“I had never seen in my practice of 25 years, this unique and deadly concoction as a method to commit suicide. The challenge for us was to find an antidote for drug Digoxin which was digoxin specific antibody fragments (Fab).
“But this is not readily available in India and moreover the cost of one vial is about USD 1600 i.e. about Rs 1,00,000 and we needed 15-20 vials (Total cost Rs. 15-20 Lac). Time was running out and patient's condition deteriorated,” said Dr Sumit Ray, Vice Chairperson of Department of Critical Care, Sir Ganga Ram Hospital.
A team of cardiologists, nephrologists and critical care specialists after a thoughtful deliberation decided to attempt charcoal-based hemoperfusion.
“This method which costs about Rs 4,500 per catridge, is used for removing drug related toxins but has been rarely been attempted for Digoxin. There has been only anecdotal references in International literature. We were pleasantly surprised by the results, as after 15 hours of hemoperfusion with 2 catridges of this activated charcoal based adsorbent, the serum digoxin levels started reducing significantly,” said Ray.
According to Dr Ashish Garg from Department of critical care, “During hemoperfusion, large volumes of blood pass through an adsorbent material to remove toxic substances from the blood. In this procedure the patient's blood is continuously perfused through a small cartridge containing charcoal granules.The charcoal granules are encapsulated with a biocompatible cellulose membrane which protects cellular blood components from having direct contact with the charcoal. However, toxic substances can easily pass the membrane and get absorbed from the plasma.”
The second challenge was to reduce propanol toxicity which was done by injecting glucagon. The patient responded well to this therapy as there was an increase in pulse rate.
The third challenge of low blood sugar levels due to high dose of insulin taken by the patient was tackled by giving Glucagon, a hormone, which interestingly is also an antidote to the other drug the patient had taken, Propanolol. He was also given large doses of glucose intravenously.
The total amount of IV glucose administered to our patient was 1,115 gms given over a period of 68 hours, said Dr Ray.
Finally, this unusual case of multiple drug overdose was managed successfully using specific pharmacologic therapy, hemoperfusion along with supportive measures .
The patient was discharged after 6 days following consultations with psychiatrist.
Presently, the doctor has come out of his mental problems and is doing fine in his profession.
This particular case was published in the March edition of Indian Journal of Critical Care Medicine.
