Rapid Rescue from Hyperammonemic Coma


Journal of Clinical Toxicology has published an article entitled “Rapid Rescue from Hyperammonemic Coma After Valproic AcidPoisoning: Dual Therapy with Continuous Renal Replacement Therapyand L-carnitine Supplementation” in its volume 9 Issue 5 written by Breeanna Murphy, Kenneth Guillotte and Shyam Kiran Gandam Venkata.


The article explains about Acute hyperammonemia following valproic acid poisoning is a medical emergency which can lead to irreversibleneurological damage, metabolic derangements, and liver failure. Although treatment with renal replacement therapyand L-carnitine supplementation is well documented, scant literature is available in using both modalities together.


The case details was as follows: We  report  a  case  with  rapid  rescue  from  life  threatening  hyperammonemic  coma  secondary  tointentional  valproic  acid  overdose  by  using  dual  therapy  of  continuous  veno-venous  hemodialysis  in  combinationwith L-carnitine supplementation. The patient presented with rapid decline in mental status requiring intubation. Thepatient’s  condition  rapidly  improved  upon  initiation  of  treatment,  and  there  were  no  apparent  sequelae  from  hisoverdose at the time of discharge.


The case was regarding a 57-year-old with a history of bipolar disorder presented to theEmergency Department after reportedly consuming 2 handfuls of hisprescribed 500 mg delayed-release valproic acid tablets approximately30 minutes prior to arrival. The patient had a brief period of alertnessin the Emergency Department followed by drowsiness, combativeness,and  progressive  deterioration  of  mental  status.  Despite  prompttreatment  with  gastric  decontamination,  the  valproic  acid  levelincreased  to>450  mcg/ml,  and  the  ammonia  level  reached>700umol/L. The  patient  developed  hyperammonemic  coma  requiringendotracheal  intubation  for  airway  protection.  Considering  thepatient’s  ongoing  risk  for  cerebral  edema  from  hyperammonemia,prompt  initiation  of  dual  therapy  with  L-carnitine  and  renalreplacement therapy using CVVHD was started in the intensive careunit.  L-carnitine  2000  mg  IV  administration  was  implementedfollowed by weight based approach of 1625 mg IV every four hours.After initiation of L-carnitine and CVVHD, there was a rapid declinein ammonia levels and valproic acid levels (Figure 1) and dramaticimprovement  in  mental  status.  CVVHD  and  L-carnitine  werediscontinued after  approximately  24  hours.  He  was  then  givenlactulose  and  rifaximin  for  hyperammonemia  maintenance  therapywhich was later tapered down and discontinued. He was extubated onhospital  day  3.  He  was  subsequently  transferred  to  a  general floorwhere his condition continued to improve. Psychiatry was consultedfor his bipolar disorder and medication overdose. He was dischargedhome on hospital day 9.


In conclusion we have presented a case in which the acute intentional overdose ofvalproic  acid  led  to  life-threatening  hyperammonemic  coma.Successful  treatment  with  both  L-carnitine  supplementation  andprompt  initiation  of  CVVHD  resulted  in  a  rapid  decline  in  serumammonia levels. The patient was ultimately discharged home and hassuffered no known sequelae from this treatment. Although additionalstudies are needed to determine the optimal treatment regimen foracute valproic acid toxicity, early initiation of dual therapy with L-carnitine can facilitate rapid improvement.


For more details regarding the article go through the below mentioned link: https://www.omicsonline.org/open-access/rapid-rescue-from-hyperammonemic-coma-after-valproic-acid-poisoning-dual-therapy-with-continuous-renal-replacement-thera.pdf


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