The use of extracorporeal life support in adolescent amlodipine overdose
A thirteen year old, 61kg young woman intentionally ingested thirty 10 mg tablets of amlodipine, six bottles of beer, and an unknown quantity of barbiturates. She presented to the Emergency Department (ED) six hours after the ingestion complaining of tiredness and increased heart rate. She had a blood pressure of 73/34 (mean 47) mmHg, heart rate of 103/min, and respiratory rate of 16/minute. Her blood pressure did not improve despite the administration of multiple boluses of normal saline, two grams of calcium chloride, and infusion of norepinephrine (0.1 mcg/kg/min). The urine toxicology screen was positive for butalbital and caffeine. The serum alcohol concentration was 0.2 g/dL. The patient was transferred to the pediatric intensive care unit (PICU). On admission to the PICU she was hypotensive and drowsy, but would awaken and respond to questions. She had nausea and vomiting. During the first 3 hrs following admission to PICU, the patient had worsening metabolic and lactic acidosis [], increased creatinine concentration, oliguria, and decreased mental status. The local Poison Control was consulted. Another gram of calcium chloride was administered. The norepinephrine infusion was increased (0.4 mcg/ kg/ min) and epinephrine infusion (0.1 mcg/kg/min) was added. Insulin (0.1 unit/ kg/ hour) and dextrose (D12.5 at 100 cc/hr) were then infused.\nDue to evidence of decreased end organ perfusion and persistent refractory hypotension, which was expected to last at least 48 hrs after the ingestion of amlodipine, the patient was electively placed on veno-arterial extracorporeal life support (VA ECLS) 15 hrs after the ingestion and 9 hrs after presentation to the ED. The patient was induced with fentanyl 10 mcg/ kg IV, paralyzed with rocuronium and intubated A 17 French (Fr) arterial cannula was placed in the right femoral artery. A 12 Fr arterial cannula was placed distal to this site to maintain perfusion to the right lower extremity. A Goretex graft was used during the insertion of the arterial cannulas to facilitate subsequent decannulation. A 21 Fr venous cannula was inserted in the left femoral vein. ECLS flow was initiated slowly and increased to 70 cc/ kg/min as tolerated. Heparin was infused to maintain the activated clotting time 160-180 seconds.\nOver the subsequent 24 hrs, the epinephrine and norepinephrine infusions were weaned off. The serum lactate and creatinine declined []. The patient was alert and followed commands. The ECLS flows were decreased and the patient was successfully decannulated after 57 hrs on ECLS. She was extubated later that day and was neurologically intact. She was discharged from the PICU to an inpatient psychiatric unit two days later.