Confusion About Infusion: Rational Volume Limits for Intravenous Lipid Emulsion During Treatment of Oral Overdoses

Abstract

After the initial report of treatment of bupropion and lamotrigine overdose by intravenous lipid emulsion, 1 Sirianni A.J. Osterhoudt K.C. Calello D.P. et al. Use of lipid emulsion in the resuscitation of a patient with prolonged cardiovascular collapse after overdose of bupropion and lamotrigine. Ann Emerg Med. 2008; 51: 412-415 Abstract Full Text Full Text PDF PubMed Scopus (224) Google Scholar additional case reports have asserted the usefulness of lipid emulsion for enteral poisonings. 2 Cave G. Harvey M. Intravenous lipid emulsion as antidote: beyond local anesthetic toxicity: a systematic review. Acad Emerg Med. 2009; 16: 815-824 Crossref PubMed Scopus (159) Google Scholar , 3 Weinberg G. Lipid emulsion infusion resuscitation for local anesthetic and other drug overdose. Anesthesiology. 2012; 117: 180-187 Crossref PubMed Scopus (169) Google Scholar In accordance with these and other reports, the American College of Medical Toxicology offered interim guidelines on lipid resuscitation therapy 4 American College of Medical ToxicologyACMT position statement: interim guidance for the use of lipid resuscitation therapy. J Med Toxicol. 2011; 7: 81-82 Crossref PubMed Scopus (72) Google Scholar ; they recommended a bolus of 1.5 mL/kg, followed by an infusion of 0.25 mL/kg/min of intravenous lipid emulsion if toxicity persists. This recommendation was based on guidelines for treatment of local anesthetic toxicity, 5 Harrop-Griffiths W, Harbey M, Meek T, et al. AAGBI safety guideline: management of severse local anaesthetic toxicity. Association of Anaesthetists of Great Britain and Ireland. 2010. Google Scholar , 6 Neal J.M. Bernards C.M. Butterworth J.F. et al. ASRA practice advisory on local anesthetic systemic toxicity. Reg Anesth Pain Med. 2010; 35: 152-161 Crossref PubMed Scopus (413) Google Scholar in which absorption is quick and toxicity short lived. In contrast to local anesthetic toxicity, prolonged absorption during enteral overdose can result in extended toxicity, with a need for continuing medical support, including a protracted infusion of lipid emulsion. Guidelines for lipid resuscitation therapy in local anesthetic toxicity set an upper limit of 10 to 12 mL/kg during the first half hour, but because of the aforementioned nature of oral overdoses, the American College of Medical Toxicology did not provide a limit on total lipid infusion volume or duration of infusion. In the absence of limits, an increasing number of cases have reported the use of large volumes of lipid to treat oral overdose. However, until definitive studies can be conducted, there is a need for rational volume limits to prevent undisciplined use of intravenous lipid emulsion. Is a 1% Plasma Lipid Concentration Helpful to Treat the Intoxicated Patient?Annals of Emergency MedicineVol. 67Issue 3PreviewWe read with interest the article by Fettiplace et al.1 The authors propose a lipid emulsion infusion regimen to induce a 1% plasma triglyceride concentration to treat a prolonged absorption after oral overdose resulting in a lengthened increased plasma concentration. Full-Text PDF