Extracorporeal Membrane Oxygenation for Severe Paraquat Intoxication: A Systematic Review of Clinical Cases A Systematic Review Study
International Journal of Medical Toxicology and Forensic Medicine,
Vol. 16 (2026),
1 January 2026
,
Page 1-9
https://doi.org/10.22037/ijmtfm.v16.50723
Abstract
Background: Paraquat is a widely used, inexpensive contact herbicide that can cause fulminant multi-organ failure and death after ingestion, and no specific antidote is available. Extracorporeal membrane oxygenation (ECMO) has been used sporadically as rescue therapy in patients with severe paraquat intoxication, but its impact on clinical outcomes remains uncertain. This study systematically reviews the existing evidence on ECMO use in paraquat poisoning.
Methods: We searched Web of Science, PubMed, Scopus, Embase, the Cochrane Library, and Google Scholar from database inception to 1 November 2023 for human studies reporting paraquat-poisoned patients treated with ECMO. Eligible designs included case reports and case series. Two reviewers independently screened records, extracted data, and assessed methodological quality using the Joanna Briggs Institute critical appraisal tools. Quantitative synthesis was descriptive, comparing survivors and non-survivors.
Results: After removal of duplicates, 21 records were screened, and 14 full-text articles were assessed for eligibility. Nine studies published between 1985 and 2023, comprising 15 ECMO-treated patients, were included. The mean age was 27.3 ± 12.4 years. Survivors started ECMO later after paraquat ingestion than non-survivors (32.6 ± 8.8 vs 7.7 ± 8.4 days, P < 0.001). Survivors also had a longer hospital stay (78.5 ± 2.1 vs 21.8 ± 33.1 days, P = 0.049). In contrast, ECMO duration, indication for ECMO, concomitant extracorporeal therapies, and ECMO configuration (veno-venous vs. veno-arterial) were not significantly associated with survival. Most survivors underwent bilateral lung transplantation during or after ECMO support.
Conclusion: The limited evidence suggests that ECMO may have a role, often alongside lung transplantation, in selected patients with paraquat poisoning. Larger registries and observational studies are needed to clarify patient selection, timing, and outcomes of ECMO in this setting.
How to Cite
References
[1] Cooke NJ, Flenley DC, Matthew H. Paraquat poisoning. Serial studies of lung function. Q J Med. 1973;42(168):683-92. [DOI: 10.1093/qjmed/42.168.683]
[2] Oghabian Z, Williams J, Mohajeri M, Nakhaee S, Shojaeepour S, Amirabadizadeh A, et al. Clinical Features, Treatment, Prognosis, and Mortality in Paraquat Poisonings: A Hospital-Based Study in Iran. J Res Pharm Pract. 2019;8(3):129-36. [DOI: 10.4103/jrpp.JRPP_19_18]
[3] Sabzghabaee AM, Eizadi-Mood N, Montazeri K, Yaraghi A, Golabi M. Fatality in paraquat poisoning. Singapore Med J. 2010;51(6):496-500. [DOI: 10.11622/smedj.2010069]
[4] Suntres ZE. Role of antioxidants in paraquat toxicity. Toxicology. 2002;180(1):65-77. [DOI: 10.1016/S0300-483X(02)00396-5]
[5] Gawarammana IB, Buckley NA. Medical management of paraquat ingestion. Br J Clin Pharmacol. 2011;72(5):745-57. [DOI: 10.1111/j.1365-2125.2011.04049.x]
[6] Houze P, Baud FJ, Mouy R, Bismuth C, Bourdon R, Scherrmann JM. Toxicokinetics of paraquat in humans. Hum Exp Toxicol. 1990;9(1):5-12. [DOI: 10.1177/096032719000900102]
[7] Dinis-Oliveira RJ, Duarte JA, Sanchez-Navarro A, Remiao F, Bastos ML, Carvalho F. Paraquat poisonings: mechanisms of lung toxicity, clinical features, and treatment. Crit Rev Toxicol. 2008;38(1):13-71. [DOI: 10.1080/1040844070166995]
[8] Li C, Cai H, Meng F, Meng F, Tang Z, Tang Y, et al. Case report: Lung transplantation for treatment of paraquat intoxication: timing of transplantation. Front Pharmacol. 2023;14:1234567. [DOI: 10.3389/fphar.2023.1234567]
[9] Song CY, Feng MX, Li L, Wang P, Lu X, Lu YQ. Tripterygium wilfordii Hook.f. ameliorates paraquat-induced lung injury by reducing oxidative stress and ferroptosis via Nrf2/HO-1 pathway. Ecotoxicol Environ Saf. 2023;252:114575. [DOI: 10.1016/j.ecoenv.2023.114575]
[10] Tang X, Sun B, He H, Li H, Hu B, Qiu Z, et al. Successful extracorporeal membrane oxygenation therapy as a bridge to sequential bilateral lung transplantation for a patient after severe paraquat poisoning. Clin Toxicol (Phila). 2015;53(9):908-13. [DOI: 10.3109/15563650.2015.1082103]
[11] Brodie D, Slutsky AS, Combes A. Extracorporeal Life Support for Adults With Respiratory Failure and Related Indications: A Review. JAMA. 2019;322(6):557-68. [DOI: 10.1001/jama.2019.10257]
[12] Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet. 2009;374(9698):1351-63. [DOI: 10.1016/S0140-6736(09)61069-2]
[13] Maier S, Rosner L, Saemann L, Sogl J, Beyersdorf F, Trummer G, et al. Extracorporeal Membrane Oxygenation in Intoxication and Overdoses: A Systematic Review. Thorac Cardiovasc Surg. 2023;71(5):e123-e130. [DOI: 10.1055/s-0042-1758432]
[14] Moola S, Munn Z, Tufanaru C, Aromataris E, Sears K, Sfetcu R, et al. Systematic reviews of etiology and risk. In: Aromataris E, Munn Z, editors. JBI Manual for Evidence Synthesis. Adelaide: JBI; 2024. [Link]
[15] Saletta JM, Garcia JJ, Carames JMM, Schliephake H, da Silva Marques DN. Quality assessment of systematic reviews on vertical bone regeneration. Int J Oral Maxillofac Surg. 2019;48(3):364-72. [DOI: 10.1016/j.ijom.2018.10.012]
[16] The Toronto Lung Transplant group. Sequential bilateral lung transplantation for paraquat poisoning. A case report. J Thorac Cardiovasc Surg. 1985;89(5):734-42. [DOI: 10.1016/S0022-5223(85)80303-]
[17] Bertram A, Haenel SS, Hadem J, Hoeper MM, Gottlieb J, Warnecke G, et al. Tissue concentration of paraquat on day 32 after intoxication and failed bridge to transplantation by extracorporeal membrane oxygenation therapy. BMC Pharmacol Toxicol. 2013;14:45. [DOI: 10.1186/2050-6511-14-45]
[18] Hsieh YW, Lin JL, Lee SY, Weng CH, Yang HY, Liu SH, et al. Paraquat poisoning in pediatric patients. Pediatr Emerg Care. 2013;29(4):487-91. [DOI: 10.1097/PEC.0b013e31828a8b5c]
[19] Jiao G, Li X, Wu B, Yang H, Zhang G, Ding Z, et al. Case Report: Delayed Lung Transplantation With Intraoperative ECMO Support for Herbicide Intoxication-Related Irreversible Pulmonary Fibrosis: Strategy and Outcome. Front Surg. 2021;8:754816. [DOI: 10.3389/fsurg.2021.754816]
[20] Wu Y, Li N, Li S, Song S. Lung transplantation in a woman with paraquat poisoning that led to pulmonary fibrosis-Widely reported by the media: A case report. Medicine (Baltimore). 2022;101(49):e32263. [DOI: 10.1097/MD.0000000000032263]
[21] Feng MX, Lu YQ. Performance of extracorporeal membrane oxygenation in patients with fatal paraquat poisoning: grasp for straws? World J Emerg Med. 2021;12(3):232-4. [DOI: 10.5847/wjem.j.issn.1920-8642.2021.03.013]
[22] Girgin NK, Unlu N, Siginak IS, Iscimen R, Kahveci F, Caglayan H. Persistent hypoxemia during extracorporeal membrane oxygenation in delayed diagnosed paraquat intoxication. Respir Case Rep. 2017;6(2):118-23. [DOI: 10.1016/j.rescr.2017.05.004]
[23] Eddleston M, Phillips MR. Self poisoning with pesticides. BMJ. 2004;328(7430):42-4. [DOI: 10.1136/bmj.328.7430.42]
[24] Jeyaratnam J. Acute pesticide poisoning: a major global health problem. World Health Stat Q. 1990;43(3):139-44. [Link]
[25] Smith LL, Wright A, Wyatt I, Rose MS. Effective treatment for paraquat poisoning in rats and its relevance to treatment of paraquat poisoning in man. Br Med J. 1974;4(5944):569-71. [DOI: 10.1136/bmj.4.5944.569]
[26] Okonek S, Hofmann A, Henningsen B. Efficacy of gut lavage, hemodialysis, and hemoperfusion in the therapy of paraquat or diquat intoxication. Arch Toxicol. 1976;36(1):43-51. [DOI: 10.1007/BF00305714]
[27] Lavergne V, Nolin TD, Hoffman RS, Roberts D, Gosselin S, Goldfarb DS, et al. The EXTRIP (EXtracorporeal TReatments In Poisoning) workgroup: guideline methodology. Clin Toxicol (Phila). 2012;50(5):403-13. [DOI: 10.3109/15563650.2012.666925]
[28] Kavousi-Gharbi S, Jalli R, Rasekhi-Kazerouni A, Habibagahi Z, Marashi SM. Discernment scheme for paraquat poisoning: A five-year experience in Shiraz, Iran. World J Exp Med. 2017;7(1):31-9. [DOI: 10.5492/wjem.v7.i1.31]
[29] Tang X, Sun B, He H, Li H, Hu B, Qiu Z, et al. Successful extracorporeal membrane oxygenation therapy as a bridge to sequential bilateral lung transplantation for a patient after severe paraquat poisoning. Clin Toxicol (Phila). 2015;53(9):908-13. [DOI: 10.3109/15563650.2015.1082103]
[30] Matthew H, Logan A, Woodruff MF, Heard B. Paraquat poisoning--lung transplantation. Br Med J. 1968;3(5621):759-63. [DOI: 10.1136/bmj.3.5621.759]
[31] Walder B, Brundler MA, Spiliopoulos A, Romand JA. Successful single-lung transplantation after paraquat intoxication. Transplantation. 1997;64(5):789-91. [DOI: 10.1097/00007890-199709150-00023]
[32] Maier S, Rosner L, Saemann L, Sogl J, Beyersdorf F, Trummer G, et al. Extracorporeal Membrane Oxygenation in Intoxication and Overdoses: A Systematic Review. Thorac Cardiovasc Surg. 2023;71(5):e123-e130. [DOI: 10.1055/s-0042-1758432]
[33] Eizadi-Mood N, Jaberi D, Barouti Z, Rahimi A, Mansourian M, Dorooshi G, et al. The efficacy of hemodialysis on paraquat poisoning mortality: A systematic review and meta-analysis. J Res Med Sci. 2022;27:74. [DOI: 10.4103/jrms.JRMS_1245_21]
- Abstract Viewed: 40 times
- PDF Downloaded: 50 times