Surviving cardiac arrest from severe metformin-associated lactic acidosis using extracorporeal membrane oxygenation and double continuous venovenous haemodialysis

Abstract

Metformin-associated lactic acidosis (MALA) is a serious condition with high mortality. This case describes a man in the mid-60s with diabetes mellitus type 2 treated with metformin developing MALA 4 days after coronary stenting for non-ST-elevation myocardial infarction. He presented acutely with severe abdominal pain, a lactate of 19 mmol/L and pH 6.74. Despite treatment for MALA, he went into refractory cardiac arrest and was connected to venoarterial extracorporeal membrane oxygenation (VA-ECMO). He suffered a massive haemothorax due to perforation of the right atrial appendage. It was repaired through a sternotomy while being given massive blood transfusions. The following days, he was on VA-ECMO and double continuous venovenous haemodialysis (CVVHD). He survived with only mild paresis of the left hand. VA-ECMO should be considered a rescue therapy alongside treatment with CVVHD in case of cardiac arrest due to severe MALA.

Keywords: Adult intensive care; Cardiovascular medicine; Dialysis; Fluid electrolyte and acid-base disturbances; Resuscitation.

Figure 1

Timeline of important events from NSTEMI (day −4) to discharge to home (day 60). Laboratory tests are marked by a circled drop and results can be seen in table 1. Locations of events and periods of haemodialysis and VA-ECMO are marked in green below the timeline. Card Dept, cardiology department; Cath, catheter laboratory; Dial, dialysis; ED, emergency department; ICU, intensive care unit; NSTEMI, non-ST-elevation myocardial infarction; OR, operating room; PCI, percutaneous coronary intervention; VA-ECMO, venoarterial extracorporeal membrane oxygenation.