A 71-year-old man was admitted to the Intensive Care Unit (ICU) due to respiratory failure. The patient had a personal history of type II diabetes mellitus, hypertension, atheromatous disease and moderate COPD, hypertensive and valvular bypass.
The patient was admitted to the ICU with a renal failure week later on receiving hemodialysis with creatinine levels of 3.48 mg/dL and with creatinine clearance estimated by the Cockroft-Gault formula of 19 mL/min continuous blood replacement.
The treatment of the patient during his stay in the ICU was enoxaparin, acetylcysteine, acetylsalicylic acid and erythropoietin as well as meropenem and vancomycin which were suspended a few days after receiving negative cultures.
On day 22 of admission, the patient suffered an episode of rapid atrial fibrillation that was reversed with two amiodarone ampoules (300 mg) and one digoxin ampoule (0.25 mg).
After the episode of atrial fibrillation, it was decided to continue with amiodarone 150 mg and a half tablet of digoxin (0.125 mg).
During the entire ICU stay, the patient was monitored and several electrocardiograms were performed and on the fourth day of starting treatment with digoxin drug levels were requested, finding a normal level of 1.6 ng/mL.
On day 33 of admission and after 12 days of treatment with digoxin, the patient had myocardial irritation, ventricular flutter and finally suffered a ventricular fibrillation with cardiorespiratory arrest that required 3 shocks cardiac rhythm and 20 minutes of cardiac arrest.
At that time, she had plasma levels of digoxin and potassium of 4 ng/mL (normal range: 0.8-2 ng/mL) and 2.84 meq/L (normal range: 3.5-5.2 meq/L), respectively.
Until then potassium had been in range and the last value of digoxin was 1.6 ng/mL.
In order to reverse severe digoxin intoxication, digoxin was suspended, intravenous potassium was administered and it was decided to treat with Ac-antidigoxyna1-3 at a dose of 3 vials of digoxin according to weight and plasma level.
From the Medical Service (SF), a preparation and administration sheet was designed.
The Ac-antidigoxyne vial (Digifab®) consists of 40 mg, which is approximately 0.5 mg of digoxin.
It is reconstituted with 4 mL of water for injections, obtaining a solution of 10 mg/mL.
After reconstitution it can be diluted in 0.9% saline solution.
Dilution should be administered slowly by intravenous infusion over at least 30 minutes.
The next day, despite the administration of 120 mg of Ac-antidigoxyne, it was found that the level of digoxin in plasma increased to 6 ng/mL, and it was decided to administer another 80 mg of digoxin i.e.
Despite the high value of digoxin, the patient did not present symptoms of digitized poisoning, since most digoxin was still bound to Ac.
On day 35 of admission, the patient remained clinically stable but high levels of digoxin persisted (8.2 ng/mL) in plasma.
From the ICU, the SF was contacted, requesting its collaboration to solve the problem still present.
After a literature search in pubmed4 and search in the database Up To To To and Micromedex5, isolated cases of poisoning digitoxyna were found in patients with severe renal insufficiency Dateres in whom combined therapy with antidig6 drugs.
It was decided to perform two sessions of plasmapheresis replacing 3.5 mg of plasmapheresis in each session, achieving a value of 2.8 ng/mL of digoxin, being possible after a few days ICU discharge.
