Successful treatment of metformin and rodenticide intoxication with prolonged hemodialysis and methylene blue: A case report
Abstract
Metformin is a first-line treatment for diabetes mellitus. In cases of suicidal overdose or chronic accumulation, lactic acidosis may develop and, if untreated, can be fatal. Renal replacement therapy plays a key role in reversing the condition. Refractory hypotension may be encountered both in the presentation of intoxication cases and as a complication of renal replacement therapy. Methylene blue is recommended to improve blood pressure in such cases. A 25-year-old male presented to the emergency department after ingesting a high dose of metformin and around 20 g of rodenticide in a suicide attempt. On admission, his condition was poor, tachycardic, with a blood pressure of 98/42 mmHg. Blood gas analysis revealed a pH of 7.015, pCO2 22.6 mmHg, pO2 64.4 mmHg, base excess -23.4 mmol/L, HCO3 5.5 mmol/L, and lactate 23 mmol/L. Conventional treatments failed, so intermittent hemodialysis was performed. Methylene blue was given for persistent hypotension, stabilizing his hemodynamics. The rodenticide contained difenacoum, a superwarfarin, but laboratory results showed no need for intervention, and no bleeding signs were observed. Blood gas values normalized during his stay in the toxicology unit. After failing a weaning trial, he tested positive for COVID-19 and was transferred to the ICU. After 23 days of care in the emergency and ICU, he was discharged in good health. Lactic acidosis from metformin overdose is a serious condition, and renal replacement therapy can…
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