Liposuction pp 789-800 | Cite as

Lipid Rescue for Local Anesthetic and Nonlocal Anesthetic Drug Toxicity

Chapter

Abstract

The occurrence of toxicity from local anesthetics has been reported, including cardiac toxicity resulting in cardiac arrhythmias and/or asystole. A variety of techniques have been used to treat local anesthetic toxicities; however, with cardiac arrest, a relatively new concept—lipid rescue—has been formulated that appears to be relatively successful. The author discusses the literature on local anesthetic toxicities and fatalities, animal research concerning lipid rescue, local anesthetic toxicities, and fatalities treated with lipid rescue, as well as the Practice Advisory on Treatment of Local Anesthetic Systemic Toxicity.

Keywords

Cardiac Arrest Lipid Infusion Lipid Emulsion Local Anesthetic Toxicity Advanced Cardiac Life Support 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
  2. 2.
    Sunshine I, Fike WW. Value of thin-layer chromatography in two fatal cases of intoxication due to lidocaine and mepivacaine. N Engl J Med. 1964;271:487–90.CrossRefPubMedGoogle Scholar
  3. 3.
    Christie JL. Fatal consequences of local anesthesia: report of five cases and a review of the literature. J Forensic Sci. 1976;21(3):671–9.CrossRefPubMedGoogle Scholar
  4. 4.
    Moore DC, Bridenbaugh DL, Thompson GE, Balfour RI, Horton WG. Factors determining doses of amide-type anesthetic drugs. Anesthesiology. 1977;47(3):263–8.CrossRefPubMedGoogle Scholar
  5. 5.
    Albright GA. Cardiac arrest following regional anesthesia with etidocaine or bupivacaine. Anesthesiology. 1979;51(4):285–7.CrossRefPubMedGoogle Scholar
  6. 6.
    Rosen M, Thigpen J, Shnider SM, Foutz SE, Levinson G, Koike M. Bupivacaine-induced cardiotoxicity in hypoxic and acidotic sheep. Anesth Analg. 1985;64(11):1089–96.CrossRefPubMedGoogle Scholar
  7. 7.
    Yukioka H, Hayashi M, Fujimori ML. Lidocaine intoxication during general anesthesia [Letter]. Anesth Analg. 1990;71(2):207–8.CrossRefPubMedGoogle Scholar
  8. 8.
    Klein JA, Kassarjdian N. Lidocaine toxicity with tumescent liposuction. Dermatol Surg. 1997;23(12):1169–74.CrossRefPubMedGoogle Scholar
  9. 9.
    Local aneasthetic toxicity. http://emedicine.medscape.com/article/1844551-overview. Accessed 22 Apr 15.
  10. 10.
    Polly LS, Santos AC. Cardiac arrest following regional anesthesia with ropivacaine. Anesthesiology. 2003;99(5):1253–4.CrossRefGoogle Scholar
  11. 11.
    Morishima HO, Pedersen H, Finster M, Hiraoka H, Tsuji A, Feldman HS, Arthur GR, Covino BG. Bupivacaine toxicity in pregnant and nonpregnant ewes. Anesthesiology. 1985;63(2):134–9.CrossRefPubMedGoogle Scholar
  12. 12.
    Santos AC, Pedersen H, Harmon TW, Morishima HO, Finster M, Arthur GR, Covino BG. Does pregnancy alter the systemic toxicity of local anesthetics? Anesthesiology. 1989;70(6):991–5.CrossRefPubMedGoogle Scholar
  13. 13.
    Morishima HO, Finster M, Arthur GR, Covino BG. Pregnancy does not alter lidocaine toxicity. Am J Obstet Gynecol. 1990;162(5):1320–4.CrossRefPubMedGoogle Scholar
  14. 14.
    Clarkson CW, Hondeghem LM. Mechanism for bupivacaine depression of cardiac conduction: fast block of sodium channels during the action potential with slow recovery from block during diastole. Anesthesiology. 1985;62(4):396–405.CrossRefPubMedGoogle Scholar
  15. 15.
    Thomas RD, Behbehani MM, Coyle DE, Denson DD. Cardiovascular toxicity of local anesthetics: an alternative hypothesis. Anesth Analg. 1986;65(5):444–50.CrossRefPubMedGoogle Scholar
  16. 16.
    Huet O, Eyrolle LJ, Mazoit JX, Ozier YM. Cardiac arrest after injection of ropivacaine for posterior lumbar plexus blockade. Anesthesiology. 2003;99(6):1451–3.CrossRefPubMedGoogle Scholar
  17. 17.
    Abbott Jr PJ, Sullivan G. Cardiovascular toxicity following preincisional intra-articular injection of bupivacaine. Arthroscopy. 1997;13(2):282.CrossRefPubMedGoogle Scholar
  18. 18.
    Heath ML. Bupivacaine toxicity and bier blocks. Anesthesiology. 1983;59(5):481.CrossRefPubMedGoogle Scholar
  19. 19.
    Moore DC, Mather LE, Bridenbaugh LD, Thompson GE, Balfour RI, Lysons DF, Horton WG. Bupivacaine (Marcaine): an evaluation of its tissue and systemic toxicity in humans. Acta Anaesthesiol Scand. 1977;21(2):109–21.CrossRefPubMedGoogle Scholar
  20. 20.
    Coyle DE, Porembka DT, Sehlhorst CS, Wan L, Behbehani MM. Echocardiographic evaluation of bupivacaine cardiotoxicity. Anesth Analg. 1994;79(2):335–9.CrossRefPubMedGoogle Scholar
  21. 21.
    Wikipedia. Bupivacaine. Available at: http://en.wikipedia.org/wiki/Bupivacaine. Accessed 12 Mar 2011.
  22. 22.
    Heavner JE, Shi B, Pitkanen M. Nitric oxide synthesis inhibition enhances bupivacaine cardiotoxicity. Reg Anesth. 1996;21(3):243–8.PubMedGoogle Scholar
  23. 23.
    Weinberg GL, VadeBoncouer T, Ramaraju GA, Garcia-Amaro MF, Cwik MJ. Pretreatment or resuscitation with a lipid infusion shifts the dose response to bupivacaine induced asystole in rats. Anesthesiology. 1998;88(4):1071–5.CrossRefPubMedGoogle Scholar
  24. 24.
    Weinberg G, Ripper R, Feinstein DL, Hoffman W. Lipid emulsion infusion rescues dogs from bupivacaine-induced cardiac toxicity. Reg Anesth Pain Med. 2003;28(3):198–202.CrossRefPubMedGoogle Scholar
  25. 25.
    Weinberg G, Paisanthasan C, Feinstein D, Hoffman W. The effect of bupivacaine on myocardial tissue hypoxia and acidosis during ventricular fibrillation. Anesth Analg. 2004;98(3):790–5.CrossRefPubMedGoogle Scholar
  26. 26.
    Clark MK. Lipid emulsion as rescue for local anesthetic-related cardiotoxicity. J Perianesth Nurs. 2008;23(2):111–7.CrossRefPubMedGoogle Scholar
  27. 27.
    Isherwood P. Lipid rescue: small trials and animal research. Anaesthesia. 2009;64(12):1380.CrossRefPubMedGoogle Scholar
  28. 28.
    Wang QG, Liu L, Xu XZ, Chen LM, Chen Y, Wang WT, Wu H. Effects of lipid emulsion on hemodynamics and pharmacokinetics of mongrel dogs with bupivacaine-induced cardiac depression. Zhonghua Yi Xue Za Zhi. 2009;89(25):1787–90.PubMedGoogle Scholar
  29. 29.
    Hicks SD, Salcido DD, Logue ES, Suffoletto BP, Empey PE, Poloyac SM, Miller DR, Callaway CW, Menegazzi JJ. Lipid emulsion combined with epinephrine and vasopressin does not improve survival in a swine model of bupivacaine-induced cardiac arrest. Anesthesiology. 2009;111(1):138–46.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Cave G, Harvey MG, Winterbottom T. Evaluation of the Association of Anaesthetists of Great Britain and Ireland lipid infusion protocol in bupivacaine induced cardiac arrest in rabbits. Anaesthesia. 2009;64(7):732–7.CrossRefPubMedGoogle Scholar
  31. 31.
    Bennett G. Anesthesia for aesthetic surgery. In: Shiffman MA, Di Giuseppe A, editors. Cosmetic surgery: art and techniques. Berlin: Springer; 2013. p. 105–44.CrossRefGoogle Scholar
  32. 32.
    Groban L, Butterworth J. Lipid reversal of bupivacaine toxicity: has the silver bullet been identified? Reg Anesth Pain Med. 2003;28(3):167–9.PubMedGoogle Scholar
  33. 33.
    Heavner JE, Arthur J, Zou J, McDaniel K, Tyman-Szram B, Rosenberg PH. Comparison of propofol with thiopentone for treatment of bupivacaine-induced seizures in rats. Br J Anaesth. 1993;71(5):715–9.CrossRefPubMedGoogle Scholar
  34. 34.
    Litz RJ, Popp M, Stehr SN, Koch T. Successful resuscitation of a patient with ropivacaine-induced asystole after axillary plexus block using lipid infusion. Anesthesia. 2006;61(8):800–1.CrossRefGoogle Scholar
  35. 35.
    Rosenblatt MA, Abel M, Fischer GW, Itzkovich CJ, Eisenkraft JB. Successful use of 20% lipid emulsion to resuscitate a patient after a presumed bupivacaine-related cardiac arrest. Anesthesiology. 2006;105(1):217–8.CrossRefPubMedGoogle Scholar
  36. 36.
    Moore DC. Lipid rescue form bupivacaine cardiac arrest: a result of failure to ventilate and maintain cardiac perfusion? Anesthesiology. 2007;106(3):636–7.CrossRefPubMedGoogle Scholar
  37. 37.
    Foxall G, McCahon R, Lamb J, Hardman JG, Bedford NM. Levobupivacaine-induced seizures and cardiovascular collapse treated with Intralipid. Anaesthesia. 2007;62(5):516–8.CrossRefPubMedGoogle Scholar
  38. 38.
    Spence AG. Lipid reversal of central nervous system symptoms of bupivacaine toxicity. Anesthesiology. 2007;107(3):516–7.CrossRefPubMedGoogle Scholar
  39. 39.
    Ludot H, Tharin JY, Belouadah M, Mazoit JX, Malinovsky JM. Successful resuscitation after ropivacaine and lidocaine-induced ventricular arrhythmia following posterior lumbar plexus block in a child. Anesth Analg. 2008;106(5):1572–4.CrossRefPubMedGoogle Scholar
  40. 40.
    McCutchen T, Gerancher JC. Early intralipid therapy may have prevented bupivacaine-associated cardiac arrest. Reg Anesth Pain Med. 2008;33(2):178–80.CrossRefPubMedGoogle Scholar
  41. 41.
    Smith HM, Jacob AK, Segura LG, Dilger JA, Torsher LC. Simulation education in anesthesia training: a case report of successful resuscitation of bupivacaine-induced cardiac arrest linked to recent stimulation training. Anesth Analg. 2008;106(5):1581–4.CrossRefPubMedGoogle Scholar
  42. 42.
    Felice K, Schumann H. Intravenous lipid emulsion for local anesthetic toxicity: a review of the literature. J Med Toxicol. 2008;4(3):184–91.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Marwick PC, Levin AI, Coetzee AR. Recurrence of cardiotoxicity after lipid rescue from bupivacaine-induced cardiac arrest. Int Anesth Analg. 2009;108(4):1344–6.Google Scholar
  44. 44.
    Zausig YA, Zink W, Keil M, Sinner B, Barwing J, Wiese CH, Graf BM. Lipid emulsion improves recovery from bupivacaine-induced cardiac arrest, but not from ropivacaine- or mepivacaine-induced cardiac arrest. Anesth Analg. 2009;109(4):1323–6.CrossRefPubMedGoogle Scholar
  45. 45.
    Charbonneau H, Marcou TA, Mazoit JX, Zetlaoui PJ, Benhamou D. Early use of lipid emulsion to treat incipient mepivacaine intoxication. Reg Anesth Pain Med. 2009;34(3):277–8.CrossRefPubMedGoogle Scholar
  46. 46.
    Wong GK, Joo DT, McDonnell C. Lipid resuscitation in a carnitine deficient child following intravascular migration of an epidural catheter. Anaesthesia. 2010;65(2):192–5.CrossRefPubMedGoogle Scholar
  47. 47.
    Cordell CL, Schubkegel T, Light TR, Ahmad F. Lipid infusion rescue for bupivacaine-induced cardiac arrest after axillary block. J Hand Surg Am. 2010;35(1):144–6.CrossRefPubMedGoogle Scholar
  48. 48.
    Man D, Podichetty VK. Lipid rescue in resuscitation of local anesthetic-induced cardiac arrest in aesthetic surgery. Plast Reconstr Surg. 2010;125(6):257e–9.CrossRefPubMedGoogle Scholar
  49. 49.
    Weinberg G. Treatment of local aesthetic systemic toxicity (LAST). Reg Anesth Pain Med. 2010;35(2):188–93.CrossRefPubMedGoogle Scholar
  50. 50.
    Zhurda T, Muzha D, Caushi GJ, Bajaktari M, Kerci M. Usefulness of lipidic solution for the treatment of systemic toxicity related to bupivacaine injected in a sub-coracoid brachial plexus block. Ann Fr Anesth Reanim. 2010;29(7–8):592–3.CrossRefPubMedGoogle Scholar
  51. 51.
    Benhamou D, Mazoit JX, Zetlaoui P. Early administration of lipid rescue after initial signs of local anesthetic-induced systemic toxicity [in French]. Ann Fr Anesth Reanim. 2010;29(11):826.CrossRefPubMedGoogle Scholar
  52. 52.
    Aveline C, Cognet F, Bonnet F. Ineffectiveness of intralipid infusion or central nervous toxicity following ultrasound-guided sciatic nerve block with lidocaine-ropivacaine solution? Interaction between carbamazepine, local anesthetic and intralipid? Eur J Anaesthesiol. 2010;27(12):l070–2.CrossRefGoogle Scholar
  53. 53.
    Uncles DR, Willers JW, Samuels TL, Chaklader A. Local anesthetic systemic toxicity treated with intravenous lipid emulsion: ineffective treatment or selection of an inadequate lipid rescue dose? Eur J Anaesthesiol. 2011;28(5):390–1.CrossRefPubMedGoogle Scholar
  54. 54.
    Schellhammer F, Milde A. Toxic lipid rescue therapy effect of local anesthesia in interventional radiology [in German]. Rofo Fortschr Geb Rontgenstr Nuklearmed. 2011;183(1):73–4.CrossRefPubMedGoogle Scholar
  55. 55.
    Weinberg G. Lipid rescue resuscitation from local anaesthetic cardiac toxicity. Toxicol Rev. 2006;25(3):139–45.CrossRefPubMedGoogle Scholar
  56. 56.
    Weinberg GL, Ripper R, Murphy P, Edelman LB, Hoffman W, Strichartz G, Feinstein DL. Lipid infusion accelerates removal of bupivacaine and recovery from bupivacaine toxicity in the isolated rat heart. Reg Anesth Pain Med. 2006;31(4):296–303.CrossRefPubMedGoogle Scholar
  57. 57.
    Weinberg G, Lin B, Zheng S, Di Gregorio G, Hiller D, Ripper R, Edelman L, Kelly K, Feinstein D. Partitioning effect in lipid resuscitation: further evidence for the lipid sink. Crit Care Med. 2010;38(11):2268–9.CrossRefPubMedGoogle Scholar
  58. 58.
    Harvey M, Cave G. Intralipid outperforms sodium bicarbonate in a rabbit model of clomipramine toxicity. Ann Emerg Med. 2007;49(2):178–85.CrossRefPubMedGoogle Scholar
  59. 59.
    Tebbutt S, Harvey M, Nicholson T, Cave G. Intralipid prolongs survival in a rat model of verapamil toxicity. Acad Emerg Med. 2006;13(2):134–9.CrossRefPubMedGoogle Scholar
  60. 60.
    Bania T, Chu J, Perez E, Su M, Hahn IH. Hemodynamic effects of intravenous fat emulsion in an animal model of severe verapamil toxicity resuscitated with atropine, calcium, and saline. Acad Emerg Med. 2007;14(2):105–11.CrossRefPubMedGoogle Scholar
  61. 61.
    Harvey M, Cave G. Intralipid infusion ameliorates propranolol induced hypotension in rabbits. J Med Toxicol. 2008;4(2):71–6.CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Sirianni AJ, Osterhoudt KC, Calello DP, Muller AA, Waterhouse MR, Goodkin MB, Weinberg GL, Henretig FM. Use of lipid emulsion in the resuscitation of a patient with prolonged cardiovascular collapse after overdose of bupropion and lamotrigine. Ann Emerg Med. 2008;51(4):412–5.CrossRefPubMedGoogle Scholar
  63. 63.
    Dreisbach AW, Greif RL, Lorenzo BJ, Reidenberg MM. Lipophilic beta-blockers inhibit rat skeletal muscle mitochondrial respiration. Pharmacology. 1993;47(5):295–9.CrossRefPubMedGoogle Scholar
  64. 64.
    Bania T, Chu J. Hemodynamic effect of intralipid in amitriptyline toxicity. Acad Emerg Med. 2006;13 Suppl 1:S117.Google Scholar
  65. 65.
    Perichon D, Turfus S, Gerostamoulos D, Graudins A. An assessment of the in vivo effects of intravenous lipid emulsion on blood drug concentration and haemodynamics following oro-gastric amitriptyline overdose. Clin Toxicol. 2013;51(4):208–15.CrossRefGoogle Scholar
  66. 66.
    Heinonen J, Litonius E, Backmann, Neuvonen P, Rosenberg P. Intravenous lipid emulsion entraps amitriptyline into plasma and can lower its brain concentration—an experimental intoxication study in pigs. Basic Clin Pharmacol Toxicol. 2013;113(3):193–200.CrossRefPubMedGoogle Scholar
  67. 67.
    Cave G, Harvey M, Willers J, Uncles D, Meek T, Picard J, Weinberg G. LIPAEMIC report: results of clinical use of intravenous lipid emulsion in drug toxicity reported to an online lipid registry. J Med Toxicol. 2014;10(2):133–42.CrossRefPubMedPubMedCentralGoogle Scholar
  68. 68.
    Haesendonck R, de Winter S, Vereist S, Sabbe M. Intravenous lipid emulsion for intentional chloroquine poisoning. Clin Toxicol. 2012;50(3):223.CrossRefGoogle Scholar
  69. 69.
    Bologa C, Lionte C, Coman A, Sorodoc L. Lipid emulsion therapy in cardiodepressive syndrome after diltiazem overdose – case report. Am J Emerg Med. 2013;31(7):1154.e3–4.CrossRefGoogle Scholar
  70. 70.
    Monteiro N, Silvestre J, Gonçalves-Pereira J, Tapadinhas C, Mendes V, Póvoa P. Severe diltiazem poisoning treated with hyperinsulinaemia-euglycaemia and lipid emulsion. Case Rep Crit Care. 2013;2013:138959.PubMedPubMedCentralGoogle Scholar
  71. 71.
    Wilson BJ, Cruikshank JS, Wiebe KL, Dias VC, Yarema MC. Intravenous lipid emulsion therapy for sustained release diltiazem poisoning: a case report. J Popul Ther Clin Pharmacol. 2012;19(2):e218–22.PubMedGoogle Scholar
  72. 72.
    Montiel V, Gougnard T, Hantson P. Diltiazem poisoning treated with hyperinsulinemic euglycemia therapy and intravenous lipid emulsion. Eur J Emerg Med. 2011;18(2):121–3.CrossRefPubMedGoogle Scholar
  73. 73.
    Boegevig S, Rothe A, Tfelt-Hansen J, Hoegberg LC. Successful reversal of life threatening cardiac effect following dosulepin overdose using intravenous lipid emulsion. Clin Toxicol (Phila). 2011;49(4):337–9.CrossRefGoogle Scholar
  74. 74.
    Castanares-Zapatero D, Wittebole X, Huberlant V, Morunglav M, Hantson P. Lipid emulsion as rescue therapy in lamotrigine overdose. J Emerg Med. 2012;42(1):48–51.CrossRefPubMedGoogle Scholar
  75. 75.
    Yurtlu BS, Hanci V, Gür A, Turan IO. Intravenous lipid infusion restores consciousness associated with olanzapine overdose. Anesth Analg. 2012;114(4):914–5.CrossRefPubMedGoogle Scholar
  76. 76.
    McAllister RK, Tutt CD, Colvin CS. Lipid 20% emulsion ameliorates the symptoms of olanzapine toxicity in a 4-year-old. Am J Emerg Med. 2012;30(6):1012.e1–2.CrossRefGoogle Scholar
  77. 77.
    Harvey M, Cave G, Shaw T. Effect of intravenous lipid emulsion and octreotide on enteric thiopentone absorption; a pilot study. Clin Toxicol. 2013;51(2):117–8.CrossRefGoogle Scholar
  78. 78.
    Franxman TJ, Al-Nabhan M, Cavallazzi RS, Speak AJ. Lipid emulsion therapy for verapamil overdose. Ann Intern Med. 2011;154(4):292.CrossRefPubMedGoogle Scholar
  79. 79.
    Liang CW, Diamond SJ, Hagg DS. Lipid rescue of massive verapamil overdose: a case report. J Med Case Rep. 2011;5:399.CrossRefPubMedPubMedCentralGoogle Scholar
  80. 80.
    French D, Armenian P, Ruan W, Wong A, Drasner K, Olson KR, Wu AH. Serum verapamil concentrations before and after intralipid therapy during treatment of an overdose. Clin Toxicol. 2011;49(4):340–4.CrossRefGoogle Scholar
  81. 81.
    Doulcourt BA, Aaron CK. Intravenous fat emulsion for refractory verapamil and atenolol induced shock: a human case report [abstract]. Clin Toxicol. 2008;46(2):119–20.Google Scholar
  82. 82.
    Finn SD, Uncles DR, Willers J, Sable N. Early treatment of an overdose with Intralipid. Anaesthesia. 2009;64(2):191–4.CrossRefPubMedGoogle Scholar
  83. 83.
    Harvey M, Cave G. Case report: successful lipid resuscitation in multi-drug overdose with predominant tricyclic antidepressant toxidrome. Int J Emerg Med. 2012;5(1):8.CrossRefPubMedPubMedCentralGoogle Scholar
  84. 84.
    Harchelroad PP, Palma A. Efficacy and safety of intravenous lipid therapy in a beta blocker overdose [abstract]. Clin Toxicol. 2008;46:634.Google Scholar
  85. 85.
    Jamaty C, Bailey B, Larocque A, Notebaert E, Sanogo K, Chauny J. Lipid emulsions in the treatment of acute poisoning: a systematic review of human and animal studies. Clin Toxicol. 2010;48(1):1–27.CrossRefGoogle Scholar
  86. 86.
    Wilson BJ, Cruikshank JS, Wiebe KL, Dias VC, Yarema MC. Intravenous lipid emulsion therapy for sustained release poisoning: a case report. J Popul Ther Clin Pharmcol. 2012;19(2):e218–22.Google Scholar
  87. 87.
    Geib AJ, Liebelt E, Manini AF, Toxicology Investigators’ Consortium (ToxIC). Clinical experience with intravenous lipid emulsion for drug-induced cardiovascular collapse. Med Toxicol. 2012;8(1):10–4.CrossRefGoogle Scholar
  88. 88.
    Picard J, Ward SC, Zumpe R, Meek T, Barlow J, Harrop-Griffiths W. Guidelines and the adoption of ‘lipid rescue’ therapy for local anaesthetic toxicity. Anaesthesia. 2009;64(2):22–5.Google Scholar
  89. 89.
    Jensen-Gadegaard P, Skjnnemand M, Damgaard-Jensen K, Gottschau B. Limited knowledge of lipid rescue therapy in local anaesthetic systemic toxicity. Dan Med Bull. 2011;58(1):A4226.PubMedGoogle Scholar
  90. 90.
    Neal JM, Bernards CM, Butterworth 4th JF, Di Gregorio G, Drasner K, Hejtmanek MR, Mulroy MF, Rosenquist RW, Weinberg GL. ASRA practice advisory on local anesthetic systemic toxicity. Reg Anesth Pain Med. 2010;35(2):152–61.CrossRefPubMedGoogle Scholar
  91. 91.
    The Association of Anaesthetists of Great Britain and Ireland. Management of severe local anaesthetic toxicity. Available at: www.aagbi.org/publications/guidelines/docs/latoxicity07. Accessed 16 Mar 2011.
  92. 92.
  93. 93.
    Rothschild L, Bern S, Oswald S, Weinberg G. Intravenous lipid emulsion in clinical toxicology. Scand J Trauma Resusc Emerg Med. 2010;18:51.CrossRefPubMedPubMedCentralGoogle Scholar
  94. 94.
    London National Patient Safety Agency. Patient Safety Alert 21, March 28, 2007. Safer practice with epidural injections and infusions. Available at: www.npsa.nhs.uk. Accessed 5 Feb 2011.

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  1. 1.TustinUSA

Personalised recommendations