LIVING OFF THE FAT OF THE LAND: LIPID INFUSION FOR THE UNKOWN OVERDOSE

Abstract

SESSION TITLE: Fellows Critical Care Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Lipid infusions are incorporated in the treatment of a variety of medication overdoses. We have found no study to date examining the use of lipids for unknown overdoses or ingestions that present lacking the signs and symptoms of a definitive toxidrome CASE PRESENTATION: A 30-year-old male with a history of drug abuse, ADHD, Crohn disease, and diverticulitis, presented to the ED from a drug and alcohol rehabilitation center with encephalopathy and incontinence. He admitted to taking a “Party Box” containing unknown hallucinogens and random pills. Urine drug screen was positive for benzodiazepine, cocaine, cannabinoid, opiate, and barbiturates. Labs showed a WBC of 16.7, chloride of 109, and bicarbonate of 21. He received IV fluids, lorazepam, and haloperidol before admission. On day 2 a rapid response was initiated for unresponsiveness. The patient had bradycardia, closed eyes, and involuntary lower extremity movement. EKG showed junctional bradycardia with rate of 38 bpm. A 1 Liter 20% IV lipid emulsion was administered over 2 hours. After 1 hour the bradycardia resolved. At 2 hours involuntary movements ceased. He was intubated for airway protection despite some improvement in mentation. By day 3 he was hemodynamically stable, awake, calm, and was extubated. DISCUSSION: For over 20 years, lipid infusions have been administered in animal models to reverse bupivacaine related cardiovascular collapse resulting in return of spontaneous circulation. Human case reports show efficacy treating lamotrigine, bupropion, calcium channel blocker, beta blocker, antipsychotic, tricyclic antidepressant, and local anesthesia systemic toxicity. Large scale human studies are absent. Although reported in the popular press for decades, parties where individuals trade various drugs—prescription or illicit—the incidence of this activity is unclear. Regulatory agencies and medical societies do not this behavior. PubMed searches for “pill party”, “fruit-salad party”, and “pharm party” returned no relevant results CONCLUSIONS: Our patient reported taking an unknown quantity of unspecified pills with subsequent cardiovascular and neurologic disturbances. Polypharmacy was manifest in our patient and drawing on the clinical signs and symptoms iabove, there was concern that this presentation could not be explained by drugs of abuse alone. To explain his bradycardia, we suspect that he may have ingested an AV nodal blocking agent. There is established benefit in using lipid infusions for specific overdoses. Data are inadequate in the routine use of lipids for unknown overdoses. The use of lipids for unknown overdoses that are associated with hemodynamic anomalies and neurological disorders merits further study, as it appears to carry a favorable risk-benefit potentia Reference #1: Weinberg GL. Lipid emulsion infusion: resuscitation for local anesthetic and other drug overdose. Anesthesiology. 2012;117(1):180–187 Reference #2: Lashari BH, Minalyan A, Khan W, Naglak M, Ward W. The Use of High-dose Insulin Infusion and Lipid Emulsion Therapy in Concurrent Beta-blocker and Calcium Channel Blocker Overdose. Cureus. 2018;10(11):e3534. Published 2018 Nov 1. doi:10.7759/cureus.3534 Reference #3: Hopkins LE, Sunkersing J, Jacques A. Too many pills to swallow: A case of a mixed overdose. J Intensive Care Soc. 2017;18(3):247–250. doi:10.1177/1751143717693860 DISCLOSURES: No relevant relationships by Firth Bowden, source=Web Response No relevant relationships by Edward Gray, source=Web Response No relevant relationships by Ali Nabavi, source=Web Response