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Cardiac Collapse Secondary to Phenytoin Toxicity in a Neonate Treated with Extracorporeal Membrane Oxygenation
Michelle Knecht1, Joseph LaRochelle2, Brian Barkemeyer1
1Louisiana State University Health Sciences Center, Department of Pediatrics, Division of Neonatology, Children's Hospital of New Orleans, 200 Henry Clay Avenue, New Orleans, LA, 70118, USA.
Insights
Neonatal phenytoin toxicity can cause cardiovascular collapse, requiring extracorporeal membrane oxygenation (ECMO) and supportive treatments. This case highlights ECMO
Area of Science:
- Neonatal Medicine
- Clinical Pharmacology
- Toxicology
Background:
- Medication toxicity is rare in neonates but poses significant risks.
- Phenytoin presents an increased risk due to its narrow therapeutic index and variable drug elimination.
- Neonates require careful monitoring for adverse drug reactions.
Observation:
- A 3-day-old male infant experienced cardiovascular collapse due to severe phenytoin toxicity (peak level 86 μg/mL).
- The infant required extracorporeal membrane oxygenation (ECMO) for cardiovascular support.
- Ancillary treatments included albumin, phenobarbital, intravenous lipid emulsion, and folic acid.
Findings:
- Severe phenytoin toxicity can lead to life-threatening cardiovascular compromise in neonates.
- Prolonged phenytoin half-life contributes to extended periods of toxicity.
- ECMO provides crucial cardiac support during neonatal medication toxicity.
Implications:
- Clinicians should consider drug toxicity in neonates with acute changes, especially those exposed to high-risk medications like phenytoin.
- Prompt recognition and management, including advanced life support like ECMO, are vital for survival.
- Ancillary treatments can aid in reducing serum drug concentrations and mitigating toxicity effects.
Introduction:
Although medication toxicity is uncommon in neonates, there are several medications used in this population that pose a risk. Phenytoin has an increased risk of toxicity given its narrow therapeutic window and variations in drug elimination.
Case Report:
We describe the case of a 3-day-old male infant who developed cardiovascular collapse secondary to severe phenytoin toxicity (max phenytoin level 86 μg/mL) and was placed on extracorporeal membrane oxygenation support (ECMO). Several ancillary treatments were utilized in an attempt to decrease serum phenytoin concentrations and limit toxicity including albumin boluses, phenobarbital administration, intravenous lipid infusion, and folic acid supplementation.
Discussion:
Although uncommon, drug toxicity should be considered in patients with acute changes who are exposed to medications with potential toxicity. With elevated levels of phenytoin, the half-life can be prolonged resulting in longer exposure to elevated levels of the drug as seen in our patient. This case report highlights the importance of ECMO utilization for cardiac support in neonates with medication toxicity and other potential ancillary treatments to decrease serum phenytoin concentrations.
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