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Fettiplace MR, Pichurko AB. Heterogeneity and bias in animal models of lipid emulsion therapy: a systematic review and meta-analysis. Clin Toxicol (Phila) 2020; 59:1-11. [PMID: 33025830 DOI: 10.1080/15563650.2020.1814316] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Clinicians utilize lipid emulsion to treat local anesthetic toxicity and non-local anesthetic toxicities, a practice supported by animal experimentation and clinical experience. Prior meta-analysis confirmed a mortality benefit of lipid emulsion in animal models of local anesthetic toxicity but the benefit of lipid emulsion in models of non-local anesthetic toxicity remains unanswered. Further, swine suffer an anaphylactoid reaction from lipid emulsions calling into question their role as a model system to study lipid, so we examined swine and non-swine dependent outcomes in models of intravenous lipid emulsion. METHODS We conducted a systematic review and meta-analysis examining the use of lipid emulsion therapy in animal models of cardiac toxicity. We quantified mortality using a random-effects odds-ratio method. Secondary outcomes included survival in the following subgroups: local-anesthetic systemic toxicity, non-local anesthetic toxicity, swine-based models, and non-swine models (e.g., rat, rabbit and dog). We assessed for heterogeneity with Cochran's Q and I2. We examined bias with Egger's test & funnel plot analysis. RESULTS Of 2784 references screened, 58 met criteria for inclusion. Treatment with lipid emulsion reduced chance of death in all models of toxicity with an odds ratio of death of 0.26 (95% CI 0.16-0.44, Z-5.21, p < 0.00001, Cohen's-d = 0.72, n = 60). Secondary outcomes confirmed a reduced chance of death in models of local anesthetic toxicity (OR 0.16 {95% CI 0.1-0.33}) and non-local anesthetic toxicity (OR 0.43 {95% CI 0.22-0.83}). Heterogeneity (Cochran's Q 132 {df = 59, p < 0.01}, I 2 = 0.55) arose primarily from animal-model and disappeared (I 2 < = 0.12) when we analyzed swine and non-swine subgroups independently. Swine only benefited in models of local anesthetic toxicity (OR 0.28 {95% CI 0.11-0.7}, p = 0.0033) whereas non-swine models experienced a homogeneous benefit across all toxins (OR 0.1 {95% CI 0.06-0.16}, p < 0.00001). Egger's test identified risk of bias with outliers on funnel plot analysis. DISCUSSION Lipid emulsion therapy reduces mortality in animal models of toxicity. Heterogeneity arises from the animal-model used. Swine only benefit in models of local anesthetic toxicity, potentially due to lipid dose, experimental design or swine's anaphylactoid reaction to lipid. Outlier analysis reinforced the need for appropriate dosing of lipid emulsion along with airway management and chest compressions in the setting of cardiac arrest.
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Affiliation(s)
- Michael R Fettiplace
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Adrian B Pichurko
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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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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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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Ok SH, Hong JM, Lee SH, Sohn JT. Lipid Emulsion for Treating Local Anesthetic Systemic Toxicity. Int J Med Sci 2018; 15:713-722. [PMID: 29910676 PMCID: PMC6001420 DOI: 10.7150/ijms.22643] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 04/12/2018] [Indexed: 02/07/2023] Open
Abstract
Lipid emulsion has been shown to be an effective treatment for systemic toxicity induced by local anesthetics, which is reflected in case reports. A systemic review and meta-analysis confirm the efficacy of this treatment. Investigators have suggested mechanisms associated with the lipid emulsion-mediated recovery of cardiovascular collapse caused by local anesthetic systemic toxicity; these mechanisms include lipid sink, a widely accepted theory in which highly soluble local anesthetics (particularly bupivacaine) are absorbed into the lipid phase of plasma from tissues (e.g., the heart) affected by local-anesthetic-induced toxicity; enhanced redistribution (lipid shuttle); fatty acid supply; reversal of mitochondrial dysfunction; inotropic effects; glycogen synthase kinase-3β phosphorylation associated with inhibition of the mitochondrial permeability transition pore opening; inhibition of nitric oxide release; and reversal of cardiac sodium channel blockade. The current review includes the following: 1) an introduction, 2) a list of the proposed mechanisms, 3) a discussion of the best lipid emulsion treatment for reversal of local anesthetic toxicity, 4) a description of the effect of epinephrine on lipid emulsion-mediated resuscitation, 5) a description of the recommended lipid emulsion treatment, and 6) a conclusion.
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Affiliation(s)
- Seong-Ho Ok
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 Beon-gil, Jinju-si, Gyeongsangnam-do, 52727, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju-si, 52727, Republic of Korea
| | - Jeong-Min Hong
- Department of Anesthesia and Pain Medicine, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Soo Hee Lee
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 Beon-gil, Jinju-si, Gyeongsangnam-do, 52727, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju-si, 52727, Republic of Korea
| | - Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 Beon-gil, Jinju-si, Gyeongsangnam-do, 52727, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju-si, 52727, Republic of Korea
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Wang Q, Yin Q, Yang J, Ke B, Yang L, Liu J, Zhang W. Evaluation of the cardiotoxicity and resuscitation of rats of a newly developed mixture of a QX-314 analog and levobupivacaine. J Pain Res 2017; 10:737-746. [PMID: 28392712 PMCID: PMC5376121 DOI: 10.2147/jpr.s126396] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective This study was designed to evaluate the cardiotoxicity of a QX-314 analog (QX-OH) and a mixture of QX-OH and levobupivacaine (LL-1) and to compare the ability to resuscitate rats after asystole induced by levobupivacaine (Levo-BUP), QX-314, QX-OH, and LL-1. Methods First, we used the “up-and-down” method to determine median dose resulting in appearance of cardiotoxicity (CD50C) and asystole (CD50A) of Levo-BUP, QX-314, QX-OH, and LL-1 in rats. Safety index (SI; ratio of CD50C compared with 2-fold median effective dose needed to produce sensory blockade) of the 4 drugs was calculated. Isobolograms were used for drug interaction analysis. Second, rats received 1.2-fold CD50A in the 4 groups. When asystole occurred, standard cardiopulmonary resuscitation was started and continued for 30 min or until return of spontaneous circulation (ROSC) with native rate–pressure product ≥30% baseline for 5 min. Results Ranking of CD50C was Levo-BUP < QX-314 ≈ QX-OH. Ranking of CD50A was Levo-BUP < QX-314 < QX-OH. However, the SI of Levo-BUP was significantly higher than that of QX-314 (10.60 vs. 1.20) or QX-OH (10.60 vs. 1.44). The SI of LL-1 was similar to that of Levo-BUP. Nonsynergistic interaction was observed for cardiac effects between QX-OH and Levo-BUP. ROSC was attained initially by 8 of 8 rats in the Levo-BUP group, 3 of 8 in the QX-314 group, 6 of 8 in the QX-OH group, and 8 of 8 in the LL-1 group. Sustained recovery was achieved in the Levo-BUP group but not in the other groups. Conclusion Levo-BUP and LL-1 are safer than QX-314 or QX-OH. Cardiac effects between QX-OH and Levo-BUP were nonsynergistic. Initial successful resuscitation could be achieved in the QX-OH- and LL-1-induced asystole, but advanced life support might be needed.
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Affiliation(s)
- Qi Wang
- Department of Anesthesiology
| | | | - Jun Yang
- Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Centre, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Bowen Ke
- Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Centre, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Linghui Yang
- Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Centre, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Jin Liu
- Department of Anesthesiology; Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Centre, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Wensheng Zhang
- Department of Anesthesiology; Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Centre, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
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Fettiplace MR, McCabe DJ. Lipid emulsion improves survival in animal models of local anesthetic toxicity: a meta-analysis. Clin Toxicol (Phila) 2017; 55:617-623. [DOI: 10.1080/15563650.2017.1288911] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Michael R. Fettiplace
- Medical Scientist Training Program, University of Illinois College of Medicine, Chicago, IL, USA
| | - Daniel J. McCabe
- Department of Emergency Medicine, John H. Stroger Cook County Hospital, Chicago, IL, USA
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Yurtlu BS, Özbilgin Ş, Yurtlu DA, Boztaş N, Kamacı G, Akaltun M, Hancı V, Yılmaz O. Intravenous lipid emulsion prolongs survival in rats intoxicated with digoxin. Am J Emerg Med 2016; 34:1112-6. [DOI: 10.1016/j.ajem.2016.03.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 03/14/2016] [Indexed: 12/20/2022] Open
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Heinonen JA, Skrifvars MB, Haasio J, Backman JT, Rosenberg PH, Litonius E. Intravenous Lipid Emulsion for Levobupivacaine Intoxication in Acidotic and Hypoxaemic Pigs. Anaesth Intensive Care 2016; 44:270-7. [DOI: 10.1177/0310057x1604400214] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Intravenous lipid emulsion is, in some countries, the recommended treatment for local anaesthetic toxicity. Systemic local anaesthetic toxicity results in hypoxaemia and acidosis, and whether this influences the effects of lipid therapy on drug concentrations and cardiovascular recovery is currently unknown. Twenty anaesthetised pigs were given a 3 mg/kg bolus of levobupivacaine followed by a five-minute phase of hypoventilation and 1 mmol/kg of lactic acid over one minute. After lactic acid infusion, pigs were treated, in randomised order, with either 20% lipid emulsion or Ringer's acetate for 30 minutes: a 1.5 ml/kg bolus followed by a 0.25 ml/kg/minute infusion. Haemodynamic parameters were recorded and blood samples were collected for pharmacokinetic analysis. There was no difference between the groups in the area under the plasma levobupivacaine concentration–time curve (AUC) or between that and AUC of unentrapped levobupivacaine in the Lipid group, or in the plasma half-lives. The cardiovascular outcome and normalisation of the electrocardiogram were similar in both groups. Five pigs developed marked hypotension: one in both groups died, while two in the Lipid group and one in the Ringer group needed adrenaline. Administration of lipid emulsion did not improve cardiovascular recovery from levobupivacaine toxicity exacerbated by acidosis and hypoxaemia. Lipid emulsion did not entrap levobupivacaine or affect levobupivacaine pharmacokinetics.
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Affiliation(s)
- J. A. Heinonen
- Department of Anaesthesia and Intensive Care Medicine, University of Helsinki, Helsinki, Finland
| | - M. B. Skrifvars
- Department of Anaesthesia and Intensive Care Medicine, Helsinki University Hospital, Helsinki, Finland
| | - J. Haasio
- Department of Anaesthesia and Intensive Care Medicine, Helsinki University Hospital, Helsinki, Finland
| | - J. T. Backman
- Department of Clinical Pharmacology, University of Helsinki and HUSLAB, Helsinki University Hospital, Helsinki, Finland
| | - P. H. Rosenberg
- Department of Anaesthesia and Intensive Care Medicine, Helsinki University Hospital, Helsinki, Finland
| | - E. Litonius
- Department of Anaesthesia and Intensive Care Medicine, Helsinki University Hospital, Helsinki, Finland
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Hoegberg LCG, Bania TC, Lavergne V, Bailey B, Turgeon AF, Thomas SHL, Morris M, Miller-Nesbitt A, Mégarbane B, Magder S, Gosselin S. Systematic review of the effect of intravenous lipid emulsion therapy for local anesthetic toxicity. Clin Toxicol (Phila) 2016; 54:167-93. [PMID: 26853119 DOI: 10.3109/15563650.2015.1121270] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Following national and regional recommendations, intravenous lipid emulsion (ILE) has become established in clinical practice as a treatment for acute local anesthetic (LA) toxicity, although evidence of efficacy is limited to animal studies and human case reports. A collaborative lipid emulsion workgroup was therefore established by the American Academy of Clinical Toxicology to review the evidence on the effect of ILE for LA toxicity. METHODS We performed a systematic review of the literature published through 15 December 2014. Relevant articles were determined based on pre-defined inclusion and exclusion criteria. Pre-treatment experiments, pharmacokinetic studies not involving toxicity and studies that did not address antidotal use of ILE were excluded. RESULTS We included 113 studies and reports. Of these, 76 were human and 38 animal studies. One publication included both a human case report and an animal study. Human studies included one randomized controlled crossover trial involving 16 healthy volunteers. The subclinical LA toxicity design did not show a difference in the effects of ILE versus saline. There was one case series and 73 case reports of ILE use in the context of toxicity (83 patients) including CNS depression or agitation (n = 45, 54%), seizures (n = 49, 59%), hypotension, hypertension, EKG changes, arrhythmias (n = 39, 47%), cardiac arrest (n = 18, 22%), cardiopulmonary resuscitation, and/or requirement for endotracheal intubation and/or mechanical ventilation (n = 35, 42%). There were 81 (98%) survivors including 63 (76%) with no reported sequelae from the LA poisoning or ILE, although the presence or absence of sequelae was not reported in 15 (18%) cases. Animal studies included 29 randomized controlled studies, three observational studies, five case series, and one case report; bupivacaine was used in 29 of these reports (76%). Of 14 controlled experiments in animals, eight showed improved survival or time to return of spontaneous circulation and five no benefit of ILE versus saline or non-ILE treatments. Combining ILE with epinephrine improved survival in five of the six controlled animal experiments that studied this intervention. The studies were heterogeneous in the formulations and doses of ILE used as well as the doses of LA. The body of the literature identified by this systematic review yielded only a very low quality of evidence. CONCLUSION ILE appears to be effective for reversal of cardiovascular or neurological features in some cases of LA toxicity, but there is currently no convincing evidence showing that ILE is more effective than vasopressors or to indicate which treatment should be instituted as first line therapy in severe LA toxicity.
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Affiliation(s)
- Lotte C G Hoegberg
- a Department of Anesthesiology, Danish Poisons Information Centre , Copenhagen University Hospital Bispebjerg , Copenhagen , Denmark
| | - Theodore C Bania
- b Department of Emergency Medicine , Mt Sinai Roosevelt, Mt Sinai St. Luke's, Icahn School of Medicine , New York , NY , USA
| | - Valéry Lavergne
- c Department of Medical Biology , Sacré-Coeur Hospital, University Of Montréal , Montréal , Canada
| | - Benoit Bailey
- d Division of Emergency Medicine, Department of Pediatrics , CHU Sainte-Justine , Montreal , Canada ;,e Centre Antipoison du Québec , Québec , Canada
| | - Alexis F Turgeon
- f Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine , CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Unit, Université Laval , Québec City , Canada
| | - Simon H L Thomas
- g National Poisons Information Service (Newcastle) and Medical Toxicology Centre , Institute of Cellular Medicine, Newcastle University , Newcastle , United Kingdom
| | - Martin Morris
- h Schulich Library of Science and Engineering , McGill University , Montréal , Canada
| | - Andrea Miller-Nesbitt
- h Schulich Library of Science and Engineering , McGill University , Montréal , Canada
| | - Bruno Mégarbane
- i Department of Medical and Toxicological Intensive Care , Lariboisière Hospital, Paris-Diderot University , Paris , France
| | - Sheldon Magder
- j Department of Critical Care , McGill University Health Centre , Montreal , Canada
| | - Sophie Gosselin
- e Centre Antipoison du Québec , Québec , Canada ;,k Department of Emergency Medicine , McGill University Health Centre , Montréal , Canada
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Intravenous Lipid Emulsion Therapy for Severe Diphenhydramine Toxicity: A Randomized, Controlled Pilot Study in a Swine Model. Ann Emerg Med 2016; 67:196-205.e3. [DOI: 10.1016/j.annemergmed.2015.05.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 05/21/2015] [Accepted: 05/28/2015] [Indexed: 11/18/2022]
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Chana AS, Mahajan RP. BJA 2014; An overview. Br J Anaesth 2015; 114:ix-xvi. [PMID: 25500411 DOI: 10.1093/bja/aeu455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- A S Chana
- Anaesthesia and Critical Care, Division of Clinical Neurosciences, Queen's Medical Centre, University of Nottingham, Nottingham NG7 2UK, UK
| | - R P Mahajan
- Anaesthesia and Critical Care, Division of Clinical Neurosciences, Queen's Medical Centre, University of Nottingham, Nottingham NG7 2UK, UK
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Harvey M, Cave G. Lipid rescue: does the sink hold water? And other controversies. Br J Anaesth 2014; 112:622-5. [DOI: 10.1093/bja/aeu010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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