RN Children's Mercy Hospital Kansas City, Missouri, United States
Introduction: Treatment tends to follow an expected pathway when a patient ingests a singular substance. When the patient has ingested multiple substances and the level of hypotension is profound the treatment is not as clear. The use of continuous renal replacement therapy (CRRT) in tandem with total plasma exchange (TPE) has been shown to be an effective treatment strategy in one specific patient situation
Description: A 16-year-old female was admitted to the pediatric intensive care unit (PICU) for polysubstance ingestion. She had consumed large amounts of alcohol and found hours later with empty bottles for prazosin, clonazepam and amphetamine. She presented to the emergency department ambulatory with stable vital signs. She progressed to a decreased level of consciousness and hypotension requiring transfer to the PICU. She was started on an epinephrine infusion en route and immediately intubated upon admission. A urine drug screen was sent showing the presence of amphetamines, cannabinoids, benzodiazepines, ethanol and nicotine. She decompensated, requiring escalation of vasoactive support; epinephrine 0.3mcg/kg/min, norepinephrine 0.3mcg/kg/min and vasopressin 1.0 milliunit/kg/min. Frequent fluid boluses were required to maintain adequate hemodynamics, over 3 liters in a 2-hour period. A hemodialysis catheter was placed and CRRT was initiated to address her severe metabolic acidosis. Single pass albumin dialysis (SPAD) was ordered to attempt to clear some of the protein bound drugs from her system. After 80 minutes of CRRT, TPE was started. Within 45 minutes of CRRT initiation vasoactives were able to be weaned. Upon completion of TPE, vasoactives were down significantly; and discontinued 3.5 hours later. She was successfully separated from CRRT and mechanical ventilation the following morning. She was discharged from the PICU that evening and discharged from the hospital within 4 days of admission
Discussion: Polysubstance ingestions are difficult to manage, the use of CRRT with SPAD in tandem with TPE can be a quick and effective strategy in both supportive therapy and clearing substances. American Society for Apheresis has designated TPE for acute toxin ingestion a Category III; meaning optimum role of TPE is not well established for this patient population but has proven effective
