Cardiogenic Shock in a Hemodialyzed Patient on Flecainide: Treatment with Intravenous Fat Emulsion, Extracorporeal Cardiac Life Support, and CytoSorb® Hemoadsorption

A 67-year-old woman with a history of end-stage renal disease on hemodialysis received a therapeutic dose (150 mg daily) of flecainide for three weeks. She was admitted to the Emergency Department for malaise and dizziness, and the electrocardiogram revealed ventricular tachycardia treated by amiodarone. Hemodynamic condition remained stable, and the toxicity of flecainide was initially not suspected until she developed within 8 hours a cardiogenic shock requiring vasopressors. The patient then received sodium bicarbonate (300 mmol) and dobutamine but experienced cardiac arrest two hours later. The administration of intravenous fat emulsion (IFE) was associated with return of spontaneous circulation, but there was a relapse of cardiovascular shock at the end of IFE infusion. The patient was placed on extracorporeal cardiac life support (ECLS), continuous hemofiltration, and hemoadsorption using the CytoSorb® cartridge. Serial determinations of serum flecainide concentration were obtained during the course of hemoadsorption, with a terminal half-life of 3.7 h during the first four hours and a global plasma clearance of 40.3 ml/min over the first 22 hours. The weaning of ECLS was possible on day 7. Intravenous fat emulsion infusion was followed by a significant increase in serum flecainide concentration. In addition, while conventional techniques of extrarenal epuration usually appear as poorly effective for flecainide removal, a mean plasma clearance of 40.3 ml/min was observed using the hemoadsorption technique based on CytoSorb® cartridge. However, the impact on the clinical course was probably extremely modest in comparison with ECLS.