LAUSR

A 36-year-old woman presented twice in one week at the emergency department (ED) with severe verapamil overdoses. At the first visit, she reported ingesting 60 tablets of 80mg verapamil and an unknown number of quetiapine 25mg and lorazepam 1mg pills. Her blood pressure was 89/28mmHg, heart rate 39 beats/min and body temperature 37.2 C. Electrocardiogram showed a complete atrioventricular block with a ventricular escape rhythm of 40 beats/min. Treatment started with insulin aspart 60 IU (1 IU/kg), 20% glucose 125mL IV, isoprenaline (boluses of 1–2mL and then titrated to 100–300 mg/h IV), epinephrine (titrated to 0.02– 1.0mg/h IV), potassium chloride (40mmol in 500mL NaCl 0.9% IV) and 10% calcium gluconate 20mL IV. Later, at the intensive care unit, symptomatic treatment included isoprenaline 100–300 mg/h IV, epinephrine 0.02–1.0mg/h IV, insulin 0.5 IU/kg/h IV and 20% glucose 0.5 gram/kg/h IV. Cardiac monitoring detected two episodes of asystole. During the first episode, the monitor showed three intervals of asystole lasting respectively 13, 15, and 20 s, respectively. In the second episode, the duration of asystole was unknown. In both episodes, she received increasing isoprenaline IV and a bolus of epinephrine 0.4mg IV. She recovered and was transferred to the medical psychiatric unit 3 days after hospital admission, and 4 days later, the patient was discharged from the hospital. One day after hospital discharge, she presented at the ED with a second overdose of 40 tablets of verapamil 80mg plus omeprazole 40mg, topiramate 100mg, quetiapine 25mg, lorazepam 1mg, and escitalopram 10mg. Vital signs were: blood pressure 80/34mmHg, heart rate 40 beats/min and a temperature of 36.2 C. The electrocardiogram showed first-degree and sometimes third-degree atrioventricular block with a ventricular escape rhythm of 40 beats/min. Treatment was the same as the prior overdose with the addition of 20% intralipid 100mL IV followed by 400mL/h over 75min (total 600mL). Following intravenous lipid emulsion therapy, she underwent continuous venovenous hemofiltration (CVVH) with an ultrafiltration volume of 2 L/h and a blood flow rate of 160mL/min, which was combined with a hemocompatible, porous, divinylbenzene copolymer beads filter (CytoSorbents Inc, Monmouth Junction, NJ, USA); treatment with CVVH and the CytoSorbR device was continued for 12 h. During treatment in the intensive care unit, the patient was alert and cooperative. There were no side effects (dialysis lines never clogged or serious adverse events). Within 48 h of admission, she was discharged from the ICU and medical psychiatric unit. The CytoSorbR device is designed for use in extracorporeal circuits to adsorb endogenous pathogenic mediators, and the extent of protein binding may determine the degree of toxicant removal [1]. The addition of intravenous lipid emulsion and CVVH with the in-line CytoSorbVR device appeared to produce faster drug clearance and faster resolution of verapamil toxicity when added to high-dose insulin, glucose, pressors, and calcium gluconate [2,3] (Figure 1).