Hydroxocobalamin and extracorporeal membrane oxygenation (ECMO) for severe refractory shock in bupropion and citalopram overdose: a case report

IntroductionManagement of refractory shock in the setting of overdose can be challenging. We describe a case of vasodilatory and cardiogenic shock after bupropion and citalopram overdose. Vasopressors and conventional therapies failed to stabilize the patient resulting in placement of venoarterial extracorporeal membrane oxygenation (VA ECMO) for patient rescue and recovery.Case summary: A 23-year-old male presented after intentional bupropion and citalopram overdose. He developed seizures, acute respiratory failure, metabolic acidosis, severe refractory vasodilatory, and cardiogenic shock. The patient received mechanical ventilation, Advanced Cardiac Life Support (ACLS), Intralipid (R) therapy, vasopressor support, and VA ECMO. Total duration of ECMO was 72 h. Serum laboratory studies drawn on the day of admission showed serum concentrations of citalopram (3400 ng/mL, reference range 9-200 ng/mL) and bupropion (597 ng/mL, reference range 50-100 ng/mL). The patient was extubated on hospital day 18 and discharged home with referral to outpatient psychiatry, 28 days after intentional overdose.IntroductionManagement of refractory shock in the setting of overdose can be challenging. We describe a case of vasodilatory and cardiogenic shock after bupropion and citalopram overdose. Vasopressors and conventional therapies failed to stabilize the patient resulting in placement of venoarterial extracorporeal membrane oxygenation (VA ECMO) for patient rescue and recovery.Case summary: A 23-year-old male presented after intentional bupropion and citalopram overdose. He developed seizures, acute respiratory failure, metabolic acidosis, severe refractory vasodilatory, and cardiogenic shock. The patient received mechanical ventilation, Advanced Cardiac Life Support (ACLS), Intralipid (R) therapy, vasopressor support, and VA ECMO. Total duration of ECMO was 72 h. Serum laboratory studies drawn on the day of admission showed serum concentrations of citalopram (3400 ng/mL, reference range 9-200 ng/mL) and bupropion (597 ng/mL, reference range 50-100 ng/mL). The patient was extubated on hospital day 18 and discharged home with referral to outpatient psychiatry, 28 days after intentional overdose.ConclusionsThis case illustrates successful recovery after hydroxocobalamin and VA ECMO in severe vasodilatory and cardiogenic shock following overdose of bupropion and citalopram.