(1496) Prolonged ECMO Requirement for an Adolescent With Amlodipine Overdose

Introduction: The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for shock after calcium channel blocker (CCB) overdose has been poorly described in pediatric literature. This case report describes a teenager with CCB overdose who was cannulated to VA-ECMO after profound vasoactive requirement and multimodal CCB antidotes for 14 days with favorable neurologic outcome.

Description: A 17 year old girl presented to the emergency room after intentional ingestion of 200mg of amlodipine. On presentation, she had cardiovascular collapse with a vasoactive-inotropic score (VIS) score of 85, requiring epinephrine, norepinephrine, and vasopressin drips. In consultation with toxicology, she was managed with high dose insulin euglycemia therapy (HIET), repeated doses of methylene blue, glucagon boluses, and lipid emulsion therapy. However, she continued to have hemodynamic instability and she was ultimately cannulated to VA-ECMO via a femoral approach for hemodynamic support within hours of arrival.

Despite the profound cardiovascular collapse, the patient never developed pulselessness or required chest compressions. She remained on ECMO support for 14 total days. Her course was complicated by fluid overload, requiring bilateral chest tubes and continuous renal replacement therapy (CRRT). Additionally, she had persistent hypoglycemia despite high concentration dextrose infusions, ultimately requiring the cessation of HIET. As her hemodynamic profile improved, attempts made to decannulate from VA-ECMO were performed at days 4, 7, 11, and 13, however, failed secondary to ongoing instability.

She was successfully decannulated on day 14 of VA-ECMO support. The patient was discharged home with rehabilitation after 2 months of hospitalization with a Pediatric Cerebral Performance Category (PCPC) score of 1.

Discussion: In 2020, the American Association of Poison Control Center reported 15,000 cases of CCB overdose in the United States. Of those 15,000 patients, few were cannulated to VA-ECMO. To our knowledge, this case report features the longest successful utilization of VA-ECMO following CCB overdose in the pediatric population with a positive outcome.