[Methylene blue against refractory hypotension].

In this case report we describe a 62-year-old man, intoxicated with losartan, an angiotensin-II receptor antagonist. The patient presented with a systolic blood pressure of 60 mmHg, metabolic acidosis, and hyperglycaemia. His condition worsened within the first hour of arrival despite infusion of four litres of saline, epinephrine, norepinephrine, and vasopressin as well as insulin and antibiotics. Intravenous methylene blue 75 mg was infused over five minutes. Within 30 minutes his systolic pressure increased to 100 mmHg, and the infusion of epinephrine could be reduced four hours later.

Mixed amlodipine/valsartan overdose treated by the molecular adsorbent recirculating system (MARS™).

CASE REPORT: We describe the case of a 58-year-old woman who developed a severe distributive shock following the intentional ingestion of a large overdose of amlodipine (480 mg) combined with valsartan (3680 mg). Extreme vasoplegia remained refractory to maximal standard therapy including fluid resuscitation, intravenous calcium, vasopressors at very high doses, hyperinsulinemia-euglycemia therapy, lipid emulsion, and methylene blue administration. Besides, the patient exhibited hyperglycemia refractory to very high doses of insulin. Due to its theoretical ability to effectively remove protein-bound drugs such as amlodipine from the circulation, albumin dialysis with the molecular adsorbent recirculating system (MARS™) was performed during two consecutive sessions. Blood was drawn for toxicokinetic calculations. Amlodipine elimination half-life during the first MARS™ session was calculated at 7.6 h. In addition, there was a rapid fall in blood glucose, requiring the introduction of a continuous infusion of glucose in order to achieve euglycemia. Moreover, a few hours after the initiation of the MARS™ therapy, the hemodynamic status was not significantly modified but a significant tapering of epinephrine infusion was possible, together with a progressive decrease of blood lactate level. However, the need for vasopressors in decreasing doses was present until day 5 post-ingestion. Eventually, the patient fully recovered and was discharged home 8 days after admission. DISCUSSION: The role of the MARS™ in the treatment of severe poisoning of calcium channel blockers is still to be defined. We were able to demonstrate a relatively short elimination half-life of amlodipine. A decreased insulin resistance and a reduction of epinephrine infusion were also observed.

Valsartan ingestions among adults reported to Texas poison control centers, 2000 to 2005.

INTRODUCTION: Little data exist on potentially adverse valsartan ingestions reported to poison control centers. METHODS: Using adult ingestions of valsartan reported to Texas poison control centers during 2000-2005, I determined the proportion of cases involving serious outcomes for selected variables and evaluated for statistical significance by calculating the rate ratio (RR) and 95% confidence interval (CI). RESULTS: Thirteen (7%) of 185 total cases involved serious outcomes. Serious outcomes were significantly more likely to occur with a maximum dose 320 mg (RR 9.06, CI 1.30-100.14) or 4 tablets (RR 9.00, CI 2.07-39.11) or where the circumstances of the exposures involved self-harm or malicious intent (RR 17.28, CI 4.98-67.13). CONCLUSIONS: The severity of the medical outcome associated with adult valsartan ingestions depended on the dose and the circumstances of the ingestion. Such information is useful for creating triage guidelines for the management of adult valsartan ingestions.