Therapeutic plasma exchange for refractory verapamil poisoning
Asaio Journal(2024)
Abstract
INTRODUCTION: Verapamil poisoning results in significant morbidity and mortality, but management is challenging due to decreased myocardial contractility and conduction. We present a case of verapamil poisoning requiring ECMO support and the use of therapeutic plasma exchange (TPE) to provide stability and enhanced drug clearance. DESCRIPTION: A 14-year-old female with depression presented after ingestion of approximately 4080 mg of extended-release verapamil. She was taken to an outside hospital and progressed to 3rd degree AV block. She was intubated and transferred to a tertiary PICU, where upon arrival, she was bradycardic and hypotensive despite high dose epinephrine and norepinephrine infusions. High-dose insulin-euglycemic and lipid emulsion therapy was initiated. She was cannulated onto VA-ECMO using a 17-French catheter into the right carotid artery and a 23-French cannula into the right internal jugular vein. Despite VA-ECMO flows of 100 ml/kg/min, she continued to require high vasoactive support. TPE of 1.5 plasma volume exchange with all 5% albumin was performed. The verapamil concentration pre-TPE was 7500 ng/ml and post-TPE was 1300 ng/ml, suggesting enhanced clearance (half-life is 3-7 hours). Following TPE, the patient’s vasoactive needs decreased. She was decannulated from ECMO after 5 days and ultimately transferred to an inpatient psychiatric facility. DISCUSSION: There are limited case reports for the use of TPE in verapamil poisoning. Verapamil is a highly protein bound medication, and the use of TPE may be an important adjunctive therapy to enhance drug clearance.
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Key words
therapeutic plasma exchange
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