Combined lipid emulsion and plasma exchange in massive pediatric bupropion overdose: Case Report

Introduction: Massive bupropion overdose in pediatric patients can result in refractory cardiogenic shock, seizures, and cardiac arrest requiring aggressive intervention. Although lipid emulsion (LE), therapeutic plasma exchange (TPE), and extracorporeal membrane oxygenation (ECMO) have been used, evidence guiding clinical management remains limited. We present a case of combined LE therapy and TPE in a pediatric patient with massive bupropion overdose. Methods: An adolescent female with intentional ingestion of 27,000 mg bupropion XL and 2,250 mg metoprolol XL experienced cardiac arrest requiring veno-arterial ECMO. Lipid emulsion therapy was followed by serial therapeutic plasma exchange. Serial urine samples quantifying bupropion and hydroxybupropion elimination were analyzed. Results: Following treatment with LE and plasma exchange, the patient rapidly improved clinically, with declining urine concentrations of bupropion and hydroxybupropion showing enhanced drug clearance. Conclusion: This case supports using combined LE therapy and TPE to enhance drug elimination and improve outcomes in massive pediatric bupropion overdose.