Post Your Cases > LIPID RESCUE THERAPY in Prothipendyl Intoxication
LIPID RESCUE THERAPY in Prothipendyl Intoxication
Objective: To describe a case of LIPID RESCUE THERAPY (LRT) in a patient with multiple drug overdose, including prothipendyl, bisoprolol, quetiapin, lorazepam and melitracen
Case report: Patient S.T., male, 32yr, 104 kg BW Patient admitted to our ICU appr. 75 minutes after having allegedly ingested 300mg bisoprolol, 2400mg prothipendyl and unknown amounts of quetiapin, trazodon and lorazepam in an attempt to committ suicide. Medical history: metabolic syndrom with hyperlipidemia, arterial hypertension, NIDDM, OSAS , adipositas and multiple psychiatric disorders including depression and borderline-syndrom. On admission alert, orientated, vital signs unremarkable. After 15 minutes cardiac arrest in asystolia without prequelae, 60 secondes of manual chest compression without ALS intervention, subsequently ROSC but ongoing hypotension. The patients state therefore fulfilled our institutional criteria for LRT (life-threatening intoxication present). LRT started about 90 minutes after ingestion (bolus and infusion totalling to 756 ml INTRALIPID 20% ®). After LRT, no more arrhythmias were observed. Treatment for hypotension consisted of cristalloids (6000ml in 12h) and noradrenaline (max.rate 0,84, tapered down to 0,13 mcg/kg/min in 12 h). Patient stayed alert, was weaned from catecholamines in less than 24h and discharged to a psychiatric ward 40 hours after admission.
Discussion. A positive effect probably related to LRT was observed. The involved drugs with a wellknown cardiac toxicity (prothipendyl, bisoprolol and quetiapin) all are candidate substances for LRT according to their liposolubility (logP 4,01, 2,22 and 1,8, respectively). In a post hoc analysis of blood samples drawn before LRT we found that only the blood levels of prothipendyl (a neuroleptic agent) reached toxic levels, ruling out a betablocker-mediated or other drug-related effect. At our institution, prothipendyl is a substance well known for producing drowsiness and somnolence in milder intoxications and coma, seizures, prolongation of QT-time and hypotension in severe ones. Asystolia is a described adverse event never seen by us in many severe intoxications. The good clinical shape of the patient and the rapid onset of a severe complication makes the cited short delay since ingestion seem plausible, what, to our opinion, also explains the good response to LRT. The effectiveness of LRT is also underlined by the fact that we, besides the very moments of CPR, never observed significant coma or deeper somnolence. To our experience, a dose of prothipendyl capable of producing asystolia should have produced some more pronounced loss of vigilance. LRT has probably contributed by a great part to the rapid recovery of the patient. No negative effects probably related to LRT were observed.
Objective:
To describe a case of LIPID RESCUE THERAPY (LRT) in a patient with multiple drug overdose, including prothipendyl, bisoprolol, quetiapin, lorazepam and melitracen
Case report:
Patient S.T., male, 32yr, 104 kg BW
Patient admitted to our ICU appr. 75 minutes after having allegedly ingested 300mg bisoprolol, 2400mg prothipendyl and unknown amounts of quetiapin, trazodon and lorazepam in an attempt to committ suicide. Medical history: metabolic syndrom with hyperlipidemia, arterial hypertension, NIDDM, OSAS , adipositas and multiple psychiatric disorders including depression and borderline-syndrom.
On admission alert, orientated, vital signs unremarkable. After 15 minutes cardiac arrest in asystolia without prequelae, 60 secondes of manual chest compression without ALS intervention, subsequently ROSC but ongoing hypotension. The patients state therefore fulfilled our institutional criteria for LRT (life-threatening intoxication present).
LRT started about 90 minutes after ingestion (bolus and infusion totalling to 756 ml INTRALIPID 20% ®). After LRT, no more arrhythmias were observed. Treatment for hypotension consisted of cristalloids (6000ml in 12h) and noradrenaline (max.rate 0,84, tapered down to 0,13 mcg/kg/min in 12 h). Patient stayed alert, was weaned from catecholamines in less than 24h and discharged to a psychiatric ward 40 hours after admission.
Discussion.
A positive effect probably related to LRT was observed.
The involved drugs with a wellknown cardiac toxicity (prothipendyl, bisoprolol and quetiapin) all are candidate substances for LRT according to their liposolubility (logP 4,01, 2,22 and 1,8, respectively).
In a post hoc analysis of blood samples drawn before LRT we found that only the blood levels of prothipendyl (a neuroleptic agent) reached toxic levels, ruling out a betablocker-mediated or other drug-related effect.
At our institution, prothipendyl is a substance well known for producing drowsiness and somnolence in milder intoxications and coma, seizures, prolongation of QT-time and hypotension in severe ones. Asystolia is a described adverse event never seen by us in many severe intoxications.
The good clinical shape of the patient and the rapid onset of a severe complication makes the cited short delay since ingestion seem plausible, what, to our opinion, also explains the good response to LRT. The effectiveness of LRT is also underlined by the fact that we, besides the very moments of CPR, never observed significant coma or deeper somnolence. To our experience, a dose of prothipendyl capable of producing asystolia should have produced some more pronounced loss of vigilance.
LRT has probably contributed by a great part to the rapid recovery of the patient.
No negative effects probably related to LRT were observed.