Introduction: Venlafaxine is an anti-depressant known to cause cardiotoxicity. We present a case of a massive venlafaxine overdose (OD) resulting in cardiogenic shock and subsequent abdominal compartment syndrome.
Case report: A 25-year-old woman presented to the ED 4 h after taking 210 tabs of 75 mg venlafaxine extended release (total ingestion 15,750 mg) and 9 tabs of bupropion 150 mg. She was intubated on arrival. Phenylephrine and vasopressin infusions were started for hypotension. Her HR was 150 and her QTc was 588 ms, which was treated with 2 g of Magnesium sulfate. Hypotension persisted despite 7 L of normal saline and the above pressors. She then developed a wide-complex tachycardia (QRS 160 ms) which was treated with sodium bicarbonate. An echocardiogram revealed an ejection fraction less than 20%; subsequently epinephrine and norepinephrine were added. Intra-aortic balloon pump therapy was added to the four pressors, yet her cardiogenic shock did not improve. She also developed fulminant hepatic failure, DIC, and a GI bleed. An abdominal ultrasound showed low flow in the inferior vena cava, portal veins, and mesenteric veins. An abdominal CT scan revealed diffuse bowel wall edema. Because of markedly elevated bladder pressures and concern for ischemic bowel and abdominal compartment syndrome, laparotomy was performed confirming the diagnosis of abdominal compartment syndrome. The patient then developed ARDS and acute renal failure. Dialysis was initiated. The patient’s family withdraw care shortly thereafter, and the patient died.
Discussion: Venlafaxine OD results in dose-dependant cardiotoxicity. In this case, cardiotoxicity manifested as QTc and QRS prolongation, as well as an overall cardiodepressant effect leading to cardiogenic shock. This patient did ingest bupropion, however it is likely the massive venlafaxine ingestion was responsible for the majority of the clinical effects. In this case the cardiogenic shock lead to both poor perfusion of the mesenteric vasculature as well as venous congestion of the liver, resulting in abdominal compartment syndrome. This phenomenon is possible with any toxin that results in cardiogenic shock.
Conclusion: Abdominal compartment syndrome resulting from liver congestion and cardiogenic shock is a potential complication of large venlafaxine overdose.