the femoral vessels. The extracorporeal circuit included a centrifugal pump and an oxygenator. Mean age was 42 +/- 15 years; the average time of external cardiac massage was 105 +/- 44 minutes. RESULTS Once the circulation was restored, 22 patients were disconnected from the extracorporeal circulation because of brain death or multiorgan failure; after 24 hours, among the 18 survivors, 6 were weaned off the pump, 9 were bridged to a ventricular assist device, and 2 patients were directly bridged to cardiac transplantation. Eight patients are alive and without any sequelae at 18 month's follow-up. CONCLUSIONS In prolonged cardiac arrest with failing conventional measures, rescue by extracorporeal support provides an ultimate therapeutic option with a good outcome in survivors. Our results encourage the wider application of ECLS for refractory cardiocirculatory arrest in selected patients. The high rate of neurologic death needs further improvements in the early phase of resuscitation maneuvers.
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Affiliation(s)
- Massimo Massetti
- Department of Thoracic and Cardiovascular Surgery, University Hospital, Caen France.
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