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What inotrope would be your first choice assuming norepinephrine is the vasopressor being used?
Thanks wish I had this a week sooner. had a massive Amlodipine (90x 10mg) and Carvidilol (180x 25mg) two weeks ago. Within 10 mins of arrival HR and MAP dropped from 95 and 75 to 50 and 40 respectively. We followed this exact algorithm but with addition of high dose glucagon push and gtt. We have great tox communication so transfer for ECMO began early. Ended up on norepi, vasopressin, neo, and epi. Barely able to maintain a map of 60, despite that she stayed pink/warm and mentated well the whole time. Interestingly, our tox did not recommend insulin, but did suggest lipid if she were to have coded prior to transfer. Any thoughts on lipid emulsion, noticed it wasn’t mentioned here?
First inotrope for me is epi.
Lipid is last ditch for peri-code patient in places without ECMO. I personally feel ALL of these patients should be at a center with access to ECMO. It is worth the transfer.
Hi Matt and Matthew,
Thank you for the great questions
Initial inotrope for me also is epinephrine but as discussed in the piece getting high dose insulin started early ie, in a bad calcium channel antagonist poisoning, I am using both early
Here is the MD Calc for calculating the dose of high dose insulin and gives some guidelines about supplemental dextrosehttps://www.mdcalc.com/high-dose-insulin-euglycemia-therapy-hiet
I strongly recommend getting your local medical toxicologist involved early or speaking to the on-call physician toxicologist at your local poison center and transfer early to place with ECMO
2. Intravenous lipid emulsion:
I also agree with Scott that intravenous lipid emulsion should be reserved for peri code or codesThere are concerns of using intravenous lipid emulsion in ECMO as the intravenous fat emulsion may cause fat deposition in EMCO circuits affecting the ability to perform ECMO and other effects.
Therefore, if ECMO going well and the patient stabilizing I would withhold the intravenous lipid emulsion as do not want to adversely affect the good thing going on ie, ECMO
However, if the patient continues to deteriorate and codes or is going to code, I would recommend intravenous lipid emulsion therapy at that time
See articleLee HM, Archer JR, Dargan PI, Wood DM. What are the adverse effects associated with the combined use of intravenous lipid emulsion and extracorporeal membrane oxygenation in the poisoned patient? Clin Toxicol 2015;53:145-150.https://www.ncbi.nlm.nih.gov/pubmed/25634667
Hi Mike and Matthew :)
Sean N. Re-doing our CCB OD order set, anyway I can compare it with yours?Thanks for the consideration either way.Dave C.
Thank you for the message
I do not have a CCB poisoning order set
You may have reviewed already but here is an article on Expert Consensus Recommendation from various toxicology societies from Critical Care Medicine you may find interesting
Experts Consensus Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults
What you do matters.