Successful use of ECMO and lipid emulsion for massive bupropion overdose: a case report

IntroductionBupropion overdose can produce seizures, arrhythmias, and shock. The toxicokinetics of massive bupropion ingestions are not well characterized.Case reportA 22-year-old female ingested an estimated 40.5 g (644 mg/kg) of extended release bupropion. Subsequently she experienced seizures, required intubation, developed torsades des pointes that progressed to cardiac arrest, and required cannulation with venous-arterial extracorporeal membrane oxygenation (VA-ECMO). Intravenous lipid emulsion was administered without adversely affecting the ECMO circuit. The patient was successfully decannulated after 84 h of ECMO support and discharged neurologically intact. Serial bupropion and hydroxybupropion serum concentrations were drawn every 6-12 h starting on hospital day one and continuing for seven days, for a total of 22 serum concentrations each.DiscussionThe patient's first bupropion and hydroxybupropion serum concentrations were 4000 ng/mL and 5300 ng/mL, respectively. Clearance of bupropion followed first order kinetics (t 1/2 = 20.6 h) while hydroxybupropion had zero order kinetics (t 1/2 = 118.5 h).ConclusionThis bupropion overdose was treated with VA-ECMO with 20% lipid emulsion therapy, without complications. In this patient, the toxicokinetics of bupropion were first-order.