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Hoffman RS, Gosselin S, Villeneuve E, Hayes BD, Hoegberg LCG, Smolinske SC. Comment on Antidotal use of lipid emulsion – the pendulum swings. Clin Toxicol (Phila) 2020; 58:1355-1356. [DOI: 10.1080/15563650.2020.1761025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Robert S. Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Sophie Gosselin
- Department of Medicine & Emergency Medicine, McGill University Health Centre, Royal Victoria Hospital, Montreal, QC, Canada
- Hôpital Charles-Lemoyne, Greenfield Park, QC, Canada
| | - Eric Villeneuve
- Department of Pharmacy, McGill University Health Centre, Montreal, QC, Canada
| | - Bryan D. Hayes
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA
| | - Lotte C. G. Hoegberg
- Department of Anesthesiology, and The Danish Poisons Information Centre, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Susan C. Smolinske
- New Mexico Poison & Drug Information Center, University of New Mexico, Albuquerque, NM, USA
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Hermes-Laufer J, Meyer M, Rudiger A, Henze J, Enselmann K, Kupferschmidt H, Müller D, Herzog A, Bettex D, Keller DI, Krüger B, Engeler J. Extracorporeal life support as bridge to recovery in yew poisoning: case reports and literature review. ESC Heart Fail 2020; 8:705-709. [PMID: 33232574 PMCID: PMC7835583 DOI: 10.1002/ehf2.12828] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 04/28/2020] [Accepted: 05/21/2020] [Indexed: 12/21/2022] Open
Abstract
Aims This short communication aims to review the treatment of cardiogenic shock in patients with yew poisoning based on two case reports from our institution, focusing on the use of extracorporeal life support (ECLS). Methods and results We report two cases of Taxus baccata poisoning treated with ECLS at our institution and review the literature based on a search in PubMed and Google Scholar on the topic of yew poisoning and ECLS. All cases were combined for analysis of demographics, ECLS therapy, and outcome. Case 1: A 35‐year‐old woman developed polymorphic ventricular tachycardia followed by cardiovascular arrest 5 h after orally ingesting a handful of yew needles. Successful resuscitation required ECLS for 72 h due to ongoing cardiac arrhythmias and cardiogenic shock. The patient left the hospital without neurological sequelae after 10 days. Case 2: A 30‐year‐old woman developed refractory cardiac arrhythmias and circulatory arrest. Resuscitation included ECLS for 71 h. T. baccata needles found by gastroscopy confirmed the diagnosis. The patient had no neurologic deficits and was transferred to psychiatry after 11 days. Review of the literature: Nine case reports were found and analysed along with our two cases. Five out of the 11 (45%) patients were female. Median (range) age was 28 (19–46) years. T. baccata needles were ingested with a suicidal intention in all patients. Median (range) duration of ECLS was 70 h (24–120 h). Eight (73%) patients had full neurological recovery. Conclusions Yew poisoning is a differential diagnosis in young psychiatric patients presenting with polymorphic ventricular tachycardia and cardiogenic shock. A characteristic cardiac contraction pattern in echocardiography may present a diagnostic clue. The early use of ECLS is a valuable bridge to recovery in most of these patients.
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Affiliation(s)
- Julia Hermes-Laufer
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland.,Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Martin Meyer
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Alain Rudiger
- Institute of Anaesthesiology, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Julian Henze
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Kai Enselmann
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Hugo Kupferschmidt
- National Poisons Information Centre, Tox Info Suisse, Associated Institute of the University of Zurich, Zurich, Switzerland
| | - Daniel Müller
- Institute of Clinical Chemistry, University Hospital Zurich, Zurich, Switzerland
| | - Aline Herzog
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Dominique Bettex
- Institute of Anaesthesiology, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Bernard Krüger
- Institute of Anaesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Judith Engeler
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
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Abstract
This article examines, using an organ-systems based approach, rapid diagnosis, resuscitation, and critical care management of the crashing poisoned patient in the emergency department. The topics discussed in this article include seizures and status epilepticus, respiratory failure, cardiovascular collapse and mechanical circulatory support, antidotes and drug-specific therapies, acute liver failure, and extracorporeal toxin removal.
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Affiliation(s)
- Aaron Skolnik
- Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA.
| | - Jessica Monas
- Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
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Chandrasekaran VP, Parthasarathy A, Muruga B, Senthamil, Tharanesh. Theophylline toxicity: Successful management of a patient with distributive shock secondary to drug overdose. Am J Emerg Med 2020; 38:2491.e1-2491.e2. [PMID: 32826106 DOI: 10.1016/j.ajem.2020.05.112] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 05/28/2020] [Accepted: 05/31/2020] [Indexed: 10/24/2022] Open
Abstract
Presenting a case of acute theophylline and salbutamol overdose with distributive shock. Twenty one years old lady presented with history of consumption of 3 gram of theophylline and 40 mg of salbutamol. On admission she had altered sensorium with the systolic blood pressure of 60 mmHg, unrecordable diastolic blood pressure and heart rate of 147/min. Investigations revealed severe metabolic acidosis, hypokalemia, hypocalcemia which was managed by intravenous fluids, vasopressors, infusion of injection calcium gluconate and injection potassium chloride. As her hemodynamic status did not improve, she has been initiated on 1.5 mL/kg of lipid emulsion as bolus and then 0.5 mL/kg/h as infusion. Her hemodynamic status improved gradually and she was discharged in 24 h. Lipid emulsion had been used in local anesthetics and many tablet overdoses. In this patient timely administration of lipid emulsion resulted in early recovery of shock.
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Affiliation(s)
- V P Chandrasekaran
- Vinayaka Mission Kirupananda Variyar Medical College, Salem, Tamil Nadu, India.
| | | | | | - Senthamil
- Sri Gokulam hospital, Salem, Tamilnadu, India
| | - Tharanesh
- Sri Gokulam hospital, Salem, Tamilnadu, India
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55
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Fan W, Yu Z, Peng H, He H, Lu Y, Qi J, Dong X, Zhao W, Wu W. Effect of particle size on the pharmacokinetics and biodistribution of parenteral nanoemulsions. Int J Pharm 2020; 586:119551. [DOI: 10.1016/j.ijpharm.2020.119551] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/18/2020] [Accepted: 06/13/2020] [Indexed: 12/16/2022]
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Stellpflug SJ, Bond ME, Henry KD, Engebretsen KM, Zantek ND. Intravenous Fat Emulsion Does Not Significantly Alter Clotting Markers in Dabigatran-Treated Blood. Indian J Hematol Blood Transfus 2020; 37:101-107. [PMID: 33707842 DOI: 10.1007/s12288-020-01309-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 06/15/2020] [Indexed: 10/24/2022] Open
Abstract
Dabigatran etexilate is an oral direct thrombin (Factor IIa) inhibitor approved for patients with atrial fibrillation and for management of risk of deep vein thrombosis and pulmonary embolism. Dabigatran offers advantages over treatment with warfarin, including limited laboratory monitoring. It is equivalent in prevention of stroke and deep vein thrombosis with essentially equivalent complication rates. In contrast to warfarin, reversal of the anticoagulation is less well established. Idarucizumab is available for reversal, however supporting research is mixed; the agent also happens to be quite expensive making availability difficult. Hemodialysis has been proposed as a method of reversal, but this is difficult in patients with life threatening hemorrhage, and is not available at many hospitals. Intravenous fat emulsion (IFE) has been used for treatment of overdose of lipophilic drugs. Most toxicologists only recommend IFE for patients in extremis after ingestion of a lipid soluble substance. Dabigatran is lipid soluble, although the pro-drug more so than the active metabolite. The authors sought to see if dabigatran-induced coagulopathy of human in vitro blood samples could be reversed with IFE. Blood samples were spiked with dabigatran or dabigatran plus IFE. Values for Ecarin clot time (ECT-primary outcome), PT/INR, and aPTT, were compared across both study arms. A total of 18 healthy volunteers were included in our study. There were no significant differences in the ECT, PT/INR, and aPTT between the dabigatran arm and the dabigatran plus IFE arm. Based on these methods, IFE does not reverse dabigatran-induced coagulopathy.
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Affiliation(s)
- Samuel J Stellpflug
- Department of Emergency Medicine, Regions Hospital, 640 Jackson Street, Saint Paul, MN 55101 USA
| | - Michael E Bond
- Department of Emergency Medicine, Regions Hospital, 640 Jackson Street, Saint Paul, MN 55101 USA
| | - Keith D Henry
- Department of Emergency Medicine, Regions Hospital, 640 Jackson Street, Saint Paul, MN 55101 USA
| | - Kristin M Engebretsen
- Department of Emergency Medicine, Regions Hospital, 640 Jackson Street, Saint Paul, MN 55101 USA
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN USA
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Romans CW, Day TK, Smith JJ. Oxidative red blood cell damage associated with propofol and intravenous lipid emulsion therapy in a dog treated for 5-fluorouracil toxicosis. J Vet Emerg Crit Care (San Antonio) 2020; 30:481-486. [PMID: 32407575 DOI: 10.1111/vec.12958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 10/31/2018] [Accepted: 11/12/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe the first documented case of oxidant-induced anemia in a dog associated with propofol and IV lipid emulsion (IVLE) treatment for 5-fluorouracil (5-FU) toxicosis. CASE SUMMARY A 2-year-old male intact mixed breed dog was presented for evaluation after ingestion of 5% 5-FU cream. Refractory reactive seizures rapidly developed, and treatment with benzodiazepines, propofol, levetiracetam, and IVLE was initiated. The dog was euthanized due to development of marked oxidant-induced anemia. NEW INFORMATION PROVIDED This report documents the first instance of oxidant-induced anemia in the dog, associated with propofol and IVLE infusion therapy prescribed for treatment of 5-FU toxicosis.
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Affiliation(s)
- Cory W Romans
- Veterinary Emergency Service, Veterinary Specialty Center, Middleton, Wisconsin
| | - Thomas K Day
- Veterinary Emergency Service, Veterinary Specialty Center, Middleton, Wisconsin
| | - Joshua J Smith
- Veterinary Emergency Service, Veterinary Specialty Center, Middleton, Wisconsin
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58
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The Use of Extracorporeal Life Support in a Patient Suffering from Venlafaxine Intoxication. A Case Report. ACTA ACUST UNITED AC 2020; 6:120-123. [PMID: 32426519 PMCID: PMC7216027 DOI: 10.2478/jccm-2020-0014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 02/26/2020] [Indexed: 02/06/2023]
Abstract
Very few reports exist on serious cardiac complications associated with intake of serotonin-noradrenaline reuptake inhibitors. This paper describes and discusses the case of a patient who ingested a dose of 17.5 g venlafaxine. She developed a full serotonergic syndrome leading to multi-organ failure, including refractory cardiovascular shock, which was managed by early implantation of an extracorporeal life support (ECLS) system as a bridging strategy. This intervention was successful and resulted in full recovery of the patient.
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Rotella JA, Greene SL, Koutsogiannis Z, Graudins A, Hung Leang Y, Kuan K, Baxter H, Bourke E, Wong A. Treatment for beta-blocker poisoning: a systematic review. Clin Toxicol (Phila) 2020; 58:943-983. [DOI: 10.1080/15563650.2020.1752918] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Joe-Anthony Rotella
- Victorian Poisons Information Centre, Austin Health, Victoria, Australia
- Department of Emergency Medicine, Northern Health, Epping, Victoria
| | - Shaun L. Greene
- Victorian Poisons Information Centre, Austin Health, Victoria, Australia
- Department of Medicine, Faculty of Medicine, University of Melbourne, Victoria, Australia
| | - Zeff Koutsogiannis
- Victorian Poisons Information Centre, Austin Health, Victoria, Australia
- Department of Emergency Medicine, Northern Health, Epping, Victoria
| | - Andis Graudins
- Victorian Poisons Information Centre, Austin Health, Victoria, Australia
- Monash Toxicology and Emergency Department, Monash Health, Victoria, Australia
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia
| | - Yit Hung Leang
- Victorian Poisons Information Centre, Austin Health, Victoria, Australia
| | - Kelvin Kuan
- Department of Emergency Medicine, Changi General Hospital, Singapore, Singapore
| | - Helen Baxter
- Austin Health Library, Austin Health, Victoria, Australia
| | - Elyssia Bourke
- Victorian Poisons Information Centre, Austin Health, Victoria, Australia
| | - Anselm Wong
- Victorian Poisons Information Centre, Austin Health, Victoria, Australia
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia
- Department of Medicine and Radiology, Centre for Integrated Critical Care, Melbourne Medical School, University of Melbourne, Victoria, Australia
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60
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Abstract
Intravenous lipid emulsion (ILE) is a widely accepted treatment for local anesthetic systemic toxicity (LAST), particularly resulting from bupivacaine. The past decade has seen interest in antidotal use of ILE for other poisonings wax and wane. Numerous anecdotes have raised enthusiasm while more rigorous reviews have cast skepticism. The truth may lie between these two poles.We illustrate the recent trends in published reports on ILE. We highlight the gaps in our knowledge and suggest sources of data that may clarify how useful ILE may be for poisonings other than LAST. We offer the example of bupropion, which is hazardous in overdose and which has a Log P (octanol-water partition coefficient) similar to that of bupivacaine.Current data sources including the AAPCC National Poison Data System (NPDS), the ACMT Toxic Investigators Consortium (ToxIC), and a voluntary online registry (www.lipidrescue.org) each give an incomplete view of the problem. We propose analysis of newer NPDS data, which will include ILE as a treatment field code beginning with the 2019 data, and a structured, prospective registry of antidotal use of ILE for poisonings other than LAST.
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Affiliation(s)
- Michael E Mullins
- Section of Medical Toxicology; Department of Emergency Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Donna L Seger
- Division of Clinical Pharmacology, Department of Medicine/Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
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61
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Arumugam S, Contino V, Kolli S. Local Anesthetic Systemic Toxicity (LAST) – a Review and Update. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00381-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Gürünlüoğlu K, Gül M, Koçbıyık A, Koç A, Üremiş N, Gürünlüoğlu S, Bağ HG, Karaca Y, Taşçi A, Gül S, Üremiş MM, Durmuş K, Demircan M. Investigation of the cardiotoxic effects of parenteral nutrition in rabbits. J Pediatr Surg 2020; 55:465-474. [PMID: 31109733 DOI: 10.1016/j.jpedsurg.2019.04.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/11/2019] [Accepted: 04/16/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Parenteral nutrition (PN) is used for the intravenous delivery of nutrients to patients who cannot take food orally. However, it is not clear whether PN also negatively impacts cardiac tissue. The present empirical study investigated the cardiac effects of PN in rabbits. METHODS The effects of PN were examined in three groups of rabbits: animals in the PN + fasting group (n = 14) had been fully fasted before receiving a full PN dose via an intravenous central catheter; the PN + oral feeding group (n = 14) received half of the daily calorie requirement as a half dose of PN via an intravenous central catheter; the third group consisted of controls (n = 14) with full enteral feeding and full enteral fluid intake with no PN and no central venous catheter. At the end of the 10-day study period, the rabbits were subjected to echocardiographic examination and euthanized. Blood and tissue samples were obtained from all groups. DNA was isolated from nucleated blood cells. Tissue samples were examined by both light and electron microscopy, relative telomere length was determined from DNA, and blood samples were analyzed biochemically. RESULTS At the end of the study, there were no statistically significant differences in weight change between the three groups. Echocardiography revealed minimally impaired diastolic function in the PN + fasting group compared to the other groups. Biochemical and histopathological analyses, relative telomere length determination, and electron micrographs showed significant cardiac damage in the PN + fasting group but not in the PN + oral feeding group or the control group. The blood biochemical analyses showed hyperglycemia and a low insulin level in the PN + fasting group but not in the other two groups. CONCLUSIONS A combination of PN and fasting may damage the cardiac muscle cells of rabbits via a mechanism involving hyperglycemia and oxidative stress. Additional enteral feeding may protect against the destructive effects of PN on cardiac tissue.
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Affiliation(s)
- Kubilay Gürünlüoğlu
- Department of Pediatric Surgery, İnönü University, Faculty of Medicine, Malatya
| | - Mehmet Gül
- Department of Pediatric Surgery, İnönü University, Faculty of Medicine, Malatya; Department of Histology and Embryolog, İnönü University, Faculty of Medicine, Malatya
| | - Alper Koçbıyık
- Istanbul Kanuni Sultan Suleyman Education and Research Hospital, Pathology Laboratory, Istanbul, Turkey
| | - Ahmet Koç
- Department of Medical Genetics, İnönü University, Faculty of Medicine, Malatya
| | - Nuray Üremiş
- Department of Medical Biochemistry, İnönü University, Faculty of Medicine, Malatya
| | - Semra Gürünlüoğlu
- Malatya, Education and Research Hospital, Pathology Laboratory, Malatya, Turkey
| | - Harika Gözükara Bağ
- Department of Biostatistics and Medical Informatics, İnönü University, Faculty of Medicine, Malatya
| | - Yücel Karaca
- Department of Cardiology, İnönü University, Faculty of Medicine, Malatya
| | - Aytaç Taşçi
- Department of Pediatric Surgery, İnönü University, Faculty of Medicine, Malatya
| | - Semir Gül
- Istanbul Kanuni Sultan Suleyman Education and Research Hospital, Pathology Laboratory, Istanbul, Turkey
| | | | - Kübra Durmuş
- Department of Medical Genetics, İnönü University, Faculty of Medicine, Malatya
| | - Mehmet Demircan
- Department of Pediatric Surgery, İnönü University, Faculty of Medicine, Malatya.
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Bupropion Overdose Complicated by Cardiogenic Shock Requiring Vasopressor Support and Lipid Emulsion Therapy. J Emerg Med 2020; 58:e47-e50. [PMID: 31911020 DOI: 10.1016/j.jemermed.2019.11.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 11/08/2019] [Accepted: 11/23/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Bupropion overdose is a commonly encountered presentation in the emergency department (ED). While the majority of cases resolve with supportive care, serious adverse effects, including seizures, cardiogenic shock, and death, can occur. Intravenous lipid emulsion (ILE) therapy has been utilized for a multitude of poisonings with varying levels of success. Although a number of cases suggest the value of ILE therapy in cases of bupropion overdose, more recent data propose that its role may be overstated. CASE REPORT A young woman presented to the ED with altered mental status complicated by seizure after bupropion overdose. She subsequently developed cardiogenic shock requiring vasopressor support. Bedside echocardiogram revealed a decreased left ventricular ejection fraction (LVEF). She received ILE therapy with significant improvement in both hemodynamic status and LVEF by bedside ultrasound. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although the majority of patients presenting with bupropion overdose improve with supportive care, life-threatening sequelae are possible. ILE therapy has shown promise in a variety of different overdose situations, although the evidence in cases of bupropion poisoning has been varied, and it has traditionally been utilized as a last-line rescue modality. Based on hemodynamic parameters and bedside ultrasound, this case suggests that early initiation of ILE therapy should be considered in these cases, as the potential benefits likely outweigh the theoretical risks.
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Ornillo C, Harbord N. Fundaments of Toxicology-Approach to the Poisoned Patient. Adv Chronic Kidney Dis 2020; 27:5-10. [PMID: 32147001 DOI: 10.1053/j.ackd.2019.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 12/05/2019] [Indexed: 12/17/2022]
Abstract
Management of the poisoned patient begins with supportive care, assessment of organ function and dysfunction, and consideration of known or suspected poisons. The possibility of multiple ingestions should be considered with intentional exposures or suicide attempts. Enteric decontamination involves treatment to prevent the absorption of toxins from the gastrointestinal system and includes the use of activated charcoal. Poisoned patients may benefit from the use if antidotes are available, or enhanced elimination as with salicylate ion trapping during urinary alkalinization. The use of intravenous lipid therapy is of clinical benefit in poisoning from bupivacaine, amitriptyline, and bupropion. Hemodialysis is the most inexpensive, widely available, and most commonly used method of extracorporeal drug removal in the treatment of poisoning. Chelators with different chemical properties can bind toxic metals, providing an essential mechanism for detoxification, and may be used in combination with extracorporeal therapies such as DFO with HD for aluminum or iron, and DMSA or DMPS with HD to treat arsenic or mercury intoxication. The use of displacers with hemodialysis can be considered to augment clearance of protein-bound toxins.
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A case of local anesthetic toxicity that wasn't: lipid rescue from self-administered benzodiazepine overdose in labor. Int J Obstet Anesth 2019; 42:109-111. [PMID: 32044218 DOI: 10.1016/j.ijoa.2019.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 12/01/2019] [Accepted: 12/15/2019] [Indexed: 11/24/2022]
Abstract
A 32-year-old G2P1 woman presented for induction of labor at term. Her past medical history included polysubstance use disorder and methadone maintenance, scant prenatal care, morbid obesity, and intimate partner violence. Her induction was progressing smoothly until the acute onset of altered mental status near to the time of delivery, several minutes after a clinician-administered epidural local anesthetic bolus for significant pain. Given concern about local anesthetic systemic toxicity, lipid emulsion was administered and resulted in an immediate and drastic clinical response. The epidural infusion bag and pump system were evaluated and found to be correct and there was no clinical suspicion of an intravascular epidural catheter. The woman remained stable and was transferred to the postpartum unit, where she experienced a similar episode of altered mental status approximately 12 h postpartum. This episode self-resolved and she was managed conservatively. Shortly after this event, it was discovered that the patient had been self-administering benzodiazepines throughout the course of her labor, in addition to her hospital staff-administered medications. Presumably, her intrapartum altered mental status was a result of self-administered benzodiazepine that was then "rescued" with lipid emulsion. This case illustrates the potential for lipid emulsion as a reversal agent for medications other than local anesthetics.
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66
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Gura KM, Calkins KL, Puder M. Use of Fish Oil Intravenous Lipid Emulsions as Monotherapy in the Pediatric Intestinal Failure Patient: Beyond the Package Insert. Nutr Clin Pract 2019; 35:108-118. [PMID: 31549454 DOI: 10.1002/ncp.10413] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
In July 2018, an intravenous lipid emulsion (ILE) composed of 100% fish oil (Omegaven, Fresenius Kabi, Bad Homburg, Germany) received Food and Drug Administration (FDA) approval as a source of fatty acids and calories for infants and children with parenteral nutrition-associated cholestasis. This soy-free fat source is rich in ω-3 fatty acids and α-tocopherol and contains few phytosterols. In comparison to conventional soybean oil ILE, this emulsion appears to be less hepatotoxic. The purpose of this paper is to guide the practitioner on the use of this alternative fat source in clinical practice and augment the material contained in the current package insert. This paper addresses various topics including the identification of which patients would benefit from fish oil ILE, dosing, administration, monitoring, potential adverse effects, and management strategies for fish oil ILE.
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Affiliation(s)
- Kathleen M Gura
- Department of Pharmacy and the Division of Gastroenterology, Hepatology & Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Kara L Calkins
- Department of Pediatrics, Division of Neonatology, David Geffen School of Medicine and UCLA, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Mark Puder
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery and the Vascular Biology Program, Boston Children's Hospital, Boston, Massachusetts, USA
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Higgins AM, LaPoint RJ, Vest MT. Intravenous lipid emulsion agglutination to Central venous catheter after treatment for intentional polysubstance overdose. Clin Toxicol (Phila) 2019; 58:428-429. [PMID: 31416360 DOI: 10.1080/15563650.2019.1650937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Amber M Higgins
- Departments of Emergency Medicine and Family Medicine, Christiana Care Health Care System, Delaware, DE, USA
| | - Randi J LaPoint
- Department of Pathology and Laboratory Medicine, Christiana Care Health Care System, Delaware, DE, USA
| | - Michael T Vest
- Section of Critical Care Medicine, Department of Medicine, Christiana Care Health Care System, Delaware, DE, USA
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Procopio GL, Patel R, Gupta A. Clinical Pearls in Medical Toxicology: Updates Ranging From Decontamination to Elimination. J Pharm Pract 2019; 32:339-346. [PMID: 31291840 DOI: 10.1177/0897190019854565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Such as any field of medicine, it is imperative to stay current with the latest advances and treatment modalities in toxicology. With the absence of rigorous randomized controlled trials, many updated guidelines are created by expert consensus and/or case reports and clinical experience. Over the past 10 years, there have been several changes in the management of drug overdoses in light of new data available. Although this is not a comprehensive review of all available antidotes, this article will focus on several important interventions including the use of gastrointestinal decontamination, hyperinsulinemic-euglycemic therapy, methylene blue, intravenous lipid emulsion, hemodialysis, and extracorporeal membrane oxygenation.
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Affiliation(s)
- Gabrielle L Procopio
- 1 Department of Pharmacy, Hackensack University Medical Center, Hackensack, NJ, USA.,2 Department of Emergency Medicine at the Hackensack Meridian School of Medicine, Seton Hall University, Nutley, NJ, USA
| | - Ruchi Patel
- 1 Department of Pharmacy, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Amit Gupta
- 1 Department of Pharmacy, Hackensack University Medical Center, Hackensack, NJ, USA.,3 Department of Emergency Medicine, Hackensack University Medical Center, Hackensack, NJ, USA
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Elke G, Hartl WH, Kreymann KG, Adolph M, Felbinger TW, Graf T, de Heer G, Heller AR, Kampa U, Mayer K, Muhl E, Niemann B, Rümelin A, Steiner S, Stoppe C, Weimann A, Bischoff SC. Clinical Nutrition in Critical Care Medicine - Guideline of the German Society for Nutritional Medicine (DGEM). Clin Nutr ESPEN 2019; 33:220-275. [PMID: 31451265 DOI: 10.1016/j.clnesp.2019.05.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Enteral and parenteral nutrition of adult critically ill patients varies in terms of the route of nutrient delivery, the amount and composition of macro- and micronutrients, and the choice of specific, immune-modulating substrates. Variations of clinical nutrition may affect clinical outcomes. The present guideline provides clinicians with updated consensus-based recommendations for clinical nutrition in adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. METHODS The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. According to the S2k-guideline classification, no systematic review of the available evidence was required to make recommendations, which, therefore, do not state evidence- or recommendation grades. Nevertheless, we considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of other societies. The liability of each recommendation was described linguistically. Each recommendation was finally validated and consented through a Delphi process. RESULTS In the introduction the guideline describes a) the pathophysiological consequences of critical illness possibly affecting metabolism and nutrition of critically ill patients, b) potential definitions for different disease phases during the course of illness, and c) methodological shortcomings of clinical trials on nutrition. Then, we make 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in critically ill patients. Among others, recommendations include the assessment of nutrition status, the indication for clinical nutrition, the timing and route of nutrient delivery, and the amount and composition of substrates (macro- and micronutrients); furthermore, we discuss distinctive aspects of nutrition therapy in obese critically ill patients and those treated with extracorporeal support devices. CONCLUSION The current guideline provides clinicians with up-to-date recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. The period of validity of the guideline is approximately fixed at five years (2018-2023).
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Affiliation(s)
- Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus 12, 24105, Kiel, Germany.
| | - Wolfgang H Hartl
- Department of Surgery, University School of Medicine, Grosshadern Campus, Ludwig-Maximilian University, Marchioninistr. 15, 81377 Munich, Germany.
| | | | - Michael Adolph
- University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany.
| | - Thomas W Felbinger
- Department of Anesthesiology, Critical Care and Pain Medicine, Neuperlach and Harlaching Medical Center, The Munich Municipal Hospitals Ltd, Oskar-Maria-Graf-Ring 51, 81737, Munich, Germany.
| | - Tobias Graf
- Medical Clinic II, University Heart Center Lübeck, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Geraldine de Heer
- Center for Anesthesiology and Intensive Care Medicine, Clinic for Intensive Care Medicine, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Axel R Heller
- Clinic for Anesthesiology and Surgical Intensive Care Medicine, University of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany.
| | - Ulrich Kampa
- Clinic for Anesthesiology, Lutheran Hospital Hattingen, Bredenscheider Strasse 54, 45525, Hattingen, Germany.
| | - Konstantin Mayer
- Department of Internal Medicine, Justus-Liebig University Giessen, University of Giessen and Marburg Lung Center, Klinikstr. 36, 35392, Gießen, Germany.
| | - Elke Muhl
- Eichhörnchenweg 7, 23627, Gross Grönau, Germany.
| | - Bernd Niemann
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Rudolf-Buchheim-Str. 7, 35392, Gießen, Germany.
| | - Andreas Rümelin
- Clinic for Anesthesia and Surgical Intensive Care Medicine, HELIOS St. Elisabeth Hospital Bad Kissingen, Kissinger Straße 150, 97688, Bad Kissingen, Germany.
| | - Stephan Steiner
- Department of Cardiology, Pneumology and Intensive Care Medicine, St Vincenz Hospital Limburg, Auf dem Schafsberg, 65549, Limburg, Germany.
| | - Christian Stoppe
- Department of Intensive Care Medicine and Intermediate Care, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, Klinikum St. Georg, Delitzscher Straße 141, 04129, Leipzig, Germany.
| | - Stephan C Bischoff
- Department for Nutritional Medicine, University of Hohenheim, Fruwirthstr. 12, 70599, Stuttgart, Germany.
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Botha H, Jennings SH, Press SA, Istvan SA. Suspected Acute Respiratory Distress Syndrome Associated With the Use of Intravenous Lipid Emulsion Therapy in a Dog: A Case Report. Front Vet Sci 2019; 6:225. [PMID: 31338370 PMCID: PMC6629765 DOI: 10.3389/fvets.2019.00225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 06/20/2019] [Indexed: 12/23/2022] Open
Abstract
A 12-year-old male neutered Bichon Frise presented to the Emergency Department for stupor and bradycardia after ingestion of chocolate covered 450 mg (90 mg/kg) tetrahydrocannabinol. The patient was hospitalized for supportive care, IV fluid therapy and monitoring in the intensive care unit. During hospitalization the patient became comatose and bradypneic. Treatment with intravenous lipid emulsion (ILE) therapy was instituted to accelerate toxin elimination, reduce the risk of complications related to progressive obtundation and shorten hospitalization time. Five hours after infusion, the patient developed severe respiratory distress and was ultimately euthanized. Post-mortem histologic evaluation of lung revealed severe pulmonary edema consistent with acute respiratory distress syndrome. There are infrequent reports of adverse effects associated with ILE therapy for toxicosis in veterinary medicine despite reports of complications such as acute respiratory distress syndrome in human literature. The purpose of this report is to describe the potential for a severe adverse event after treatment of a toxicosis with ILE therapy.
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Affiliation(s)
- Heike Botha
- ECC Resident at The Veterinary Specialty Hospital, San Diego, CA, United States
| | - Samuel Hollis Jennings
- MSpVM, DACVP Diagnostic Pathologist, Ethos Diagnostic Science, San Diego, CA, United States
| | - Saya A Press
- DACVECC at The Veterinary Specialty Hospital, San Diego, CA, United States
| | - Stephanie A Istvan
- DACVECC at The Veterinary Specialty Hospital, San Diego, CA, United States
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Stoppe C, Nesterova E, Elke G. Nutritional support in patients with extracorporeal life support and ventricular assist devices. Curr Opin Crit Care 2019; 24:269-276. [PMID: 29847341 DOI: 10.1097/mcc.0000000000000512] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW Extracorporeal life support (ECLS) including venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VAD) provide mechanical pulmonary and circulatory support, respectively, in patients with acute pulmonary or cardiovascular failure. This review discusses recently published data regarding specific topics of nutritional support in patients with ECLS and VAD. RECENT FINDINGS ECLS may aggravate loss of endogenous and exogenous micronutrients and macronutrients. Observational studies have shown that enteral nutrition is feasible and most commonly used in patients with ECLS. Indirect calorimetry may be feasible for measuring energy expenditure during ECLS. Specific tools are available to assess malnutrition or nutrition risk in patients with VAD but require further validation in the perioperative setting. If parenteral nutrition is indicated, the use of intravenous lipid emulsions may be associated with membrane oxygenator dysfunction of the ECLS device or increased infectious risk in patients with VAD. SUMMARY Despite the exponential use of ECLS and VAD over the last decade, the role of nutrition on clinical outcome in this patient population remains an important but yet underinvestigated field.
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Affiliation(s)
- Christian Stoppe
- Department of Intensive Care Medicine, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Ekaterina Nesterova
- Department of Anesthesiology and Intensive Care Medicine, National Pirogov Surgical Medical Center, Moscow, Russia
| | - Gunnar Elke
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Haidar I, Harding IH, Bowater IC, McDowall AW. Physical Characterization of Halofantrine-Encapsulated Fat Nanoemulsions. J Pharm Sci 2019; 108:2153-2161. [PMID: 30703385 DOI: 10.1016/j.xphs.2019.01.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 12/06/2018] [Accepted: 01/18/2019] [Indexed: 02/07/2023]
Abstract
We report the colloidal characterization of halofantrine (Hf)-laden soybean oil fat emulsions. Hf increased the zeta potential, at all pH values, of the fat emulsions. Concomitant with this, the isoelectric point (i.e.p.) of the emulsion increased to higher pH values. The emulsion was destabilized by a small amount of Hf; interestingly, however, this was ameliorated by increasing the amount of Hf. The particle size and polydispersity of the fat emulsion reflected this with a small Hf concentration resulting in a significant increase in both particle size and polydispersity, but less so as the Hf concentration was increased. Emulsions lost stability as the pH approached the i.e.p. and this effect was greatest for the small Hf concentration emulsions. Cryogenic transmission electron microscopy showed the presence of beading or string-like behavior leading to gross distortions of the spherical shape for highly unstable emulsions. We conclude that to maintain good stability for Hf-laden soybean oil emulsions, the pH of the emulsion should be kept away from its i.e.p, and also that the drug concentration should be maintained at a relatively high value.
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Affiliation(s)
- Iman Haidar
- Department of Chemistry and Biochemistry, Faculty of Science I, Lebanese University, Hadath, Beirut, Lebanon
| | - Ian H Harding
- Department of Chemistry and Biotechnology, Faculty of Science, Engineering and Technology, Swinburne University of Technology, Melbourne, Australia.
| | - Ian C Bowater
- Department of Chemistry and Biotechnology, Faculty of Science, Engineering and Technology, Swinburne University of Technology, Melbourne, Australia
| | - Alasdair W McDowall
- Howard Hughes Medical Institute, California Institute of Technology, Pasadena, California 91125; University of Queensland, Brisbane, Queensland 4072, Australia
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Zeballos JL, Strichartz GR. Tuning Up the Life Saver. Anesth Analg 2019; 128:199-201. [DOI: 10.1213/ane.0000000000003863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Petersen KM, Bøgevig S, Petersen TS, Jensen TB, Dalhoff KP, Henriksen T, Poulsen HE, Christensen MB. Hemodynamic Effects of Intravenous, High-Dose Lipid Emulsion With and Without Metoprolol Infusion in Healthy Volunteers: A Randomized Clinical Trial. Clin Pharmacol Ther 2018; 105:1009-1017. [PMID: 30412277 DOI: 10.1002/cpt.1281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 10/15/2018] [Indexed: 11/09/2022]
Abstract
In a double-blinded, randomized, crossover trial, we investigated the hemodynamic effects of high-dose intravenous lipid emulsion (ILE) with/without metoprolol. Ten healthy volunteers each completed 4 trial days (placebo + ILE; metoprolol + placebo; metoprolol + ILE; placebo + placebo) in random order. Metoprolol was administered as an initial bolus (10 mg), followed by an infusion (50 mg) from 5 to 30 minutes. ILE was administered as a bolus at 12.5 minutes (2.5 mL/kg), followed by a 15-minute infusion (0.25 mL/kg per minute). On metoprolol + ILE days (compared with metoprolol + placebo) after 120 minutes, mean heart rates were significantly higher (difference, 5.5 beats per minute (bpm); 95% confidence interval (CI), 3.0-8.1 bpm; P < 0.001), and average relative cardiac output was higher (difference, 10 percentage points; 95% CI, 5-15 percentage points; P < 0.001). The hemodynamic effect of ILE developed gradually. ILE had no effect on plasma metoprolol or major adverse events. In conclusion, high-dose ILE has relatively marginal and delayed hemodynamic effects that may have limited clinical relevance in the short-term clinical toxicological setting.
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Affiliation(s)
- Kasper Meidahl Petersen
- Department and laboratory of Clinical Pharmacology, Bispebjerg, and Frederiksberg University Hospital, Copenhagen, Denmark
| | - Søren Bøgevig
- Department and laboratory of Clinical Pharmacology, Bispebjerg, and Frederiksberg University Hospital, Copenhagen, Denmark
| | - Tonny Studsgaard Petersen
- Department and laboratory of Clinical Pharmacology, Bispebjerg, and Frederiksberg University Hospital, Copenhagen, Denmark
| | - Thomas Bo Jensen
- Department and laboratory of Clinical Pharmacology, Bispebjerg, and Frederiksberg University Hospital, Copenhagen, Denmark
| | - Kim Peder Dalhoff
- Department and laboratory of Clinical Pharmacology, Bispebjerg, and Frederiksberg University Hospital, Copenhagen, Denmark
| | - Trine Henriksen
- Department and laboratory of Clinical Pharmacology, Bispebjerg, and Frederiksberg University Hospital, Copenhagen, Denmark
| | - Henrik Enghusen Poulsen
- Department and laboratory of Clinical Pharmacology, Bispebjerg, and Frederiksberg University Hospital, Copenhagen, Denmark
| | - Mikkel Bring Christensen
- Department and laboratory of Clinical Pharmacology, Bispebjerg, and Frederiksberg University Hospital, Copenhagen, Denmark
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Smolinske S, Hoffman RS, Villeneuve E, Hoegberg LCG, Gosselin S. Utilization of lipid emulsion therapy in fatal overdose cases: an observational study. Clin Toxicol (Phila) 2018; 57:197-202. [DOI: 10.1080/15563650.2018.1504954] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Susan Smolinske
- New Mexico Poison and Drug Information Center, University of New Mexico, Albuquerque, NM, USA
| | - Robert S. Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, NY, USA
| | - Eric Villeneuve
- Department of Pharmacy, McGill University Health Centre, Montreal, Canada
| | - Lotte C. G. Hoegberg
- Department of Anesthesiology and the Danish Poisons Information Centre, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Sophie Gosselin
- Centre Antipoison du Québec, McGill University Health Centre, Hôpital Charles Lemoyne, Quebec, Canada
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Low dose Intralipid resuscitation improves survival compared to ClinOleic in propranolol overdose in rats. PLoS One 2018; 13:e0202871. [PMID: 30161186 PMCID: PMC6116996 DOI: 10.1371/journal.pone.0202871] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 08/10/2018] [Indexed: 12/15/2022] Open
Abstract
Background Medication overdose is a prevalent issue and despite mixed reports of efficacy, the use of intravenous lipid emulsions, notably Intralipid®, for the management of toxicity from lipid-soluble drugs is becoming increasingly prevalent. Whether alternative lipid emulsion formulations have similar efficacy for resuscitation compared to Intralipid is not known. Here, we compared the efficacy of Intralipid and ClinOleic® for resuscitation following overdose with the lipid-soluble beta-adrenergic antagonist propranolol. Methods Male Sprague-Dawley rats (age 3–4 months) were anesthetized with isoflurane and instrumented for direct hemodynamic assessments. In Study One, rats (n = 22) were pre-treated with Intralipid 20% (n = 12) or ClinOleic 20% (n = 10) to determine whether the hemodynamic effects of propranolol could be prevented. In Study Two, rats were randomly assigned to Intralipid 20% (1, 2, or 3 mL/kg IV, n = 21) or ClinOleic 20% (1, 2, or 3 mL/kg IV, n = 20) resuscitation groups following propranolol overdose (15 mg/kg IV). In Study Three the effect of Intralipid 20% (1 mL/kg IV, n = 3) and ClinOleic 20% (1 mL/kg IV, n = 3) in the absence of propranolol was investigated. The primary endpoint in all studies was survival time (up to a maximum of 120 minutes), and secondary endpoints were time to achieve 50%, 75%, and 90% of baseline hemodynamic parameters. Results In Study One, pre-treatment with Intralipid prior to propranolol administration resulted in prolonged survival compared to pre-treatment with ClinOleic at low doses (1 mL/kg; P = 0.002), but provided no benefit at higher doses (3 mL/kg; P = 0.95). In Study Two, Intralipid conferred a survival advantage over ClinOleic, with 18/21 rats surviving 120 minutes in the Intralipid group and only 4/20 survivors in the ClinOleic group (P<0.0001). Median survival times (with interquartile ranges) for rats treated with Intralipid, and ClinOleic, and saline were 120 (80.5–120) min, 21.5 (3.25–74.5) min, and 1 (0.25–2.5) min respectively (P<0.001). Only 3/21 rats in the Intralipid group survived less than 30 minutes, whereas 12/20 ClinOleic treated rats had survival times of less than 30 minutes. The number of rats achieving 75%, and 90% of baseline mean arterial pressure was also greater in the Intralipid group (P<0.05 for both values). Treatment in Study Three did not alter survival times. Conclusions Low-dose Intralipid (1, 2, or 3 mL/kg IV) confers a survival advantage up to 120 minutes post-propranolol overdose (the end-point of the experiment) and better hemodynamic recovery compared to ClinOleic (1, 2, or 3 mL/kg IV) in rats with propranolol overdose. As health care centres choose alternate intravenous lipid emulsions, limited availability of Intralipid could impact efficacy and success of overdose treatment for lipid-soluble drugs.
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Toxicology of Avermectins and Milbemycins (Macrocyclic Lactones) and the Role of P-Glycoprotein in Dogs and Cats. Vet Clin North Am Small Anim Pract 2018; 48:991-1012. [PMID: 30139545 DOI: 10.1016/j.cvsm.2018.07.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Overdoses of macrocyclic lactones in dogs and cats can result in such signs as tremors, ataxia, seizures, coma, and blindness. Dogs with the ABCB1-1Δ gene defect are predisposed to macrocyclic lactone toxicosis at lower dosages than dogs without the defect. Intravenous lipid emulsion therapy has been suggested for treatment of macrocyclic lactone toxicosis but evidence of efficacy is limited. Initial decontamination and supportive care remain the mainstays of therapy for macrocyclic lactone toxicosis.
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Gwaltney-Brant S, Meadows I. Intravenous Lipid Emulsions in Veterinary Clinical Toxicology. Vet Clin North Am Small Anim Pract 2018; 48:933-942. [PMID: 30115370 DOI: 10.1016/j.cvsm.2018.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Use of intravenous lipid emulsion (ILE) as an antidote for severe cardiotoxicity and neurotoxicity has expanded in the veterinary world in the past decade. Despite advances in understanding of potential mechanisms of action of antidotal ILE, knowledge gaps remain in efficacy, appropriate dosing rates for various toxicants, and potential adverse reactions. Use of ILE in management of toxicoses of veterinary patients should be considered investigational, and should not be first-line treatment of most toxicoses, especially where established treatment protocols have good likelihood of positive outcomes. Use of ILE in veterinary toxicology cases requires judicious assessment of individual cases and proper informed consent of clients.
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Affiliation(s)
| | - Irina Meadows
- ASPCA Animal Poison Control Center, 1717 South Philo Road, Suite 36, Urbana, IL 61802, USA
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Abstract
The use of intravenous lipid emulsion (ILE) therapy as antidote in systemic toxicity of certain agents has gained widespread support. There are increasing data suggesting use of ILE in reversing from local anesthetic-induced systemic toxicity severe, life-threatening cardiotoxicity, although findings are contradictory. Efficiency of ILE was demonstrated in animal studies in the treatment of severe impairment of cardiac functions, via a mechanism for trapping lipophilic drugs in an expanded plasma lipid compartment (“lipid sink”). In patients with hemodynamic compromise and/or cardiovascular collapse due to lipid-soluble agents, ILE may be considered for resuscitation in the acute setting by emergency physicians. The most common adverse effects from standard ILE include hypertriglyceridemia, fat embolism, infection, vein irritation, pancreatitis, electrolyte disturbances and allergic reactions. The advantages of ILE include an apparent wide margin of safety, relatively low cost, long shelf-life, and ease of administration.
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Affiliation(s)
- Ozgur Karcioglu
- Department of Emergency Medicine, University of Health Sciences, Istanbul Education and Research Hospital, Istanbul, Turkey. E-mail.
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Abstract
PURPOSE OF REVIEW Enthusiasm for regional anesthesia has been driven by multimodal benefits to patient outcomes. Despite widespread awareness and improved techniques (including the increasing use of ultrasound guidance for block placement), intravascular sequestration and the attendant risk of local anesthetic systemic toxicity (LAST) remains. Intravenous lipid emulsion (ILE) for the treatment of LAST has been endorsed by anesthetic regulatory societies on the basis of animal study and human case report data. The accumulated mass of reporting now permits objective interrogation of published literature. RECENT FINDINGS Although incompletely elucidated the mechanism of action for ILE in LAST seemingly involves beneficial effects on initial drug distribution (i.e., pharmacokinetic effects) and positive cardiotonic and vasoactive effects (i.e., pharmacokinetic effects) acting in concert. Recent systematic review by collaborating international toxicologic societies have provided reserved endorsement for ILE in bupivacaine-induced toxicity, weak support for ILE use in toxicity from other local anesthetics, and largely neutral recommendation for all other drug poisonings. Work since publication of these recommendations has concluded that there is a positive effect on survival for ILE when animal models of LAST are meta-analyzed and evidence of a positive pharmacokinetic effect for lipid in human models of LAST. SUMMARY Lipid emulsion remains first-line therapy (in conjunction with standard resuscitative measures) in LAST. Increasing conjecture as to the clinical efficacy of ILE in LAST, however, calls for high-quality human data to refine clinical recommendations.
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Khasawneh W, Bani Hani S. Intravenous Lipid Emulsion Overdose in Infancy: A Case Report and Overview of Opportunities, Challenges and Prevention. DRUG SAFETY - CASE REPORTS 2018; 5:13. [PMID: 29556886 PMCID: PMC5859004 DOI: 10.1007/s40800-018-0079-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Medication errors remain among the major problems seen in hospitals. Such errors can relate to the prescription, dispensation, or administration of drugs. Human factors account for most of these mistakes, but other factors such as infusion pump programming defects should always be considered. Worldwide, medication errors have been reported to affect 2-30% of patients, depending on the institution. Intravenous lipid emulsion (ILE) infusion is frequently used as part of total parenteral nutrition in patients of all ages with feeding and gastrointestinal issues. ILE overdose has been previously reported, with variable clinical outcomes. We report a case of accidental ILE (Intralipid) overdose in a 3-month-old male infant who fully recovered after single-volume blood exchange transfusion. We also review reported cases and summarize potential solutions for ILE overdose. Our review indicates that ILE infusion is a high-risk medication, and opportunities for errors remain even in the best hospital set-ups. Attention should be directed towards proper prescription, dosing, dispensation, and administration. Most of the cases indicate the safety breach was at the nursing drug-administration level, with improper pump use or programming, together with other fluid infusion rate switching, being the main possible defects. Strategies targeting the areas of weakness in the drug-delivery pathway are needed. Special attention should be paid towards nursing duties and working hours. In addition, nursing staff should receive frequent education sessions and should be required to pass competency modules regularly. An error-prevention plan should be established and implemented. This plan needs full collaboration between physicians, pharmacists, and nursing staff.
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Affiliation(s)
- Wasim Khasawneh
- Department of Pediatrics, Jordan University of Science and Technology, PO Box 3030, Irbid, 22110, Jordan.
| | - Salar Bani Hani
- Department of Pediatrics, Jordan University of Science and Technology, PO Box 3030, Irbid, 22110, Jordan
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Baker KA, Austin EB, Wang GS. Antidotes: Familiar Friends and New Approaches for the Treatment of Select Pediatric Toxicological Exposures. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2017. [DOI: 10.1016/j.cpem.2017.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Haidar I, Harding IH, Bowater IC, Eldridge DS, Charman WN. The role of lecithin degradation on the pH dependent stability of halofantrine encapsulated fat nano-emulsions. Int J Pharm 2017; 528:524-535. [DOI: 10.1016/j.ijpharm.2017.06.040] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 06/06/2017] [Accepted: 06/12/2017] [Indexed: 11/24/2022]
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Chhabra N, DesLauriers C, Wahl M, Bryant SM. Management of severe bupropion poisoning with intravenous lipid emulsion. Clin Toxicol (Phila) 2017. [PMID: 28644682 DOI: 10.1080/15563650.2017.1337909] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Bupropion toxicity is characterized by central nervous system and cardiovascular toxicity. Intravenous lipid emulsion (ILE) has been suggested as a treatment by some for the treatment of refractory bupropion toxicity. This recommendation is based largely on published case reports and cases presented at scientific meetings. The objective of this study is to characterize the outcomes of patients with suspected bupropion toxicity in which ILE was administered and the indications for its use. METHODS Electronic records from one regional poison center were searched for intentional bupropion ingestions from 1 January 2009 through 31 December 2015. Cases in which ILE was administered or death was listed as the outcome were further analyzed. RESULTS There were 1274 cases of suspected bupropion ingestion reported during the study period with 14 reported deaths. Nine cases of ILE administration were identified. Of these, four patients expired and five survived. One of the survivors had neurologic sequelae necessitating placement in a long-term care facility. Patient complications after ILE administration were common and included continued hypotension in 7 cases, recurrent seizures in 3 patients, ARDS in two patients, and renal failure in one patient. CONCLUSIONS The high mortality and complication rate after ILE in this study sample does not reflect the positive outcome benefit seen in previous published case reports. Further characterization of the efficacy and complications of ILE in bupropion toxicity is needed.
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Affiliation(s)
- Neeraj Chhabra
- a Department of Emergency Medicine , Cook County Hospital (Stroger), Toxikon Consortium , Chicago , IL , USA
| | | | | | - Sean M Bryant
- a Department of Emergency Medicine , Cook County Hospital (Stroger), Toxikon Consortium , Chicago , IL , USA.,b Illinois Poison Center , Chicago , IL , USA
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87
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Pişkin Ö, Aydın BG. Effects of insulin+glucose pretreatment on bupivacaine cardiotoxicity in rats. Hum Exp Toxicol 2017; 37:451-457. [PMID: 28565972 DOI: 10.1177/0960327117712384] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A mistaken overdose of bupivacaine into systemic circulation may cause severe cardiovascular side effects. The aim of this study was to assess the effects of pretreatment with combined intra venous lipid emulsion (ILE) and high-dose insulin therapy against cardiotoxicity caused by bupivacaine intoxication. The rats were divided into the following three groups: Group B received a saline pretreatment plus a bupivacaine, group L received ILE pretreatment plus a bupivacaine, and in group I, insulin with glucose was infused intravenously, plus ILE pretreatment plus a bupivacaine. The electrocardiogram tracing, invasive arterial pressure, and heart rate (HR) of rats were monitored continuously. Arterial blood gas analysis was performed in all groups. Arterial blood gas analysis revealed that the baseline pH, PaO2, and PaCO2 values were similar between groups ( p > 0.05). Widening of Q, R, and S wave complex was found 46.8 ± 16.7, 92.0 ± 5.80, and 106.5 ± 17.9 s after initiation of bupivacaine infusion in groups B, L, and I, respectively. Time elapsed until 25% reduction of HR 127.3 ± 17.7, 248.4 ± 34.1, and 260.1 ± 51.3 s for groups B, L, and I, and 25% reduction of mean arterial pressure 107.6 ± 14.1, 253.2 ± 36.3, and 292 ± 57.7 s for groups B, L, and I, respectively. Arrhythmia was observed after 142.2 ± 27.5, 180.7 ± 17.8, and 190.7 ± 19.2 s for groups B, L, and I, respectively. Finally, asystole occurred after 560.1 ± 76.4, 782.4 ± 63.0, and 882.5 ± 105.1 s for groups B, L, and I, respectively. This finding indicates that the survival time of rats administered pretreatment with ILE plus insulin+glucose and those given ILE was observed to be longer.
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Affiliation(s)
- Ö Pişkin
- Department of Anesthesiology and Reanimation, School of Medicine, Bulent Ecevit University, Zonguldak, Turkey
| | - B G Aydın
- Department of Anesthesiology and Reanimation, School of Medicine, Bulent Ecevit University, Zonguldak, Turkey
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88
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89
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Sekimoto K, Tobe M, Saito S. Local anesthetic toxicity: acute and chronic management. Acute Med Surg 2017; 4:152-160. [PMID: 29123854 PMCID: PMC5667269 DOI: 10.1002/ams2.265] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 12/30/2016] [Indexed: 01/12/2023] Open
Abstract
Local anesthetics are commonly used medicines in clinical settings. They are used for pain management during minor interventional treatments, and for postoperative care after major surgeries. Cocaine is the well‐known origin of local anesthetics, and the drug and related derivatives have long history of clinical usage for more than several centuries. Although illegal use of cocaine and its abuse are social problem in some countries, other local anesthetics are safely and effectively used in clinics and hospitals all over the world. However, still this drug category has several side‐effects and possibilities of rare but serious complications. Acute neurotoxicity and cardiac toxicity are derived from unexpected high serum concentration. Allergic reactions are observed in some cases, especially following the use of ester structure drugs. Chronic toxicity is provoked when nerve fibers are exposed to local anesthetics at a high concentration for a long duration. Adequate treatments for acute toxic reactions can secure complete recovery of patients, and careful use of drugs prevents long‐lasting neurological complications. In addition to respiratory and circulatory management, effectiveness of lipid rescue in the acute toxicity treatment has been certified in many clinical guidelines. Prevention of the use of high concentration of local anesthetics is also validated to be effective to decrease the possibility of nerve fiber damage.
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Affiliation(s)
- Kenichi Sekimoto
- Department of Anesthesiology Gunma University Graduate School of Medicine Maebashi Japan
| | - Masaru Tobe
- Department of Anesthesiology Gunma University Graduate School of Medicine Maebashi Japan
| | - Shigeru Saito
- Department of Anesthesiology Gunma University Graduate School of Medicine Maebashi Japan
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90
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Vitamins, Amino Acids and Drugs and Formulations Used in Nutrition. SIDE EFFECTS OF DRUGS ANNUAL 2017. [DOI: 10.1016/bs.seda.2017.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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91
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Forsberg M, Forsberg S, Edman G, Höjer J. No support for lipid rescue in oral poisoning: A systematic review and analysis of 160 published cases. Hum Exp Toxicol 2016; 36:461-466. [DOI: 10.1177/0960327116679715] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Lipid rescue is used as treatment of various poisonings despite weak scientific evidence. Some experimental studies have indicated a positive effect, but others have not. Clinical studies are lacking, wherefore a systematic review of virtually all published human case reports is presented. The case reports were searched for in PubMed and Web of Science and examined by two experts according to an assessment form grading the probability for a causal connection between lipid rescue and improved symptoms. A total of 160 cases were finally included, of which 30 had no positive effect of lipid rescue. Among the 130 included cases with alleged positive effect, 94 were oral poisonings and 36 were cases with local anesthetic systemic toxicity (LAST). The experts’ assessment resulted in a “certain” causal connection in three cases with LAST but not in oral poisoning. Moreover, the mean assessment score among the oral poisonings was significantly worse than the corresponding score in the cases with LAST. The average log p-value of the main toxins among the oral poisonings was significantly lower than the corresponding p-value in the cases with LAST. Among the oral poisonings, 91% had received some other resuscitative treatment more or less simultaneously with lipid rescue. Considering the findings of this study and the increasingly reported adverse effects of lipid rescue, it’s reasonable to strictly limit its use in clinical practice. We would not recommend it in oral poisonings.
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Affiliation(s)
- M Forsberg
- Department of Surgery, Norrtälje Sjukhus, TioHundra AB, Sweden
| | - S Forsberg
- Department of Anaesthesiology and Intensive Care, Norrtälje Sjukhus, TioHundra AB, Sweden
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Swedish Poisons Information Centre, Stockholm, Sweden
| | - G Edman
- Department of Psychiatry, Norrtälje sjukhus, TioHundra AB, Sweden
| | - J Höjer
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Swedish Poisons Information Centre, Stockholm, Sweden
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92
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Gosselin S, Hoegberg LC, Hayes BD, Ghannoum M, Hoffman RS, Odigwe C, Tariq M, Ojiako KC, Iroegbu NA. Reader Comments. Proc (Bayl Univ Med Cent) 2016. [DOI: 10.1080/08998280.2016.11929508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Sophie Gosselin
- McGill University Health Centre, Montreal Centre Antipoison du Québec Poison and Drug Information Service, Alberta
| | | | - Bryan D. Hayes
- Department of Emergency Medicine, Harvard Medical School and Massachusetts General Hospital
| | | | - Robert S. Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine
| | - Chibuzo Odigwe
- Department of Medicine, Palmetto Health Richland, Columbia, SC
| | - Madiha Tariq
- Department of Medicine, Presence St. Joseph Hospital, Chicago, IL
| | - Kizito C. Ojiako
- Rosalind Franklin University of Medicine and Science, Chicago, IL
| | - Nkem A. Iroegbu
- Department of Clinical Medicine, University of Illinois at Chicago
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93
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Gosselin S, Hoegberg LCG, Hoffman RS, Graudins A, Stork CM, Thomas SHL, Stellpflug SJ, Hayes BD, Levine M, Morris M, Nesbitt-Miller A, Turgeon AF, Bailey B, Calello DP, Chuang R, Bania TC, Mégarbane B, Bhalla A, Lavergne V. Evidence-based recommendations on the use of intravenous lipid emulsion therapy in poisoning. Clin Toxicol (Phila) 2016; 54:899-923. [DOI: 10.1080/15563650.2016.1214275] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Sophie Gosselin
- Department of Emergency Medicine, McGill University Health Centre, Montréal, Québec, Canada
- Centre Antipoison du Québec, Montréal, Québec, Canada
- Province of Alberta Drug Information Services, Calgary, Alberta, Canada
| | - Lotte C. G. Hoegberg
- Danish Poisons Information Centre, Anaesthesiology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Robert. S. Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, NY, USA
| | - Andis Graudins
- Monash Clinical Toxicology Service, Program of Emergency Medicine, Monash Health and School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Christine M. Stork
- Upstate NY Poison Center, Syracuse, NY, USA
- Department of Emergency Medicine, Upstate Medical University, Syracuse, New York, USA
| | - Simon H. L. Thomas
- National Poisons Information Service (Newcastle) and Medical Toxicology Centre, Institute of Cellular Medicine, Newcastle University, Newcastle, UK
| | | | - Bryan D. Hayes
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael Levine
- Department of Emergency Medicine, Section of Medical Toxicology, University of Southern California, Los Angeles, CA, USA
| | - Martin Morris
- Schulich Library of Science and Engineering, McGill University, Montréal, Québec, Canada
| | - Andrea Nesbitt-Miller
- Schulich Library of Science and Engineering, McGill University, Montréal, Québec, Canada
| | - Alexis F. Turgeon
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, and CHU de Québec, Université Laval Research Center, Population Health and Optimal Health Practices Unit, Université Laval, Québec City, Québec, Canada
| | - Benoit Bailey
- Division of Emergency Medicine, Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
- Centre Antipoison du Québec, Quebec, Canada
| | - Diane P. Calello
- Medical Toxicology, Department of Emergency Medicine, Morristown Medical Center, Emergency Medical Associates, Morristown, NJ, USA
| | - Ryan Chuang
- Department of Emergency Medicine, Division of Clinical Pharmacology and Toxicology, University of Calgary, Poison and Drug Information Service, Calgary, Alberta, Canada
| | | | - Bruno Mégarbane
- Department of Medical and Toxicological Intensive Care, Lariboisière Hospital, Paris-Diderot University, INSERM UMRS1144, Paris, France
| | - Ashish Bhalla
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Valéry Lavergne
- Department of Medical Biology, Sacré-Coeur Hospital, University of Montréal, Montréal, Québec, Canada
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94
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Mullins ME. Advancing the science of antidotal use of lipid emulsion. Clin Toxicol (Phila) 2016; 54:897-898. [PMID: 27596915 DOI: 10.1080/15563650.2016.1216558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Michael E Mullins
- a Division of Emergency Medicine , Washington University School of Medicine , Saint Louis , MO , USA
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95
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Rosenberg PH. Current evidence is not in support of lipid rescue therapy in local anaesthetic systemic toxicity. Acta Anaesthesiol Scand 2016; 60:1029-32. [PMID: 27465522 DOI: 10.1111/aas.12743] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- P. H. Rosenberg
- Department of Anaesthesiology and Intensive Care; University of Helsinki; Helsinki Finland
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96
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Anez-Bustillos L, Dao DT, Baker MA, Fell GL, Puder M, Gura KM. Intravenous Fat Emulsion Formulations for the Adult and Pediatric Patient: Understanding the Differences. Nutr Clin Pract 2016; 31:596-609. [PMID: 27533942 DOI: 10.1177/0884533616662996] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Intravenous fat emulsions (IVFEs) provide essential fatty acids (EFAs) and are a dense source of energy in parenteral nutrition (PN). Parenterally administered lipid was introduced in the 17th century but plagued with side effects. The formulation of IVFEs later on made it a relatively safe component for administration to patients. Many ingredients are common to all IVFEs, yet the oil source(s) and its (their) percentage(s) makes them different from each other. The oil used dictates how IVFEs are metabolized and cleared from the body. The fatty acids (FAs) present in each type of oil provide unique beneficial and detrimental properties. This review provides an overview of IVFEs and discusses factors that would help clinicians choose the optimal product for their patients.
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Affiliation(s)
- Lorenzo Anez-Bustillos
- Vascular Biology Program and the Department of Surgery. Boston Children's Hospital, Boston, Massachusetts, USA
| | - Duy T Dao
- Vascular Biology Program and the Department of Surgery. Boston Children's Hospital, Boston, Massachusetts, USA
| | - Meredith A Baker
- Vascular Biology Program and the Department of Surgery. Boston Children's Hospital, Boston, Massachusetts, USA
| | - Gillian L Fell
- Vascular Biology Program and the Department of Surgery. Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mark Puder
- Vascular Biology Program and the Department of Surgery. Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kathleen M Gura
- Department of Pharmacy, Boston Children's Hospital, Boston, Massachusetts, USA
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97
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Höjer J, Jacobsen D, Neuvonen PJ, Rosenberg PH. Lipid Rescue - Efficacy and Safety Still Unproven. Basic Clin Pharmacol Toxicol 2016; 119:345-8. [DOI: 10.1111/bcpt.12607] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 04/08/2016] [Indexed: 12/12/2022]
Affiliation(s)
- Jonas Höjer
- Swedish Poisons Information Center; Karolinska Institute; Stockholm Sweden
| | - Dag Jacobsen
- Department of Acute Medicine; Oslo University Hospital; Oslo Norway
| | - Pertti J. Neuvonen
- Department of Clinical Pharmacology; Helsinki University Hospital and University of Helsinki; Helsinki Finland
| | - Per H. Rosenberg
- Department of Anaesthesiology and Intensive Care Medicine; Helsinki University Hospital and University of Helsinki; Helsinki Finland
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