Pediatr Emerg Med J.  2023 Oct;10(4):149-154. 10.22470/pemj.2023.00759.

An adolescent female with intentional ingestion of a large amount of metformin requiring extracorporeal membrane oxygenation and continuous renal replacement therapy

• Lessner K
• McKinney L
• Anderson I
• Shih CY
• Carmody JB
• Dominy M

• KMID: 2546289
• DOI: http://doi.org/10.22470/pemj.2023.00759

Abstract

Acute overdose of metformin can show potentially fatal lactic acidosis. Management should be directed towards close monitoring of renal function and hemodynamics. Patients may require dialysis or extracorporeal membrane oxygenation in cases of hemodynamic instability. This case presents an adolescent with massive metformin ingestion estimated at 100 g leading to metformin-associated lactic acidosis and subsequent respiratory failure, cardiovascular collapse, and acute kidney injury. The complications were successfully managed with venoarterial extracorporeal membrane oxygenation, continuous renal replacement therapy, and mechanical ventilation.

Keyword

Acidosis, Lactic; Adolescent; Dialysis; Extracorporeal Membrane Oxygenation; Metformin; Poisons

Figure

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  Fig. 1. Trend of serum concentrations of lactate (solid line) and metformin (dashed line) during the hospitalization, with relation to extracorporeal removal techniques (solid arrows: initiation of hemodialysis and transition to continuous renal replacement therapy [from left to right]; dotted arrows: ECMO cannulation and decannulation). Ongoing lactic acidosis and shock prompted transition from hemodialysis (hour 7) to continuous venovenous hemodiafiltration (hour 11) and venoarterial ECMO (cannulation at hour 20, decannulation at hour 81). After the initiation of ECMO, lactate concentration began to downtrend and normalized around 48 hours. Norepinephrine and epinephrine were discontinued at hour 30 and 79, respectively. The peak concentration of lactate was 31.9 mmol/L, which was measured 17 hours after initiation of dialysis and 4 hours after initiation of ECMO. The peak concentration of metformin was 76 μg/mL, which was measured 8 hours after the initiation of dialysis. ECMO: extracorporeal membrane oxygenation.

Reference

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