Metformin overdose
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Lactic acidosis treated with vasopressin: case report A 49-year-old man developed lactic acidosis after ingesting an overdose of metformin in a suicide attempt; he was successfully treated with vasopressin [Pitressin]. The man presented to the emergency department with irritability and impaired consciousness 3 hours after ingesting approximately 40-45g of metformin. He was sedated, intubated and ventilated, but became haemodynamically unstable. Norepinephrine, epinephrine, insulin, glucose and hydrocortisone were initiated. Investigations revealed hyperkalaemia, severe acidosis and a lactate level of 34 mmol/L. The man was moved to the ICU to begin continuous veno-venous haemofiltration (CVVH). Upon arrival, he had a systolic BP of 80-100mm Hg and a central venous pressure of 19mm Hg. Arterial blood glass (ABG) analysis revealed the following: pH 6.8, paO2 50 kPa and PaCO2 >10 kPa. His blood sugar level was 11 g/L, and his lactate level was beyond the maximum titration limit of the ABG machine. Despite the initiation of CVVH and administration of bicarbonate, his metabolic acidosis did not improve. An IV vasopressin infusion was started at a dose of 6 IU/h, resulting in a rapid improvement in BP, increase in pH and reduction in epinephrine requirements. Epinephrine was discontinued the following morning, and norepinephrine was gradually withdrawn over several days. He became haemodynamically stable, and vasopressin was gradually tapered and discontinued. A tracheostomy was performed, followed by withdrawal of ventilation 3 days later. He was discharged to the high dependency unit and then to a medical ward before leaving the hospital. Author comment: "Lactic acidosis is not due to tissue hypoxemia and anaerobic metabolism but to reduction of cell redox function. The negative inotropism effect of metformin could also contribute to the ability of hepatocytes to extract circulating lactate." Al-Makadma YS, et al. Successful management of high-dose metformin intoxication. Role of vasopressin in the management of severe lactic acidosis. Middle East Journal of Anesthesiology 20: 873-5, No. 6, 2010 - Saudi 803056280 Arabia
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Reactions 2 Jul 2011 No. 1358
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