Abstract: SA-PO294
Effectiveness of Hemodialysis and L-Carnitine in Severe Valproate Overdose
Session Information
- Trainee Case Reports - VI
October 27, 2018 | Location: Exhibit Hall, San Diego Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Reports
- 1700 Pharmacology (PharmacoKinetics, -Dynamics, -Genomics)
Authors
- Rehman, Mubasshar, Mount Sinai Saint Luke''s and mount Sinai West, Bronx, New York, United States
- Azhar, Ambreen, mount sinai st lukes, New York, New York, United States
- Pollack-Zollman, Martine, Mount Sinai Hospital, NY, New York, United States
Introduction
Valproic acid (VPA) is used to treat seizure disorders and psychiatric illnesses. Acute VPA intoxication usually results in mild, self-limited CNS depression. VPA and its metabolites are low molecular weight, osmotically active acids and anions that may cause elevated osmolar and anion gap metabolic acidosis, hypocalcemia, hypernatremia, hyperammonemia with or without hepatic failure, cerebral edema leading to death if ingested in large doses.
Prospective studies are lacking with regard to the management of VPA overdose, and the available data is mainly from case reports or retrospective studies. We present a case of sodium valproate overdose where hemodialysis was used due to rapid clinical deterioration
Case Description
A 24 year old female with seizure disorder on VPA and prior suicide attempts was brought to the ED with incoherent speech and encephalopathy after ingesting 100 tabs (100mg each) of VPA
Shortly after arrival, she became agitated and required mechanical ventilation and pressor support. VPA level was >1200μg/ml along with AGMA, osmolar gap, hypernatremia, hypocalcemia and hyperammonemia (see table). CT head was negative for cerebral edema. She was admitted for acute VPA Toxicity. Charcoal suspension via NGT and L-carnitine infusion were initiated. Due to rapid clinical deterioration, she required a single 6 hour session of emergent hemodialysis with an Optiflux F160 dialyzer, Qb 400cc/min. Following dialysis, she clinically improved and VPA level was 439μg/ml at 24hrs
Discussion
Our patient presented with classic symptoms and lab abnormalities seen in acute VPA toxicity. Due to its low molecular weight and high free serum levels at supratherapeutic doses, hemodialysis seems an effective treatment. Mitochondial dysfunction and carnitine depletion occurs with VPA toxicity which leads to hyperammonemia. Retrospective studies suggest the use of L-carnitine to reverse these defects and hemodialysis can also be used for further ammonia clearance