1
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Sumer RW, Woods WA. Cardiac Arrest in Special Populations. Cardiol Clin 2024; 42:289-306. [PMID: 38631796 DOI: 10.1016/j.ccl.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Best practices in cardiac arrest depend on continuous high-quality chest compressions, appropriate ventilatory management, early defibrillation of shockable rhythms, and identification and treatment of reversible causes. Although most patients can be treated according to highly vetted treatment guidelines, some special situations in cardiac arrest arise where additional skills and preparation can improve outcomes. Situations covered in this section involve cardiac arrest in context of electrical injuries, asthma, allergic reactions, pregnancy, trauma, electrolyte imbalances, toxic exposures, hypothermia, drowning, pulmonary embolism, and left ventricular assist devices.
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Affiliation(s)
- Ravi W Sumer
- Department of Emergency Medicine, 4601 Dale Road, Modesto, CA 95356-8713, USA.
| | - William A Woods
- Department of Emergency Medicine, University of Virginia Health System, PO Box 800699, Charlottesville, VA 22908-0699, USA
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2
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Lavonas EJ, Akpunonu PD, Arens AM, Babu KM, Cao D, Hoffman RS, Hoyte CO, Mazer-Amirshahi ME, Stolbach A, St-Onge M, Thompson TM, Wang GS, Hoover AV, Drennan IR. 2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2023; 148:e149-e184. [PMID: 37721023 DOI: 10.1161/cir.0000000000001161] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.
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3
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Ollier M, Giles S, Gosselin S. The Occasional intralipid emulsion therapy. CANADIAN JOURNAL OF RURAL MEDICINE 2023; 28:195-200. [PMID: 37861604 DOI: 10.4103/cjrm.cjrm_62_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Affiliation(s)
- Mary Ollier
- Departement of Family Medicine Temerty School of Medicine, University of Toronto, Toronto, Canada
| | - Sarah Giles
- Northern Ontario School of Medicine University, Thunder Bay, Ontario, Canada
| | - Sophie Gosselin
- Centre Intégré De Santé Et Services Sociaux De La Montérégie-Centre; Centre Antipoison Du Québec; Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Quebec, Canada
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4
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Levine M, Brent J, Wiegand T, Maguire B, Cohen N, Vaerrier D, Beuhler M, Leikin JB, Ganetsky M, Stellpflug S, Ruha AM, Carey J, Geib AJ, Cao DJ, Kleinschmidt K, Vohra R, Riley BD, Moore P, Schwarz E, Neavyn M, Rusyniak DE, Greene S, Nogar J, Manini A, Wermuth M, Pizon A, Hendrickson RG, Griswold M, Aldy K, Wax P, Spyres MB, Campleman S, Macdonald E, Finkelstein Y. Lipid emulsion therapy during management of the critically-ill poisoned patient: a prospective cohort study. Clin Toxicol (Phila) 2023; 61:584-590. [PMID: 37655788 DOI: 10.1080/15563650.2023.2248372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 08/07/2023] [Accepted: 08/10/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Despite conflicting data, intravenous lipid emulsion has emerged as a potential antidote. The "lipid sink" theory suggests that following intravenous administration of lipid, lipophilic drugs are sequestered in the vascular compartment, thereby reducing their tissue concentrations. This study sought to determine if survival is associated with the intoxicant's degree of lipophilicity. METHODS We reviewed all cases in the Toxicology Investigators Consortium's lipid sub-registry between May 2012 through December 2018. Information collected included demographics, exposure circumstances, clinical course, management, disposition, and outcome. The primary outcome was survival after lipid emulsion therapy. Survival was stratified by the log of the intoxicant's octanol-water partition coefficient. We also assessed the association between intoxicant lipophilicity and an increase in systolic blood pressure after lipid emulsion administration. RESULTS We identified 134 patients, including 81 (60.4%) females. The median age was 40 years (interquartile range 21-75). One hundred and eight (80.6%) patients survived, including 45 (33.6%) with cardiac arrest during their intoxication. Eighty-two (61.2%) were hypotensive, and 98 (73.1%) received mechanical ventilation. There was no relationship between survival and the log of the partition coefficient of the intoxicant on linear analysis (P = 0.89) or polynomial model (P = 0.10). Systolic blood pressure increased in both groups. The median (interquartile range) systolic blood pressure before lipid administration was 68 (60-78) mmHg for those intoxicants with a log partition coefficient < 3.6 compared with 89 (76-104) mmHg after lipid administration. Among those drugs with a log partition coefficient > 3.6, the median (interquartile range) was 69 (60-84) mmHg before lipid and 89 (80-96) mmHg after lipid administration. CONCLUSION Most patients in this cohort survived. Lipophilicity was not correlated with survival or the observed changes in blood pressure. The study did not address the efficacy of lipid emulsion.
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Affiliation(s)
- Michael Levine
- Department of Emergency Medicine, University of California, Los Angeles, CA, USA
| | | | - Timothy Wiegand
- Department of Emergency Medicine, Division of Medical Toxicology, University of Rochester, Rochester, NY, USA
| | - Bryan Maguire
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Neta Cohen
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - David Vaerrier
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | | | - Jerrold B Leikin
- Division of Environmental and Occupational Health Science and the Occupational and Environmental Medicine Service of UI Health, University of Illinois Chicago, Chicago, IL, USA
| | - Michael Ganetsky
- Department of Emergency Medicine, Division of Medical Toxicology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Samuel Stellpflug
- Department of Emergency Medicine, Regions Hospital, St. Paul, MN, USA
| | - Anne-Michelle Ruha
- Department of Medical Toxicology, Banner University Medical Center, Phoenix, AZ, USA
| | - Jennifer Carey
- Department of Emergency Medicine, University of Massachusetts, Worchester, MA, USA
| | | | - Dazhe James Cao
- Department of Emergency Medicine, Division of Medical Toxicology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kurt Kleinschmidt
- Department of Emergency Medicine, Division of Medical Toxicology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rais Vohra
- Department of Emergency Medicine, Division of Medical Toxicology, University of California San Francisco-Fresno Medical Center, Fresno, CA, USA
| | - Brad D Riley
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Phillip Moore
- Department of Emergency Medicine, Penn State University College of Medicine, Hershey, PA, USA
| | - Evan Schwarz
- Department of Emergency Medicine, University of California, Los Angeles, CA, USA
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University, St. Louis, MO, USA
| | - Mark Neavyn
- Department of Emergency Medicine, Hartford Hospital, Hartford, CT, USA
| | - Daniel E Rusyniak
- Department of Emergency Medicine, Division of Medical Toxicology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Spencer Greene
- Department of Emergency Medicine, HCA Houston Healthcare - Kingwood, University of Houston College of Medicine, Houston, TX, USA
| | - Joshua Nogar
- Department of Emergency Medicine, North Shore University, Manhasset, NY, USA
| | - Alex Manini
- Department of Emergency Medicine, Division of Medical Toxicology, Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, New York, NY, USA
| | - Mary Wermuth
- Department of Emergency Medicine, Division of Medical Toxicology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Anthony Pizon
- Department of Emergency Medicine, Division of Medical Toxicology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert G Hendrickson
- Department of Emergency Medicine, Division of Medical Toxicology, Oregon Health Science University, Portland, OR, USA
| | - Matthew Griswold
- Department of Emergency Medicine, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Kim Aldy
- American College of Medical Toxicology, Phoenix, AZ, USA
| | - Paul Wax
- American College of Medical Toxicology, Phoenix, AZ, USA
| | - Meghan Beth Spyres
- Department of Medical Toxicology, Banner University Medical Center, Phoenix, AZ, USA
| | | | - Erin Macdonald
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Yaron Finkelstein
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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5
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Mullins ME. Lipid emulsion in the poisoned patient - a few answers, but more questions remain. Clin Toxicol (Phila) 2023; 61:565-566. [PMID: 37815249 DOI: 10.1080/15563650.2023.2254489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 10/11/2023]
Affiliation(s)
- Michael E Mullins
- Editor Division of Medical Toxicology, Department of Emergency Medicine, WA University School of Medicine, St Louis, MO, USA
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6
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Sumer RW, Woods WA. Cardiac Arrest in Special Populations. Emerg Med Clin North Am 2023; 41:485-508. [PMID: 37391246 DOI: 10.1016/j.emc.2023.05.001] [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: 07/02/2023]
Abstract
Best practices in cardiac arrest depend on continuous high-quality chest compressions, appropriate ventilatory management, early defibrillation of shockable rhythms, and identification and treatment of reversible causes. Although most patients can be treated according to highly vetted treatment guidelines, some special situations in cardiac arrest arise where additional skills and preparation can improve outcomes. Situations covered in this section involve cardiac arrest in context of electrical injuries, asthma, allergic reactions, pregnancy, trauma, electrolyte imbalances, toxic exposures, hypothermia, drowning, pulmonary embolism, and left ventricular assist devices.
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Affiliation(s)
- Ravi W Sumer
- Department of Emergency Medicine, 4601 Dale Road, Modesto, CA 95356-8713, USA.
| | - William A Woods
- Department of Emergency Medicine, University of Virginia Health System, PO Box 800699, Charlottesville, VA 22908-0699, USA
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7
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Fettiplace MR, Weinberg G. Lipid emulsion for xenobiotic overdose: PRO. Br J Clin Pharmacol 2023; 89:1708-1718. [PMID: 36454165 PMCID: PMC10175108 DOI: 10.1111/bcp.15620] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 09/16/2022] [Accepted: 09/22/2022] [Indexed: 12/03/2022] Open
Abstract
Infusion of lipid emulsion for drug overdose arose as a treatment for local anaesthetic systemic toxicity (LAST) initially based on laboratory results in animal models with the subsequent support of favourable case reports. Following successful translation to the clinic, practitioners also incorporated lipid emulsion as a treatment for non-local anaesthetic toxicities but without formal clinical trials. Recent clinical trials demonstrate a benefit of lipid emulsion in antipsychotic, pesticide, metoprolol and tramadol overdoses. Formal trials of lipid emulsion in LAST may never occur, but alternative analytic tools indicate strong support for its efficacy in this indication; for example, lipid emulsion has obviated the need for cardiopulmonary bypass in most cases of LAST. Herein, we describe the pre-clinical support for lipid emulsion, evaluate the most recent clinical studies of lipid emulsion for toxicity, identify a possible dose-based requirement for efficacy and discuss the limitations to uncontrolled studies in the field.
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Affiliation(s)
- Michael R. Fettiplace
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, 02114
| | - Guy Weinberg
- Department of Anesthesiology, University of Illinois College of Medicine, Chicago, IL 60622 USA
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8
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Jaffal K, Chevillard L, Mégarbane B. Lipid Emulsion to Treat Acute Poisonings: Mechanisms of Action, Indications, and Controversies. Pharmaceutics 2023; 15:pharmaceutics15051396. [PMID: 37242638 DOI: 10.3390/pharmaceutics15051396] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 04/24/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023] Open
Abstract
Biodetoxification using intravenous lipid emulsion (ILE) in acute poisoning is of growing interest. As well as for local anesthetics, ILE is currently used to reverse toxicity caused by a broad-spectrum of lipophilic drugs. Both pharmacokinetic and pharmacodynamic mechanisms have been postulated to explain its possible benefits, mainly combining a scavenging effect called "lipid sink" and cardiotonic activity. Additional mechanisms based on ILE-attributed vasoactive and cytoprotective properties are still under investigation. Here, we present a narrative review on lipid resuscitation, focusing on the recent literature with advances in understanding ILE-attributed mechanisms of action and evaluating the evidence supporting ILE administration that enabled the international recommendations. Many practical aspects are still controversial, including the optimal dose, the optimal administration timing, and the optimal duration of infusion for clinical efficacy, as well as the threshold dose for adverse effects. Present evidence supports the use of ILE as first-line therapy to reverse local anesthetic-related systemic toxicity and as adjunct therapy in lipophilic non-local anesthetic drug overdoses refractory to well-established antidotes and supportive care. However, the level of evidence is low to very low, as for most other commonly used antidotes. Our review presents the internationally accepted recommendations according to the clinical poisoning scenario and provides the precautions of use to optimize the expected efficacy of ILE and limit the inconveniences of its futile administration. Based on their absorptive properties, the next generation of scavenging agents is additionally presented. Although emerging research shows great potential, several challenges need to be overcome before parenteral detoxifying agents could be considered as an established treatment for severe poisonings.
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Affiliation(s)
- Karim Jaffal
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, 75010 Paris, France
- INSERM UMRS-1144, Paris-Cité University, 75006 Paris, France
| | - Lucie Chevillard
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, 75010 Paris, France
- INSERM UMRS-1144, Paris-Cité University, 75006 Paris, France
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, 75010 Paris, France
- INSERM UMRS-1144, Paris-Cité University, 75006 Paris, France
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9
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Stanton MT. Part
II
: Interactive case: Toxicology and poison control. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022. [DOI: 10.1002/jac5.1725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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10
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Lazar AE, Gurzu S, Kovecsi A, Perian M, Cordos B, Gherghinescu MC, Enache LS. Cardio Protective Effects of Lipid Emulsion against Ropivacaine-Induced Local Anesthetic Systemic Toxicity—An Experimental Study. J Clin Med 2022; 11:jcm11102784. [PMID: 35628910 PMCID: PMC9142945 DOI: 10.3390/jcm11102784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 05/04/2022] [Accepted: 05/13/2022] [Indexed: 11/16/2022] Open
Abstract
Inadvertent intravascular injection of local anesthetics (LA) during regional anesthesia causes Local Anesthetic Systemic Toxicity (LAST). Theories of lipid rescue in the case of LAST proved that the administration of lipids in LAST has beneficial effects. One possible mechanism of action is based on the lipophilic properties of LA which allow plasma-free LA to be bound by the molecules of Lipid Emulsion (LE). The association LA–LE is shuttled towards organs such as liver and the kidneys, and the half-life of LA is shortened. The main objective of this experimental study was to assess the possible cardio-prophylactic effect of LE administration before the induction of LAST by intravenous administration of Ropivacaine. This was an experimental, interventional, prospective, and non-randomized study. The subjects were divided into groups and received, under general anesthesia, LE 20% first 0.3–0.4 mL, followed by 0.1 mL Ropivacaine 2 mg/mL, or Ropivacaine alone. At the end of the experiment, the subjects were sacrificed, and tissue samples of kidney, heart and liver were harvested for histopathological examination. LE, when administered as prophylaxis in Ropivacaine-induced LAST, had protective cardiac effects in rats. The LE known side effects were not produced if the substance was administered in the low doses used for LAST prophylaxis.
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Affiliation(s)
- Alexandra Elena Lazar
- Department of Anesthesiology, Emergency Clinical County Hospital, University of Medicine, Science and Technology “George Emil Palade”, 540136 Tirgu Mures, Romania;
| | - Simona Gurzu
- Department of Morphopathology, Emergency Clinical County Hospital, University of Medicine, Science and Technology “George Emil Palade”, 540136 Tirgu Mures, Romania;
- Correspondence:
| | - Attila Kovecsi
- Department of Morphopathology, Emergency Clinical County Hospital, University of Medicine, Science and Technology “George Emil Palade”, 540136 Tirgu Mures, Romania;
| | - Marcel Perian
- Department of Physiology, University of Medicine, Science and Technology “George Emil Palade”, 540136 Tirgu Mures, Romania;
| | - Bogdan Cordos
- Veterinary Experimental Base, University of Medicine, Science and Technology “George Emil Palade”, 540136 Tirgu Mures, Romania;
| | - Mircea Constantin Gherghinescu
- Department of Surgery, Emergency Clinical County Hospital, University of Medicine, Science and Technology “George Emil Palade”, 540136 Tirgu Mures, Romania;
| | - Liviu Sorin Enache
- Emergency Clinical County Hospital Tirgu Mures, University “Dimitrie Cantemir”, 540136 Tirgu Mures, Romania;
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11
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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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Mullins ME, Seger DL. Authors’ reply to Comment on antidotal use of lipid emulsion. Clin Toxicol (Phila) 2020; 58:1357-1358. [DOI: 10.1080/15563650.2020.1775243] [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)
- Michael E. Mullins
- Section of Medical Toxicology, Department of Emergency Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Donna L. Seger
- Tennessee Poison Center, Vanderbilt University Medical Center, Nashville, TN, USA
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13
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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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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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15
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Klučka J, Juřenčák T, Kosinová M, Petr Š, Kratochvíl M, Sedláčková Y, Tomáš N, Pelclová D, Jabandžiev P. Intralipid infusion in paediatric patient with quetiapine and lamotrigine intoxication. MONATSHEFTE FUR CHEMIE 2019. [DOI: 10.1007/s00706-019-02423-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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16
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Bartlett JW, Walker PL. Management of Calcium Channel Blocker Toxicity in the Pediatric Patient. J Pediatr Pharmacol Ther 2019; 24:378-389. [PMID: 31598101 DOI: 10.5863/1551-6776-24.5.378] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Calcium channel blockers (CCBs) are commonly prescribed cardiovascular medications used in several disease states including hypertension, coronary artery disease, and atrial fibrillation. Inadvertent exposure or intentional overdose of CCBs may result in hypotension, bradycardia, dysrhythmias, conduction disturbances, and hyperglycemia. In the most severe cases, CCB toxicity can lead to rapid cardiovascular collapse. Given the risk of significant morbidity and mortality associated with CCB toxicity, it is important that health care professionals are able to recognize and treat patients who present with a potentially toxic ingestion. Due to the paucity of literature in managing pediatric patients with severe CCB toxicity, treatment strategies for pediatric patients are mostly limited to case reports and extrapolation from expert consensus recommendations for adults. All pediatric patients with a potentially toxic CCB ingestion should be evaluated in the emergency department. Activated charcoal may be considered for asymptomatic patients presenting within an hour of ingestion. Symptomatic patients should be placed under cardiac monitoring and treatments to stabilize the patient's hemodynamics should not be delayed. Traditional first-line IV therapies include small boluses of fluids, calcium, and vasopressors. High-dose insulin has been proposed to independently increase inotropy and improve CCB-induced hypoinsulinemia and insulin resistance that results from CCB inhibition of insulin release from pancreatic β-islet cells. High-dose insulin is recommended as first-line therapy for adults and shows promising efficacy and safety in several pediatric case reports. Intravenous lipid emulsion may be considered in patients who are refractory to first-line therapies, although the data for pediatric patients are extremely limited.
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17
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Bornstein K, Montrief T, Anwar Parris M. Successful Management of Adolescent Bupropion Overdose with Intravenous Lipid Emulsion Therapy. J Pediatr Intensive Care 2019; 8:242-246. [PMID: 31673461 DOI: 10.1055/s-0039-1693483] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 06/11/2019] [Indexed: 12/12/2022] Open
Abstract
Bupropion overdose in the pediatric setting poses significant potential for toxicity. We present the case of a 15-year-old female patient presenting with intentional bupropion overdose resulting in generalized tonic-clonic seizures, severe acidosis, vomiting, and tachycardia after ingestion of between 1,650 to 9,000 mg (24-133 mg/kg) of bupropion. The patient was admitted to pediatric intensive care unit (PICU) where toxicity was resolved promptly following administration of intravenous lipid emulsion (ILE) infusion. ILE is a first-line treatment for other forms of toxicity including unintended local anesthetic administration. ILE use is not a first-line treatment in this setting, but this case presents a positive subsequent patient outcome.
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Affiliation(s)
- Kasha Bornstein
- University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Tim Montrief
- Department of Emergency Medicine, University of Miami, Jackson Memorial Hospital/Miller School of Medicine, Miami, United States
| | - Mehruba Anwar Parris
- Department of Emergency Medicine, University of Miami, Jackson Memorial Hospital/Miller School of Medicine, Miami, United States
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Paneta M, Waring WS. Literature review of the evidence regarding intravenous lipid administration in drug-induced cardiotoxicity. Expert Rev Clin Pharmacol 2019; 12:591-602. [PMID: 31106655 DOI: 10.1080/17512433.2019.1621163] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Intravenous lipid emulsion (ILE) administration is capable of reversing the acute cardiac and neurological toxicity caused by local anesthetic agents. In recent years, ILE has also been explored as a potential antidote for cardiotoxicity caused by non-anesthetic agents too. Areas covered: The potential mechanisms, safety, and efficacy of this approach are considered. Data were sought from published reports listed in PubMed and EMBASE, and abstracts of meetings of the North American Congress of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxicologists. There were reports involving 298 patients where ILE has been administered for severe drug toxicity. Clinical improvement was observed in 57 of 59 patients with local anesthetic toxicity (96.6%); there were 239 patients where toxicity was due to non-anesthetic agents, and ILE apparently improved clinical outcome in 215 (72.1%). Expert opinion: Response rates were similar between ILE treated toxicity caused by lipid soluble and non-lipid soluble drugs. Potential adverse effects of ILE include interference with laboratory assays, acute pancreatitis, and adult respiratory distress syndrome, although the rate of occurrence is difficult to ascertain.
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Affiliation(s)
- Maria Paneta
- a Acute Medical Unit , York Teaching Hospital NHS Foundation Trust , York , UK
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