A case report of severe overdose of valproate, quetiapine, and promethazine treated with direct hemoperfusion

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Some severely intoxicated patients require extracorporeal drug removal by blood purification. We report a case involving an intentional overdose of quetiapine (QTP), promethazine (PMZ) and valproate (VPA), with successful removal by direct hemoperfusion (DHP). A man in his 30's with a history of schizophrenia and suicide attempts was admitted to our hospital 9 hours after taking 450 mg of QTP, 900 mg of PMZ, and 7,600 mg of VPA. On arrival, he was comatose, with a Japan coma scale score of III-200. His temperature was 37℃, and the blood pressure was 90/60 mmHg. DHP was initiated with activated charcoal (Hemosorba, Asahi Medical Co.). Sixty min after initiation, he became irritable, and 75 min after initiation, DHP treatment was discontinued. After DHP, serum QTP, PMZ, and VPA levels decreased from 169 to 139 ng/mL, 55.2 to 42.5 ng/mL, and 95 to 73 μg/mL, respectively. The clearance of QTP, PMZ, and VPA was 117.5, 126.7, and 96.8 mL/min, respectively. Within 4 hrs after DHP, the patient became alert, and was discharged on day 2. Our case indicated that the effective removal of QTP, PMZ, and VPA by DHP was associated with clinical improvement.