Alex Hubbard, MD
Pediatrics Resident
Cincinnati Children's Hospital Medical Center
Cincinnati, Ohio
Disclosure information not submitted.
Lauren House, PharmD
Pediatric Clinical Pharmacist
Memorial Health University Medical Center
SAVANNAH, Georgia, United States
Disclosure information not submitted.
Jessica Lee, MD MHS
Pediatric Intensivist
Memorial Health University Medical Center
SAVANNAH, Georgia, United States
Disclosure information not submitted.
Title: Low-Dose Lipid Emulsion for Pediatric Vasoplegic Shock due to Quetiapine and Fluvoxamine Overdose
Case Report Body:
Introduction: Intravenous lipid emulsion (ILE) therapy is used to treat severe lipophilic drug toxicity. There is a paucity of research guiding pediatric ILE dosing ranges. We present a pediatric case of quetiapine and fluvoxamine overdose successfully resuscitated with low dose ILE therapy.
Description: A 17-year-old male, with history of depression, presented to an ER unresponsive, 14 hours after a suicide attempt where he ingested 130 mg/kg quetiapine and 32 mg/kg fluvoxamine.
Vitals: GCS 3 HR 140 BP 80/40
ABG 7.16/94/300/33.5/1.6 lactate 7.8 mMol/L
He was intubated, received fluid resuscitation, activated charcoal, sodium bicarbonate, and started on a norepinephrine infusion prior to PICU transfer.
PICU course:
Vitals: GCS 3T HR 154 BP 80/30
ABG 7.28/41/77/19.3/-7.1 lactate 8.9mMol/L
Patient had vasoplegic shock with a mean arterial pressure (MAP) of 46 despite fluid resuscitation, sodium bicarbonate, norepinephrine (29 mcg/min), epinephrine (11 mcg/min) and vasopressin (16 mU/min) infusions. At hour 5 of PICU admission, he received a 20 % lipid emulsion bolus, 1 ml/kg over 1 minute, followed by 0.05 ml/kg/min continuous infusion for 2 hours. Within 30 minutes, hemodynamics improved. Labs were unobtainable for 19 hours after ILE was given. Within 24 hours, sodium bicarbonate, epinephrine and vasopressin were weaned off. Norepinephrine was weaned off by hospital day 3. He was extubated on hospital day 5, with full neurological recovery. He developed severe rhabdomyolysis (creatinine kinase 448, 929 U/L) and subsequent AKI, requiring 19 days of hemodialysis (HD) starting on hospital day 2. He was successfully weaned off HD, and discharged to inpatient psychiatry.
Discussion: Recommended ILE dosing includes a 1.5 mL/kg 20% lipid emulsion bolus, followed by a continuous infusion of 0.25 mL/kg/min. Due to supply shortage, the patient received only 66% and 20% of the recommended bolus and continuous infusion dose respectively. ILE treats lipophilic drug toxicity via redistribution from target organs into the intravascular compartment, direct positive inotropy, and calcium channel modulation. This case highlights successful use of low-dose ILE in the treatment of vasoplegic shock secondary to antipsychotic and SSRI toxicity. More research regarding safe and appropriate pediatric dosing ranges in ILE therapy is needed.