Lipid rescue of massive verapamil overdose: a case report

Liang, Conrad W; Diamond, Sarah; Hagg, Daniel

doi:10.1186/1752-1947-5-399

Cited by 49 publications

(31 citation statements)

References 26 publications

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“…These findings are in contrast to several animal and human studies that have demonstrated hemodynamic benefit with ILE administration in various drug classes, including calcium channel blockers, 19,23,24 amiodarone, 48 betablockers, 15 and tricyclic antidepressants. 20,26,28 The observational nature of our study, compared to the randomized, controlled design of many of the animal and human studies, is the most likely explanation for the difference.…”

Section: Discussioncontrasting

confidence: 99%

“…Unlike previously published human case reports, we enrolled consecutive patients that received ILE therapy and our results included patients that survived or died after the administration of ILE. The majority of published case reports on the utility of ILE in this setting have positive outcomes, [22][23][24][25][26][27][28][29][30][31][32] although negative case reports on the effect of ILE in overdose patients have also been published. 54,55 Limitations Our study has several limitations.…”

Section: Discussionmentioning

confidence: 99%

“…[15][16][17][18][19][20][21] To date, the human data on the effectiveness of ILE for cardiovascular toxins has been limited to small case series and reports, and review articles. [22][23][24][25][26][27][28][29][30][31][32] A recently published systematic review on the use of ILE in nonlocal anesthetic overdoses found current evidence to be heterogeneous and low quality. 33 Moreover, several publications have demonstrated adverse effects with its use, including interference with laboratory investigations such as the complete blood count (CBC) and electrolytes.…”

Section: Importancementioning

confidence: 99%

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A cohort study of unstable overdose patients treated with intravenous lipid emulsion therapy

Mithani

Dong

Wilmott

et al. 2016

CJEM

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Objectives: Intravenous lipid emulsion (ILE) has been used increasingly over the last decade for a range of drug overdoses. Although the use of ILE in local anesthetic toxicity (LAST) is well established, the hemodynamic effectiveness of ILE in non-LAST poisonings is still unclear. Thus, the primary objective of this study was to examine a cohort of poisoned patients in whom ILE was administered. Methods: Consecutive patients were identified by calls to a regional poison center from May 1, 2012 to May 30, 2014. Patients were enrolled if they ingested a drug, developed hemodynamic instability, failed conventional treatment, and received ILE therapy. Data were collected by medical record review. The primary outcome was the change in mean arterial pressure (MAP) in the first hour after ILE administration. Secondary outcomes included survival, length of stay, and the effect of drug class on patient outcome. Results: Thirty-six patients were enrolled. Agents ingested included calcium channel blockers and beta blockers (10/36, 27.8%), tricyclic antidepressants (5/36, 13.9%), bupropion (3/36, 8.3%), and antiepileptic agents (1/36, 2.8%). Seventeen patients (47.2%) ingested multiple agents. Twenty-five patients survived (69.0%). Overall, MAP increased by 13.79 mm Hg (95% CI 1.43-26.15); this did not meet our a priori definition of clinical significance. Conclusions: Our study did not find a clinically important improvement in MAP after ILE administration. Until future research is done to more definitively study its efficacy, ILE should remain a potential treatment option for hemodynamically unstable overdose patients only after conventional therapy has failed. RÉSUMÉObjectif: Le recours à l'émulsion lipidique intraveineuse (ELI) a connu une augmentation au cours de la dernière décennie dans le traitement de divers types de surdosage. Si l'utilisation de l'ELI dans le traitement de la toxicité des anesthésiques locaux est bien établie, l'efficacité hémodynamique de l'ELI dans les cas d'intoxication causée par d'autres substances que les anesthésiques locaux, elle, est incertaine. L'étude décrite ici avait donc pour objectif principal d'examiner une cohorte de patients intoxiqués, traités par une ELI. Méthode: Le repérage des patients consécutifs s'est fait à l'aide des appels reçus dans un centre antipoisons régional, du 1er mai 2012 au 30 mai 2014. Ont été retenus ceux qui avaient pris des médicaments, présentaient de l'instabilité hémodynamique, n'avaient pas réagi au traitement habituel et avaient été traités par une ELI. La collecte de données a été réalisée à l'aide des dossiers médicaux. Le principal critère d'évaluation consistait en la mesure des variations de la pression artérielle moyenne (PAM) au cours de la première heure suivant l'administration de l'ELI; les critères secondaires d'évaluation comprenaient la survie, la durée du séjour et l'effet de la classe de médicaments sur l'évolution de l'état de santé. Résultats: Ont participle à l'étude 36 patients. Différents types de médicaments avaient été ...

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Section: Discussioncontrasting

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Importancementioning

confidence: 99%

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A cohort study of unstable overdose patients treated with intravenous lipid emulsion therapy

Mithani

Dong

Wilmott

et al. 2016

CJEM

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“…Liang et al (11) concluded that intravenous lipid treatment was found to be effective in massive calcium channel blocker overdose, and its early start in the case of hemodynamic compromise was recommended.…”

Section: Discussionmentioning

confidence: 99%

Therapeutic effects of intralipid and medialipid emulsionsin a rat model of verapamil toxicity

Şahin¹,

Çelebi²,

Güngör³

et al. 2016

Turk J Med Sci

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Eighteen adult Sprague Dawley rats weighing between 300 and 400 g were divided into three groups. The rats were adapted to the environment by being kept at 20 Background/aim: Lipid emulsions are promising as a potential new therapy for severe verapamil overdose. Our purpose is to draw attention to the choice of solution by investigating the efficacy of intralipid 20% or medialipid 20% in verapamil overdose. Materials and methods:Eighteen adult Sprague Dawley rats were randomly divided into three groups: control (saline; Group C), intralipid 20% (Group I), and medialipid 20% (Group M). Rats were anesthetized with ketamine. Blood gas analysis, baseline heart rate (HR b ), and mean arterial pressure (MAP b ) were evaluated. Verapamil at 2.5 mg kg -1 min -1 was infused until the HR b and MAP b decreased by 50% and the times to HR 0 and MAP 0 were recorded. Treatment solutions of the groups were administered as 12.4 mL kg -1 in 5 min.Results: While HR did not show a difference, MAP showed statistically significant differences among the groups. Intralipid 20% was more efficient than the other two treatments at an early stage; however, as the administration time progressed, medialipid 20% also turned out to be more efficient than the control treatment. Conclusion:Our findings indicate that in a toxicity model of rats produced with verapamil, intralipid 20% and medialipid 20% solutions partially eliminate cardiac-depressant effects and increase the survival rate.

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“…The majority of these cases involve verapamil or diltiazem. Nifedipine was cited in two publications in which both patients survived [7,24]. There are three published toxic cases of another dihydropyridine, amlodipine, where ILE was included in therapy; two survived [7,16].…”

Section: Discussionmentioning

confidence: 99%

Pilot Trial of Intravenous Lipid Emulsion Treatment for Severe Nifedipine-Induced Shock

et al. 2016

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Animal studies and human case reports show promise in using lipid rescue to treat refractory calcium channel antagonist toxicity. However, the majority of research and clinical experience has focused on non-dihydropyridine agents. Thus, we sought to investigate the value of lipid emulsion (ILE) therapy for dihydropyridine-induced shock. This IACUC-approved study utilized seven swine that were sedated with alpha-chloralose, mechanically ventilated, and instrumented for drug delivery and hemodynamic measures. After stabilization and basal measures, nifedipine (0.01875 mg/kg/ min) was infused until imminent cardiac arrest (seizure, end tidal CO2 < 10 mmHg, bradydysrhythmia, or pulseless electrical activity). Animals then received a 7 mL/kg bolus of 20% lipid emulsion via central catheter. Lipid circulation was visually confirmed by the presence of fat in peripheral arterial blood. Hemodynamics were continuously monitored until 10 min after lipid bolus. Surviving animals were euthanized. Pre-and post-lipid treatment parameters were analyzed using the Wilxocon signed rank test (p <0.05 significant). Nifedipine toxicity was characterized by vasodilatory hypotension, impaired vascular contractility, and tachycardia with terminal bradycardia. The median time to imminent cardiac arrest from start of nifedipine infusion was 218 min. Lipid treatment did not improve hemodynamics or restore circulation in any animal. There was no benefit from lipid rescue in this model of nifedipine toxicity. Further study of ILE for dihydropyridine toxicity is warranted but initial animal model results are not promising.

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Lipid rescue of massive verapamil overdose: a case report

Cited by 49 publications

References 26 publications

A cohort study of unstable overdose patients treated with intravenous lipid emulsion therapy

A cohort study of unstable overdose patients treated with intravenous lipid emulsion therapy

Therapeutic effects of intralipid and medialipid emulsionsin a rat model of verapamil toxicity

Pilot Trial of Intravenous Lipid Emulsion Treatment for Severe Nifedipine-Induced Shock

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