Tox Cards: Intralipid Rescue
Author: Jenna Otter, MD (Emergency Medicine resident at Temple University Hospital) // Edited by: Cynthia Santos, MD (Assistant Professor Emergency Medicine, Toxicology, Rutgers University Hospital), Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital), and Brit Long, MD (@long_brit)
A 17 year old girl presents to the emergency room after overdose with reported 60 bupropion at an unknown time period prior to being found. She was somnolent and seizing on EMS arrival, and they promptly intubated the patient and brought her to your emergency department. In the resuscitation bay she loses pulses, and CPR is initiated.
- Intralipid was researched by Dr. Weinberg, an anesthesiologist, who found its use by chance in local anesthetic toxicity experiments with rats in the 1990s.1
- His research team found that lipids increase resistance to local anesthetic toxicity, which was the opposite of his initial hypothesis.
- Subsequent series of experiments in rats and dogs found that those given lipid were more likely to be successfully resuscitated in local anesthetic toxicity.
- In 2006, the first 2 case reports2,3 of patients with local anesthetic toxicity successfully treated with intralipid were published. These cases involved the inadvertent instillation of bupivacaine and ropivicaine, respectively, intravenously during orthopedic surgeries, resulting in asystolic cardiac arrest. In both cases, the patients achieved ROSC after intralipid was administered in the code.
Intralipid is purported to work via 2 mechanisms: as a “lipid sink” and by providing a source of cardiac fuel.4
- It binds lipophilic drug and carries it to the liver and muscles (i.e. away from the brain) where it is taken up intracellularly.
- The heart uses triglycerides as major fuel source and positive inotropic effects have been demonstrated in vivo.
Both mechanisms continue to be questioned and are the subject of ongoing research.
Does intralipid work for ORAL lipophilic medication overdose?
The kinetics of metabolism change with oral overdose compared with intravenous. There have been numerous case reports suggesting it is effective in oral overdose of some medications.
Case reports of the positive effect of intralipid administration have been shown in the following oral medication overdoses:
How to administer it:
If 20% Intralipid:
- 1.5 cc/kg initial bolus (typically will be about 100cc)
- Followed by 0.25 cc/kg/min x 10 min after achieving ROSC
- Repeat bolus 1 or 2 times if persistent cardiovascular collapse
- Can double infusion rate to 0.5 cc/kg/min if persistently low BP
- Not to exceed 10-12 cc/kg over the first 30 min (in 70kg person 700-840 cc total in 30 min)15
- The adverse effects reported with high dose intralipid treatment include pancreatitis, direct hepatic toxicity, thrombophlebitis, and Lipid Overload Syndrome which is characterized by sudden onset of:
- Headache, fever, jaundice, hepatosplenomegaly
- Respiratory distress
- Spontaneous hemorrhage
- Anemia, leukopenia, thrombocytopenia, coagulopathy
- These adverse effects are associated with high doses and fast rates of infusion of Intralipid infusion.16
- Intralipid circulating in the blood can cause spuriously elevated hemoglobin and platelet count and may affect results of electrolyte lab tests.18, 19
- Intralipid may clog machines that rely on small caliber tubing and membranes such as ECMO circuits and dialysis machines.
Pearls for using intralipid:
- Less muscle mass = possibly less effective therapy because the medication bound to intralipid molecules gets sequestered in muscle4, 18
- It has been observed that smaller-sized patients have higher risk of overdose from local anesthetic toxicity20
- Fettiplace et al demonstrated a transient elevation in drug tissue concentration seen in skeletal muscle4, so less muscle = less storage space for the lipid-bound drug.
- GOOD BASIC LIFE SUPPORT IS IMPERATIVE
- Intralipid is just part of the treatment; high quality CPR is important to continue during resuscitation and will move the intralipid-bound drug into the muscles and liver.
This post is sponsored by www.ERdocFinder.com, a supporter of FOAM and medical education, who with their sponsorship are making FOAM material more accessible to emergency physicians around the world.
- Weinberg et al. Pretreatment or resuscitation with a lipid infusion shifts the dose-response to bupivacaine induced asystole in rats. Anesthesiology 1998;88:1071-5.
- Rosenblatt et al. Successful use of a 20% lipid emulsion to resuscitate a patient after a presumed bupivacaine related cardiac arrest. Anesth 2006;105:217-8.
- Litz et al. Successful resuscitation of a patient with ropivicaine-induced asystole arter axillary plexus block using lipid infusion. Anesth 2006;61:8oo-801.
- Fettiplace et al. Multimodal contributions to detoxification of acute pharmacotoxicity by a triglyceride micro-emulsion. J Control Release. 2015 Jan 28; 198: 62-70. doi:10.1016/j.jconrel.2014.11.018.
- Sirianni et al. Use of Lipid Emulsion in the resuscitation of a patient with prolonged cardiovascular collapse after overdose of bupropion and lamotrigine. Annals Em Med. 2008 April; vol 51.4:412-415.
- Blaber MS, et al. “Lipid Rescue” for Tricyclic Antidepressant Cardiotoxicity. Emerg Med. 2012 Jan 11. [Epub ahead of print]
- Argawala R, et al. Prolonged use of intravenous lipid emulsion in a severe tricyclic antidepressant overdose. J Med Toxicol. 2014 Jun:10(2):210-4.
- Jakkala-Saibaba R, et al. Treatment of cocaine overdose with lipid emulsion. Anesthesia. 2011 Dec;66(12):1168-70.
- Young AC, Velez LI, Kleinschmidt KC. Intravenous fat emulsion therapy for intentional sustained-release verapamil overdose. Resuscitation. 2009. May;80(5):591-3. Epub 2009 Mar 17.
- McAllister RK, Tutt CD, Colvin CS. Lipid 20% emulsion ameliorates the symptoms of olanzapine toxicity in a 4-year-old. Am J Emerg Med. 2011 Jun 2 [Epub ahead of print]
- Finn SD, et al. Early treatment of a quetiapine and sertraline overdosewith Intralipid Anesthesia. 2009 Feb;64(2):191-4.
- Montiel V, Gougnard T, Hantson P. Diltiazem poisoning treated with hyperinsulinemic euglycemia therapy and intravenous lipid emulsion. Eur J Emerg Med. 2011 Apr;18(2):121-3.
- Thompson AM, et al. Intravenous lipid emulsion and high-dose insulin as adjunctive therapy for propranolol toxicity in a pediatric patient. Am J Health Syst Pharm. 2016 Jun 15;73(12):880-5.
- Muraro L, et al. Intralipid in acute caffeine intoxication: a case report. J Anesth. 2016 Oct;30(5):895-9.
- Hayes BD, et al. Systematic review of clinical adverse events reported after acute intravenous lipid emulsion administration. Clin Toxicol (Phila). 2016 Jun;54(5):365-404.
- Hiller DB, et al. Safety of high volume lipid emulsion infusion: a first approximation of LD50 in rats. Reg Anesth Pain Med. 2010 Mar-Apr;35(2):140-4.
- Matt Zuckerman. Episode 25 Lipid Rescue Part 2. ToxNow Podcast. Feb 27, 2015. http://toxnow.org/archives/359#.WUV5NmgrLic.
- Grunbaum AM, et al. Review of the effect of intravenous lipid emulsion on laboratory analyses. Clin Toxicol (Phila). 2016;54(2):92-102.
- Barrington MJ, Kluger R. Ultrasound guidance reduces the risk of local anesthetic systemic toxicity following peripheral nerve blockade. Reg Anesth Pain Med. 2013;38:289-97.