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Peruch M, Giacomello E, Radaelli D, Concato M, Addobbati R, Fluca AL, Aleksova A, D’Errico S. Subcellular Effectors of Cocaine Cardiotoxicity: All Roads Lead to Mitochondria-A Systematic Review of the Literature. Int J Mol Sci 2023; 24:14517. [PMID: 37833964 PMCID: PMC10573028 DOI: 10.3390/ijms241914517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023] Open
Abstract
Cocaine abuse is a serious public health problem as this drug exerts a plethora of functional and histopathological changes that potentially lead to death. Cocaine causes complex multiorgan toxicity, including in the heart where the blockade of the sodium channels causes increased catecholamine levels and alteration in calcium homeostasis, thus inducing an increased oxygen demand. Moreover, there is evidence to suggest that mitochondria alterations play a crucial role in the development of cocaine cardiotoxicity. We performed a systematic review according to the Preferred Reporting Items for Systemic Reviews and Meta-Analysis (PRISMA) scheme to evaluate the mitochondrial mechanisms determining cocaine cardiotoxicity. Among the initial 106 articles from the Pubmed database and the 17 articles identified through citation searching, 14 final relevant studies were extensively reviewed. Thirteen articles included animal models and reported the alteration of specific mitochondria-dependent mechanisms such as reduced energy production, imbalance of membrane potential, increased oxidative stress, and promotion of apoptosis. However, only one study evaluated human cocaine overdose samples and observed the role of cocaine in oxidative stress and the induction of apoptosis though mitochondria. Understanding the complex processes mediated by mitochondria through forensic analysis and experimental models is crucial for identifying potential therapeutic targets to mitigate or reverse cocaine cardiotoxicity in humans.
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Affiliation(s)
- Michela Peruch
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy; (M.P.); (E.G.); (D.R.); (M.C.); (A.L.F.); (A.A.)
| | - Emiliana Giacomello
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy; (M.P.); (E.G.); (D.R.); (M.C.); (A.L.F.); (A.A.)
| | - Davide Radaelli
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy; (M.P.); (E.G.); (D.R.); (M.C.); (A.L.F.); (A.A.)
| | - Monica Concato
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy; (M.P.); (E.G.); (D.R.); (M.C.); (A.L.F.); (A.A.)
| | - Riccardo Addobbati
- Institute for Maternal and Child Health, IRCCS “Burlo Garofolo”, 34137 Trieste, Italy;
| | - Alessandra Lucia Fluca
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy; (M.P.); (E.G.); (D.R.); (M.C.); (A.L.F.); (A.A.)
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, 34149 Trieste, Italy
| | - Aneta Aleksova
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy; (M.P.); (E.G.); (D.R.); (M.C.); (A.L.F.); (A.A.)
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, 34149 Trieste, Italy
| | - Stefano D’Errico
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy; (M.P.); (E.G.); (D.R.); (M.C.); (A.L.F.); (A.A.)
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Shastry S, Manoochehri O, Richardson LD, Manini AF. Cocaethylene cardiotoxicity in emergency department patients with acute drug overdose. Acad Emerg Med 2023; 30:82-88. [PMID: 36000306 PMCID: PMC9918638 DOI: 10.1111/acem.14584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/10/2022] [Accepted: 08/20/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Cocaine use results in over 500,000 emergency department (ED) visits annually across the United States and ethanol co-ingestion is reported in 34% of these. Commingling cocaine with ethanol results in the metabolite cocaethylene (CE), which is metabolically active for longer than cocaine alone. Current literature on the cardiotoxicity of CE compared to cocaine alone is limited and lacks consensus. This study aims to fill this gap in the literature and examine cardiovascular events in cocaine use as confirmed by urine toxicology versus CE exposure. METHODS This was a secondary data analysis of a prospective cohort study of adult patients with acute drug overdose at two urban tertiary care hospital EDs over 4 years. Patients with positive urinary cocaine metabolites were analyzed, and outcomes were compared between patients with overdose and confirmed presence of cocaine on urine toxicology (cocaine group) and patients with cocaine and ethanol use (CE group). The primary outcome was cardiac arrest. Secondary outcomes included myocardial injury and hyperlactatemia. Data were analyzed using multivariable regression models. RESULTS We enrolled a total of 199 patients (150 cocaine, 49 CE). Rates of cardiac arrest were significantly higher in the CE group compared to cocaine (6.1% vs. 0.67%, p = 0.048). Cocaine was significantly associated with myocardial injury compared to CE exposure (mean initial troponin 0.01 ng/ml vs. 0.16 ng/ml, p = 0.021), while hyperlactatemia was associated with CE exposure (mean initial lactate 4.1 mmol/L vs. 2.9 mmol/L, p = 0.038). CONCLUSIONS When compared to cocaine exposure alone, CE exposure in ED patients with acute drug overdose was significantly associated with higher occurrence of cardiac arrest, higher mean lactate concentrations, and lower occurrence of myocardial injury.
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Affiliation(s)
- Siri Shastry
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Omid Manoochehri
- Emergency Medicine Residency, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lynne D. Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alex F. Manini
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Division of Medical Toxicology, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, New York, New York, USA
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García-Ramos S, Fernandez I, Zaballos M. Lipid emulsions in the treatment of intoxications by local anesthesics and other drugs. Review of mechanisms of action and recommendations for use. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:421-432. [PMID: 35871141 DOI: 10.1016/j.redare.2021.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 03/25/2021] [Indexed: 06/15/2023]
Abstract
Intravenous lipid emulsions (ILEs) have been used widely for the treatment of local anesthetic (LA) poisoning and have been proposed as a treatment for intoxication by other drugs. However, the degree of evidence for this kind of therapy is not strong, as it comes mostly from clinical cases. The aim of this narrative review is to describe the proposed mechanisms of action for ILEs in poisoning by LA and other drugs and to evaluate recent studies in animals that support the recommendations for their use and the experience in humans that support the use of ILESs in both LA and other drug poisoning. For this purpose, a search was performed in the Embase, Medline and Google Scholar databases covering relevant articles over the last 10 years. In the case of AL poisoning, we recommend applying the protocols dictated by international guidelines, knowing that the degree of evidence is not very high. In poisoning by other drugs, ILEs are recommended in serious situations induced by liposoluble xenobiotics that do not respond to standard treatment.
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Affiliation(s)
- S García-Ramos
- Servicio de Anestesia y Reanimación, Hospital Universitario Gregorio Marañón, Madrid, Spain.
| | - I Fernandez
- Servicio de Anestesia y Reanimación, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - M Zaballos
- Servicio de Anestesia y Reanimación, Hospital Universitario Gregorio Marañón, Madrid, Spain; Departamento de Toxicología, Universidad Complutense de Madrid, Madrid, Spain
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Saasouh W, Nikam A, Hachwa B. Intravenous Lipid Emulsion for the Treatment of Perioperative Cocaine Intoxication. Cureus 2021; 13:e19146. [PMID: 34868781 PMCID: PMC8629685 DOI: 10.7759/cureus.19146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2021] [Indexed: 11/17/2022] Open
Abstract
Symptomatic cocaine intoxication in the preoperative period is a potentially life-threatening condition, especially before emergent surgery. The anesthesiologist is faced with a dilemma where the patient is deemed unsafe for induction of general anesthesia but also in need of immediate surgical intervention. Cocaine is a local anesthetic and, as such, has been proposed to respond to lipid emulsion treatment as other local anesthetics would. We present a case supporting this statement and review the relevant published literature on the topic.
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Affiliation(s)
- Wael Saasouh
- Anesthesiology, Detroit Medical Center, NorthStar Anesthesia, Detroit, USA
| | - Anuja Nikam
- Medicine, Michigan State University, Detroit, USA
| | - Bachar Hachwa
- Anesthesiology, Detroit Medical Center, NorthStar Anesthesia, Detroit, USA
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Relationship between cocaine and cocaethylene blood concentration with the severity of clinical manifestations. Am J Emerg Med 2021; 50:404-408. [PMID: 34481259 DOI: 10.1016/j.ajem.2021.08.057] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 08/19/2021] [Accepted: 08/22/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Poisonings resulting from the abuse of drugs currently represent a serious problem for public health. Among the main agents involved, cocaine stands out. It became one of the most abused drugs around the world, and one of the main reasons for visits to the emergency department due to the use of illicit substances. The use of cocaine is primarily in combination with alcoholic beverages. There are few studies that correlate cocaine blood concentration and the severity of clinical manifestations in patients evaluated at Emergency Department. The aim of the present study was to verify the possible relationship between the blood concentration of cocaine and cocaethylene (product of the interaction of cocaine with ethanol) with the severity of the clinical manifestations presented by patients with cocaine intoxication. METHODS Blood levels were measured by high-performance liquid chromatography (HPLC) and the severity of clinical manifestations was assessed using the Stimulant Intoxication Score (SIS). To establish this relationship, Pearson's chi-square statistical test (x2) was used for categorical variables and Student's t for continuous variables, with statistical significance of 5% (p < 0.05). RESULTS Of the 81 patients included in the study, 77.8% were men with a mean age of 32.5 years ± 8.5 and mean of SIS 3.4 ± 2.5. Considering the toxicological analysis results, 24.7% of the blood samples were positive. The mean of cocaine and cocaethylene concentrations were 0.34 μg/mL ± 0.45 and 0.38 μg/mL ± 0.34, respectively. The blood concentration of cocaine and cocaethylene has not been shown to be useful information for the treatment and prognosis of patients, but blood levels of these substances at the time of treatment, regardless of their concentration, may be an indicator of severity, showing that any concentrations of these substances should be considered as potentially toxic. CONCLUSION The application of the SIS score proved to be an important alternative capable of predicting the severity of the patients due to cocaine intoxication in a fast and simplified way.
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García-Ramos S, Fernandez I, Zaballos M. Lipid emulsions in the treatment of intoxications by local anesthesics and other drugs. Review of mechanisms of action and recommendations for use. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 69:S0034-9356(21)00143-2. [PMID: 34140161 DOI: 10.1016/j.redar.2021.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 01/24/2021] [Accepted: 03/25/2021] [Indexed: 11/21/2022]
Abstract
Intravenous lipid emulsions (ILEs) have been used widely for the treatment of local anesthetic (LA) poisoning and have been proposed as a treatment for intoxication by other drugs. However, the degree of evidence for this kind of therapy is not strong, as it comes mostly from clinical cases. The aim of this narrative review is to describe the proposed mechanisms of action for ILEs in poisoning by LA and other drugs and to evaluate recent studies in animals that support the recommendations for their use and the experience in humans that support the use of ILESs in both LA and other drug poisoning. For this purpose, a search was performed in the Embase, Medline and Google Scholar databases covering relevant articles over the last 10 years. In the case of AL poisoning, we recommend applying the protocols dictated by international guidelines, knowing that the degree of evidence is not very high. In poisoning by other drugs, ILEs are recommended in serious situations induced by liposoluble xenobiotics that do not respond to standard treatment.
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Affiliation(s)
- S García-Ramos
- Servicio de Anestesia y Reanimación, Hospital Universitario Gregorio Marañón, Madrid, España.
| | - I Fernandez
- Servicio de Anestesia y Reanimación, Hospital Universitario Gregorio Marañón, Madrid, España
| | - M Zaballos
- Servicio de Anestesia y Reanimación, Hospital Universitario Gregorio Marañón, Madrid, España; Departamento de Toxicología, Universidad Complutense de Madrid, Madrid, España
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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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Royle K, Bandt C. Intravenous lipid emulsion to treat suspected cocaine toxicosis in a dog. THE CANADIAN VETERINARY JOURNAL = LA REVUE VETERINAIRE CANADIENNE 2020; 61:49-52. [PMID: 31892754 PMCID: PMC6909416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
A 6-month-old puppy was treated for suspected cocaine toxicosis. Supportive care was initiated but clinical signs worsened and treatment with intravenous lipid emulsion (ILE) was instituted. Clinical signs rapidly resolved in response to treatment with ILE.
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Affiliation(s)
- Kirsty Royle
- Canada West Veterinary Specialists, 1988 Kootenay Street, Vancouver, British Columbia V5M 4Y3
| | - Carsten Bandt
- Canada West Veterinary Specialists, 1988 Kootenay Street, Vancouver, British Columbia V5M 4Y3
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Yousefsani BS, Mohajeri SA, Moshiri M, Jafarian AH, Hosseinzadeh H. Effect of Intravenous Lipid Emulsion on Clozapine Acute Toxicity in Rats. J Pharmacopuncture 2019; 22:147-153. [PMID: 31673444 PMCID: PMC6820469 DOI: 10.3831/kpi.2019.22.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 04/15/2019] [Accepted: 05/31/2019] [Indexed: 11/30/2022] Open
Abstract
Objectives Many studies have been reported the efficacy of intravenous lipid emulsion (ILE) as an antidote on acute lipophilic drug toxicity. Clozapine, highly lipophilic dibenzodiazepine neuroleptics, is an important medication in the schizophrenia therapy regimen. Acute intoxication with antipsychotics is one of the main reasons for the referral of poisoned patients to the hospital. We expected that ILE could be used for the therapy of acute clozapine intoxicated patients. Methods We used two groups of consisting of six male rats. Both groups received a toxic dose of clozapine (40 mg/kg) intravenously, via the tail vein. After 15 minutes, they were treated with intravenous infusion of 18.6 mg/kg normal saline (NS group), or 18.6 mg/kg ILE 20% (ILE group). We evaluated blood pressure (BP) and heart rate by power lab apparatus through the tail artery, ataxia by a rat rotary circle, seizure scores and death in multiple times after starting clozapine administration. For biochemical and pathological evaluations the samples of tissue and blood were taken. Results Our results demonstrated that ILE 20% could return hypotension-induced clozapine better than normal saline. Furthermore, ataxia and seizure have rectified more rapidly and deaths reduced. Clozapine administration causes pancreatitis and lung injury but fat emulsion did not show an optimal effect on tissue damages caused by clozapine toxicity. Conclusion In conclusion, ILE can remove toxic signs of clozapine same as other lipophilic medicines, however, clinical uses of ILE for this intention requires more appraisement to determine the precise implication and safety.
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Affiliation(s)
- Bahareh Sadat Yousefsani
- Research Institute for Islamic and Complementary Medicine, Iran University of Medical Sciences, Tehran, Iran.,School of Persian Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Ahmad Mohajeri
- Department of Pharmacodynamy and Toxicology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Moshiri
- Department of Pharmacodynamy and Toxicology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amir Hossein Jafarian
- Cancer Molecular Pathology Research Center, Ghaem Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hossein Hosseinzadeh
- Department of Pharmacodynamy and Toxicology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.,Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
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Kien NT, Giang NT, Van Manh B, Cuong NM, Van Dinh N, Pho DC, The Anh V, Khanh DT, Quang Thuy L, Van Dong P. Successful intralipid-emulsion treatment of local anesthetic systemic toxicity following ultrasound-guided brachial plexus block: case report. Int Med Case Rep J 2019; 12:193-197. [PMID: 31303799 PMCID: PMC6605765 DOI: 10.2147/imcrj.s207317] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 06/01/2019] [Indexed: 12/30/2022] Open
Abstract
Background Local anesthetic systemic toxicity (LAST) is a life-threatening complication that may follow application of LAs through various routes. Despite increasing usage of LA techniques in a large number of health-care settings, contemporary awareness of LAST and understanding of its management are inadequate. Case presentation We report two cases who suffered LAST following brachial plexus block for surgery on the upper extremity. The first patient received an ultrasound-guided supraclavicular block with 300 mg lidocaine (6 mg/kg) and 50 mg ropivacaine (1 mg/kg) in 25 mL without epinephrine, and the second patient received an ultrasound guided interscalene block with 200 mg lidocaine (4.5 mg/kg) and 45 mg ropivacaine (1 mg/kg) supplemented with epinephrine 1:200,000. Both patients presented with symptoms of central nervous and respiratory system depression, the first roughly 10 minutes after injection, and the second immediately after withdrawal of the needle. In both cases, thorough recovery was obtained using lipid-emulsion therapy. Conclusion The complication of LAST following ultrasound-guided brachial plexus block could be treated successfully applying the American Society of Regional Anesthesia and Pain Medicineprotocol of intravenous administration of lipid emulsion.
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Affiliation(s)
- Nguyen Trung Kien
- Center of Emergency, Critical Care Medicine, and Clinical Toxicology, Military Hospital 103, Vietnam Military Medical University, Hanoi, Vietnam
| | - Nguyen Truong Giang
- Department of Cardiothoracic Surgery, Military Hospital 103, Vietnam Military Medical University, Hanoi, Vietnam
| | - Bui Van Manh
- Center of Emergency, Critical Care Medicine, and Clinical Toxicology, Military Hospital 103, Vietnam Military Medical University, Hanoi, Vietnam
| | - Nguyen Manh Cuong
- Department of Anesthesia and Pain Medicine, Military Hospital 103, Vietnam Military Medical University, Hanoi, Vietnam
| | - Ngo Van Dinh
- Department of Anesthesia and Pain Medicine, Military Hospital 103, Vietnam Military Medical University, Hanoi, Vietnam
| | - Dinh Cong Pho
- Faculty of Medicine, Vietnam Military Medical University, Hanoi, Vietnam
| | - Vu The Anh
- Department of Anesthesia and Pain Medicine, Military Hospital 103, Vietnam Military Medical University, Hanoi, Vietnam
| | - Dao Thi Khanh
- Department of Pharmacy, Military Hospital 103, Vietnam Military Medical University, Hanoi, Vietnam
| | - Luu Quang Thuy
- Center of Anesthesia and Surgical Intensive Care, Vietduc University Hospital, Hanoi, Vietnam
| | - Pham Van Dong
- Anesthesia and Pain Medicine, Cho Ray Hospital, Ho Chi Minh City, Vietnam
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Abstract
The experimental use of lipid emulsion for local anesthetic toxicity was originally identified in 1998. It was then translated to clinical practice in 2006 and expanded to drugs other than local anesthetics in 2008. Our understanding of lipid resuscitation therapy has progressed considerably since the previous update from the American Society of Regional Anesthesia and Pain Medicine, and the scientific evidence has coalesced around specific discrete mechanisms. Intravenous lipid emulsion therapy provides a multimodal resuscitation benefit that includes both scavenging (eg, the lipid shuttle) and nonscavenging components. The intravascular lipid compartment scavenges drug from organs susceptible to toxicity and accelerates redistribution to organs where drug (eg, bupivacaine) is stored, detoxified, and later excreted. In addition, lipid exerts nonscavenging effects that include postconditioning (via activation of prosurvival kinases) along with cardiotonic and vasoconstrictive benefits. These effects protect tissue from ischemic damage and increase tissue perfusion during recovery from toxicity. Other mechanisms have diminished in favor based on lack of evidence; these include direct effects on channel currents (eg, calcium) and mass-effect overpowering a block in mitochondrial metabolism. In this narrative review, we discuss these proposed mechanisms and address questions left to answer in the field. Further work is needed, but the field has made considerable strides towards understanding the mechanisms.
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Prevalence of cocaine and derivatives in blood and urine samples of trauma patients and correlation with injury severity: a prospective observational study. Eur J Trauma Emerg Surg 2017; 45:159-165. [PMID: 29116350 DOI: 10.1007/s00068-017-0868-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 10/30/2017] [Indexed: 12/28/2022]
Abstract
PURPOSE The abuse of cocaine and its derivatives presents a likely risk factor for injury. Trauma incurred by cocaine and derivative abusers may be more severe than that incurred by non-users. OBJECTIVES To ascertain the presence of cocaine and its derivatives in trauma patients and to correlate RTS (Revised Trauma Score) and ISS (Injury Severity Score) with the presence of cocaine and its derivatives in blood and urine samples. METHODS All trauma victims treated in an emergency unit between November 11, 2012 and September 15, 2013 were included in the study. Blood and urine samples were collected on admission to hospital. RTS and ISS scores were then compared with the presence or absence of cocaine and its derivatives in the samples. The associations between RTS < 7.84 and ISS > 16 and the independent variables were evaluated by the gross odds ratio values, determined by univariate logistic regression. Multivariate analysis was performed using multivariate logistic regression. RESULTS Of 453 patients (83.7% male) included in the study, 28.6% presented ISS > 16 and 33.6% presented RTS < 7.84. A total of 435 samples were collected, and 86 (19.8%) provided positive samples for cocaine, 48 (11%) for crack and 69 (15.9%) for cocaethylene. Compared to other patients, drug users showed a greater probability of RTS < 7.84 (2.18 times greater) and a greater probability of ISS > 16 (1.76 times greater). CONCLUSION For the trauma patients included in our study, the use of cocaine and its derivatives was shown to be associated with more severe traumas, as demonstrated by their RTS and ISS scores.
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Insulin Signaling in Bupivacaine-induced Cardiac Toxicity: Sensitization during Recovery and Potentiation by Lipid Emulsion. Anesthesiology 2016; 124:428-42. [PMID: 26646023 DOI: 10.1097/aln.0000000000000974] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The impact of local anesthetics on the regulation of glucose homeostasis by protein kinase B (Akt) and 5'-adenosine monophosphate-activated protein kinase (AMPK) is unclear but important because of the implications for both local anesthetic toxicity and its reversal by IV lipid emulsion (ILE). METHODS Sprague-Dawley rats received 10 mg/kg bupivacaine over 20 s followed by nothing or 10 ml/kg ILE (or ILE without bupivacaine). At key time points, heart and kidney were excised. Glycogen content and phosphorylation levels of Akt, p70 s6 kinase, s6, insulin receptor substrate-1, glycogen synthase kinase-3β, AMPK, acetyl-CoA carboxylase, and tuberous sclerosis 2 were quantified. Three animals received Wortmannin to irreversibly inhibit phosphoinositide-3-kinase (Pi3k) signaling. Isolated heart studies were conducted with bupivacaine and LY294002-a reversible Pi3K inhibitor. RESULTS Bupivacaine cardiotoxicity rapidly dephosphorylated Akt at S473 to 63 ± 5% of baseline and phosphorylated AMPK to 151 ± 19%. AMPK activation inhibited targets downstream of mammalian target of rapamycin complex 1 via tuberous sclerosis 2. Feedback dephosphorylation of IRS1 to 31 ± 8% of baseline sensitized Akt signaling in hearts resulting in hyperphosphorylation of Akt at T308 and glycogen synthase kinase-3β to 390 ± 64% and 293 ± 50% of baseline, respectively. Glycogen accumulated to 142 ± 7% of baseline. Irreversible inhibition of Pi3k upstream of Akt exacerbated bupivacaine cardiotoxicity, whereas pretreating with a reversible inhibitor delayed the onset of toxicity. ILE rapidly phosphorylated Akt at S473 and T308 to 150 ± 23% and 167 ± 10% of baseline, respectively, but did not interfere with AMPK or targets of mammalian target of rapamycin complex 1. CONCLUSION Glucose handling by Akt and AMPK is integral to recovery from bupivacaine cardiotoxicity and modulation of these pathways by ILE contributes to lipid resuscitation.
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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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16
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Fettiplace MR, Weinberg G. Past, Present, and Future of Lipid Resuscitation Therapy. JPEN J Parenter Enteral Nutr 2015; 39:72S-83S. [DOI: 10.1177/0148607115595979] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 06/22/2015] [Indexed: 01/18/2023]
Affiliation(s)
- Michael R. Fettiplace
- Department of Anesthesiology, University of Illinois College of Medicine, Chicago, Illinois
- Research & Development Service, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois
- Neuroscience Program, University of Illinois at Chicago, Chicago, Illinois
| | - Guy Weinberg
- Department of Anesthesiology, University of Illinois College of Medicine, Chicago, Illinois
- Research & Development Service, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois
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