The Role of Extracorporeal Membrane Oxygenation in Cyanide Poisoning

Öz

Cyanide affects organs through mitochondrial degradation. Recently, extracorporeal membrane oxygenation (ECMO) has been used to preserve vital organ functions in poisonings and has saved antidote therapy time. We presented a case of cyanide poisoning who underwent ECMO and had brain death. A 28-year-old patient was brought in with oral cyanide intake 30 minutes ago. He was hypotensive, tachycardic, and in a coma. There was lactic acidosis. Global hypokinesia in the heart was observed on echocardiography. Venoarterial ECMO was planned to maintain perfusion. In preparation for ECMO, ventricular fibrillation developed, defibrillation was performed, and the rhythm reverted to atrial fibrillation. Before ECMO administration, hydroxocobalamin was given at the 4th hour of cyanide intake. Blood pressure increased after the antidote. Although blood pressure improved, venoarterial ECMO was performed at the 4th hour, considering that perfusion might deteriorate again due to high lactate levels and malignant arrhythmia. Brain death was diagnosed on the second day. The transplant was cancelled because the transplant committee was concerned about complications with cyanide. The patient died on the third day. It is known that cyanide disrupts intracellular metabolism and causes brain damage independent of perfusion. Therefore, ECMO failed to prevent permanent brain damage in cyanide poisoning.

Anahtar Kelimeler

• Cyanide
• ECMO
• Hydroxycobalamin
• Emergency Medicine

SİYANÜR ZEHİRLENMESİNDE EKSTRAKORPOREAL MEMBRAN OKSİJENİZASYONUNUN ROLÜ

Öz

Siyanür, mitokondriyal bozulmayla organları etkiler. Son zamanlarda, zehirlenmelerde hayati organ fonksiyonunu korumak ve antidot tedavisi için zaman kazanmak için ekstrakorporeal membran oksijenizasyonu (EKMO) kullanılmaktadır. Siyanür zehirlenmesinde, EKMO uygulanan ve beyin ölümü gerçekleşen olguyu sunduk. Yirmi sekiz yaşında hasta, 30 dakika önce ağızdan siyanür alımıyla getirildi. Hipotansif, taşikardik ve komadaydı. Laktik asidozu mevcuttu. Ekokardiyografide kalpte global hipokinezi izlendi. Perfüzyonun devamlılığı için venoarteriyel EKMO planlandı. EKMO uygulamasına hazırlanırken ventriküler fibrilasyon gelişti, defibrilasyon uygulandı ve ritm atriyal fibrilasyona döndü. EKMO uygulamasından önce, siyanür alımının 4. saatinde hidroksikobalamin verildi. Antidottan sonra kan basıncı yükseldi. Kan basıncı düzelse de yüksek laktat düzeyleri ve malign aritmi nedeniyle perfüzyonun tekrar bozulabileceği öngörülerek 4. saatte venoarteriyel EKMO uygulandı. İkinci gün beyin ölümü tanısı kondu. Organ nakli komitesi siyanürle ilgili komplikasyonlardan endişe duyduğu için organ naklini iptal edildi. Hasta üçüncü gün öldü. Siyanürün intrasellüler metabolizmayı bozduğu ve perfüzyondan bağımsız olarak beyin hasarına neden olduğu bilinmektedir. Bu nedenle, EKMO’nun siyanür zehirlenmesinde kalıcı beyin hasarını önleyememiştir.

Anahtar Kelimeler

• Siyanür
• ECMO
• Hidroksikobalamin
• Acil Tıp

Kaynakça

1. 1. Henretig FM, Kirk MA, McKay CA. Hazardous Chemical Emergencies and Poisonings. Longo DL, editor. NEJM.2019;(25):380:1638-55.
2. 2. Hall AH, Linden CH, Kulig KW, Rumack BH. Cyanide poisoning from laetrile ingestion: role of nitrite therapy. Pediatrics. 1986;78(2):269-72.
3. 3. Hall AH, Rumack BH. Hydroxycobalamin/sodium thiosulfate as a cyanide antidote. J Emerg Med. 1987;5(2):115-21.
4. 4. Thompson JP, Marrs TC. Hydroxocobalamin in cyanide poisoning. Clin Toxicol. 2012; 50(10):875-85.
5. 5. Rachinger J, Fellner FA, Stieglbauer K, Trenkler J. MR changes after acute cyanide intoxication. AJNR Am J Neuroradiol. 2002;23(8):1398-401.
6. 6. Masson R, Colas V, Parienti JJ, Lehoux P, Massetti M, Charbonneau P et al. A comparison of survival with and without extracorporeal life support treatment for severe poisoning due to drug intoxication. Resuscitation. 2012;83(11):1413-7.
7. 7. Guglin M, Zucker MJ, Bazan VM, Bozkurt B, El Banayosy A, Estep JD et al. Venoarterial ECMO for Adults. J Am Coll Cardiol. 2019;73(6):698-716
8. 8. Zakharov S, Vaneckova M, Seidl Z, Diblik P, Kuthan P, Urban P et al. Successful use of hydroxocobalamin and sodium thiosulfate in acute cyanide poisoning: a case report with follow-up. Basic Clin Pharmacol Toxicol. 2015;117(3):209-12.

9. 9. Ravishankar DK, Kashi SH, Lam FT. Organ transplantation from donor who died of cyanide poisoning: a case report. Clin Transplant. 1998;12(2):142-3.
10. 10. Wood DM, Dargan PI, Jones AL. Poisoned patients as potential organ donors: postal survey of transplant centres and intensive care units. Crit Care. 2003;7(2):147-54.
11. 11. Fortin JL, Ruttimann M, Capellier G, Bigorie A, Ferlicot S, Thervet E. Successful organ transplantation after treatment of fatal cyanide poisoning with hydroxocobalamin. Clin Toxicol. 2007;45(5):468-71.
12. 12. Hendrix RJ, Martins PN, Stoff JS, Ahearn A, Bozorgzadeh A, Movahedi B. Successful renal transplantation after presumed cyanide toxicity treated with hydroxocobalamin and review of the literature. Case Rep Transplant. 2018;2018:3753479.
13. 13. Drugs.com. Erişim tarihi: 21 Nisan 2021: https://www.drugs.com/price-guide/cyanokit.
14. 14. Harvey MJ, Gaies MG, Prosser LA. US and international in-hospital costs of extracorporeal membrane oxygenation: a systematic review. Appl Health Econ Health Policy. 2015;13(4):341-57.