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A cohort study of unstable overdose patients treated with intravenous lipid emulsion therapy. CAN J EMERG MED 2016; 19:256-264. [DOI: 10.1017/cem.2016.396] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjectivesIntravenous lipid emulsion (ILE) has been used increasingly over the last decade for a range of drug overdoses. Although the use of ILE in local anesthetic toxicity (LAST) is well established, the hemodynamic effectiveness of ILE in non-LAST poisonings is still unclear. Thus, the primary objective of this study was to examine a cohort of poisoned patients in whom ILE was administered.MethodsConsecutive patients were identified by calls to a regional poison center from May 1, 2012 to May 30, 2014. Patients were enrolled if they ingested a drug, developed hemodynamic instability, failed conventional treatment, and received ILE therapy. Data were collected by medical record review. The primary outcome was the change in mean arterial pressure (MAP) in the first hour after ILE administration. Secondary outcomes included survival, length of stay, and the effect of drug class on patient outcome.ResultsThirty-six patients were enrolled. Agents ingested included calcium channel blockers and beta blockers (10/36, 27.8%), tricyclic antidepressants (5/36, 13.9%), bupropion (3/36, 8.3%), and antiepileptic agents (1/36, 2.8%). Seventeen patients (47.2%) ingested multiple agents. Twenty-five patients survived (69.0%). Overall, MAP increased by 13.79 mm Hg (95% CI 1.43–26.15); this did not meet oura prioridefinition of clinical significance.ConclusionsOur study did not find a clinically important improvement in MAP after ILE administration. Until future research is done to more definitively study its efficacy, ILE should remain a potential treatment option for hemodynamically unstable overdose patients only after conventional therapy has failed.
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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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Release of Endotoxin After an Arrest. Crit Care Med 2016; 43:2687-8. [PMID: 26575661 DOI: 10.1097/ccm.0000000000001337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lv D, Bai Z, Yang L, Li X, Chen X. Lipid emulsion reverses bupivacaine-induced apoptosis of h9c2 cardiomyocytes: PI3K/Akt/GSK-3β signaling pathway. ENVIRONMENTAL TOXICOLOGY AND PHARMACOLOGY 2016; 42:85-91. [PMID: 26809062 DOI: 10.1016/j.etap.2016.01.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 01/02/2016] [Accepted: 01/05/2016] [Indexed: 06/05/2023]
Abstract
Some findings have suggested that the rescue of bupivacaine (BPV)-induced cardiotoxicity by lipid emulsion (LE) is associated with inhibition of mitochondrial permeability transition pore (mPTP). However, the mechanism of this rescue action is not clearly known. In this study, the roles of phosphoinositide 3-kinase (PI3K)/Akt and glycogen synthase kinase-3β (GSK-3β) in the molecular mechanism of LE-induced protection and its relationship with mPTP were explored. h9c2 cardiomyocytes were randomly divided into several groups: control, BPV, LE, BPV+LE. To study the effect of LE on mPTP, atractyloside (Atr, 20 μM, mPTP opener) and cyclosporine A (CsA, 10 μM, mPTP blocker) were used. To unravel whether LE protects heart through the PI3K/Akt/GSK-3β signaling pathway, cells were treated with LY294002 (LY, 30 μM, PI3K blocker) or TWS119 (TWS 10 μM, GSK-3β blocker). Later mitochondrial respiratory chain complexes, apoptosis, opening of mPTP and phosphorylation levels of Akt/GSK-3β were measured. LE significantly improved the mitochondrial functions in h9c2 cardiomyocytes. LE reversed the BPV-induced apoptosis and the opening of mPTP. The effect of LE was not only enhanced by CsA and TWS, but also abolished by Atr and LY. LE also increased the phosphorylation levels of Akt and GSK-3β. These results suggested that LE can reverse the apoptosis in cardiomyocytes by BPV and a mechanism of its action is inhibition of mPTP opening through the PI3K/Akt/GSK-3β signaling pathway.
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Affiliation(s)
- Danni Lv
- Ning Xia Medical University, Yin Chuan, China.
| | - Zhixia Bai
- Department of Anesthesiology, Tumor Hospital, General Hospital of Ning Xia Medical University, Yin Chuan, China.
| | - Libin Yang
- Department of Anesthesiology, First People's Hospital, Shi Zui Shan, China.
| | - Xiaohui Li
- Ning Xia Medical University, Yin Chuan, China.
| | - Xuexin Chen
- Department of Anesthesiology, Tumor Hospital, General Hospital of Ning Xia Medical University, Yin Chuan, China.
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Park S, Hwang IW, Kim JS, Kang HC, Park SY, Gil HW, Song HY, Hong SY. The effects of nonyl phenoxypolyethoxyl ethanol on cell damage pathway gene expression in SK-NSH cells. Korean J Intern Med 2015; 30:873-83. [PMID: 26552463 PMCID: PMC4642017 DOI: 10.3904/kjim.2015.30.6.873] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 11/24/2014] [Accepted: 02/13/2015] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND/AIMS Most pesticide formulations contain both chief and additive ingredients. But, the additives may not have been tested as thoroughly as the chief ingredients. The surfactant, nonyl phenoxypolyethoxylethanol (NP40), is an additive frequently present in pesticide formulations. We investigated the effects of NP40 and other constituents of a validamycin pesticide formulation on cell viability and on the expression of genes involved in cell damage pathways. METHODS The effects of validamycin pesticide ingredients on cell viability and of NP40 on the mRNA expression of 80 genes involved in nine key cellular pathways were examined in the human neuroblastoma SK-N-SH cell line. RESULTS The chemicals present in the validamycin pesticide formulation were cytotoxic to SK-N-SH cells and NP40 showed the greatest cytotoxicity. A range of gene expression changes were identified, with both up- and down-regulation of genes within the same pathway. However, all genes tested in the necrosis signaling pathway were down-regulated and all genes tested in the cell cycle checkpoint/arrest pathway were up-regulated. The median fold-change in gene expression was significantly higher in the cell cycle checkpoint/arrest pathway than in the hypoxia pathway category (p = 0.0064). The 70 kDa heat shock protein 4 gene, within the heat shock protein/unfolded protein response category, showed the highest individual increase in expression (26.1-fold). CONCLUSIONS NP40 appeared to be particularly harmful, inducing gene expression changes that indicated genotoxicity, activation of the cell death (necrosis signaling) pathway, and induction of the 70 kDa heat shock protein 4 gene.
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Affiliation(s)
- Samel Park
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Il-woong Hwang
- Pesticide Intoxication Institute, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Jin-sheon Kim
- Pesticide Intoxication Institute, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Hyo-chul Kang
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Su-Yeon Park
- Biostatistical Consulting Unit, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Hyo-wook Gil
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Ho-yeon Song
- Department of Microbiology, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Sae-yong Hong
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
- Correspondence to Sae-yong Hong, M.D. Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, 31 Suncheonhyang 6-gil, Dongnam-gu, Cheonan 31151, Korea Tel: +82-41-570-3682 Fax: +82-41-574-5762 E-mail:
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Heinonen JA, Litonius E, Pitkänen M, Rosenberg PH. Incidence of severe local anaesthetic toxicity and adoption of lipid rescue in Finnish anaesthesia departments in 2011-2013. Acta Anaesthesiol Scand 2015; 59:1032-7. [PMID: 25939497 DOI: 10.1111/aas.12545] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 03/11/2015] [Accepted: 04/07/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND Although the incidence of severe local anaesthetic systemic toxicity (LAST) has been declining, the risk of LAST still remains. There are no national treatment guidelines for LAST in Finland. We performed a national survey of the occurrence of LAST and its treatment in 2011-2013. METHODS A structured electronic questionnaire was sent to the anaesthesia department chiefs of all Finnish public hospitals (n = 45) in spring 2014. We collected information about the occurrence and outcome of LASTs and existence of treatment protocols. RESULTS The questionnaire response rate was 100% covering approximately 95% of all regional anaesthesias managed by anaesthesiologists in Finnish hospitals. The total number of regional anaesthesias, excluding spinal anaesthesia, performed by anaesthesiologists was approximately 211,700 during the survey period. Fifteen cases of LAST were reported (0.7 : 10,000); all patients recovered without negative sequelae. Fourteen patients, in five of whom ultrasound guidance had been applied, developed central nervous system toxicity symptoms and only one cardiac symptoms. Lipid emulsion was given to this latter patient, and to four of the other 14. The relative risk (95% confidence intervals) for occurrence of LAST in non-academic hospital vs. university hospitals was 3.3 (1.0-10.3; P = 0.04). Treatment protocols for LAST included lipid emulsion in 47% of the departments. CONCLUSIONS The incidence of LAST in Finland is very low. Several departments have adopted lipid emulsion treatment for LAST despite lack of national recommendations and knowledge of the possible mechanism of action.
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Affiliation(s)
- J. A. Heinonen
- Department of Anaesthesiology and Intensive Care Medicine; University of Helsinki; Helsinki Finland
| | - E. Litonius
- Department of Anaesthesiology and Intensive Care Medicine; Helsinki University Hospital; Helsinki Finland
| | - M. Pitkänen
- Department of Anaesthesiology; Orthopaedic Hospital Orton; Invalid Foundation; Helsinki Finland
| | - P. H. Rosenberg
- Department of Anaesthesiology and Intensive Care Medicine; University of Helsinki; Helsinki Finland
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Agarwala R, Ahmed SZ, Wiegand TJ. Prolonged use of intravenous lipid emulsion in a severe tricyclic antidepressant overdose. J Med Toxicol 2015; 10:210-4. [PMID: 24173885 DOI: 10.1007/s13181-013-0353-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Intravenous lipid emulsion (ILE) resuscitation is now frequently being used for severe overdoses due to lipophilic drugs. However, the optimal dose, duration, and safety are still unclear. CASE REPORT A patient with refractory cardiovascular collapse following an amitriptyline overdose was treated with ILE with initial improvement. Instability recurred after ILE discontinuation and lipid therapy was restarted, but high-dose treatment was complicated by severe lipemia. A low-dose infusion was instead used, and the patient did not experience further toxicity despite amitriptyline levels in the toxic range for 21 days. He survived to discharge without long-term sequelae. DISCUSSION A low-dose infusion of ILE was well tolerated and may have successfully prevented recurrent toxicity in a case of severe tricyclic antidepressant overdose.
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Affiliation(s)
- Ravi Agarwala
- Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA,
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Surfactant toxicity in a case of (4-chloro-2-methylphenoxy) acetic acid herbicide intoxication. Hum Exp Toxicol 2014; 34:848-55. [DOI: 10.1177/0960327114559612] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: Self-poisoning with (4-chloro-2-methylphenoxy) acetic acid (MCPA) is a common reason for presentation to hospitals, especially in some Asian countries. We encountered a case of a 76-year-old woman who experienced unconsciousness, shock and respiratory failure after ingesting 100 mL MCPA herbicide. We determined whether the surfactant in the formulation was the chemical responsible for the toxic symptom in this patient. Design: 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) cell viability and lactate dehydrogenase (LDH) cytotoxicity assays were performed on human brain neuroblastoma SK-N-SH cells. The expressions of 84 genes in 9 categories that are implicated in cellular damage pathways were quantified using an RT2 Profiler™ PCR array on a human neuronal cell line challenged with polyoxyethylene tridecyl ether (PTE). Setting: Pesticide intoxication institute in university hospital. Interventions: Extracorporeal elimination with intravenous lipid emulsion. Measurements: Cell viability and gene expression. Main Results: In the MTT assay, MCPA only minimally decreased cell viability even at concentrations as high as 1 mM. Cells treated with 1-methoxy-2-propanol, dimethylamine and polypropylene glycol exhibited minimal decreases in viability, whilst the viability of cells challenged with PTE decreased dramatically; only 15.5% of cells survived after exposure to 1 µM PTE. Similarly, the results of the LDH cytotoxicity assay showed that MCPA had very low cytotoxicity, whilst cells treated with PTE showed incomparably higher LDH levels ( p < 0.0001). PTE up-regulated the expressions of genes implicated in various cell damage pathways, particularly genes involved in the inflammatory pathway. Conclusions: The surfactant PTE was likely the chemical responsible for the toxic symptom in our patient.
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Shenoy S, Lankala S, Adigopula S. Management of calcium channel blocker overdoses. J Hosp Med 2014; 9:663-8. [PMID: 25066023 DOI: 10.1002/jhm.2241] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 07/01/2014] [Accepted: 07/08/2014] [Indexed: 11/09/2022]
Abstract
Calcium channel blockers (CCBs) are some of the most commonly used medications in clinical practice to treat hypertension, angina, cardiac arrhythmias, and some cases of heart failure. Recent data show that CCBs are the most common of the cardiovascular medications noted in intentional or unintentional overdoses.(1) Novel treatment approaches in the form of glucagon, high-dose insulin therapy, and intravenous lipid emulsion therapies have been tried and have been successful. However, the evidence for these are limited to case reports and case series. We take this opportunity to review the various treatment options in the management of CCB overdoses with a special focus on high-dose insulin therapy as the emerging choice for initial therapy in severe overdoses.
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Affiliation(s)
- Sundeep Shenoy
- Division of Inpatient Medicine, University of Arizona, Tucson, Arizona
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Lipid Rescue Reverses the Bupivacaine-induced Block of the Fast Na+ Current (INa) in Cardiomyocytes of the Rat Left Ventricle. Anesthesiology 2014; 120:724-36. [DOI: 10.1097/aln.0b013e3182a66d4d] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Abstract
Background:
Cardiovascular resuscitation upon intoxication with lipophilic ion channel–blocking agents has proven most difficult. Recently, favorable results have been reported when lipid rescue therapy is performed, i.e., the infusion of a triglyceride-rich lipid emulsion during resuscitation. However, the mechanism of action is poorly understood.
Methods:
The authors investigate the effects of a clinically used lipid emulsion (Lipovenös® MCT 20%; Fresenius Kabi AG, Bad Homburg, Germany) on the block of the fast Na+ current (INa) induced by the lipophilic local anesthetic bupivacaine in adult rat left ventricular myocytes by using the whole cell patch clamp technique.
Results:
Bupivacaine at 10 µm decreased INa by 54% (−19.3 ± 1.9 pApF−1vs. −42.3 ± 4.3 pApF−1; n = 17; P < 0.001; VPip = −40 mV, 1 Hz). Addition of 10% lipid emulsion in the presence of bupivacaine produced a 37% increase in INa (−26.4 ± 2.8 pApF−1; n = 17; P < 0.001 vs. bupivacaine alone). To test whether these results could be explained by a reduction in the free bupivacaine concentration by the lipid (lipid-sink effect), the authors removed the lipid phase from the bupivacaine–lipid mixture by ultracentrifugation. Also, the resulting water phase led to an increase in INa (+19%; n = 17; P < 0.001 vs. bupivacaine), demonstrating that part of the bupivacaine had been removed during ultracentrifugation. The substantially less lipophilic mepivacaine (40 µm) reduced INa by 27% (n = 24; P < 0.001). The mepivacaine–lipid mixture caused a significant increase in INa (+17%; n = 24; P < 0.001). For mepivacaine, only a small lipid-sink effect could be demonstrated (+8%; n = 23; P < 0.01), reflecting its poor lipid solubility.
Conclusion:
The authors demonstrate lipid rescue on the single-cell level and provide evidence for a lipid-sink mechanism.
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Harvey M, Cave G, Ong B. Intravenous lipid emulsion-augmented plasma exchange in a rabbit model of clomipramine toxicity; survival, but no sink. Clin Toxicol (Phila) 2014; 52:13-9. [DOI: 10.3109/15563650.2013.866242] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Gil HW, Park JS, Park SH, Hong SY. Effect of intravenous lipid emulsion in patients with acute glyphosate intoxication. Clin Toxicol (Phila) 2013; 51:767-71. [PMID: 23869655 DOI: 10.3109/15563650.2013.821129] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Although glyphosate intoxication has been considered minimally toxic in animals, severe toxicity has been observed in humans due to surfactant. We aimed to examine the potential therapeutic effects of intravenous lipid emulsion (ILE) on the patients with acute glyphosate intoxication. METHODS This study enrolled 64 glyphosate-intoxicated patients with allocation to two groups: those treated with ILE (ILE group, n = 22), and control patients treated with only supportive (conservative) care. Control patients were selected by matching for the amount ingested and time since ingestion. Twenty-two control patients were separately selected from the 42 patients receiving supportive care only. In ILE group, 20% lipid emulsion product was injected intravenously at the rate of 20 mL/h for the patients who ingested less than 100 ml of glyphosate. In the patients who ingested more than 100 ml of glyphosate, the loading dose was 500 ml for 2-3 h according to the status of the patients, followed by a maintenance dose of 1000 ml for the next 24 h. RESULTS Thirteen patients received high dose of ILE because the ingestion amount was more than 100 ml. None of the ILE group suffered from the complication of hypotension, while approximately 41% of the control group developed the complication. Additionally, arrhythmia was not observed in the ILE group. The incidence of mental change, respiratory failure, and acute kidney injury was similar between the two groups. CONCLUSIONS ILE administration was associated with lower incidence of hypotension and arrhythmia in patients with acute glyphosate intoxication. ILE administration seems to be an effective treatment modality in patients who ingested sufficient amount of glyphosate herbicide that is expected to bring about significant toxicity.
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Affiliation(s)
- Hyo-Wook Gil
- Department of Internal Medicine, College of Medicine, Soonchunhyang University Cheonan Hospital , Cheonan , Republic of Korea
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