Authors (including presenting author) :
ChungSW(1), KwokKH(1), KuSW(1), NgSL(1), LeungKY(1)
Affiliation :
(1)Paediatric Intensive Care Unit, Hong Kong Children’s Hospital
Keyword 1: :
Calcium Channel Blocker
Keyword 4: :
Extracorporeal support
Introduction :
While overdose cases contribute to PICU admissions, toxicology remains an understudied field in Paediatrics. Presentation of calcium channel blocker (CCB) overdose can range from mild effects to life-threatening toxicity. Its unique toxicokinetics makes it one of the challenges in intensive care. Management is mostly referenced from adult experience. Variations in treatment is observed between units, reflecting the paucity in paediatric-specific evidence and protocols.
Objectives :
This case series highlights refractory CCB overdose cases, providing a review on clinical presentations in teenagers, and management currently adopted by respective units, thereby emphasises the need for multi-faceted treatment tailored to individual presentation, importance of predefined triggers for consideration of extracorporeal support, vigilance for delayed deterioration, and treatment-related adverse effects.
Methodology :
This is an observational retrospective case series. Data were collected from the PICU clinical information system. Subjects include patients referred to HKCH for consideration of extracorporeal support after CCB overdose, from January 2020 to December 2025. We describe our experience in early structural integration of extracorporeal support alongside multimodal therapies, including dialysis-based techniques, in refractory CCB overdose.
Result & Outcome :
Four teenagers (aged 16-17) were referred to HKCH, a tertiary centre, for consideration of extracorporeal support concerning persistent haemodynamic instability despite fluid boluses, calcium infusion, high-dose insulin, glucagon, high dose inotropes and vasopressors (VIS 91.7-305.3), intralipid, hydrocortisone, and methylene blue. All had persistent metabolic acidosis and evolving organ impairment. One patient underwent VAECMO shortly after transferral, with vasopressors running despite supraphysiological ECMO flow rate (110mL/kg/min). Continuous renal replacement therapy (CRRT) was initiated with ECMO, further treated with 2 sessions of haemoadsorption using Cytosorb, and 2 sessions of single-pass albumin dialysis (SPAD). Another patient required VAECMO support, with concomitant CRRT to aid CCB clearance. One patient was successfully managed with SPAD. One was initially stabilised on vasoactive agents along with adjunct therapies, however experienced recurrence of hypotension requiring resumption of vasopressor, also repeated gastrointestinal decontamination. One patient had myocardial injury, residual organ dysfunction and impaired sensorium. Complications other patients encountered include bowel ischaemia, pancreatitis, and nephrocalcinosis, these improved with conservative management. There was no major issue related to extracorporeal support. Three patients survived to discharge. One patient remains inpatient for organ support and rehabilitation. Early structural integration of extracorporeal support and dialysis alongside multimodal therapies, appears feasible and effective in refractory CCB overdose. Establishment of evidence-based guidelines and advocacy for interdisciplinary collaborations would be beneficial in improving CCB overdose outcomes.
