Intralipid in acute caffeine intoxication: a case report

Abstract

Caffeine is arguably the most widely used stimulant drug in the world. Here we describe a suicide attempt involving caffeine overdose whereby the patient's severe intoxication was successfully treated with the prompt infusion of Intralipid. A 19-year-old man was found in an agitated state at home by the volunteer emergency team about 1 h after the intentional ingestion of 40 g of caffeine (tablets). His consciousness decreased rapidly, followed quickly by seizures, and electrocardiographic monitoring showed ventricular fibrillation. Advanced life support maneuvers were started immediately, with the patient defibrillated 10 times and administered 5 mg epinephrine in total and 300 + 150 mg of amiodarone (as well as lidocaine and magnesium sulfate). The cardiac rhythm eventually evolved to asystole, necessitating the intravenous injection of epinephrine to achieve the return of spontaneous circulation. However, critical hemodynamic instability persisted, with the patient's cardiac rhythm alternating between refractory irregular narrow complex tachycardia and wide complex tachycardia associated with hypotension. In an attempt to restore stability we administered three successive doses of Intralipid (120 + 250 + 100 mg), which successfully prevented a severe cardiovascular collapse due to a supra-lethal plasma caffeine level (>120 mg/L after lipid emulsion). The patient survived without any neurologic complications and was transferred to a psychiatric ward a few days later. The case emphasizes the efficacy of intravenous lipid emulsion in the resuscitation of patients from non-local anesthetic systemic toxicity. Intralipid appears to act initially as a vehicle that carries the stimulant drug away from heart and brain to less well-perfused organs (scavenging mechanism) and then, with a sufficient drop in the caffeine concentration, possibly as a tonic to the depressed heart.

The clinical toxicology of caffeine: A review and case study

“…In cases of overdose, often intentional but sometimes undetermined and unintentional, at least 5 g or more (i.e., often around 10 g but up to 50 g) have been ingested leading to fatalities particularly if the individuals are not treated in time or at all. However, doses up to 50 g have also been treated successfully otherwise [ 29 , 30 ]. Some have indicated that after a dose of around 1 g, toxic symptoms begin to manifest, a dose of 2 g requires hospitalization, while higher doses (e.g., typically 5 g or more) could be lethal [ 27 , 28 , 31 ].…”

“…The approach for management or treatment depends upon the particular patient’s symptoms, physical condition and the circumstances of their ingestion. For example, a mild overdose of 1 g with an individual displaying only mild side effects (e.g., restlessness, irritability, palpitations) might simply be monitored and perhaps administered a benzodiazepine whereas someone with a massive overdose might require numerous interventions [ 30 , 38 ]. Hemodialysis has also been effectively employed to reduce caffeine in plasma while decreasing morbidity in cases of intoxication [ 38 , 46 , 47 , 140 , 141 ].…”

“…Regarding decontamination, activated charcoal is preferred and is considered by some as “essential” as caffeine adsorbs well to the activated charcoal and is often employed if the patient presents within a reasonable time frame (i.e., 1–2 h) [ 30 , 38 , 48 , 145 ]. Whole bowel irrigation could hypothetically be employed in a case where extremely large amounts of sustained release caffeine have been ingested.…”

“…With respect to enhanced elimination the use of intralipid has apparently shown some success while hemodialysis alone or in combination with intralipid also seems successful [ 29 , 30 , 38 , 153 , 155 ]. The “intralipid” is a lipid emulsion that is administered intravenously and by acting as a “lipid sink” is able to remove caffeine (which displays some lipophilicity as an amphiphilic molecule) from tissues such as the brain and heart.…”

“…The “intralipid” is a lipid emulsion that is administered intravenously and by acting as a “lipid sink” is able to remove caffeine (which displays some lipophilicity as an amphiphilic molecule) from tissues such as the brain and heart. Although, it should be noted that some have taken issue with the use of the term, “sink” to describe the effects of intralipid, instead stating that its actions more accurately reflect a “shuttle” or a “scavenger” that moves drugs from more to less perfused organs [ 30 ]. These same authors have also pointed out that intralipid may cause unintended consequences by interfering with other medications which are administered as a result of caffeine intoxication such as esmolol and especially amiodarone (i.e., more lipophilic compounds which may themselves be “shuttled”), causing them to lose efficacy in the desired organs.…”