lipid rescue

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i know this has been threaded back in 2007 on the anesthesia forum, but you ER guys should know about this. my brother, an anesthesiologist just told me about someone saved in his town from bupivacaine OD.

basically, bupivacaine OD (and others, perhaps) can be saved by infusing lipid emulsions. prior to this discovery, bupivicaine cardiac arrest was treated with cardiopulmonary bypass. now you just infuse lipid emulsion, eg, Interlipid.

this may work for other OD's also, like TCA, sertraline, CCB, BB, etc.

see www.lipidrescue.org for more info

any of you guys ever use this?

Yep. The key indicators are: lipophilicity of the toxin, serious toxicity, and absence of a safer, more established antidote. The thought is that the lipid emulsifies the lipophilic toxin and sequesters it. Pretty cool stuff.

Of note, Intralipid is essentially the lipid component of TPN (you can use 20% or 30%) and mentioning this may help your pharmacist get you what you need faster.

Originally Posted by WilcoWorld

Yep. The key indicators are: lipophilicity of the toxin, serious toxicity, and absence of a safer, more established antidote. The thought is that the lipid emulsifies the lipophilic toxin and sequesters it. Pretty cool stuff.

Of note, Intralipid is essentially the lipid component of TPN (you can use 20% or 30%) and mentioning this may help your pharmacist get you what you need faster.

OMG have you gotten to use it? I've been practically carrying around a bag o' intralipid waiting for a chance to do it.

Outside of the anesthesia literature there are really only case reports. I keep hoping for a good propranolol OD to use it.

Originally Posted by njac

OMG have you gotten to use it? I've been practically carrying around a bag o' intralipid waiting for a chance to do it.

Outside of the anesthesia literature there are really only case reports. I keep hoping for a good propranolol OD to use it.

Although it might work, a cheesy green chile chicken enchilada doesn't count as a bag of Intralipid.

600th post!

Originally Posted by njac

I keep hoping for a good propranolol OD to use it.

Don't look forward to it. Fear using it.

Having had to resort to it for several patients, it is not some miracle. I have found that it gives a region of stability where you can try other interventions.

Ann-Jennette Geib put together a case series using the ToxIC consortium of poison centers. The data was presented at NAACT this year. The data on CCB poisoning was not favorable. While the N was very low (10 total patients I believe, with 3 CCBs). 2 of the 3 CCB poisoning patients died. If you include my case report presented the prior year (which could not be included as it was previously presented at the meeting) the success rate is dismal.

The literature is developing a strong confirmation bias, if you look at the case reports. Many of the patients who were given IFE were not that sick and had not failed other treatments.

Keep in mind, there are substantial differences in the pharmacokinetics and dynamics of the local anesthetics versus the cardioactive drugs. LAs have a very rapid redistribution. Pulling some of the drug off the sodium channel gives you more channels to work with. The drug left in the intravascular space redistributes out, so that when the lipid based LA redistributes, it does not have toxic amounts.

CCBs and many BBs don't do that. They need to be metabolized. You basically hope that by getting some BP, you get enough liver perfusion to substantially change the intravascular concentrations before the drug comes out of the lipid fraction. At the same time, you perfuse the rest of the GI tract and create a lipid sponge that can enhance drug absorption. None of the experimental models use oral medications; they all use IV. This is one of the weaknesses. The models also ended the experiments at 6 hours. My experience is that the patients do great, then die 12-24 hours later.

So, stick with conventional stuff first and foremost. There are few BB or CCB intoxicated patients that I can't make better with 4-6 units/kg/hr of insulin. If you run into the situation where things have failed and you are considering needed IFE 1) call a toxicologist and 2) look for something you can add once your patient gets BP: IABP, ECMO, veno-veno-bypass, etc. Something to get good liver perfusion. Sadly, most of these drugs are not very amenable to hemodialysis.

Originally Posted by paiute

i know this has been threaded back in 2007 on the anesthesia forum, but you ER guys should know about this. my brother, an anesthesiologist just told me about someone saved in his town from bupivacaine OD.

basically, bupivacaine OD (and others, perhaps) can be saved by infusing lipid emulsions. prior to this discovery, bupivicaine cardiac arrest was treated with cardiopulmonary bypass. now you just infuse lipid emulsion, eg, Interlipid.

this may work for other OD's also, like TCA, sertraline, CCB, BB, etc.

see www.lipidrescue.org for more info

any of you guys ever use this?

Yup! Its pretty well known in EM. Lipid is being studied for many overdoses as well. I was particularly moved by a case out of CHOP that was published in Annals of EM using intralipid in the resuscitation of teenager with lithium and bupropion overdose. It is just one of many case reports, but it was striking!

Originally Posted by BADMD

So, stick with conventional stuff first and foremost. There are few BB or CCB intoxicated patients that I can't make better with 4-6 units/kg/hr of insulin. If you run into the situation where things have failed and you are considering needed IFE 1) call a toxicologist and 2) look for something you can add once your patient gets BP: IABP, ECMO, veno-veno-bypass, etc. Something to get good liver perfusion. Sadly, most of these drugs are not very amenable to hemodialysis.

I love Insulin for CCB OD! I agree totally with using standard therapies...great advice!

Thymeless, speaking of intralipid, how much do you guys do in terms of regional anesthesia at Mayo?

I'm doing an anesthesia sub-I right now and regional blocks are becoming a developing interest for me in the ED . . .

Originally Posted by Tiger26

Thymeless, speaking of intralipid, how much do you guys do in terms of regional anesthesia at Mayo?

I'm doing an anesthesia sub-I right now and regional blocks are becoming a developing interest for me in the ED . . .

I think regional anesthesia is a growing passion of many EM practitioners. I have been able to do femoral nerve blocks, hematoma blocks, inferior alveolar and other dental blocks, flexor sheath blocks, and periauricular blocks.

There are plenty of opportunities to do more and push the limits of current practice. You can read and bring that knowledge to the ED, you can use one of your three elective months to get further specialization (there is always someone at the hospital doing it if it is being done anywhere . You also do a month of Anesthesia as an intern and they would be happy to help refine your practice further. There is plenty of opportunity for customization of your training.

Cheers,
TL

Originally Posted by ThymeLess

I think regional anesthesia is a growing passion of many EM practitioners. I have been able to do femoral nerve blocks, hematoma blocks, inferior alveolar and other dental blocks, flexor sheath blocks, and periauricular blocks.

There are plenty of opportunities to do more and push the limits of current practice. You can read and bring that knowledge to the ED, you can use one of your three elective months to get further specialization (there is always someone at the hospital doing it if it is being done anywhere . You also do a month of Anesthesia as an intern and they would be happy to help refine your practice further. There is plenty of opportunity for customization of your training.

Cheers,
TL

Thanks TL for that detailed synopsis--the amount of customization was just one of the really appealing things about training there.

Originally Posted by paiute

this may work for other OD's also, like TCA, sertraline, CCB, BB, etc.

any of you guys ever use this?

There is an excellent literature review published in Clinical Toxicology last month. It's well established for bupivicaine. The literature for verapamil and propranolol is somewhat mixed. The only literature for TCAs is in rabbits and rats. There is a smattering of case reports for other ingestions.

I suggested it as a last resort for a bad TCA in our region. The intensivist happened to be a moonlighting critical care fellow who either felt like trying it out or was as worried as I was about the patient. I tell myself it helped, but in reality, the patient probably survived because of an excellent physician and RN staff.