VA-ECMO and HIET for toxic cardiogenic shock in an elderly patient following severe poly-intoxication: A case report

This case report presents the successful use of high-dose insulin euglycemic therapy (HIET) and venous arterial extracorporeal membrane oxygenation (VA-ECMO) in managing severe toxic cardiogenic shock following poly-intoxication in an elderly patient. A 67-year-old woman, with a history of depression, previous suicide attempts and chronic renal failure, overdosed on multiple cardiovascular active agents including metoprolol (β-blocker), nifedipine (calcium channel blocker), nortriptyline (tricyclic antidepressant), venlafaxine (serotonin-noradrenaline reuptake inhibitor), and temazepam (benzodiazepine) were reported. Initial treatment with vasopressors, HIET and supportive measures stabilized her condition temporarily. Despite these interventions, the patient developed catecholamine-refractory shock with progressive multiorgan failure, requiring escalation to VA-ECMO as a bridge to recovery. VA-ECMO resulted in hemodynamic stabilization, enabling vasopressor withdrawal and decannulation after three days. The patient survived the acute toxic phase without irreversible neurological injury. However, the course was complicated by vascular complications, prolonged mechanical ventilation, renal replacement therapy, severe functional decline and eventually death eight months later. This case illustrates that VA-ECMO may provide effective temporary circulatory support in severe reversible toxic cardiogenic shock, even in elderly patients with significant comorbidity. However, the substantial burden of long-term morbidity and prolonged recovery should be carefully weighed during multidisciplinary decision-making.