Abstract: PO0903
Caffeine Overdose Requiring Extracorporeal Mechanical Oxygenation (ECMO) and Hemodialysis
Session Information
- Fluid, Electrolytes, and Clinical Events with Dialysis: Getting to the "Heart" of the Matter
November 04, 2021 | Location: On-Demand, Virtual Only
Abstract Time: 10:00 AM - 12:00 PM
Category: Dialysis
- 701 Dialysis: Hemodialysis and Frequent Dialysis
Authors
- Lundeen, Luke, Hennepin Healthcare, Minneapolis, Minnesota, United States
- Wang, Connie J., Hennepin Healthcare, Minneapolis, Minnesota, United States
Introduction
Caffeine (1,3,7-trimethylxanthine) is the most widely consumed psychostimulant in the world. It is considered safe if consumed in moderation but can lead to cardiovascular collapse if the dose exceeds 150-200mg/kg. Extracorporeal removal of caffeine with intermittent hemodialysis (IHD) has been reported to improve outcomes. However, continuous veno-venous hemodiafiltration (CVVHDF), which is a routinely used extracorporeal therapy in patients with severe hypotension, is traditionally less favored for caffeine overdose because of inadequate rate of clearance. We present a case of combination therapy using both IHD and CVVHDF in the treatment of life-threatening caffeine overdose.
Case Description
A 33-year-old female weighing 63kg presented after ingestion of approximately 100g of guarana powder (22g of caffeine). She presented with refractory ventricular tachycardia (140-170 BPM) and severe hypotension (blood pressure 50/40 mmHg) resistant to 4 vasopressors at maximal dose. She required extracorporeal membrane oxygenation (ECMO). Baseline renal function was normal. IHD was initiated with blood flow rate (BFR) 200ml/min and dialysate flow rate (DFR) 500ml/min, which was gradually increased over 4 hours to a BFR of 400ml/min and DFR of 800ml/min; IHD continued for an additional 4 hours at this rate. During this 8-hour IHD treatment, her initial 4 pressor doses were halved, and she was transitioned to CVVHDF; the caffeine level remained unavailable. However, after 12 hours of CVVHDF, the patient did not experience continued hemodynamic improvement, so IHD was reinitiated for 12 hours. Following this second prolonged session of IHD, she was weaned down to moderate doses of just two pressors. She was then transitioned back to CVVHDF for an additional 36 hours, at which time she was able to come off ECMO and all pressors. She had a full neurologic recovery. We later received a serum caffeine level of 425mg/L (drawn soon after arrival at the hospital), which is the second-highest level ever reported; the established lethal concentration is 80mg/L.
Discussion
Despite continuous dialytic therapies being generally favored in patients with hemodynamic instability, a combination of IHD and CVVHDF may be used for hemodynamically unstable patients who ingest extremely high dose of caffeine. However, in such patients, continuous therapies are unlikely to supplant prolonged and repeated IHD treatment sessions.