CCB overdose and pressor

Q: Which of the following is the choice of pressor in Calcium Channel Blocker (CCB) induced hypotension? - Pick one

A) Norepinephrine

B) Vasopressin

Answer: A

In CCB overdose or exaggerated response, there is a need for a direct-acting agent with 

• positive inotropy
• positive chronotropy, and
• vasoconstrictive effects

Based on this, norepinephrine (NE) appears to be the best initial choice for a pressor.

If NE has reached its maximum infusion dose, Epinephrine and Dopamine (with similar properties) can be added. NE takes precedence over 'epi' and 'dopa' due to its relatively less arrhythmogenic effect at higher doses.

CCB toxicity requires a multi-front approach, along with pressors with

• IV boluses of isotonic crystalloid
• IV calcium infusion
• IV glucagon
• IV high-dose insulin and glucose
• IV lipid emulsion therapy (+/-)
• ECMO (as a last resort)

#toxicity

#pharmacology

#hemodynamic

References:

1. St-Onge M, Anseeuw K, Cantrell FL, Gilchrist IC, Hantson P, Bailey B, Lavergne V, Gosselin S, Kerns W 2nd, Laliberté M, Lavonas EJ, Juurlink DN, Muscedere J, Yang CC, Sinuff T, Rieder M, Mégarbane B. Experts Consensus Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults. Crit Care Med. 2017 Mar;45(3):e306-e315. doi: 10.1097/CCM.0000000000002087. PMID: 27749343; PMCID: PMC5312725.

2. Alshaya OA, Alhamed A, Althewaibi S, Fetyani L, Alshehri S, Alnashmi F, Alharbi S, Alrashed M, Alqifari SF, Alshaya AI. Calcium Channel Blocker Toxicity: A Practical Approach. J Multidiscip Healthc. 2022 Aug 30;15:1851-1862. doi: 10.2147/JMDH.S374887. PMID: 36065348; PMCID: PMC9440664.

3. Finn D, Stevens J, Tolkacz M, Robinson J, Mangla J, Iacco A. Calcium Channel Blocker Overdose: What Role Does Extracorporeal Membrane Oxygenation Have in Support? A Systematic Review of the Literature. ASAIO J. 2024 May 1;70(5):404-408. doi: 10.1097/MAT.0000000000002129. Epub 2024 Jan 2. PMID: 38165982.