How much is enough? a case of digoxin toxicity

SESSION TITLE: Critical Care Case Report Posters 24 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 12:00 pm - 12:45 pm INTRODUCTION: Digoxin toxicity manifests as nausea, vomiting, visual changes, altered mental status, hyperkalemia, and cardiovascular collapse. Digoxin-specific antibody fragments serve as a therapeutic option in patients with digoxin toxicity. However, there are no specific indications for giving it. CASE PRESENTATION: A 76-year-old female with a medical history of atrial fibrillation maintained on digoxin, apixiban, s/p pacemaker presented to the ER with vomiting, difficulty in breathing, diarrhea and encephalopathy. Patient was in septic shock and anion gap metabolic acidosis. Patient was started on fluid boluses, antibiotics and initiated norepinephrine drip. Digoxin level on arrival was >5, creatinine was 5.9. EKG showed V-paced rhythm with underlying atrial fibrillation. Cardiology was consulted, advised on supportive care and digoxin-specific antibody fragments, digoxin level came down to 0.78. On day 2, patient's renal function worsened, was started on dialysis. Post dialysis patient was more confused, and was intubated. Digoxin levels were elevated in the setting of AKI on CKD. On day 3 early morning, patient was DNR, DNI. She eventually coded and was pronounced deceased. DISCUSSION: Considering the narrow therapeutic index, digoxin dosing should be monitored. Digoxin has an elimination half-life of approximately 36 hours in a patient with normal renal function. Taboul et et al. reported 51 patients with cardiac glycoside intoxication managed in an intensive care unit with cardiac pacing. Overall mortality was 13% 1. Fab fragment is the first-line therapy 2. In regards to pacemakers, it can be considered to be protective in digoxin toxicity as it provides a paced rhythm, decreasing the chances for a malignant rhythm. In our patient no classic EKG changes noted because of paced rhythm. CONCLUSIONS: Our patient has digoxin toxicity in the setting of AKI. Digoxin-specific antibody fragments are used when there is life-threatening arrhythmia. There is no clear indication for the antibody fragments usage. Further research is needed into optimal dosing protocols for digoxin-specific antibody usage for non-life-threatening toxicity. REFERENCE #1: 1. Bridwell RE, Baker KA, Hoyte CO, Ng PC. Digoxin Toxicity in a Patient with Pacemaker: A Case Report. Cureus. 2019 Nov 2;11(11):e6056. doi: 10.7759/cureus.6056. PMID: 31819839; PMCID: PMC6886726. REFERENCE #2: 2. Hassan SA, Goyal A. Digoxin Immune Fab. [Updated 2022 Nov 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556101/ DISCLOSURES: No relevant relationships by Muhammad Ali No relevant relationships by Huzefa Bhopalwala No disclosure on file for Adnan Bhopalwala No relevant relationships by Nakeya Dewaswala No relevant relationships by Subramanya shyam Ganti No relevant relationships by Dedeepya Gullapalli No relevant relationships by Sai Kommineni No relevant relationships by Avinash Vangara