Abstract
Use of intravenous fat emulsion (IFE) for the treatment of poisoned patients in extremis is increasing. Little literature exists describing failures and complications of IFE. We describe two cardiac arrests temporally associated with IFE. A 50-year-old woman presented after ingesting 80 total tablets of metoprolol 25 mg and bupropion 150 mg. Bradycardia and hypotension were refractory to calcium salts, catecholamines, and high dose insulin (HDI). With a pulse of 40/min and mean arterial pressure (MAP) of 30 mmHg, 100 mL of 20 % IFE was given; within 30 s, brady-asystolic arrest occurred. Pulses returned after 3 min of CPR. The patient died on hospital day 4 of multisystem organ failure (MSOF). A 53-year-old man presented after ingesting of 3,600 mg of diltiazem and 1,200 mg of propranolol. Bradycardia and hypotension were refractory to calcium salts, catecholamines, HDI, bicarbonate, and atropine. With a pulse of 30/min and a MAP of 40 mmHg, 150 mL of 20 % IFE was given; within 1 min, a brady-asystolic arrest occurred. Pulses returned after 6 min of CPR. The patient died on hospital day 7 of MSOF. Reported cases of IFE failures or potential complications are sparse. This report adds only case experience, not clarity. We report two cardiac arrests that were temporally associated with IFE.
References
Stellpflug SJ, Harris CR, Engebretsen KM, Cole JB, Holger JS (2010) Intentional overdose with cardiac arrest treated with intravenous fat emulsion and high dose insulin. Clin Toxicol 48:227–229
Stellpflug SJ, Fritzlar SJ, Cole JB, Engebretsen KM, Holger JS (2011) Cardiotoxic overdose treated with intravenous fat emulsion and high-dose insulin in the setting of hypertrophic cardiomyopathy. J Med Toxicol 7(2):151–153
Geib AJ, Liebelt E, Manini AF (2012) Toxicology Investigators’ Consortium (ToxIC). Clinical experience with intravenous lipid emulsion for drug-induced cardiovascular collapse. J Med Toxicol 8(1):10–14
Cave G, Harvey M (2009) Intravenous lipid emulsion as antidote beyond local anesthetic toxicity: a systematic review. Acad Emerg Med 16:815–824
Jamaty C, Bailey B et al (2010) Lipid emulsions in the treatment of acute poisoning: a systematic review of human and animal studies. Clin Toxicol 48:1–27
Sirianni AL, Osterhoudt KC, Calello DP, Muller AA, Waterhouse MR, Goodkin MB, Weinberg GL, Henretig FM (2008) Use of lipid emulsion in the resuscitation of a patient with prolonged cardiovascular collapse after overdose of bupropion and lamotrigine. Ann Emerg Med 51(4):412–415
Weinberg GL (2011) Intravenous lipid emulsion: why wait to save a life? Emerg Med Austral 23(2):113–115
ACMT Position Statement (2011) Interim guidance for the use of lipid resuscitation therapy. J Med Toxicol 7(1):81–82
Murray DB, Bateman DN (2011) Use of intravenous lipids. Not yet in all overdoses with failed resuscitation. BMJ : 342:d2265
Buckley NA, Dawson AH (2013) The intralipid genie is out of the bottle-spin and wishful thinking. Anaesth & Int Care 41(2):154–156
Bologa C, Lionte C, Coman A, Sorodoc L (2013) Lipid emulsion therapy in cardiodepressive syndrome after diltiazem overdose—case report. Am J Emerg Med. Jul 31(7): 1154.e3-4
Meehan TJ, Gummin DD, Kostic MA, Cattapan SE, Waghray R, Bryant SM (2009) Beta blocker toxicity successfully treated with intravenous fat emulsion: a case series. Clin Toxicol 47(7):735, abstract #163
Package Insert, Lopressor, Novartis Pharmaceuticals, March 2013
Minton NA, Goode AG, Henry JA (1987) The effect of a lipid suspension on amitriptyline disposition. Arch Toxicol 60:467–479
Cave G, Harvey M, Quinn P, Heys D (2013) Hypertonic sodium bicarbonate versus intravenous lipid emulsion in a rabbit model of intravenous flecainide toxicity: no difference, no sink. Clin Toxicol 51:394–397
Dunn C, Bird SB, Gaspari R (2012) Intralipid fat emulsion decreases respiratory failure in a rat model of parathion exposure. Acad Emerg Med 19(5):504–509
Perichon D, Turfus S, Gerostamoulos D, Graudins A (2013) An assessment of the in vivo effects of intravenous lipid emulsion on blood drug concentration and haemodynamics following oro-gastric amitriptyline overdose. Clin Toxicol 51:208–215
Perichon D, Turfus S, Graudins A (2013) Intravenous lipid emulsion does not improve hemodynamics or survival in a rodent model of oral verapamil poisoning. Clin Toxicol 51:277, abstract #53
Lange DB, Schwartz D, DaRoza G, Gair R (2012) Use of intravenous lipid emulsion to reverse central nervous system toxicity of an iatrogenic local anesthetic overdose in a patient on peritoneal dialysis. Ann Pharmacother Dec 46:e37
Niiya T, Litonius E, Petaja L, Neuvonen PJ, Rosenberg PH (2010) Intravenous lipid emulsion sequesters amiodarone in plasma and eliminates its hypotensive action in pigs. Ann Emerg Med 56(4):402–408
Carreiro S, Blum J, Jay G, Hack JB (2013) Intravenous lipid emulsion alters the hemodynamic response to epinephrine in a rat model. J Med Toxicol 9(3):220–225
Pentel P, Peterson CD (1980) Asystole complicating physostigmine treatment of tricyclic antidepressant overdose. Ann Emerg Med 9(Nov):588–590
Acknowledgment
This manuscript is written in US English and is 2,183 words in length. We have no commercial associations or conflicts of interest to report, and all authors made substantial contributions to the manuscript. No funding was used in production of the paper.
This project was presented at the 2011 North American Congress of Clinical Toxicology as a poster presentation. The reference is listed below:
Cole JB, Ellsworth H, Engebretsen KM, Stellpflug SJ. Failure of High Dose Insulin and Intravenous Fat Emulsion in 2 Patients With Poison-Induced Cardiogenic Shock. Clin Toxicol. 2011; 49(6): 537–8 (abstract #55)
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Cole, J.B., Stellpflug, S.J. & Engebretsen, K.M. Asystole Immediately Following Intravenous Fat Emulsion for Overdose. J. Med. Toxicol. 10, 307–310 (2014). https://doi.org/10.1007/s13181-014-0382-7
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DOI: https://doi.org/10.1007/s13181-014-0382-7