1
|
Zaballos M, Fernández I, Rodríguez L, García S, Varela O, Quintela O, Anadón MJ, Almendral J. Effects of intravenous lipid emulsions on the reversal of pacing-induced ventricular arrhythmias and electrophysiological alterations in an animal model of ropivacaine toxicity. Clin Toxicol (Phila) 2022; 60:902-911. [PMID: 35658706 DOI: 10.1080/15563650.2022.2080075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Ropivacaine is considered to have a wider margin of cardiovascular safety. However, several reports of ventricular arrhythmias (VA) due to ropivacaine toxicity have been documented. Intravenous lipid emulsions (ILEs) have recently been used successfully in the treatment of local anesthetic intoxication. The main objective of the present study was to evaluate the efficacy of the ILEs in the prevention of pacing-induced-VA and electrophysiological alterations in an animal model of ropivacaine toxicity. METHODS Nineteen pigs were anesthetized and instrumentalized. A baseline programmed electrical ventricular stimulation protocol (PEVSP) to induce VA was performed. Ropivacaine (5 mg·kg-1 + 100 μg·kg-1·min-1) followed by normal saline infusion (control group n = 8) or intralipid 20% (1.5 mL·kg-1 + 0.25 mL·kg-1·min-1) for the ILE group (n = 8), were administered three minutes after the ropivacaine bolus. PEVSP was repeated 25 min after the onset of ropivacaine infusion. Pacing-induced VA and electrophysiological abnormalities were assessed in both groups. A sham-control group (n = 3) without ropivacaine infusion was included. RESULTS Most of the electrophysiological parameters evaluated were affected by ropivacaine: PR interval by 28% (p = 0.001), AV interval by 40% (p = 0.001), sinus QRS by 101% (p = 0.001), paced QRS at a rate of 150 bpm by 258% (p = 0.001), and at 120 bpm by 241% (p = 0.001). Seven animals (87.5%) in the control group and eight animals (100%) in the ILE group developed sustained-VA (p = 0.30). Successful resuscitation occurred in 100% of animals in the ILE group vs. 57% of animals in the control group, p = 0.038. Pacing-induced-VA terminated at the first defibrillation attempt in 75% of the animals in the ILE group vs. 0% in the control group, p = 0.01. CONCLUSION Ropivacaine strongly altered the parameters of ventricular conduction, thus facilitating the induction of VA. ILEs did not prevent pacing-induced VA. However, facilitated resuscitation and termination of VA were delivered at the first defibrillation attempt compared to the control group.
Collapse
Affiliation(s)
- Matilde Zaballos
- Department of Forensic Medicine, Psychiatry and Pathology, Department of Anaesthesiology, Faculty of Medicine, Complutense University, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Ignacio Fernández
- Department of Anesthesiology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Lucia Rodríguez
- Department of Anesthesiology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Sergio García
- Department of Anesthesiology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Olalla Varela
- Department of Anesthesiology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Oscar Quintela
- Department of Forensic Medicine, Psychiatry and Pathology, Faculty of Medicine, Complutense University, Madrid, Spain
| | - María-José Anadón
- Head Department of Forensic Medicine, Psychiatry and Pathology, Faculty of Medicine, National Institute of Toxicology and Forensic Science, Complutense University, Madrid, Spain
| | - Jesús Almendral
- Electrophysiology Arrhythmia Unit, Hospital Monteprincipe Grupo HM Hospitales, University CEU-San Pablo, Madrid, Spain
| |
Collapse
|
3
|
Gosselin S, Hoegberg LCG, Hoffman RS, Graudins A, Stork CM, Thomas SHL, Stellpflug SJ, Hayes BD, Levine M, Morris M, Nesbitt-Miller A, Turgeon AF, Bailey B, Calello DP, Chuang R, Bania TC, Mégarbane B, Bhalla A, Lavergne V. Evidence-based recommendations on the use of intravenous lipid emulsion therapy in poisoning. Clin Toxicol (Phila) 2016; 54:899-923. [DOI: 10.1080/15563650.2016.1214275] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Sophie Gosselin
- Department of Emergency Medicine, McGill University Health Centre, Montréal, Québec, Canada
- Centre Antipoison du Québec, Montréal, Québec, Canada
- Province of Alberta Drug Information Services, Calgary, Alberta, Canada
| | - Lotte C. G. Hoegberg
- Danish Poisons Information Centre, Anaesthesiology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Robert. S. Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, NY, USA
| | - Andis Graudins
- Monash Clinical Toxicology Service, Program of Emergency Medicine, Monash Health and School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Christine M. Stork
- Upstate NY Poison Center, Syracuse, NY, USA
- Department of Emergency Medicine, Upstate Medical University, Syracuse, New York, USA
| | - Simon H. L. Thomas
- National Poisons Information Service (Newcastle) and Medical Toxicology Centre, Institute of Cellular Medicine, Newcastle University, Newcastle, UK
| | | | - Bryan D. Hayes
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael Levine
- Department of Emergency Medicine, Section of Medical Toxicology, University of Southern California, Los Angeles, CA, USA
| | - Martin Morris
- Schulich Library of Science and Engineering, McGill University, Montréal, Québec, Canada
| | - Andrea Nesbitt-Miller
- Schulich Library of Science and Engineering, McGill University, Montréal, Québec, Canada
| | - Alexis F. Turgeon
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, and CHU de Québec, Université Laval Research Center, Population Health and Optimal Health Practices Unit, Université Laval, Québec City, Québec, Canada
| | - Benoit Bailey
- Division of Emergency Medicine, Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
- Centre Antipoison du Québec, Quebec, Canada
| | - Diane P. Calello
- Medical Toxicology, Department of Emergency Medicine, Morristown Medical Center, Emergency Medical Associates, Morristown, NJ, USA
| | - Ryan Chuang
- Department of Emergency Medicine, Division of Clinical Pharmacology and Toxicology, University of Calgary, Poison and Drug Information Service, Calgary, Alberta, Canada
| | | | - Bruno Mégarbane
- Department of Medical and Toxicological Intensive Care, Lariboisière Hospital, Paris-Diderot University, INSERM UMRS1144, Paris, France
| | - Ashish Bhalla
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Valéry Lavergne
- Department of Medical Biology, Sacré-Coeur Hospital, University of Montréal, Montréal, Québec, Canada
| |
Collapse
|
4
|
Heinonen JA, Schramko AA, Skrifvars MB, Litonius E, Backman JT, Mervaala E, Rosenberg PH. The effects of intravenous lipid emulsion on hemodynamic recovery and myocardial cell mitochondrial function after bupivacaine toxicity in anesthetized pigs. Hum Exp Toxicol 2016; 36:365-375. [DOI: 10.1177/0960327116650010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Local anesthetic toxicity is thought to be mediated partly by inhibition of cardiac mitochondrial function. Intravenous (i.v.) lipid emulsion may overcome this energy depletion, but doses larger than currently recommended may be needed for rescue effect. In this randomized study with anesthetized pigs, we compared the effect of a large dose, 4 mL/kg, of i.v. 20% Intralipid® ( n = 7) with Ringer’s acetate ( n = 6) on cardiovascular recovery after a cardiotoxic dose of bupivacaine. We also examined mitochondrial respiratory function in myocardial cell homogenates analyzed promptly after needle biopsies from the animals. Bupivacaine plasma concentrations were quantified from plasma samples. Arterial blood pressure recovered faster and systemic vascular resistance rose more rapidly after Intralipid than Ringer’s acetate administration ( p < 0.0001), but Intralipid did not increase cardiac index or left ventricular ejection fraction. The lipid-based mitochondrial respiration was stimulated by approximately 30% after Intralipid ( p < 0.05) but unaffected by Ringer’s acetate. The mean (standard deviation) area under the concentration–time curve (AUC) of total bupivacaine was greater after Intralipid (105.2 (13.6) mg·min/L) than after Ringer’s acetate (88.1 (7.1) mg·min/L) ( p = 0.019). After Intralipid, the AUC of the lipid-un-entrapped bupivacaine portion (97.0 (14.5) mg·min/L) was 8% lower than that of total bupivacaine ( p < 0.0001). To conclude, 4 mL/kg of Intralipid expedited cardiovascular recovery from bupivacaine cardiotoxicity mainly by increasing systemic vascular resistance. The increased myocardial mitochondrial respiration and bupivacaine entrapment after Intralipid did not improve cardiac function.
Collapse
Affiliation(s)
- JA Heinonen
- Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - AA Schramko
- Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - MB Skrifvars
- Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - E Litonius
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - JT Backman
- Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - E Mervaala
- Department of Pharmacology, University of Helsinki, Helsinki, Finland
| | - PH Rosenberg
- Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
5
|
Damitz R, Chauhan A. Parenteral emulsions and liposomes to treat drug overdose. Adv Drug Deliv Rev 2015; 90:12-23. [PMID: 26086091 DOI: 10.1016/j.addr.2015.06.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 06/02/2015] [Accepted: 06/10/2015] [Indexed: 11/25/2022]
Abstract
Drug overdoses from both pharmaceutical and recreational drugs are a major public health concern. Although some overdoses may be treated with specific antidotes, the most common treatment involves providing supportive care to allow the body to metabolize and excrete the toxicant. In many cases, supportive care is limiting, ineffective, and expensive. There is a clear medical need to improve the effectiveness of detoxification, in particular by developing more specific therapies or antidotes for these overdoses. Intravenous lipid emulsions (ILEs) have been investigated as a potential treatment for overdoses of local anesthetics and other hydrophobic drugs. While ILE therapy has been successful in several cases, its use beyond local anesthetic systemic toxicity is controversial and its mechanism of detoxification remains a subject of debate. ILEs were not originally developed to treat overdose, but clarifying the mechanisms of detoxification observed with ILE may allow us to design more effective future treatments. Liposomes are highly biocompatible and versatile formulations, thus it was a natural step to explore their use for drug overdose therapy as well. Several researchers have designed liposomes using a variety of approaches including surface charge, pH gradients, and inclusion of enzymes in the liposome core to optimize the formulations for detoxification of a specific drug or toxicant. The in vitro results for drug sequestration by liposomes are very promising and animal trials have in some cases shown comparable performance to ILE at reduced lipid dosing. This narrative review summarizes the current status and advances in the use of emulsions and liposomes for detoxification and also suggests several areas in which studies are needed for developing future therapies.
Collapse
|