Post Your Cases > LIPID RESCUE THERAPY in an Intoxication with Diltiazem and Candesartan

Objective: to report a case of unsuccessful lipid rescue therapy in an intoxication involving dilitiazem and candesartan.
Case report:
Patient I.H., 69 yr female, BW 70 kg
Patient ingested 3600mg diltiazem, 160mg candesartan, 1350mg oxazepam, 800mg simvastatin, 100mg citalopram and 5500mg naproxen in an attempt to commit suicide. Delay to hospital app. 2 h.
On arrival, the patient was drowsy, awakeable, oriented with slurred speech. Her vital signs showed HF 55 bpm in sinus rhythm, oxygen saturation 88% breathing ambient air and RR 50/35 measured via cuff; metabolic acidosis in BGA.
Ongoing deterioration of perfusion pressure, occurence of AV-nodal rhythm with symptomatic bradycardia despite of infusion of big amounts of cristalloids and adrenaline and noradrenaline in rapidly increasing dosages, therefore fulfilling our institutional criteria for LRT (life-threatening intoxication present). Preserved RVF/LVF with signs of hypovolemia in TTE.
We started LRT about 1,5 hours after the patient arrived (i.e. 2,5 to 3,5 hours after ingestion), and administered a total of 700ml of INTRALIPID ® 20% as bolus and infusion.
The presentation of the patient did not change in any aspect during the infusion except for ongoing deterioration of hemodynamics. Half an hour after LRT, a trend towards fewer phases of AV-nodal rhythm in monitor ECG was observed.
Patient was intubated and prone-positioned for respiratory failure and put on CVVHD for treating metabolic acidosis. Hypoperfusion with lactacidosis remained resistant to treatment, the patient died the day after admission after a final treatment trial with glucagon in refractory vasoplegic shock, remarkably with near to normal left ventricular function until the very last hours.
Discussion:
No positive effects probably related to LRT were observed.
Both diltiazem and candesartan are candidate drugs for LRT judged by their liposolubility (logP 4,53 and 7,43, respectively). No post hoc drug screening is available for this case, so an intoxication with an unknown substance not suceptible to the properties of LRT cannot be outruled. The clinical course strongly suggests the presence of potent vasodilators, anyway.
The time period between ingestion and start of LRT was estimated with 2,5 to 3,5 hours based on data given by relatives not directly witnessing the intake of the drugs. In our experience, such estimations are questionable to a great extent, so a longer delay could be a possible explanation for failing LRT.
No negative effects probably related to LRT were observed.
December 18, 2013 | Unregistered Commenterstefan poechacker