Case Report: Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) as a Bridge Therapy for Tricyclic Antidepressants Toxicity

Abstract

Background: Tricyclic antidepressants (TCAs) are neuropsychiatric agents ideal for overdose cardiac toxicity, which manifested as refractory hypotension, dysrhythmias, cardiogenic shock and cardiac arrest. In this situation, veno-arterial Extracorporeal Membrane Oxygenation (VA-ECMO), as the last resort, may be life saving.

Case Report: We report a 26- year-old female patient with a history TCAs toxicity presented with cardiac arrest. Return of spontaneous circulation (ROSC) achieved after 5 cycles of CPR. TCA was positive in urine then came later positive in serum sample (> 1000 ng/ml). Bedside echocardiography revealed severe cardiomyopathy (ejection fraction 35%) and global hyperkinesia. The decision was extracorporeal life support (ECLS) and veno-arterial Extracorporeal Membrane Oxygenation (VA-ECMO) was instituted. After 24 hours of hemodynamic stabilization on the VA-ECMO, inotropic support started tapering, QRS duration was normalized, the patient tolerated low pump flow 1,5 l/min and even sedation vacation. ECMO was weaned off on the 6th day and the patient was extubated on the 9th day of ICU admission.

Discussion: Management of our patient initially involved basic resuscitation with airway protection, good hydration, CPR upon cardiac arrest and post-ROSC support of circulation up to initiation of VA ECMO. Few case reports were published documenting VA ECMO indication in TCA toxicity patients. The most distingusible points are that, all patients were successfully weaned off from the VA ECMO and early ECMO intervention since TCA ingestion was crucial.

Conclusion: VA ECMO is a therapeutic option as a bridge for recovery in TCA and induced cardiac toxicity.