Clin Res Cardiol 97:878–881 (2008)

DOI 10.1007/s00392-008-0700-7 ORIGINAL PAPER

Nikolaus Alexander Haas ECMO for cardiac rescue in a neonate

Christine Wegendt
Rainer Schäffler with accidental amiodarone overdose
Günther Kirchner
Eva Welisch
Katharina Kind
Ute Blanz
Deniz Kececioglu

j Abstract Intravenous (IV) amiodarone hydrochloride has proven to be

Received: 8 January 2008
Accepted: 7 July 2008
Published online: 18 August 2008
This case study was supported by hospital
funding.
Dr. N.A. Haas, MD (&) Æ C. Wegendt, MD
R. Schäffler, MD Æ G. Kirchner, MD
E. Welisch, MD Æ K. Kind, ECCP
U. Blanz, MD Æ D. Kececioglu, MD, PhD
Dept. of Congenital Heart Defects
Heart and Diabetes Center
North-Rhine Westphalia
Georgstrasse 11
32545 Bad Oeynhausen, Germany
Tel.: +49-5731/97-3620
Fax: +49-5731/97-2131
E-Mail: nikhaas@hdz-nrw.de
a very effective antiarrhythmic treatment option for a variety of
ventricular and supraventricular arrhythmias in adults and paediatric
patients. Amiodarone is known to have significant side effects and these
especially include profound hypotension in animals and adults, vasodi-
latation, negative inotropic effects, and significant bradycardia especially
when administered intravenously. Special caution is warranted in
patients with decreased contractility and end-stage heart failure. We
present a case of accidental amiodarone overdose in a newborn treated
for atrial flutter resulting in cardiovascular collapse. The patient could be
rescued by rapid initiation of VA-ECMO treatment. The patient survived
without neurological damage.
j Key words ECMO – amiodarone overdose –
resuscitation – neonate – atrial flutter

Amiodarone-related haemodynamic side effects

Introduction seem to be less pronounced in paediatric patients
than in adults [5] and less compared to other anti-
Intravenous (IV) amiodarone hydrochloride has
arrhythmic agents; thus amiodarone has been used in
proven to be a very effective antiarrhythmic treat-
infants and children with depressed myocardial
ment option for a variety of ventricular and supra-
function and even in the early postoperative period.
ventricular arrhythmias in adults and paediatric
We present a case of accidental amiodarone overdose
patients. Amiodarone is known to have significant
in a newborn treated for atrial flutter resulting in
side effects and these especially include profound
cardiovascular collapse.
hypotension in animals and adults, vasodilatation,
negative inotropic effects, and significant bradycardia
especially when administered intravenously. A pro-
spective randomized multicenter study in 67 paedi- Case report
atric patients revealed a high rate (mean 36%) of
significant hypotension after bolus administration of Due to acute fetal tachycardia with cardiac impair-
amiodarone and these effects were dose dependent ment, the male baby was born via caesarean section at
[19]. Special caution is warranted in patients with 37 weeks of gestation, the birth weight was 3,670 g,
CRC 700

decreased contractility and end-stage heart failure. APGAR 9/7/8, pH 7.29. Atrial tachycardia with heart
Cases of cardiovascular collapse are reported [16]. rates between 200 and 240 per min persisted postna-

ECMO for amiodarone overdose
Fig. 1 Six-lead ECG immediately after admission
revealing the typical signs of atrial flutter
tally, there was left ventricular dilatation and
impairment. Therefore the child was transferred to
our unit for further treatment.
On admission the heart rate was 230 per min,
the ECG showed typical atrial flutter with various
AV-conduction (see Fig. 1). Clinically, there was
haemodynamic impairment with cold extremities, the
capillary filling time was 3 s, the blood pressure 60/
25 mmHg, the respiratory rate was 64 per min.
Echocardiography revealed a dilated left ventricle
with impaired function (LVEDD 25 mm, LVESD
19 mm, FS 25%, see Fig. 2).
In preparation for electrical cardioversion and to
ascertain persistent rhythm stabilization an amio-
darone bolus was initiated at a prescribed rate of
5 mg/kg over 1 h. Due to a calculation error, the
threefold dosage was prepared (15 mg/kg) and star-
ted at the prescribed rate. Within 30 min there was
marked reduction in the patients heart rate
decreasing from 230 to 200 per min after 10 min and
Fig. 2 Transthoracic ECHO obtained on admission.
There is marked reduction in cardiac function, the
calculated FS (fraction of shortening) was 25%, the
left ventricular end-diastolic diameter was 25 mm,
the end-systolic diameter 19 mm
N.A. Haas et al. 879
I
II
III
aVR
aVL
aVF
190 after 20 min, then there was acute reduction in
effective heart rate due to 2:1 and 3:1 block, simul-
taneously the blood pressure deteriorated necessi-
tating repetitive epinephrine bolus administration,
and subsequently cardiothoracic massage and intu-
bation. Increasing epinephrine boluses and a con-
tinuous infusion at increasing rate was necessary to
stabilize the patient. Finally after 45 min the calcu-
lation error was detected, the infusion was stopped
immediately, electrical cardioversion was performed
(2 J) and further efforts were taken to stabilize the
patient by conventional measures. However, there
was continuous deterioration of the clinical status
requiring repetitive cardiothoracic massage and
additional bolus administrations of epinephrine to
maintain adequate blood pressure and heart rate.
Thus the decision was made to establish veno-arte-
rial ECMO for cardiac support.
Cannulation was performed about 2 h after the
beginning of the amiodarone infusion via the internal
880 Clinical Research in Cardiology, Volume 97, Number 12 (2008)
Ó Steinkopff Verlag 2008
jugular vein and the common carotid artery using
standard techniques. We used an 8F heparine coated
BiomedicusÒ canula for arterial access and a 10F
BiomedicusÒ canula for venous cannulation. Flow was
generated by a CentriMagÒ pump and ¼ in. heparine
coated tubing, the oxygenator used was a Hilite
800 LTÒ. The priming volume was about 220 ml with
a maximum length of 3 m total, however, the tubing
was shortened significantly to adjust to the patient.
Priming was performed with normal saline, 20% of
human albumin and packed blood cells to achieve a
haematocrit of about 30%. The initial flow used was
180 ml/kg per min and adjusted to serum lactate
levels, blood pressure and clinical assessment. The
child improved significantly within the following
hours and ECMO-flow could be reduced to 50% after
24 h. There were no significant changes in electrolytes
and renal function was adequate under minimal
diuretic stimulation. Successful decannulation was
performed after 36 h and the common carotid artery
could be reconstructed. The further clinical course
was uneventful, the child was discharged home 9 days
after ECMO decannulation. Today, 12 months after
the event, the child is neurologically normal and the
carotid artery is patent without stenosis.
Discussion
Perinatal atrial flutter is a potentially lethal arrhyth-
mia and management of this disorder may be difficult
and is discussed controversial. Fetal AF is a serious
and threatening rhythm disorder, particularly when it
causes hydrops, it may be associated with fetal death
or neurological damage. Treatment is required and
primarily aimed at reaching an adequate ventricular
rate and preferably conversion to sinus rhythm [15].
Intravenous (IV) amiodarone hydrochloride is an
effective antiarrhythmic treatment option for neonatal
arrhythmias and especially atrial flutter [5, 7, 12].
In general, amiodarone can induce significant
cardiovascular depression mainly characterized by
immediate reduction in cardiac contractility and
vasodilatation [14, 21]. In adults, significant impair-
ment of left ventricular performance especially in pa-
tients with pre-existing left ventricular dysfunction
[13]. The sensitivity to a drug’s negative inotropic ac-
tion is markedly increased in functionally impaired
myocardium that has been shown in animal models
using clinically relevant doses of amiodarone; in failing
hearts, such effects become more readily evident than
they do in normal hearts after high doses of amioda-
rone [11]. Many of these side effects are, however, not
present when the bolus is administered over 1 h [6, 10].
In paediatric patients, adverse events have been
reported but were uncommon. Intravenous amioda-
rone bolus was applied for life-threatening tachyar-
rhythmias in children and transient hypotension
during loading was corrected with volume or low dose
calcium. A slower administration of the drug seems to
minimize the hemodynamic effect of a rapid bolus
injection. [17]. However, Ng and co-workers [16]
presented a case report of a cardiovascular stable
infant with supraventricular tachycardia who had a
variety of arrhythmias requiring cardiopulmonary
resuscitation for a prolonged period of time after ra-
pid loading with IV amiodarone. A similar case was
reported in a 36 weeks gestation newborn who
developed electromechanical dissociation after a bo-
lus load of amiodarone [9]. Thus—the haemody-
namic side effects seem to be closely correlated to the
timeframe of amiodarone application and rapid bolus
administration need to be avoided especially in im-
paired cardiac function. Unfortunately blood/plasma
levels of amiodarone, levels of troponin or BNP that
would provide us with valuable information of the
toxicity at the time of cardiovascular collapse, were
not determined.
Resuscitation ECMO is established in many centres
for various reasons including acute cardiac failure
due to myocarditis/cardiomyopathy, postoperative
failure, after resuscitation and arrhythmias [1, 18, 20,
22]. The first report suggesting ECMO for intoxica-
tions has been published in 1994 [4]). Other cases
of successful ECMO for various intoxications with
cardiotoxic drugs have been described [2, 3, 8]. In
general intact neurological survival can be achieved
when ECMO initiation can be obtained without sig-
nificant delay and according to standardised hospital
protocols.
Despite the tragic and inadvertent medication
error, rapid recognition of the underlying cause
and consequent ECMO initiation led to an excel-
lent outcome in our patient. A subsequent careful
clinical review of this serious case of accidental
overdosing with an antiarrhythmic drug including a
review of the treatment protocols was performed
according to our hospital critical event reporting
system. The treatment protocols were adjusted
accordingly, i.e. especially the amiodarone doses used
in small children <10 kg bw were limited to syringe
pumps containing a maximum of 50 mg amiodarone
per 50 ml syringe.
We believe that supportive therapy of the cardio-
vascular system is the most important goal in com-
parable cases and ECMO can maintain cardiac output
and vital organ perfusion while allowing time for drug
redistribution, metabolism and clearance.

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