Introduction: Metformin is a frequently prescribed medication for conditions such as diabetes mellitus with known life-threatening side effects of refractory lactic acidosis and associated risk for cardiovascular compromise. These complications are commonly seen in adult patients with intentional metformin ingestion. However, intentional metformin ingestion is rare in the pediatric population, which leads to therapeutic challenges. We present a unique case of intentional metformin ingestion in an adolescent female resulting in refractory lactic acidosis who received early veno-arterial extracorporeal membrane oxygenation (VA ECMO) support leading to recovery in the intensive care unit (ICU). Description: A 17-year-old female was admitted to the ICU after intentional ingestion of 85 grams of metformin. On arrival, her physical exam was pertinent of bilateral clonus, dilated pupils and GCS 13. Lab work demonstrated lactatemia (lactate 5.2 mg/dl). Attempts to manage with charcoal were aborted due to emesis. Ultimately, dialysis catheter was placed hemodialysis initiated. Despite dialysis attempt, metabolic lactic acidosis continued to worsen (peak lactate 24 mg/dl, pH 7.13). At this time, she was hemodynamically stable. Echocardiogram demonstrated an ejection fraction of 70%. Potential benefits of cannulation and initiation of VA ECMO were discussed with toxicology due to risk of impending cardiac failure with persistent lactic acidosis, and decision made to proceed with cannulation within 24 hours of presentation. Follow-up echocardiograms on day two and day four of hospitalization, respectively, demonstrated subsequent decline in cardiac contractility (EF 32%) and then recovery (EF 67%). Lactic acid improved on hospital day 3, and she was decannulated successfully on hospital day 5. She received psychiatric support during hospitalization and at discharge. Discussion: Our case highlights a rare presentation of metformin ingestion supported by VA ECMO and demonstrates the importance of prompt ECMO initiation, especially in cases where initial dialysis attempts are unable effectively clear toxin. While we highlight one case, ongoing investigation in the pediatric population is needed to evaluate risks and benefits of early ECMO initiation for metformin ingestion.
Pouncey et al. (Sun,) studied this question.