Table 1.
Vital signs and laboratory measures and events during the admission.
| Hours and days after ingestion | Vitals signs and pertinent laboratory values |
Events and interventions | Diltiazem level (ng/mL) |
|---|---|---|---|
| 8 hours (presentation) | Vitals: HR 77 bpm, BP 102/56 mmHg (MAP 71) |
Calcium, glucagon, high-dose insulin, fluids, lipid emulsion, and vasopressors started | — |
|
| |||
| 19 hours | Vitals: HR 78 bpm, supported BP 112/38 mmHg (MAP 53) PAC: CI 5.7 L/min/m2, SVRi 535 dynes·sec/cm5/m2 ABG: pH 6.96, pCO2 41 mmHg, pO2 110, HCO3 9 mmol/L Labs: lactate 8.7 mmol/L; potassium 3.1 mmol/L; glucose 430 mg/dL; AST 79 U/L |
PAC placed, transvenously paced at 80 bpm due to interval development of prolonged sinus pauses; methylene blue attempted; CVVH begun | — |
|
| |||
| 23 hours | — | — | 1140 |
|
| |||
| 25 hours | Immediately before ECMO cannulation: Vitals: HR 96 bpm (paced), supported BP 93/48 mmHg (MAP 63) PAC: CI 4.1 L/min/m2, SVRi 804 dynes·sec/cm5/m2 Labs: lactate >12.2 mmol/L; potassium 2.2 mmol/L; AST 3112 U/L, INR 2.4 |
V-A ECMO cannulation, total circuit flow 4.8–5.1 L/min (ECMO CI 2.9–3.1 L/min/m2) | — |
|
| |||
| 39 hours | — | — | 9450 |
|
| |||
| 44 hours | — | — | 7120 |
|
| |||
| 51 hours | Hemodynamics: HR 100 (paced; asystolic when pacemaker is off), total ECMO circuit flow 4.6 L/min (ECMO CI 2.7 L/min/m2) Labs: lactate >18 mmol/L; potassium 4.9 mmol/L |
Abdominal compartment syndrome, to operating room for exploration, evacuation of ascites, and temporary closure | 13150 |
|
| |||
| 71 hours | Labs: lactate 15.4 mmol/L; potassium 8.1 mmol/L; aPTT 63 seconds (heparinized), INR 2.3 TTE: LV EF 10–15% and a severe decrease in right ventricular systolic function; no evidence of tamponade |
Persistent elevation in potassium and lactate with increasing abdominal distension; prompted exploration where ischemic small bowel and colon were found along with a large retroperitoneal hematoma; resected and left in discontinuity | 2020 |
|
| |||
| 90 hours | — | Developed bilateral lower-extremity compartment syndrome requiring fasciotomies | 6340 |
|
| |||
| Day 5 | — | Underwent abdominal reexploration with creation of an end ileostomy and 3 mucous fistulae | — |
|
| |||
| Day 7 | — | Regained sinus rhythm and downtitrated vasopressors; unable to wean from ECMO | — |
|
| |||
| Day 8 | — | Developed a GI bleed in the setting of refractory thrombocytopenia, anticoagulation for ECMO, and autoanticoagulation from acute liver injury | — |
|
| |||
| Day 9 | — | Transitioned to comfort cares and died | — |
HR: heart rate; BP: blood pressure, MAP: mean arterial pressure; PAC: pulmonary artery catheter; CI: cardiac index; SVRi: systemic vascular resistance index; ABG: arterial blood gas; CVVH: continuous venovenous hemofiltration; V-A ECMO: venoarterial extracorporeal membrane oxygenation; AST: aspartate aminotransferase; INR: international normalized ratio; LV EF: left ventricular ejection fraction.