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J Thorac Cardiovasc Surg 2000;120:424
© 2000 The American Association for Thoracic Surgery

Letters to the editor

Cardiopulmonary bypass and severe drug intoxication

Massimo Massetti, MD, Piergiorgio Bruno, MD, Gerard Babatasi, MD, PhD, Eugenio Neri, MD, André Khayat, MD

Thoracic and Cardiovascular Surgery Department
University Hospital
Avenue de la "Cote de Nacre" 14033 Caen, France

To the editor:

I congratulate Pasic and colleagues for their successful case reported in the February 2000 issue of the Journal (2000;119:379-80), but I have some comments. The article concerns severe drug intoxication necessitating resuscitation and hemodynamic assistance. They chose conventional cardiopulmonary bypass (CPB) instituted via the sternotomy approach. The delay between the onset of the intractable electrical and hemodynamic instabilities and the beginning of CPB was 45 minutes. During this period the patient underwent external manual heart massage and mechanical ventilation. The time from the start of extracorporeal life support until the hemodynamic state became stable was 16 hours 43 minutes. The postoperative course was uneventful. In their discussion, the authors stated that the thoracic approach for CPB under these circumstances is preferable to percutaneous CPB, which can be instituted through the femoral vessels. This procedure does not require the chest to be opened, but it includes several important disadvantages, such as possible distention of the cardiac ventricles, ischemic leg complications, and hemorrhage.

Our experience with the same life-threatening events comprises 7 patients. All of them had severe acute intoxication with different cocktails of antiarrhythmic drugs with the possible intention of committing suicide. All patients were treated by peripheral CPB through the femoral vessels. The mean delay between the cardiac arrest and the beginning of CPB was 78.5 minutes, and the femoral-femoral bypass was performed while patients were being resuscitated with closed chest massage.

The first 3 patients had severe ischemic complications of the distal leg; 2 patients died and 1 patient underwent fasciotomy for a lower leg compartment syndrome. After that, distal limb ischemia was accomplished by a tube inserted distally into the superficial femoral artery and connected to the side port of the cardiopulmonary support arterial line. The mean flow was about 200 mL/min. The duration of reperfusion necessary to recover normal hemodynamics was well correlated with the estimated half-life of the ingested drugs—56.8 hours. The late postoperative period was uneventful in all cases.

On the basis of our experience, we think that severe drug intoxication complicated by cardiogenic shock must be treated by temporary circulatory support. Because CPB can be performed while patients are being resuscitated with closed chest massage, the femoral-femoral approach is preferred; it is rapid and easy to accomplish in the operating room, emergency room, or intensive care unit. Concerning the problem of distention of the cardiac ventricles, we observe that the intoxication etiology does not compromise ventricular recovery. In these particular rescue situations, the key to success is the institution, as soon as possible, of femoro-femoral CPB associated with the prevention of distal limb ischemia. Without this therapeutic option, these potentially reversible drug overdoses will continue to be fatal.

12/8/107825 doi:10.1067/mtc.2000.107825




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 Ann. Thorac. Surg.Home page
M. Massetti, M. Tasle, O. Le Page, R. Deredec, G. Babatasi, D. Buklas, S. Thuaudet, P. Charbonneau, M. Hamon, G. Grollier, et al.
Back from Irreversibility: Extracorporeal Life Support for Prolonged Cardiac Arrest
Ann. Thorac. Surg., January 1, 2005; 79(1): 178 - 183.
[Abstract] [Full Text] [PDF]

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