Intravenous Lipid Emulsion as Antidote (review)

October 2, 2009, 3:14 pm

★★★★☆

Intravenous Lipid Emulsion as Antidote Beyond Local Anesthetic Toxicity: A Systematic Review Cave G, Harvey M. Acad Emerg Med Sept. 2009;16:815-824.

BACKGROUND: Use of intravenous lipid emulsion (ILE) has gained acceptance among anesthesiologists for treatment of life-threatening local anesthetic toxicity.  In recent years,  animal studies and case reports have been published suggesting that ILE may also be effective in resuscitating cardiovascular collapse caused by lipophilic drugs.  METHODS:  A systematic review of the medical literature was carried out to answer the question: “Does the evidence support administration of ILE as antidote in lipophilic drug toxicity, beyond that of local anesthetics?”  Two reviewers selected and abstracted relevant literature. Disagreements were resolved by discussion and consensus. RESULTS: Fourteen relevant animal studies were found. In these models, ILE seemed to improve hemodynamic markers in toxicity induced by the lipophilic drugs clomipramine, verapamil, and propranolol, but not the hydrophilic drug atenolol.  Four human case reports were identified in which ILE seemed to benefit patients toxic from bupropion/lamotrigine, verapamil/atenolol, atenolol alone, and sertraline/quetiapine  Both the animal studies and the human case reports were affected by many limitations.  CONCLUSION: Available data, though limited,  suggest that ILE may be beneficial in treating life-threatening cardiotoxicity induced by highly lipophilic drugs.  Physicians managing these cases should follow established guidelines and consult at an early stage with a poison center. (66 references)

COMMENT:  This thoughtful review is well worth reading. Although ILE is not yet ready for routine use in the early stages of resuscitation, many toxicologists would recommend it as a last-ditch effort when a lipophilic drug has caused cardiovascular collapse not improved by standard treatment.  The strongest statement to this effect has been by Jeffrey Brent in a recent editorial: “It is fair to say that based on what we know so far, no patient dying of cadiotoxic drug poisoning should do so without a trial of lipid rescue;” (Crit Care Med 2009;37:1157-8) Interested readers may want to check out the Lipid Rescue website .


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