Antihypertensives/bupropion/insulin/soya oil emulsion
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Cardiogenic shock and bradyasystolic arrest: 2 case reports Two patients developed cardiogenic shock after and overdose of bupropion and antihypertensives. Treatment with high-dose insulin and soya oil emulsion [IV fat emulsion; IFE] was followed by bradyasystolic arrest; both patients died. Patient 1 was a 50-year-old woman who presented with profound bradycardia and hypotension following an overdose of metoprolol 50mg and bupropion XL 150mg [total of 80 tablets; doses and time to reaction onset not stated]. Despite treatment with IV hydration, calcium, glucagon and a high-dose insulin (HDI) infusion of 10 U/kg/h, her condition persisted, with a pulse rate of 40bpm and a mean arterial pressure of 30mm Hg. She received 1.5 mL/kg of 20% soya oil emulsion as a bolus, but within 30 seconds she went into bradyasystolic arrest. CPR was performed and her pulses returned. She died of multi-system organ failure on hospital day 4, despite pacemaker and intra-aortic balloon pump implantation. Post-mortem bupropion and hydroxybupropion concentrations were 130 ng/mL and 480 ng/mL, respectively. Patient 2 was a 53-year-old man who presented with profound hypotension and bradycardia after an overdose of a month’s supply of diltiazem SR 120mg and propranolol 20mg [doses, routes and time to reaction onset not stated]. His condition persisted despite treatment with IV fluids, calcium, epinephrine [adrenaline], atropine, dopamine and HDI infusion of 10 U/kg/h. A bolus of 1.5 mL/kg of 20% soya oil emulsion was administered and, within 1 minute, he went into bradyasystolic arrest. CPR was performed and he regained his pulses. He died of multi-system organ failure on hospital day 7, despite treatment with vasopressors and pacemaker and intra-aortic balloon pump implantation. Tests revealed propranolol and diltiazem concentrations of 53 ng/mL (day 2) and 100 ng/mL (day 5), respectively. Author comment: "[I]t is possible our patients were dependent upon HDI for inotropic support and IFE rendered HDI ineffective. . . An interaction between IFE and HDI must be contemplated." Cole JB, et al. Failure of High Dose Insulin and Intravenous Fat Emulsion in 2 patients with Poison-Induced Cardiogenic Shock. 2011 North American Congress 803062953 of Clinical Toxicology : abstr. 55, 21 Sep 2011. - USA
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Reactions 19 Nov 2011 No. 1378
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