Introduction: Caffeine toxicity causes dose-dependent effects, including seizures, wide-complex tachyarrhythmias, and cardiovascular collapse. Toxicity is usually reported after ingestion > 1.2g, with deaths more common at 5–10 g. We present a pediatric case of toxic caffeine ingestion causing multiorgan failure managed with therapeutic plasma exchange (TPE) and continuous renal replacement hemodiafiltration (CRRT).
Description: A 16-year-old female with polycystic ovarian syndrome, migraines, anxiety, and major depressive disorder with previous suicide attempts intentionally ingested about 17 grams of caffeine. She arrived obtunded, seizing, and in sinus tachycardia with premature ventricular contractions that progressed to wide-complex tachycardia and hypotension. She was intubated and treated with anticonvulsants, epinephrine infusion, and propofol for transport. In the PICU, a 240 bpm wide-complex tachycardia was treated with a 100 mg lidocaine load, three synchronized cardioversions, and titration of an esmolol infusion for rate control.
The initial caffeine level was 241 mcg/mL (therapeutic range 5-20 mcg/mL). A 1.5-volume TPE with 5% albumin lowered her caffeine levels to 165 mcg/mL. Afterwards, CRRT at standard clearance reduced caffeine levels to 65 mcg/mL after 15 hours. She developed rhabdomyolysis (creatine kinase peaked at 140,295 units/L) and bilateral lower-extremity compartment syndrome, requiring three-stage fasciotomy and debridement. At high clearance, CRRT decreased caffeine levels from 88 to 41 mcg/mL in 12 hours; continued CRRT normalized levels. Ongoing kidney dysfunction necessitated intermittent hemodialysis for four weeks. The patient remained in the PICU for 32 days, with 11 days of intubation. After PICU discharge, she has stage 2 chronic kidney disease without dialysis requirements, uses an ankle–foot orthosis for ambulation, and has mild memory impairment but is active in school.
Discussion: Caffeine is widely accessible yet can be fatal in excess. Its low molecular weight, minimal protein binding, and small volume of distribution favor clearance with dialysis. This case highlights that combined TPE and CRRT may rapidly reduce toxic levels and manage rhabdomyolysis, supporting early extracorporeal therapy in severe pediatric caffeine poisoning.
