Pediatric Cardiac

Laws, Jennifer1; King, Jennifer1; Bruccoleri, Rebecca2; Vandevoorde, Rene3; Bridges, Brian1

1Vanderbilt University Medical Center, Department of Pediatrics, Division of Critical Care, Nashville, USA.

2Vanderbilt University Medical Center, Division of Clinical Pharmacology, Nashville, USA.

3Vanderbilt University Medical Center, Department of Pediatrics, Division of Nephrology, Nashville, USA

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.