LIPID EMULSION THERAPY FOR LIFE-THREATENING FLECAINIDE TOXICITY

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: We present a case of flecainide (FLC) toxicity secondary to renal failure treated with intravenous lipid emulsion (ILE) therapy. CASE PRESENTATION: The patient is 63 year old female history stage IVB uterine carcinosarcoma, chronic kidney disease and supraventricular tachycardia (SVT) on FLC. She was admitted intra-abdominal hemorrhagic metastases. A rapid response called due hypotension, she noted be oliguric for the previous 24 hours serum creatinine 2.5 mg/dL (baseline 1.3 mg/dL) hyponatremic (126 mmol/L). EKG showed new wide complex rhythm, at 78bpm, QRS widening 280ms, prolonged QTc 631. subsequently suffered tachyarrhythmic cardiac arrest (CA), refractory two shocks, return spontaneous circulation after treatment sodium bicarbonate (NaHCO3). FLC discontinued started hypertonic NaHCO3 drip, but frequent pushes were required correct complex. hypotension progressed requiring high dose infusions epinephrine (15 mcg/min) norepinephrine (90 mcg/min). ILE infusion started, 20% 1.5 mL/kg administered over 5 minutes, followed by an 0.25 mL/kg/minute hours. level drawn during came back elevated 1.35 mcg/mL (therapeutic 0.20-1.0 mcg/mL). In 48 following ILE, there resolution arrhythmias, vasopressor requirements reduced more than 50% DISCUSSION: class 1C antiarrhythmic that inhibits Na+ channels used prevention SVT. It has narrow therapeutic range about 30% renally excreted making acute injury risk toxicity. Other factors are hyponatremia hypokalemia. Characteristic signs include lethargy changes such as PR prolongation. These can progress brady or CA seen in our patient. Standard care administration which acts both load compete binding alkalinizing agent decreases ionized receptor-binding form However, when fails, few other well studied options. One VA-ECMO not candidate. therapy, hypothesized work creating sink sequester drug also some positive ionotropy. CONCLUSIONS: patient, resulted significant clinical improvement. Unfortunately, improvement did sustain several days overall poor prognosis, eventually transitioned comfort measures. REFERENCE #1: Subedi R, Dean Chaudhary A. Flecainide failure. Proc (Bayl Univ Med Cent). 2018 May 9;3(3):328-330. #2: Ghataoura Patil S. toxicity: presentation emergency department literature review. BMJ Rep. 2020 Feb 28;13(2):e232691. doi: 10.1136/bcr-2019-232691. PMID: 32114494; PMCID: PMC7050315. #3: Valentino MA, Panakos A, Ragupathi L, Williams J, Pavri BB. Toxicity: Report Systematic Review its Electrocardiographic Patterns Management. Cardiovasc Toxicol. 2017 Jul;17(3):260-266. 10.1007/s12012-016-9380-0. 27435408. DISCLOSURES: No relevant relationships Rebecca Fieles, source=Web Response David Gerber, Brian Park, Harry Rockower, Diana Solomon, Yanika Wolfe,