Evidence-based recommendations on the use of intravenous lipid emulsion therapy in poisoning

Abstract

Background: Although intravenous lipid emulsion (ILE) was first used to treat life-threatening local anesthetic (LA) toxicity, its use has expanded to include both non-local anesthetic (non-LA) poisoning and less severe manifestations of toxicity. A collaborative workgroup appraised the literature and provides evidence-based recommendations for the use of ILE in poisoning. Methods: Following a systematic review of the literature, data were summarized in four publications: LA and non-LA poisoning efficacy, adverse effects, and analytical interferences. Twenty-two toxins or toxin categories and three clinical situations were selected for voting. Voting statements were proposed using a predetermined format. A two-round modified Delphi method was used to reach consensus on the voting statements. Disagreement was quantified using RAND/UCLA Appropriateness Method. Results: For the management of cardiac arrest, we recommend using ILE with bupivacaine toxicity, while our recommendations are neutral regarding its use for all other toxins. For the management of life-threatening toxicity, (1) as first line therapy, we suggest not to use ILE with toxicity from amitriptyline, non-lipid soluble beta receptor antagonists, bupropion, calcium channel blockers, cocaine, diphenhydramine, lamotrigine, malathion but are neutral for other toxins, (2) as part of treatment modalities, we suggest using ILE in bupivacaine toxicity if other therapies fail, but are neutral for other toxins, (3) if other therapies fail, we recommend ILE for bupivacaine toxicity and we suggest using ILE for toxicity due to other LAs, amitriptyline, and bupropion, but our recommendations are neutral for all other toxins. In the treatment of non-life-threatening toxicity, recommendations are variable according to the balance of expected risks and benefits for each toxin. For LA-toxicity we suggest the use of Intralipid V R 20% as it is the formulation the most often reported. There is no evidence to support a recommendation for the best formulation of ILE for non-LAs. The voting panel is neutral regarding ILE dosing and infusion duration due to insufficient data for non-LAs. All recommendations were based on very low quality of evidence. Conclusion: Clinical recommendations regarding the use of ILE in poisoning were only possible in a small number of scenarios and were based mainly on very low quality of evidence, balance of expected risks and benefits, adverse effects, laboratory interferences as well as related costs and resources. The workgroup emphasizes that dose-finding and controlled studies reflecting human poisoning scenarios are required to advance knowledge of limitations, indications, adverse effects, effectiveness, and best regimen for ILE treatment.

Dramatic resuscitation with Intralipid in an epinephrine unresponsive cardiac arrest following overdose of amitriptyline and propranolol

“…The propofol infusion that this patient received delivered 10–40 mg/kg/hour of ILE for 16 hours. This is in the region of half the recommended dose of 50 mg/kg/hour (or 0.25 mL/kg/hour of 20% ILE) 5. Following the relapse and repeat bolus, an infusion of ILE was started and continued for 14 hours, after which time the patient remained stable.…”

Use of intravenous lipid therapy in a cat with carprofen overdose

“…Recommended dosing regimen is a 1.5 mL/kg bolus over 2‐3 minutes followed by a continuous rate infusion at a rate of 0.25 mL/kg/min over 1 hour. In human patients, it is suggested that ILE doses should be limited to a maximum of 10% of the total blood volume to avoid lipid overload and limit possible complications arising from increased triglyceride concentrations . The dose chosen in this patient was similar to the recommended dose listed in the position statement from the ACMT on ILE.…”

“…In human patients, it is suggested that ILE doses should be limited to a maximum of 10% of the total blood volume to avoid lipid overload and limit possible complications arising from increased triglyceride concentrations. 25 The dose chosen in this patient was similar to the recommended dose listed in the position statement from the ACMT on ILE. At the author's institution, repeat doses are given every 2-6 hours based upon the persistence of clinical signs, as well as the presence of lipemia within the serum.…”

Intralipid treatment for Alzheimer Disease

“…The workgroup emphasizes that dose-finding and controlled studies reflecting human poisoning scenarios are required to advance knowledge of limitations, indications, adverse effects, effectiveness, and best regimen for ILE treatment [49].…”