The Efficacy of Albumin Dialysis in the Reversal of Refractory Vasoplegic Shock Due to Amlodipine Toxicity.

OBJECTIVES: Calcium channel blockers are highly protein-bound medications frequently used in the management of hypertension. Overdose results in severe hypotension and is the fourth most common cause of toxicity-related deaths in the United States. Management is mostly supportive, with currently no standard role for targeted drug removal. The protein-bound nature of these medications presents the option of utilizing albumin dialysis for their removal and for the reversal of associated shock. DESIGN AND SUBJECTS: We present two cases of life-threatening intentional amlodipine overdoses successfully treated with albumin dialysis. Both patients experienced profound distributive shock in the setting of preserved cardiac contractility that was refractory to maximal vasoactive agent support. INTERVENTIONS AND RESULTS: After initiation of albumin dialysis, the patients showed rapid hemodynamic improvement and were able to be weaned off vasopressor support. CONCLUSIONS: These cases demonstrate the safety and efficacy of albumin dialysis in the management of near-fatal calcium channel blocker overdoses related to amlodipine and offer an additional therapeutic option apart from conventional supportive care. Importantly, these cases were not associated with impaired cardiac contractility, thereby making venoarterial extracorporeal membrane oxygenation a less preferable option. Furthermore, this therapeutic benefit of albumin dialysis can potentially be extended to the management of toxicity related to other highly protein-bound drugs and toxins.

Intra-Abdominal Hypertension and Abdominal Compartment Syndrome: An Underappreciated Cause of Acute Kidney Injury.

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome are increasingly recognized in both medical and surgical critically ill patients and are predictive of death and the development of acute kidney injury. Although there are many risk factors for the development of IAH, in the era of goal-directed therapy for shock, brisk volume resuscitation and volume overload are the most common contributors. Abdominal examination is an unreliable predictor of intra-abdominal pressure (IAP), but IAP can be easily measured in a reproducible and reliable manner by a number of simple bedside techniques. Prompt recognition and intervention to decrease IAP and improve vital organ perfusion are essential to minimize the negative effects of IAH on somatic and visceral organ functions.