Use of Veno-Arterial Extracorporeal Membrane Oxygenation in Methadone Poisoning

ABSTRACT. Poisoning with opioids, including methadone, occupies one of the leading positions in the structure of acute chemical poisonings with narcotic drugs. Often, these poisonings cause severe complications, which in some cases result in death. Traditional approaches to the treatment of these patients are in most cases limited and may be ineffective in the development of serious complications, such as refractory cardiogenic shock or acute respiratory distress syndrome; against this background, ECMO can serve not only as a method of supporting vital functions, but also as a means correction of metabolic disorders, providing optimal conditions for the body. An additional aspect that highlights the relevance of ECMO for methadone poisoning is the increasing availability of this technique in clinical practice and its potential for use in settings where other treatment methods have failed.

The purpose of this work is to demonstrate the first experience of using extracorporeal membrane oxygenation in severe methadone poisoning.

Results. Patient Sh., 27 years old, was found by the Emergency Medical Service (EMT) at home. At the time of examination, emergency medical services specialists examined the patient (GCS 3 points, bradypnea, hypotension, hypothermia), tracheal intubation was performed to ensure airway patency, and vasopressor support with norepinephrine was initiated. The patient was urgently taken to the intensive care unit, where effective circulatory arrest occurred, refractory to the ongoing intensive therapy, and therefore a specialized EMS ECMO team was called and VA ECMO was initiated.

The patient was hospitalized in the intensive care unit of the regional vascular center (ICU RSC) of the N.V. Sklifosovsky Research Institute for Emergency Medicine, where the clinical diagnosis of “methadone poisoning” was established. Alcohol intoxication” (according to ICD-10 T40.3).

Against the background of combined intensive therapy, restoration of cardiorespiratory function was noted, which made it possible to wean the VA ECMO system on the 4th day.

On the 20th day (from the moment of hospitalization in the hospital), the patient in a stable somatic status was discharged from the N.V. Sklifosovsky Research Institute for Emergency Medicine.

Conclusion. The observation we presented shows the effectiveness and feasibility of using VA ECMO in the development of refractory cardiogenic shock in methadone poisoning.

1. Daugherty LE. Extracorporeal membrane oxygenation as rescue therapy for methadone-induced pulmonary edema. Pediatr Emerg Care. 2011;27(7):633–634. PMID: 21730798 https://doi.org/10.1097/PEC.0b013e3182225161

2. Alinejad S, Kazemi T, Zamani N, Hoffman RS, Mehrpour O. A systematic review of the cardiotoxicity of methadone. EXCLI J. 2015;14:577–600. PMID: 26869865 https://doi.org/10.17179/excli2015-553 eCollection 2015.

3. Beurton A, Goncalves R, Imbault J, Repusseau B, Ouattara A. Refractory cardiogenic shock caused by methadone poisoning and treated with hybrid extracorporeal membrane oxygenation. Therapie. 2022;77(6):737– 739. PMID: 35300873 https://doi.org/10.1016/j.therap.2022.02.004

4. Klinicheskie rekomendatsii – Ostrye otravleniya opioidnymi narkoticheskimi veshchestvami – 2022-2023-2024 (24.08.2022) – Utverzhdeny Minzdravom RF. Moscow, 2022. (In Russ.) Available at: https://disuria.ru/_ld/12/1239_kr22T40MZ.pdf [Accessed Aug 29, 2025]

5. Abramson DW, Quinn DK, Stern TA. Methadone-associated QTc prolongation: a case report and review of the literature. Prim Care Companion J Clin Psychiatry. 2008;10(6):470–476. PMID: 19287558 https://doi.org/10.4088/pcc.v10n0609

6. Perifericheskaya veno-arterial’naya ekstrakorporal’naya membrannaya oksigenatsiya pered transplantatsiey serdtsa. Moscow; 2015. (In Russ.) Available at: https://transpl.ru/files/rto/perefer-abo-pered-transpl.pdf [Accessed Aug 28, 2025]

7. Zhuravel SV, Kosolapov DA, Ketskalo MV. The Organization of Extracorporeal Membrane Oxygenation Programs for Acute Respiratory Failure in Adult Patients in a multidisciplinary hospital. Review of Experience in Regensburg (Germany). Transplantologiya. The Russian Journal of Transplantation. 2014;(4):28–32. (In Russ.)

8. Upchurch C, Blumenberg A, Brodie D, MacLaren G, Zakhary B, Hendrickson RG. Extracorporeal membrane oxygenation use in poisoning: a narrative review with clinical recommendations. Clin Toxicol (Phila). 2021;59(10):877–887. PMID: 34396873 https://doi.org/10.1080/15563650 2021.1945082

9. Eap CB, Buclin T, Baumann P. Interindividual variability of the clinical pharmacokinetics of methadone: implications for the treatment of opioid dependence. Clin Pharmacokinet. 2002;41(14):1153–1193. PMID: 12405865 https://doi.org/10.2165/00003088&200241140&00003

10. de Castro J, Aguirre C, Rodríguez Sasiaín JM, Gómez E, Garrido MJ, Calvo R. The effect of changes in gastric pH induced by omeprazole on the absorption and respiratory depression of methadone. Biopharm Drug Dispos. 1996;17(7):551–563. PMID: 8894114 https://doi.org/10.1002/(SICI)1099081X(199610)17:73.0.CO;2-1

11. Ng M, Wong ZY, Ponampalam R. Extracorporeal cardio-pulmonary resuscitation in poisoning: A scoping review article. Resusc Plus. 2023;13:100367. PMID: 36860990 https://doi.org/10.1016/j.resplu.2023.100367 eCollection 2023 Mar.

12. Joncke Koen, Thelinge Nathanaël, Dewolf Philippe et al. A systematic review of current ECPR protocols. A step towards standardization. Resusc Plus. 2020:3:100018. PMID: 34223301 https://doi.org/10.1016/j.resplu.2020.100018

13. Eap CB, Cuendet C, Baumann P. Binding of dmethadone, lmethadone, and dlmethadone to proteins in plasma of healthy volunteers: role of the variants of alpha 1acid glycoprotein. Clin Pharmacol Ther. 1990;47(3):338– 346. PMID: 2311335 https://doi.org/10.1038/clpt.1990.37

14. Almehmi A, Malas AM, Yousufuddin M, Rosencrance JG. Methadoneinduced torsade de pointes in a patient with normal baseline QT interval. W V Med J. 2003;100(4):147–148. PMID: 15471174

15. El-Sherif N, Turitto G, Boutjdir M. Acquired Long QT Syndrome and Electrophysiology of Torsade de Pointes. Arrhythm Electrophysiol Rev. 2019;8(2):122–130. PMID: 31114687 https://doi.org/10.15420/aer.2019.8.3

16. Afshari R, Maxwell S, Bateman D. Hemodynamic effects of methadone and dihydrocodeine in overdose. Clin Toxicol (Phila). 2007;45(7):763– 772. PMID: 17852162 https://doi.org/10.1080/15563650701502691

17. Ghadri JR, Wittstein IS, Prasad A, Sharkey S, Dote K, Akashi YJ, et al. International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology. Eur Heart J. 2018;39(22):2032–2046. PMID: 29850871 https://doi.org/10.1093/eurheartj/ehy076