She had a history of bone marrow transplantation due to aplastic anemia 6 months ago and currently not taken any medication. Keywords: Herb-drug interactions Fat emulsions, intravenous Tachycardia, ventricular Heart arrest ToxicityĪ 36-year-old female visited the outpatient clinic for a routine follow-up and suffered an episode of loss of consciousness as she was leaving the hospital. ![]() However, VT with pulse continued, so ILE therapy was attempted, which led to the resolution of VT. Synchronized cardioversion was then performed and amiodarone was administered. Cardiopulmonary resuscitation was performed, and return of spontaneous circulation with VT was achieved. Soon after coming to the hospital, she went into cardiac arrest. She had taken an unknown herbal decoction three days before visiting the hospital. A 36-year-old woman with aplastic anemia presented with mental changes. We report a case of herbal intoxication leading to refractory VT, which was successfully treated with ILE therapy. If refractory ventricular tachycardia (VT) is caused by herbal products and shows no response to conventional therapy, intravenous lipid emulsion (ILE) therapy can be considered. ![]() However, many herbs can be toxic and even life-threatening. Clinicians managing poisoned patients with both of these novel treatment modalities should be aware of these potential complications.Ĭardiovascular toxicity Complications ECMO Intralipid® Overdose Poisoning.Herbal products have been used for therapeutic purposes for a long time. There is in vitro and clinical evidence that the combined use of ILE and extracorporeal membrane oxygenation may be associated with fat deposition in the VA-ECMO circuits and increased blood clot formation. In two of these case reports, the authors specifically stated that ILE did not cause any mechanical complications with the VA-ECMO the other seven reports made no comment as to whether there were any complications or not. Nine case reports were identified where ILE was used with VA-ECMO for the management of circulatory failure/instability secondary to cardiotoxic drug poisoning. In a prospective observational study of 9 neonates on VA-ECMO receiving intravenous nutrition, layering and agglutination were seen in four sets of VA-ECMO tubing and blood clots were found in seven circuits. An in vitro study involving the continuous infusion of 20% ILE at 3 mL/h for 24 h demonstrated layering (separation of intact fat emulsion from blood) and agglutination (clumping resulting in little or no flow of fat emulsion through the circuit) in all circuits within 30 min of starting the fat emulsion infusion.Īn observational study based in 42 centres that regularly used 'fat emulsion' during VA-ECMO treatment reported cracking of stopcocks (the valve which restricts flow in the VA-ECMO tubing) (n = 10, 23.8%) fat emulsion agglutination (n = 11, 26.2%) clogging and associated malfunction of the membrane oxygenator (n = 2, 4.8%) and increased blood clot formation in the circuits (n = 2, 4.8%). Finally all cases posted on were reviewed to determine if they related to the use of ILE with VA-ECMO and no new cases were identified. In addition, the abstracts published between 20 inclusive of those from the North American Congress of Clinical Toxicology and the congresses of the European Association of Poisons Centres and Clinical Toxicologists were searched to identify additional cases and 2 were found. PubMed and OVID (1966 to 9 June 2014) and EMBASE (1947 to 9 June 2014) were searched to identify publications relating to studies and/or case reports where ILE had been used at the same time when VA-ECMO was used - 7 were identified. To ascertain the adverse effects associated with the combined use of ILE and ECMO in the poisoned patient. There have been reports of mechanical problems, including fat emulsion agglutination, clogging, increased blood clot formation and even cracking of parts of the machine, in patients concurrently receiving VA-ECMO and ILE as part of parenteral nutrition. Intravenous lipid emulsion (ILE) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) are being used together or in close succession in the management of circulatory failure secondary to cardiotoxic drug poisoning.
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