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Life-Threatening Amlodipine Over Dose Requiring ECMO Support Treated by High-Cut-Off Dialysis and Cytosorb

Julius J Schmidt*, Markus Busch, Sascha David, W. Nikolaus Kuhn Velten, Marius M Hoeper, Jan T Kielstein

Calcium Channel Blockers (CCBs) may cause profound vasopressor resistant hypotension in case of intoxication. Recently, the EXTRIP workgroup recommended against the use of Extra Corporeal Treatment Modalities (ECTM) for the elimination of amlodipine. Anecdotal evidence suggests that Veno-Arterial Extra Corporeal Membrane Oxygenation (VA-ECMO) may be beneficial in patients with severe shock due to amlodipine intoxication.

We report a case of severe amlodipine poisoning (total amlodipine intake 625 mg), in which we used awake-VA- ECMO support for hemodynamic stabilization. A combination of a HCO dialyzer and the Cytosorb^® adsorber was used to eliminate amlodipine in two consecutive treatment sessions. Amlodipine dialyzer clearance and Cytosorb^® adsorber clearance were 13.8 (-2,3–20.4) mL/min and 17.5 (9.6–25.6) mL/min, respectively. Clearance levels varied depending on drug plasma levels. During this treatment, initial amlodipine levels fell by 48% and 15% with a total eliminated amount of 242 and 352 μg of amlodipine, respectively, in the dialysate. EXTRIP criteria for dialyzability could not be met by the investigated modalities. ECMO therapy was discontinued after three days and the patient fully recovered.

In conclusion, VA-ECMO support can be used for hemodynamic stabilization of patients with severe amlodipine poisoning, while the extracorporeal elimination techniques used in this setting were unable to remove a meaningful amount of drug.