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De Baerdemaeker K, Foxton E, Wood DM, Archer JRH, Layne K, Wolfe C, Dargan PI. Intravenous lipid emulsion interference in coagulation testing: an ex vivo analysis. Clin Toxicol (Phila) 2024:1-5. [PMID: 38958109 DOI: 10.1080/15563650.2024.2370324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 06/13/2024] [Indexed: 07/04/2024]
Abstract
INTRODUCTION Intravenous lipid emulsion is used in the rescue treatment of certain poisonings. A complication is interference with laboratory analyses. The aim of this study was to determine the impact of intravenous lipid emulsion on routine laboratory analysis of coagulation parameters ex vivo and determine if any of the analytical techniques remain reliable. METHODS Samples were obtained from 19 healthy volunteers and divided in triplicate. One sample served as a control, and the other two were diluted to simulate the treatment of an average adult with Intralipid® 20 per cent Fresenius Kabi 100 mL (dilution-1) or 500 mL (dilution-2). Coagulation tests performed were prothrombin time, activated prothrombin time, D-dimer concentration and fibrinogen. Coagulation testing was performed by three techniques. Test-1 was performed on a Sysmex CN6000 analyzer. Test-2 was performed with a manual mechanical endpoint method using the semi-automated Stago KC4 Delta. Test-3 involved high-speed centrifugation before repeat testing on the Sysmex CN6000 analyzer. RESULTS For test-1, only nine (47 per cent) samples in dilution-1 could be analyzed for coagulation tests, and no coagulation tests could be analyzed for dilution-2 because of lipaemia. For test-2 and test-3, all samples could be analyzed, and all results of both testing methods fell within the limits of the laboratory reference range. DISCUSSION Difficulties in laboratory analysis of patients having received intravenous lipid emulsion are due to multiple factors. Most automated coagulation analyzers use optical measurements, which can be unreliable in the presence of a high intravenous lipid concentration. By altering the lipaemia in the testing solution using high-speed centrifugation or by using manual mechanical endpoint detection, we were able to obtain reliable results. These findings are limited by the use of an ex vivo method and healthy volunteers. CONCLUSIONS This ex vivo model confirms that Intralipid® interferes with routine coagulation studies. It is important that clinicians are aware and inform their laboratories of its administration.
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Affiliation(s)
- Klara De Baerdemaeker
- Emergency Medicine, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - Eleanor Foxton
- Haemostasis & Thrombosis Laboratory, Synovis, London, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - John R H Archer
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Kerry Layne
- Acute Medicine, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
| | - Caitlin Wolfe
- Atlantic Canada Poison Centre, Halifax, Canada
- Department of Emergency Medicine, Dalhousie University, Halifax, Canada
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
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Gheat HS, Fayed MM, Elgazzar FM, Draz EI, El-Kelany RS. The possible therapeutic role of intravenous lipid emulsion in acute aluminium phosphide poisoning: a randomized controlled clinical trial. Toxicol Res (Camb) 2024; 13:tfae090. [PMID: 38883412 PMCID: PMC11170490 DOI: 10.1093/toxres/tfae090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 05/21/2024] [Accepted: 06/02/2024] [Indexed: 06/18/2024] Open
Abstract
Introduction Aluminum phosphide (ALP) is a highly toxic rodenticide and the mortality rates caused by it have been demonstrated up to 70-100% in various studies. Unfortunately, there is no specific antidote to manage its toxic effects. This study aimed to assess the biochemical and clinical efficacy and safety of intravenous lipid emulsion as an adjuvant therapy in acute aluminum phosphide poisoning. Patients and methods Sixty-four cases with acute ALP poisoning were stratified according to severity by the Poison Severity Score into severe and moderate groups (32 patients each). Patients were then randomly allocated into either receiving intravenous lipid emulsion in addition to the conventional treatment or receiving the conventional treatment only by using block randomization. Results Treatment by ILE resulted in a significant improvement in the survival time, the mean arterial blood pressure, arterial blood gases, and a significant reduction in serum lactate levels. The need for intubation and mechanical ventilation was insignificantly lower in the intervention groups compared to control groups. However, the reduction in mortality rate in the patients of intervention groups compared with control groups was found to be non-significant. Intravenous lipid emulsion use in acute ALP poisoning significantly prolonged the survival time, improved the metabolic acidosis, decreased the serum lactate levels and increased the mean arterial blood pressure and hospital stay in the intervention groups. And insignificantly decreased the mortality rate, need of intubation and mechanical ventilation, and the total dose of vasopressors.
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Affiliation(s)
- Hafsa Salah Gheat
- Forensic Medicine and Clinical Toxicology at Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Tanta University-Medical collages complex-Al-Geish Street-Tanta,Gharbia 31527, Egypt
| | - Manar M Fayed
- Forensic Medicine and Clinical Toxicology at Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Tanta University-Medical collages complex-Al-Geish Street-Tanta,Gharbia 31527, Egypt
| | - Fatma M Elgazzar
- Forensic Medicine and Clinical Toxicology at Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Tanta University-Medical collages complex-Al-Geish Street-Tanta,Gharbia 31527, Egypt
| | - Eman I Draz
- Clinical Toxicology at Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Tanta University-Medical collages complex-Al-Geish Street-Tanta, Gharbia 31527 Egypt
| | - Rabab S El-Kelany
- Forensic Medicine and Clinical Toxicology at Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Tanta University-Medical collages complex-Al-Geish Street-Tanta,Gharbia 31527, Egypt
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3
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Kulikov OA, Shlyapkina VI, Brodovskaya EP, Al-Khadj Aioub AM, Ageev VP, Zharkov MN, Yakobson DE, Sokushev DS, Pyataev NA, Sukhorukov GB. Phototoxicity in vitro and safety in vivo of the emulsion photosensitizer based on furanocoumarins of Heracleum sosnowskyi. Eur J Pharm Biopharm 2024; 198:114257. [PMID: 38479564 DOI: 10.1016/j.ejpb.2024.114257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 01/05/2024] [Accepted: 03/10/2024] [Indexed: 04/19/2024]
Abstract
The use of plants such as giant hogweed as raw materials for the manufacture of dosage forms has been little explored. In this study, we utilized furanocoumarins from the Heracleum sosnowskyi plant to create an experimental emulsion dosage form (EmFHS). The EmFHS was finely dispersed (481.8 nm ± 71.1 nm), shelf-stable, and contained predominantly 8-methoxypsoralen at a concentration of 1 mg/ml. Phototoxicity analysis of EmFHS for THP-1 cells under UV (365 nm) irradiation showed an IC50 of 19.1 µg/ml (24 h) and 6.3 µg/ml (48 h). In relation to spheroids (L929), EmFHS exhibited a phototoxic effect in the concentration range of 31.25-125 µg/ml8-MOP. A full phototoxic effect was observed 48 h after UV irradiation. The phototoxic effect of EmFHS in vitro was dose-dependent and comparable to the effect of emulsion synthetic 8-methoxypsoralen and chlorin e6 solution. EmFHS cytotoxicity was caused solely by UV radiation, and toxicity in the dark was minimal. EmFHS, administered at a dose of 3 mg/kg8-MOP, was found to be safe after a single intravenous administration to rats. It had a photosensitizing effect in the form of local photodermatitis when exposed to UV irradiation at a dose of 44 J/cm2. The biokinetics of emulsion furanocoumarins showed that the phototoxic effect of EmFHS is due to the high penetration ability of the emulsion into cells of spheroids. At the same time, it has a low degree of cumulation when administered intravenously. The obtained data suggest that EmFHS may be a promising treatment for PUVA therapy of various dermatological diseases. Additionally, the plant Heracleum sosnowskyi shows potential as a basis for creating new dosage forms with phototherapeutic effects.
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Affiliation(s)
- Oleg A Kulikov
- National Research Ogarev Mordovia State University, Bolshevistskaya Str. 68, 430005 Saransk, Russia.
| | - Vasilisa I Shlyapkina
- National Research Ogarev Mordovia State University, Bolshevistskaya Str. 68, 430005 Saransk, Russia
| | - Ekaterina P Brodovskaya
- National Research Ogarev Mordovia State University, Bolshevistskaya Str. 68, 430005 Saransk, Russia
| | - Amina M Al-Khadj Aioub
- National Research Ogarev Mordovia State University, Bolshevistskaya Str. 68, 430005 Saransk, Russia
| | - Valentin P Ageev
- National Research Ogarev Mordovia State University, Bolshevistskaya Str. 68, 430005 Saransk, Russia
| | - Mikhail N Zharkov
- National Research Ogarev Mordovia State University, Bolshevistskaya Str. 68, 430005 Saransk, Russia
| | - Denis E Yakobson
- National Research Ogarev Mordovia State University, Bolshevistskaya Str. 68, 430005 Saransk, Russia
| | - Daniil S Sokushev
- National Research Ogarev Mordovia State University, Bolshevistskaya Str. 68, 430005 Saransk, Russia
| | - Nikolay A Pyataev
- National Research Ogarev Mordovia State University, Bolshevistskaya Str. 68, 430005 Saransk, Russia
| | - Gleb B Sukhorukov
- School of Engineering and Materials Science, Queen Mary University of London, Mile End Road E1 4NS London, United Kingdom
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Tsuji M, Nii M, Furuta M, Baba S, Maenaka T, Matsunaga S, Tanaka H, Sakurai A. Intravenous lipid emulsion for local anaesthetic systemic toxicity in pregnant women: a scoping review. BMC Pregnancy Childbirth 2024; 24:138. [PMID: 38355477 PMCID: PMC10865663 DOI: 10.1186/s12884-024-06309-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 01/30/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Local anaesthetic systemic toxicity (LAST) is a rare but life-threatening complication that can occur after local anaesthetic administration. Various clinical guidelines recommend an intravenous lipid emulsion as a treatment for local anaesthetic-induced cardiac arrest. However, its therapeutic application in pregnant patients has not yet been established. This scoping review aims to systematically identify and map the evidence on the efficacy and safety of intravenous lipid emulsion for treating LAST during pregnancy. METHOD We searched electronic databases (Medline, Embase and Cochrane Central Register Controlled Trials) and a clinical registry (lipidrescue.org) from inception to Sep 30, 2022. No restriction was placed on the year of publication or the language. We included any study design containing primary data on obstetric patients with signs and symptoms of LAST. RESULTS After eliminating duplicates, we screened 8,370 titles and abstracts, retrieving 41 full-text articles. We identified 22 women who developed LAST during pregnancy and childbirth, all presented as case reports or series. The most frequent causes of LAST were drug overdose and intravascular migration of the epidural catheter followed by wrong-route drug errors (i.e. intravenous anaesthetic administration). Of the 15 women who received lipid emulsions, all survived and none sustained lasting neurological or cardiovascular damage related to LAST. No adverse events or side effects following intravenous lipid emulsion administration were reported in mothers or neonates. Five of the seven women who did not receive lipid emulsions survived; however, the other two died. CONCLUSION Studies on the efficacy and safety of lipids in pregnancy are scarce. Further studies with appropriate comparison groups are needed to provide more robust evidence. It will also be necessary to accumulate data-including adverse events-to enable clinicians to conduct risk-benefit analyses of lipids and to facilitate evidence-based decision-making for clinical practice.
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Affiliation(s)
- Makoto Tsuji
- Department of Obstetrics and Gynecology, Saiseikai Mastusaka General Hospital, Mastusaka, Mie, Japan
- Japan Resuscitation Council, Shinjuku, Tokyo, Japan
| | - Masafumi Nii
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Tsu, Mie, Japan.
- Japan Resuscitation Council, Shinjuku, Tokyo, Japan.
| | - Marie Furuta
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Kyoto, Japan
- Japan Resuscitation Council, Shinjuku, Tokyo, Japan
| | - Shinji Baba
- Department of Obstetrics and Gynecology, Tokyo Metropolitan Tama Medical Center, Fuchu, Tokyo, Japan
- Japan Resuscitation Council, Shinjuku, Tokyo, Japan
| | - Takahide Maenaka
- Regional Medical Care Planning Division, Health Policy Bureau, Ministry of Health, Labour and Welfare, Tokyo, Japan
- Japan Resuscitation Council, Shinjuku, Tokyo, Japan
| | - Shigetaka Matsunaga
- Department of Obstetrics and Gynecology, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
- Japan Resuscitation Council, Shinjuku, Tokyo, Japan
| | - Hiroaki Tanaka
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Tsu, Mie, Japan
- Japan Resuscitation Council, Shinjuku, Tokyo, Japan
| | - Atsushi Sakurai
- Department of Acute Medicine, Division of Emergency and Critical Care Medicine, Nihon University School of Medicine, Itabashi, Tokyo, Japan
- Japan Resuscitation Council, Shinjuku, Tokyo, Japan
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Wilks MF, Hoyte C, Cumpston KL, Hassanian-Moghaddam H, Tse ML, Ferrer-Dufol A, Thiermann H. The Clinical Toxicology Recommendations Collaborative: purpose, organization, and methodology. Clin Toxicol (Phila) 2024; 62:76-81. [PMID: 38465693 DOI: 10.1080/15563650.2024.2321324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 02/14/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION Scientific societies aim to provide a collective voice and unified stance on important issues. The Clinical Toxicology Recommendations Collaborative was formed in 2016 to develop evidence- and consensus-based recommendations for the management of patients exposed to common and/or serious poisonings for which the management is unclear or controversial. ORGANIZATION The Clinical Toxicology Recommendations Collaborative is led jointly by the American Academy of Clinical Toxicology, the Asia Pacific Association of Medical Toxicology, and the European Association of Poison Centres and Clinical Toxicologists. The Governance Committee is chaired by a Past-President of one of these Societies and comprised of the six Presidents and Immediate Past-Presidents of the three Societies. A Steering Committee oversees the process of each project workgroup. METHODOLOGY The overall process is guided by standards set forth by the Institute of Medicine for developing trustworthy guidelines and the Appraisal of Guidelines for Research and Evaluation Instrument. Systematic reviews are produced using the framework set in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology. Workgroup members jointly review the evidence and prepare statements on which they vote anonymously using a 9-point Likert scale. A two-round modified Delphi method is used to reach a consensus on clinical recommendations using the RAND/UCLA Appropriateness Method. Final recommendations are approved by unanimous consent of the workgroup and are expressed as both levels of evidence and strength of recommendations. LIMITATIONS The major limitations of the Clinical Toxicology Recommendations Collaborative process centre around the amount and quality of evidence, the assessment of that evidence, and the voting of the panel. CONCLUSIONS By using a transparent evidence- and consensus-based approach to produce systematic reviews and clinical recommendations, the Clinical Toxicology Recommendations Collaborative aims to create an international framework for clinical toxicology education and decision-making and foster positive change for the benefit of poisoned patients.
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Affiliation(s)
- Martin F Wilks
- Swiss Centre for Applied Human Toxicology, University of Basel, Basel, Switzerland
- Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Christopher Hoyte
- Rocky Mountain Poison and Drug Safety, Denver Health, Denver, CO, USA
- Department of Emergency Medicine, University of CO School of Medicine, Aurora, CO, USA
| | - Kirk L Cumpston
- Department of Emergency Medicine, Division of Clinical Toxicology, VA Commonwealth University Health System, Richmond, VA, USA
| | - Hossein Hassanian-Moghaddam
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Clinical Toxicology, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Man-Li Tse
- Hong Kong Poison Information Centre, Hospital Authority, K2A, United Christian Hospital, Kwun Tong, HKSAR
| | - Ana Ferrer-Dufol
- Unit of Clinical Toxicology, Clinical University Hospital, Spain Zaragoza
| | - Horst Thiermann
- Bundeswehr Institute of Pharmacology and Toxicology, Munich, Germany
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6
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Anya OC, Ajayi ER, Solanke HR, Ohanaka AI, Ubana KD. The Use of Intralipid Infusions in the Prevention of Embryo Implantation Failure. Cureus 2024; 16:e53368. [PMID: 38435143 PMCID: PMC10907924 DOI: 10.7759/cureus.53368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2024] [Indexed: 03/05/2024] Open
Abstract
Intralipids have been suggested to suppress uterine natural killer cell activity, which could potentially improve implantation rates in women with recurrent loss. We report a case of a 41-year-old African woman with recurrent pregnancy loss who had elevated uterine killer cell activity and for whom intralipid infusion was used to achieve pregnancy. We recommend routine uterine natural killer cell testing for women with recurrent pregnancy loss and further research on newer intravenous lipid emulsions in fertility medicine.
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Affiliation(s)
- Okorie C Anya
- Reproductive Medicine, Primecare Fertility Clinic, Abuja, NGA
| | - Eniola R Ajayi
- Public Health, Central Michigan University College of Medicine, Michigan, USA
| | - Henry R Solanke
- Food Safety and Quality Assurance, Sensei Ag, Aldergrove, CAN
| | - Adaeze I Ohanaka
- Obstetrics and Gynaecology, South Qunfudah General Hospital, Jizan, SAU
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Peer EM, Quitt J, Marsch S, Loosen G. Venoarterial extracorporeal membrane oxygenation in combination with Levosimendan as a bridge to recovery for a case of severe yew intoxication in a 13-year-old patient. Clin Case Rep 2023; 11:e8203. [PMID: 38033695 PMCID: PMC10682237 DOI: 10.1002/ccr3.8203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/17/2023] [Accepted: 10/28/2023] [Indexed: 12/02/2023] Open
Abstract
In an adolescent patient with severe yew intoxication and consecutive cardiac arrest, non-responsive to conventional resuscitation necessitating extracorporeal life support, Levosimendan has been implemented in the early acute phase of hemodynamic stabilization, without obvious side effects. However, the additive value of this treatment in severe yew intoxication remains speculative.
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Affiliation(s)
- Eva Maria Peer
- Intensive Care Unit, Department of Acute MedicineUniversity Hospital BaselBaselSwitzerland
| | - Jonas Quitt
- Anaesthesiology, Department of Acute MedicineUniversity Hospital BaselBaselSwitzerland
| | - Stephan Marsch
- Intensive Care Unit, Department of Acute MedicineUniversity Hospital BaselBaselSwitzerland
| | - Gregor Loosen
- Intensive Care Unit, Department of Acute MedicineUniversity Hospital BaselBaselSwitzerland
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Maki J, Hanaki Y, Yanagita RC, Kikumori M, Kovba A, Washizaki A, Tsukano C, Akari H, Irie K. Biological evaluation of a phosphate ester prodrug of 10-methyl-aplog-1, a simplified analog of aplysiatoxin, as a possible latency-reversing agent for HIV reactivation. Biosci Biotechnol Biochem 2023; 87:1453-1461. [PMID: 37682524 DOI: 10.1093/bbb/zbad128] [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: 08/07/2023] [Accepted: 08/31/2023] [Indexed: 09/09/2023]
Abstract
10-Methyl-aplog-1 (10MA-1), a simplified analog of aplysiatoxin, exhibits a high binding affinity for protein kinase C (PKC) isozymes with minimal tumor-promoting and pro-inflammatory activities. A recent study suggests that 10MA-1 could reactivate latent human immunodeficiency virus (HIV) in vitro for HIV eradication strategy. However, further in vivo studies were abandoned by a dose limit caused by the minimal water solubility of 10MA-1. To overcome this problem, we synthesized a phosphate ester of 10MA-1, 18-O-phospho-10-methyl-aplog-1 (phos-10MA-1), to improve water solubility for in vivo studies. The solubility, PKC binding affinity, and biological activity of phos-10MA-1 were examined in vitro, and the biological activity was comparable with 10MA-1. The pharmacokinetic studies in vivo were also examined, which suggest that further optimization for improving metabolic stability is required in the future.
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Affiliation(s)
- Jumpei Maki
- Division of Food Science and Biotechnology, Graduate School of Agriculture, Kyoto University, Kyoto, Japan
| | - Yusuke Hanaki
- Department of Applied Biological Science, Faculty of Agriculture, Kagawa University, Kagawa, Japan
| | - Ryo C Yanagita
- Department of Applied Biological Science, Faculty of Agriculture, Kagawa University, Kagawa, Japan
| | - Masayuki Kikumori
- Division of Food Science and Biotechnology, Graduate School of Agriculture, Kyoto University, Kyoto, Japan
| | - Anastasiia Kovba
- Center for the Evolutionary Origins of Human Behavior, Kyoto University, Aichi, Japan
| | - Ayaka Washizaki
- Center for the Evolutionary Origins of Human Behavior, Kyoto University, Aichi, Japan
| | - Chihiro Tsukano
- Division of Food Science and Biotechnology, Graduate School of Agriculture, Kyoto University, Kyoto, Japan
| | - Hirofumi Akari
- Center for the Evolutionary Origins of Human Behavior, Kyoto University, Aichi, Japan
| | - Kazuhiro Irie
- Division of Food Science and Biotechnology, Graduate School of Agriculture, Kyoto University, Kyoto, Japan
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Lavonas EJ, Akpunonu PD, Arens AM, Babu KM, Cao D, Hoffman RS, Hoyte CO, Mazer-Amirshahi ME, Stolbach A, St-Onge M, Thompson TM, Wang GS, Hoover AV, Drennan IR. 2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2023; 148:e149-e184. [PMID: 37721023 DOI: 10.1161/cir.0000000000001161] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.
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Ollier M, Giles S, Gosselin S. The Occasional intralipid emulsion therapy. CANADIAN JOURNAL OF RURAL MEDICINE 2023; 28:195-200. [PMID: 37861604 DOI: 10.4103/cjrm.cjrm_62_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Affiliation(s)
- Mary Ollier
- Departement of Family Medicine Temerty School of Medicine, University of Toronto, Toronto, Canada
| | - Sarah Giles
- Northern Ontario School of Medicine University, Thunder Bay, Ontario, Canada
| | - Sophie Gosselin
- Centre Intégré De Santé Et Services Sociaux De La Montérégie-Centre; Centre Antipoison Du Québec; Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Quebec, Canada
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11
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Markert C, Heilmann RM, Kiwitz D, Doerfelt R. Intravenous lipid emulsion for the treatment of poisonings in 313 dogs and 100 cats (2016-2020). Front Vet Sci 2023; 10:1272705. [PMID: 37841477 PMCID: PMC10568331 DOI: 10.3389/fvets.2023.1272705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/13/2023] [Indexed: 10/17/2023] Open
Abstract
Introduction The aim of this retrospective study was to analyze the effect and potential adverse effects of intravenous lipid emulsion (ILE) in poisoned dogs and cats over a 5 years period. Methods Medical records of 313 dogs and 100 cats receiving ILE between 2016-2020 were analyzed for suspected toxicant, clinical signs, ILE dosages and frequency, the effect and adverse effects of ILE, and patient outcome. Results Dogs and cats were poisoned with mostly unidentified toxicants (48%), rodenticides (8%), recreational drugs and nuts (7% each) and other toxicants. Clinical signs included neurologic deficits (63%), cardiovascular signs (29%), thermoregulation (21%) or gastrointestinal abnormalities (17%). Treatment with ILE was initiated within a median of 6.0 h (1.0-91.0 h) after poisoning. Dogs and cats received a total amount of median 8.0 mL/kg (1.5-66.6 mL/kg) and 15.8 mL/kg (1.8-69.4 mL/kg) ILE, respectively. A positive effect was observed in 74% of the patients, whereas clinical signs worsened in 4% of the patients after ILE administration. No subjective effect was detected in 22% of the patients. Suspected or possible adverse effects of ILE occurred in 6% of the patients, including neurological signs (temporarily reduced consciousness and ataxia), bradycardia, hyperthermia, vomiting, diarrhea, respiratory distress, worsening of the general behavior, facial swelling, and thrombophlebitis. The overall survival rate was 96%. One dog who potentially experienced adverse events was euthanized. Conclusion ILE treatment was successful in most patients but can be associated with adverse effects. Administration of ILE should be carefully selected on an individual basis after weighing the possible benefits against potential adverse effects.
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Affiliation(s)
- Carina Markert
- Veterinary Clinic for Small Animals, Hofheim, Germany
- Department for Small Animals, College of Veterinary Medicine, University of Leipzig, Leipzig, Germany
| | - Romy Monika Heilmann
- Department for Small Animals, College of Veterinary Medicine, University of Leipzig, Leipzig, Germany
| | | | - René Doerfelt
- LMU Small Animal Clinic, Ludwig-Maximilians-Universität München, Munich, Germany
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Haines KL, Ohnuma T, Hornik CD, Grisel B, Leraas H, Trujillo CN, Krishnamoorthy V, Raghunathan K, Wischmeyer PE. Change to Mixed-Lipid Emulsion From Soybean Oil-Based Lipid Emulsion in Pediatric Patients. JAMA Netw Open 2023; 6:e2332389. [PMID: 37669048 PMCID: PMC10481238 DOI: 10.1001/jamanetworkopen.2023.32389] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/28/2023] [Indexed: 09/06/2023] Open
Abstract
Importance Critically ill pediatric patients often require parenteral nutrition (PN) in the intensive care unit (ICU). Literature suggests mixed lipid emulsions (LE) with soybean oil reduction strategies may improve outcomes. Objective To examine the association of a hospital-wide switch to a mixed-lipid formula (4-OLE) with pediatric outcomes. Design, Setting, and Participants Retrospective cohort study at a large US academic referral center. Pediatric patients aged 1 month to 17 years requiring parenteral nutrition from May 2016 to September 2019 were included. Data were analyzed from October 2020 to February 2023. Exposure In 2017, Duke University Health System fully converted to a soybean oil/MCT/olive/fish oil lipid (4-OLE) from pure soybean oil-based LE in pediatric patients. Pediatric patients before the change (Intralipid [IL] group) were compared with patients after (4-OLE group). Main Outcomes and Measures Clinical outcomes were compared between treatment periods via multivariable regression models. The primary outcome was hospital length of stay (LOS). Fourteen secondary outcomes included hospital mortality of any cause, 30-day or 90-day readmission, pneumonia, urinary tract infections (UTIs), total caloric delivery, and liver function tests (aspartate aminotransferase, alanine transaminase, alkaline phosphatase, and total bilirubin). Results A total of 684 children dependent on PN were identified (342 were critically ill), with 30% (206 children) in the preswitch (IL) period and 70% (478 children) in the postswitch (4-OLE) period; 123 were male (59.7%). In comparing IL vs 4-OLE, there was a significant difference in median (IQR) age (4.0 [1.2-13.0] vs 3.0 [0.8-9.0] years, respectively; P = .04), without difference in body mass index or baseline comorbidities except for significant differences in cancer diagnosis (26 patients in the IL group [12.6%] vs 29 patients in the 4-OLE group [6.1%]; P = .004) and chronic obstructive pulmonary disease (24 patients in the IL group [11.7%] vs 30 patients in the 4-OLE group [6.3%]; P = .02). In the all children cohort, 4-OLE was associated with shorter hospital LOS (IRR, 0.81; 95% CI, 0.05-0.78), and reduced UTI risk (OR, 0.33; 95% CI, 0.18-0.64). In the ICU cohort, 4-OLE was associated with shorter hospital LOS (IRR, 0.81; 95% CI, 0.78-0.83), and reduced UTI risk (OR, 0.23; 95% CI, 0.11-0.51). Other secondary outcomes were not significant. Conclusions and Relevance In this observational study of clinical outcomes among children dependent on PN, a switch to 4-OLE in a large academic hospital was associated with a significant decrease in hospital LOS in ICU and non-ICU patients. These findings suggest switching to a soy-LE sparing strategy using 4-OLE is feasible, safe, and associated with improved clinical outcomes in pediatric PN patients.
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Affiliation(s)
- Krista L. Haines
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
- The Critical Care and Perioperative Epidemiologic Research Unit, Duke University Medical Center, Durham, North Carolina
| | - Tetsu Ohnuma
- The Critical Care and Perioperative Epidemiologic Research Unit, Duke University Medical Center, Durham, North Carolina
- Departement of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Chi Dang Hornik
- Division of Pediatric Critical Care, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Braylee Grisel
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
- The Critical Care and Perioperative Epidemiologic Research Unit, Duke University Medical Center, Durham, North Carolina
| | - Harold Leraas
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Charles N. Trujillo
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Vijay Krishnamoorthy
- The Critical Care and Perioperative Epidemiologic Research Unit, Duke University Medical Center, Durham, North Carolina
- Departement of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Karthik Raghunathan
- The Critical Care and Perioperative Epidemiologic Research Unit, Duke University Medical Center, Durham, North Carolina
- Departement of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Paul E. Wischmeyer
- Departement of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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Belza C, Courtney-Martin G, Wong-Sterling S, Garofalo E, Silva C, Yanchis D, Avitzur Y, Wales PW. Composite lipid emulsion use and essential fatty acid deficiency in pediatric patients with intestinal failure with high parenteral nutrition dependence: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2023; 47:930-937. [PMID: 37392380 DOI: 10.1002/jpen.2544] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND Reports of essential fatty acid deficiency (EFAD) in patients receiving parenteral nutrition (PN) and a composite lipid (mixed oil intravenous lipid emulsion [MO ILE]) are predominantly when managed by lipid restriction. The objective of this study was to determine the prevalence of EFAD in patients with intestinal failure (IF) who are PN dependent without lipid restriction. METHODS We retrospectively evaluated patients, ages 0-17 years, followed by our intestinal rehabilitation program between November 2020 and June 2021 with PN dependency index (PNDI) of >80% on a MO ILE. Demographic data, PN composition, PN days, growth, and plasma fatty acid profile were collected. A plasma triene-tetraene (T:T) ratio >0.2 indicated EFAD. Summary statistics and Wilcoxon rank sum test evaluated to compare between PNDI category and ILE administration (grams/kilograms/day). P < 0.05 was considered significant. RESULTS Twenty-six patients (median age, 4.1 years [interquartile range (IQR) = 2.4-9.6]) were included. The median duration of PN was 1367 days (IQR = 824-3195). Sixteen patients had a PNDI of 80%-120% (61.5%). Fat intake for the group was 1.7 g/kg/day (IQR = 1.3-2.0). The median T:T ratio was 0.1 (IQR = 0.1-0.2) with no values >0.2. Linoleic and arachidonic acid were low in 85% and 19% of patients, respectively; however, Mead acid was normal in all patients. CONCLUSION This report is the largest to date on the EFA status of patients with IF on PN. These results suggest that, in the absence of lipid restriction, EFAD is not a concern when using MO ILEs in children receiving PN for IF.
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Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Canada
| | - Glenda Courtney-Martin
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
- Research Institute, The Hospital for Sick Children, Toronto, Canada
- Department of Nutritional Sciences, University of Toronto, Toronto, Canada
| | - Sylvia Wong-Sterling
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Canada
| | - Elizabeth Garofalo
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Canada
| | - Carina Silva
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Canada
| | - Dianna Yanchis
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Canada
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Paul W Wales
- Research Institute, The Hospital for Sick Children, Toronto, Canada
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
- Cincinnati Center of Excellence in Intestinal Rehabilitation (CinCEIR), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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14
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Mullins ME. Lipid emulsion in the poisoned patient - a few answers, but more questions remain. Clin Toxicol (Phila) 2023; 61:565-566. [PMID: 37815249 DOI: 10.1080/15563650.2023.2254489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 10/11/2023]
Affiliation(s)
- Michael E Mullins
- Editor Division of Medical Toxicology, Department of Emergency Medicine, WA University School of Medicine, St Louis, MO, USA
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15
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Juárez-Martínez A, Madrigal-Anaya JDC, Rodríguez-Torres YP, Dorado-García R, Montes-Ventura DM, Jiménez-Ruiz A. Zinc Phosphide Poisoning: From A to Z. TOXICS 2023; 11:555. [PMID: 37505522 PMCID: PMC10386637 DOI: 10.3390/toxics11070555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/16/2023] [Accepted: 06/17/2023] [Indexed: 07/29/2023]
Abstract
Zinc phosphide is a rodenticide that is used in agricultural, urban and industrial environments in México. After ingestion, it reacts with hydrochloric acid, hydrolyzing into phosphine. It causes cellular hypoxia via mitochondrial toxicity, resulting in multiple organ dysfunction and death. There is no antidote or specific treatment for zinc phosphide toxicity. We present the case of a 45-year-old female who ingested zinc phosphide with suicidal intent. On arrival at the emergency department, she had multisystemic disorders. Supportive care, decontamination and antidotal therapy were initiated. Subsequently, she evolved to clinical improvement with a resolution of the biochemical abnormalities of tissue hypoperfusion. She was discharged on day 7 without complications. In this review, we provide updated therapeutic options and discuss their specific pathophysiological basis.
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16
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Vega Díaz EN, Miranda Barros AA, Castelo Reyna MA, Tenelanda López D, Tubon I. Negative Outcomes Associated with Medication in Neonates on Parenteral Nutrition Therapy. Pediatr Rep 2023; 15:360-372. [PMID: 37368365 DOI: 10.3390/pediatric15020032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 05/15/2023] [Accepted: 05/19/2023] [Indexed: 06/28/2023] Open
Abstract
OBJECTIVE In Ecuador, studies on clinical daily practice problems focused on parenteral nutrition in neonates are scarce. Therefore, this research aimed to identify negative results associated with medications (NRAM) in neonates with parenteral nutrition (PN) in a third-level hospital in Ecuador. MATERIAL AND METHODS An observational, prospective, descriptive study was designed in the neonatology area of a tertiary-level public hospital, where, for over four months, the medical records, PN prescriptions, and pharmacy-managed databases of 78 patients were analyzed. Drug-related problems (DRPs) as possible causes of NRAM were classified through administrative, physicochemical, and clinical validation. RESULTS DRPs classified as follows were found: 78.81% by physicochemical, 17.62% by clinical, and 3.57% by administrative validation. The NRAM were 72% quantitatively uncertain, 16% needed, and 11% quantitatively ineffective. CONCLUSION The NRAM associated with DRPs were statistically related to prematurity condition, APGAR score, PN time, and the number of medications administered, which suggests the need to create a nutritional therapy committee at the health facility.
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Affiliation(s)
- Evelin Nataly Vega Díaz
- Agencia Nacional de Regulación, Control y Vigilancia Sanitaria (ARCSA), Quito 090112, Ecuador
| | - Aida Adriana Miranda Barros
- Grupo de Investigación de Tecnología y Atención Farmacéutica del Ecuador (GITAFEC), Escuela Superior Politécnica de Chimborazo (ESPOCH), Riobamba 060155, Ecuador
| | - Monica Alexandra Castelo Reyna
- College of Mechanics, School of Industrial Maitance, Escuela Superior Politécnica de Chimborazo (ESPOCH), Riobamba 060155, Ecuador
| | - Dennys Tenelanda López
- School of Dentistry, Universidad Nacional de Chimborazo (UNACH), Riobamba 060110, Ecuador
- College of Natural Resources, Escuela Superior Politécnica de Chimborazo (ESPOCH), Riobamba 060155, Ecuador
| | - Irvin Tubon
- Carrera de Biotecnología, Facultad de Ciencia e Ingeniería en Alimentos y Biotecnología, Dirección de Investigación y Desarrollo, Ambato 180207, Ecuador
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17
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Fettiplace MR, Weinberg G. Lipid emulsion for xenobiotic overdose: PRO. Br J Clin Pharmacol 2023; 89:1708-1718. [PMID: 36454165 PMCID: PMC10175108 DOI: 10.1111/bcp.15620] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 09/16/2022] [Accepted: 09/22/2022] [Indexed: 12/03/2022] Open
Abstract
Infusion of lipid emulsion for drug overdose arose as a treatment for local anaesthetic systemic toxicity (LAST) initially based on laboratory results in animal models with the subsequent support of favourable case reports. Following successful translation to the clinic, practitioners also incorporated lipid emulsion as a treatment for non-local anaesthetic toxicities but without formal clinical trials. Recent clinical trials demonstrate a benefit of lipid emulsion in antipsychotic, pesticide, metoprolol and tramadol overdoses. Formal trials of lipid emulsion in LAST may never occur, but alternative analytic tools indicate strong support for its efficacy in this indication; for example, lipid emulsion has obviated the need for cardiopulmonary bypass in most cases of LAST. Herein, we describe the pre-clinical support for lipid emulsion, evaluate the most recent clinical studies of lipid emulsion for toxicity, identify a possible dose-based requirement for efficacy and discuss the limitations to uncontrolled studies in the field.
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Affiliation(s)
- Michael R. Fettiplace
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, 02114
| | - Guy Weinberg
- Department of Anesthesiology, University of Illinois College of Medicine, Chicago, IL 60622 USA
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18
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Jaffal K, Chevillard L, Mégarbane B. Lipid Emulsion to Treat Acute Poisonings: Mechanisms of Action, Indications, and Controversies. Pharmaceutics 2023; 15:pharmaceutics15051396. [PMID: 37242638 DOI: 10.3390/pharmaceutics15051396] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 04/24/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023] Open
Abstract
Biodetoxification using intravenous lipid emulsion (ILE) in acute poisoning is of growing interest. As well as for local anesthetics, ILE is currently used to reverse toxicity caused by a broad-spectrum of lipophilic drugs. Both pharmacokinetic and pharmacodynamic mechanisms have been postulated to explain its possible benefits, mainly combining a scavenging effect called "lipid sink" and cardiotonic activity. Additional mechanisms based on ILE-attributed vasoactive and cytoprotective properties are still under investigation. Here, we present a narrative review on lipid resuscitation, focusing on the recent literature with advances in understanding ILE-attributed mechanisms of action and evaluating the evidence supporting ILE administration that enabled the international recommendations. Many practical aspects are still controversial, including the optimal dose, the optimal administration timing, and the optimal duration of infusion for clinical efficacy, as well as the threshold dose for adverse effects. Present evidence supports the use of ILE as first-line therapy to reverse local anesthetic-related systemic toxicity and as adjunct therapy in lipophilic non-local anesthetic drug overdoses refractory to well-established antidotes and supportive care. However, the level of evidence is low to very low, as for most other commonly used antidotes. Our review presents the internationally accepted recommendations according to the clinical poisoning scenario and provides the precautions of use to optimize the expected efficacy of ILE and limit the inconveniences of its futile administration. Based on their absorptive properties, the next generation of scavenging agents is additionally presented. Although emerging research shows great potential, several challenges need to be overcome before parenteral detoxifying agents could be considered as an established treatment for severe poisonings.
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Affiliation(s)
- Karim Jaffal
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, 75010 Paris, France
- INSERM UMRS-1144, Paris-Cité University, 75006 Paris, France
| | - Lucie Chevillard
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, 75010 Paris, France
- INSERM UMRS-1144, Paris-Cité University, 75006 Paris, France
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, 75010 Paris, France
- INSERM UMRS-1144, Paris-Cité University, 75006 Paris, France
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19
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Silva F, Veiga F, Paulo Jorge Rodrigues S, Cardoso C, Cláudia Paiva-Santos A. COSMO Models for the Pharmaceutical Development of Parenteral Drug Formulations. Eur J Pharm Biopharm 2023; 187:156-165. [PMID: 37120066 DOI: 10.1016/j.ejpb.2023.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/31/2023] [Accepted: 04/21/2023] [Indexed: 05/01/2023]
Abstract
The aqueous solubility of active pharmaceutical ingredients is one of the most important features to be considered during the development of parenteral formulations in the pharmaceutical industry. Computational modelling has become in the last years an integral part of pharmaceutical development. In this context, ab initio computational models, such as COnductor-like Screening MOdel (COSMO), have been proposed as promising tools for the prediction of results without the effective use of resources. Nevertheless, despite the clear evaluation of computational resources, some authors had not achieved satisfying results and new calculations and algorithms have been proposed over the years to improve the outcomes. In the development and production of aqueous parenteral formulations, the solubility of Active Pharmaceutical Ingredients (APIs) in an aqueous and biocompatible vehicle is a decisive step. This work aims to study the hypothesis that COSMO models could be useful in the development of new parenteral formulations, mainly aqueous ones.
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Affiliation(s)
- Fernando Silva
- Department of Pharmaceutical Technology, Faculty of Pharmacy of the University of Coimbra, University of Coimbra, Coimbra, Portugal; REQUIMTE/LAQV, Group of Pharmaceutical Technology, Faculty of Pharmacy of the University of Coimbra, University of Coimbra, Coimbra, Portugal.
| | - Francisco Veiga
- Department of Pharmaceutical Technology, Faculty of Pharmacy of the University of Coimbra, University of Coimbra, Coimbra, Portugal; REQUIMTE/LAQV, Group of Pharmaceutical Technology, Faculty of Pharmacy of the University of Coimbra, University of Coimbra, Coimbra, Portugal
| | - Sérgio Paulo Jorge Rodrigues
- Coimbra Chemistry Centre, Chemistry Department, Faculty of Sciences and Technology of the University of Coimbra of the University of Coimbra, Coimbra, Portugal
| | - Catarina Cardoso
- Laboratórios Basi, Parque Industrial Manuel Lourenço Ferreira, lote 15, 3450-232 Mortágua, Portugal
| | - Ana Cláudia Paiva-Santos
- Department of Pharmaceutical Technology, Faculty of Pharmacy of the University of Coimbra, University of Coimbra, Coimbra, Portugal; REQUIMTE/LAQV, Group of Pharmaceutical Technology, Faculty of Pharmacy of the University of Coimbra, University of Coimbra, Coimbra, Portugal
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20
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Thurgur L, Durr KM, Cortel-LeBlanc M. Just the Facts: Intravenous lipid emulsion. CAN J EMERG MED 2023; 25:187-189. [PMID: 36538264 DOI: 10.1007/s43678-022-00416-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 11/11/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Lisa Thurgur
- Department of Emergency Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.
| | - Kevin M Durr
- Department of Emergency Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
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21
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Zaballos M, Fernández I, Melone A, Rodríguez L, Varela O, García S, Quintela O, Vazquez E, Anadón MJ, Almendral J. Sodium bicarbonate reverts electrophysiologic cardiotoxicity of ropivacaine faster than lipid emulsions in a porcine model. Basic Clin Pharmacol Toxicol 2023; 132:211-222. [PMID: 36479999 PMCID: PMC10107242 DOI: 10.1111/bcpt.13822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/09/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022]
Abstract
Ropivacaine has been described as a safer local anaesthetic (LA); however, serious cardiotoxic accidents have been reported. Intravenous-lipid-emulsion (ILE) therapy during LA intoxication seems to act as an antidote. Sodium bicarbonate is the standard treatment for sodium channel blocker drug toxicity. We compared both antidotes on the reversion of electrophysiologic toxicity induced by ropivacaine. Ropivacaine 5 mg kg-1 was administered in 24 pigs, and 3 min later, the animals received ILE: 1.5 ml kg-1 + 0.25 ml kg-1 min-1 (ILE group); sodium bicarbonate: 2 mEq kg-1 + 1 mEq kg-1 h-1 (NaHCO3 group); saline solution (CTL group). Electrophysiological parameters were evaluated for 30 min. The area under the curve (AUC) for the first 5 or 30 min was compared between groups. Ropivacaine induced a lengthening of the PR interval by 17% (P = 0.0001), His-ventricle-interval by 58% (P = 0.001), sinus QRS complex by 56% (P = 0.0001), paced QRS at 150 bpm by 257% (P = 0.0001), and at 120 bpm by 143% (P = 0.0001) in all groups. At 5 min after treatment, sinus QRS in the NaHCO3 group was shorter than that in the CTL group (AUCQRS5 , P = 0.003) or ILE group (AUCQRS5 , P = 0.045). During the first minute, seven of the animals in the NaHCO3 group vs. two in the ILE or 0 in the CTL group recovered more than 30% of the sinus QRS previously lengthened by ropivacaine (P = 0.003). Sodium bicarbonate reversed the electrophysiological toxicity of ropivacaine faster than ILE and control groups.
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Affiliation(s)
- Matilde Zaballos
- Department of Toxicology, Faculty of Medicine, Complutense University, Madrid, Spain.,Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ignacio Fernández
- Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Arturo Melone
- Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Lucía Rodríguez
- Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Olalla Varela
- Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Sergio García
- Department of Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Oscar Quintela
- Department of Toxicology, Faculty of Medicine, Complutense University, Madrid, Spain.,National Institute of Toxicology and Forensic Science, Madrid, Spain
| | - Elena Vazquez
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Jesús Almendral
- Director of the Electrophysiology Laboratory and Arrhythmia Unit, Hospital Monteprincipe, Grupo HM Hospitales, University CEU-San Pablo, Madrid, Spain
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22
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Oster E, Čudina N, Pavasović H, Prevendar Crnić A, Božić F, Fadel C, Giorgi M. Intoxication of dogs and cats with common stimulating, hallucinogenic and dissociative recreational drugs. Vet Anim Sci 2023; 19:100288. [PMID: 36798946 PMCID: PMC9926018 DOI: 10.1016/j.vas.2023.100288] [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: 02/01/2023] Open
Abstract
Pets can have accidental, intentional, or malicious exposure to illicit drugs. It is a growing concern over the last decade because there is an increase in usage of illicit drugs in humans and diagnosis is difficult. Owners are often not aware of exposure, or they are reluctant to admit possession of recreational drugs in the household due to potential legal consequences. In addition, illicit drugs sold on the black market are often adulterated with other substances resulting in non-specific clinical presentation and aggravation of symptoms. There are affordable onsite diagnostic tests on the market which could facilitate diagnosis of intoxication with illicit drugs, but they give a lot of false positive results due to low specificity of the tests. In this paper we gathered information about the most common recreational drugs such as amphetamines, methamphetamine, 3,4-methylenedioxy-methamphetamine (MDMA), phencyclidine (PCP), lysergic acid diethylamide (LSD), psilocybin mushrooms and cocaine in terms of toxicokinetic properties, mechanism of toxic action, clinical presentation and treatment in dogs and cats.
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Affiliation(s)
- Ena Oster
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Zagreb, Croatia
| | - Nikola Čudina
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Zagreb, Croatia
| | - Hrvoje Pavasović
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Zagreb, Croatia
| | - Andreja Prevendar Crnić
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Zagreb, Croatia
| | - Frane Božić
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Zagreb, Croatia
| | - Charbel Fadel
- Department of Veterinary Medicine, University of Sassari, Italy
| | - Mario Giorgi
- Department of Veterinary Sciences, University of Pisa, Italy,Corresponding author at: Department of Veterinary Sciences, University of Pisa, Pisa, Italy.
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23
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Matsuoka M, Imai T, Iwabuchi S, Kinoshita K. Successful Treatment of Amoxapine-Induced Intractable Seizures With Intravenous Lipid Emulsion. J Emerg Med 2023; 64:62-66. [PMID: 36450616 DOI: 10.1016/j.jemermed.2022.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 10/03/2022] [Accepted: 10/21/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Amoxapine is a second-generation tricyclic antidepressant with a greater seizure risk than other antidepressants. If administered in large amounts, amoxapine can cause severe toxicity and death. Therefore, it is necessary to terminate seizures immediately if amoxapine toxicity occurs. However, intractable seizures often occur in these patients. We describe a case of intractable seizures caused by amoxapine poisoning, in which intravenous lipid emulsion (ILE) was used successfully. CASE REPORT A 44-year-old woman with a history of depression ingested 3.0 g of amoxapine during a suicide attempt. Although she was initially treated with intravenous diazepam, her seizures persisted. Levetiracetam and phenobarbital were then administered, but seizures persisted. Hence, ILE was injected for over 1 min. At 2 min after ILE administration, the patient's status seizures ceased. Recurrence of seizures was observed 30 min after ILE, and the seizures disappeared after re-administration of ILE. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ILE may be effective in amoxapine intoxication. Emergency physicians may consider ILE as an adjunctive therapy for amoxapine poisoning with a high mortality rate. ILE should be implemented carefully with monitoring of total dosage and adverse events.
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Affiliation(s)
- Masaru Matsuoka
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Toru Imai
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Sou Iwabuchi
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Kosaku Kinoshita
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
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Banstola B, Gamage PL, Jiang W, Mudalige T. Analysis of phospholipids and triacylglycerols in intravenous lipid emulsions. J Pharm Biomed Anal 2023; 222:115112. [DOI: 10.1016/j.jpba.2022.115112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 10/10/2022] [Accepted: 10/15/2022] [Indexed: 03/13/2023]
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Ryan MS, McIntyre J, Bramwell LD, Ojha S. Accidental lipid overdose in a preterm infant: A case report. J Neonatal Perinatal Med 2023; 16:577-586. [PMID: 37718874 DOI: 10.3233/npm-231221] [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: 09/19/2023]
Abstract
BACKGROUND Intravenous lipid emulsions (ILEs) provide essential fatty acids during parenteral nutrition (PN). Serious adverse events including death can occur from overdose. We report an accidental overdose in a preterm infant. METHOD On Day 2 of life, a 29-week gestational age (GA) twin was accidentally given 47.5 mL of Intralipid20% (≈3x daily amount) in 50-minutes. RESULTS No apparent clinical deterioration occurred, although blood samples were lipaemic. Outcomes at 2 years corrected GA were similar to that of his twin. Service changes were made to infusion packaging and administration to avoid similar errors. CONCLUSIONS Medication errors in neonates are unfortunately common. Published articles usually focus on poor outcomes, which can increase the distress for parents of children where errors have occurred. Publishing the full spectrum of outcomes instead allows parents and professionals to be aware of all possibilities and lessons learnt, even if serious harm was avoided.
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Affiliation(s)
- M S Ryan
- Centre for Perinatal Research, Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - J McIntyre
- Neonatal Unit, Derby Children's Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | | | - S Ojha
- Centre for Perinatal Research, Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
- Neonatal Unit, Derby Children's Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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Wiener BG, Hoffman RS. Intralipid administration in case of a severe venlafaxine overdose in a patient with previous gastric bypass surgery. Toxicol Rep 2022; 10:45. [PMID: 36583133 PMCID: PMC9792686 DOI: 10.1016/j.toxrep.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022] Open
Affiliation(s)
- Brian G. Wiener
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, USA,New York City Poison Control Center, New York, NY, USA,Corresponding author at. Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, USA.
| | - Robert S. Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York, USA,New York City Poison Control Center, New York, NY, USA
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Schreiber N, Manninger M, Pätzold S, Reisinger AC, Hatzl S, Hackl G, Högenauer C, Eller P. Cardiogenic shock due to yew poisoning rescued by VA-ECMO: case report and literature review. Channels (Austin) 2022; 16:167-172. [PMID: 35942511 PMCID: PMC9367666 DOI: 10.1080/19336950.2022.2104886] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Ingestion of leaves of the European yew tree (Taxus baccata) can result in fatal cardiac arrhythmias and acute cardiogenic shock. This cardiotoxicity derives from taxine alkaloids that block cardiac voltage-gated sodium and calcium channels. Prompt initiation of venoarterial extracorporeal membrane oxygenation is essential to bridge these critically ill patients to recovery, as there is no antidote available. We here report a 39-year old patient with toxic cardiogenic shock after yew poisoning, who was successfully rescued by venoarterial extracorporeal membrane oxygenation and had a full neurological recovery. This report emphasizes the role of intoxications as reversible causes of cardiac arrest and adds further evidence to the body of existing literature thus encouraging the early use of venoarterial extracorporeal membrane oxygenation in patients with yew poisoning and cardiogenic shock.
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Affiliation(s)
- Nikolaus Schreiber
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Graz, Austria
| | - Martin Manninger
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Sascha Pätzold
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Alexander C Reisinger
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Graz, Austria
| | - Stefan Hatzl
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Graz, Austria
| | - Gerald Hackl
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Graz, Austria
| | - Christoph Högenauer
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Philipp Eller
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Graz, Austria
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Haines KL, Ohnuma T, Trujillo C, Osamudiamen O, Krishnamoorthy V, Raghunathan K, Wischmeyer PE. Hospital change to mixed lipid emulsion from soybean oil-based lipid emulsion for parenteral nutrition in hospitalized and critically ill adults improves outcomes: a pre-post-comparative study. Crit Care 2022; 26:317. [PMID: 36258222 PMCID: PMC9578223 DOI: 10.1186/s13054-022-04194-8] [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] [Received: 07/18/2022] [Accepted: 10/07/2022] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Early data suggest use of a mixed lipid emulsion (LE) with a soybean oil reduction strategy in parenteral nutrition (PN) may improve clinical outcomes. Duke University Hospital made a full switch to a Soybean oil/MCT/Olive/Fish Oil lipid (4-OLE) from pure soybean oil-based LE (Intralipid, Baxter Inc) in May 2017. Since 4-OLE has limited evidence related to its effects on clinical outcome parameters in US hospitals, evidence for clinical benefits of switching to 4-OLE is needed. Therefore, we examined the clinical utility of a hospital-wide switch to 4-OLE and its effect on patient outcomes. METHODS We conducted a single-center retrospective cohort study among adult patients (> 18 years) requiring PN from 2016 to 2019. Our primary exposure was treatment period (1-year pre-4-OLE switch versus 2-year post). We used multivariable regression models to examine our primary outcomes, the association of treatment period with hospital length of stay (LOS), and secondary outcomes liver function, infections, and ICU LOS. Analyses were stratified into critically ill and entire adult cohort. RESULTS We identified 1200 adults hospitalized patients. 28% of PN patients (n = 341) were treated pre-4-OLE switch and 72% post-4-OLE (n = 859). In the adult cohort, 4-OLE was associated with shorter hospital LOS (IRR 0.97, 95% CI 0.95-0.99, p = 0.039). The ICU cohort included 447 subjects, of which 25% (n = 110) were treated pre-4-OLE switch and 75% (n = 337) were post-switch. ICU patients receiving 4-OLE were associated with shorter hospital LOS (IRR 0.91, 95% CI 0.87-0.93, p < 0.0001), as well as a shorter ICU LOS (IRR 0.90, 95% CI 0.82-0.99, p = 0.036). 4-OLE ICU patients also had a significantly lower delta total bilirubin (- 1.6, 95% CI - 2.8 to - 0.2, p = 0.021) and reduced urinary tract infection (UTI) rates (OR 0.50, 95% CI 0.26-0.96, p = 0.038). There were no associations in AST, ALT, or total bilirubin in ICU and all adult patients. CONCLUSION 4-OLE was successfully implemented and reduced soybean oil LE exposure in a large academic hospital setting. The introduction of 4-OLE was associated with reduced LOS, UTI rates, and mitigated hepatic dysfunction in critically ill patients. Overall, these findings prove a switch to a soybean oil-LE sparing strategy using 4-OLE is feasible and safe and is associated with improved clinical outcomes in adult PN patients.
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Affiliation(s)
- Krista L. Haines
- grid.189509.c0000000100241216Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC USA ,grid.189509.c0000000100241216The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, Durham, NC USA
| | - Tetsu Ohnuma
- grid.189509.c0000000100241216The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, Durham, NC USA
| | - Charles Trujillo
- grid.189509.c0000000100241216Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC USA ,grid.189509.c0000000100241216The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, Durham, NC USA ,grid.414179.e0000 0001 2232 0951Department of Anesthesiology, Duke University School of Medicine, Duke University Medical Center (DUMC), Mail # 41, 2301 Erwin Road, 5692 HAFS, Box 3094, Durham, NC 27710 USA
| | - Obanor Osamudiamen
- grid.189509.c0000000100241216Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC USA ,grid.189509.c0000000100241216The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, Durham, NC USA ,grid.414179.e0000 0001 2232 0951Department of Anesthesiology, Duke University School of Medicine, Duke University Medical Center (DUMC), Mail # 41, 2301 Erwin Road, 5692 HAFS, Box 3094, Durham, NC 27710 USA
| | - Vijay Krishnamoorthy
- grid.189509.c0000000100241216The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, Durham, NC USA ,grid.414179.e0000 0001 2232 0951Department of Anesthesiology, Duke University School of Medicine, Duke University Medical Center (DUMC), Mail # 41, 2301 Erwin Road, 5692 HAFS, Box 3094, Durham, NC 27710 USA
| | - Karthik Raghunathan
- grid.189509.c0000000100241216The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, Durham, NC USA ,grid.414179.e0000 0001 2232 0951Department of Anesthesiology, Duke University School of Medicine, Duke University Medical Center (DUMC), Mail # 41, 2301 Erwin Road, 5692 HAFS, Box 3094, Durham, NC 27710 USA
| | - Paul E. Wischmeyer
- grid.189509.c0000000100241216The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, Durham, NC USA ,grid.414179.e0000 0001 2232 0951Department of Anesthesiology, Duke University School of Medicine, Duke University Medical Center (DUMC), Mail # 41, 2301 Erwin Road, 5692 HAFS, Box 3094, Durham, NC 27710 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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DeMel D, Gleeson M, Schachterle K, Thomer A. Successful treatment of ivermectin overdose in a bearded dragon (Pogona vitticeps) using gastric lavage and intravenous lipid emulsion. J Vet Emerg Crit Care (San Antonio) 2022; 32:680-684. [PMID: 35708909 DOI: 10.1111/vec.13218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 04/06/2021] [Accepted: 04/16/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe the clinical signs and outcome following ivermectin overdose in a bearded dragon. This case also describes the novel use of intravenous lipid emulsion (ILE) as a rescue therapy in reptiles, as well as the use of aggressive gastrointestinal decontamination. CASE SUMMARY A 4-year-old female intact bearded dragon (Pogona vitticeps) (0.6 kg) was admitted to the ICU at a specialty hospital following accidental overdose of 40 mg (66.7 mg/kg) of ivermectin enterally. The patient was physically inverted to allow passive reflux of the medication, then sedated for gastric lavage. A 20% ILE was administered intravenously due to the high risk for fatality. Additional treatments included 2 doses of activated charcoal, as well as SC fluids, enteral nutrition, and sucralfate. The patient was profoundly sedate until day 4 when mild improvements in mentation were noted. The patient started ambulating on its own on day 6 and was discharged from the hospital on day 13. The patient was alive 720 days postdischarge. NEW OR UNIQUE INFORMATION PROVIDED This is the first case report describing the events following ivermectin overdose and the use of ILE therapy and activated charcoal in a bearded dragon. These therapies were tolerated with no adverse effects noted in this patient. This report provides evidence that complete recovery from ivermectin overdose is possible.
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Affiliation(s)
- Danielle DeMel
- ACCESS Specialty Animal Hospital, Culver City, California, USA
| | - Molly Gleeson
- ACCESS Specialty Animal Hospital, Culver City, California, USA
| | | | - Amanda Thomer
- ACCESS Specialty Animal Hospital, Culver City, California, USA
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Evidence for the effectiveness of immunologic therapies in women with subfertility and/or undergoing assisted reproduction. Fertil Steril 2022; 117:1144-1159. [PMID: 35618357 DOI: 10.1016/j.fertnstert.2022.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 01/23/2023]
Abstract
Implantation is a critical step in the establishment of a successful pregnancy, depending on a complex immune-endocrine dialogue between the developing embryo and maternal endometrium. Research suggests that altered immunity in the maternal decidua results in implantation impairment and failure. Immunomodulatory drugs have, thus, been widely used in assisted conception to aid embryo implantation, despite an absence of consensus on their effectiveness and safety. We conducted a systematic review and meta-analysis of interventional studies investigating the use of immunomodulators in women undergoing assisted reproduction. Evidence was uncertain of an effect for most of the included interventions, owing to heterogeneous findings and a paucity of high-quality studies. For certain patient subgroups, however, the use of specific immunomodulatory therapies may offer some benefit. There is a need for further large randomized controlled trials to corroborate these findings.
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Lazar AE, Gurzu S, Kovecsi A, Perian M, Cordos B, Gherghinescu MC, Enache LS. Cardio Protective Effects of Lipid Emulsion against Ropivacaine-Induced Local Anesthetic Systemic Toxicity—An Experimental Study. J Clin Med 2022; 11:jcm11102784. [PMID: 35628910 PMCID: PMC9142945 DOI: 10.3390/jcm11102784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 05/04/2022] [Accepted: 05/13/2022] [Indexed: 11/16/2022] Open
Abstract
Inadvertent intravascular injection of local anesthetics (LA) during regional anesthesia causes Local Anesthetic Systemic Toxicity (LAST). Theories of lipid rescue in the case of LAST proved that the administration of lipids in LAST has beneficial effects. One possible mechanism of action is based on the lipophilic properties of LA which allow plasma-free LA to be bound by the molecules of Lipid Emulsion (LE). The association LA–LE is shuttled towards organs such as liver and the kidneys, and the half-life of LA is shortened. The main objective of this experimental study was to assess the possible cardio-prophylactic effect of LE administration before the induction of LAST by intravenous administration of Ropivacaine. This was an experimental, interventional, prospective, and non-randomized study. The subjects were divided into groups and received, under general anesthesia, LE 20% first 0.3–0.4 mL, followed by 0.1 mL Ropivacaine 2 mg/mL, or Ropivacaine alone. At the end of the experiment, the subjects were sacrificed, and tissue samples of kidney, heart and liver were harvested for histopathological examination. LE, when administered as prophylaxis in Ropivacaine-induced LAST, had protective cardiac effects in rats. The LE known side effects were not produced if the substance was administered in the low doses used for LAST prophylaxis.
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Affiliation(s)
- Alexandra Elena Lazar
- Department of Anesthesiology, Emergency Clinical County Hospital, University of Medicine, Science and Technology “George Emil Palade”, 540136 Tirgu Mures, Romania;
| | - Simona Gurzu
- Department of Morphopathology, Emergency Clinical County Hospital, University of Medicine, Science and Technology “George Emil Palade”, 540136 Tirgu Mures, Romania;
- Correspondence:
| | - Attila Kovecsi
- Department of Morphopathology, Emergency Clinical County Hospital, University of Medicine, Science and Technology “George Emil Palade”, 540136 Tirgu Mures, Romania;
| | - Marcel Perian
- Department of Physiology, University of Medicine, Science and Technology “George Emil Palade”, 540136 Tirgu Mures, Romania;
| | - Bogdan Cordos
- Veterinary Experimental Base, University of Medicine, Science and Technology “George Emil Palade”, 540136 Tirgu Mures, Romania;
| | - Mircea Constantin Gherghinescu
- Department of Surgery, Emergency Clinical County Hospital, University of Medicine, Science and Technology “George Emil Palade”, 540136 Tirgu Mures, Romania;
| | - Liviu Sorin Enache
- Emergency Clinical County Hospital Tirgu Mures, University “Dimitrie Cantemir”, 540136 Tirgu Mures, Romania;
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Marena GD, Ramos MADS, Lima LC, Chorilli M, Bauab TM. Galleria mellonella for systemic assessment of anti-Candida auris using amphotericin B loaded in nanoemulsion. THE SCIENCE OF THE TOTAL ENVIRONMENT 2022; 807:151023. [PMID: 34662607 DOI: 10.1016/j.scitotenv.2021.151023] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 06/13/2023]
Abstract
Galleria mellonella is a model that uses adult larvae to assess the prophylactic, therapeutic, and acute toxic potential of substances. Given their benefits, G. mellonella models are being employed in investigations of systemic infections caused by highly resistant microorganisms. Among the multiresistant microorganisms, we highlight Candida auris, a yeast with high mortality potential and resistance. Among the potential drugs, amphotericin B (AmB) stands out; however, microbial resistance episodes and side effects caused by low selectivity have been observed. The incorporation of AmB into a nanoemulsion (NE) can contribute to the control of C. auris infections and resistance as well as decrease the side effects of this drug. This study aimed to develop AmB-loaded NE (NEA) and evaluate its antifungal action against C. auris in G. mellonella. NEs were obtained by using sunflower oil and cholesterol as the oily phase, polyoxyethylene 20 cetyl ether (Brij® 58) and soy phosphatidylcholine as the surfactant system, and PBS buffer as the aqueous phase. An alternative in vivo assay with G. mellonella for acute toxicity and infection was performed using adult stage larvae (200 mg to 400 mg). According to the obtained results, NE and NEA exhibited sizes of 43 and 48 nm, respectively. The PDI was 0.285 and 0.389 for NE and NEA, respectively. The ZP showed electronegativity for both systems, with -3.77 mV and -3.80 mV for NE and NEA, respectively. Acute toxicity showed that free AmB had greater acute toxicity potential than NEA. The survival assay showed high larval viability. NEA had a better antifungal profile against systemic infection in G. mellonella. It is concluded that the alternative model proved to be an efficient in vivo assay to determine the toxicity and evaluate the therapeutic property of free AmB and NEA in systemic infections caused by C. auris.
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Affiliation(s)
- Gabriel Davi Marena
- Department of Drugs and Medicines, São Paulo State University (UNESP), School of Pharmaceutical Sciences, Campus Araraquara, São Paulo State 14.800-903, Brazil
| | - Matheus Aparecido Dos Santos Ramos
- Department of Drugs and Medicines, São Paulo State University (UNESP), School of Pharmaceutical Sciences, Campus Araraquara, São Paulo State 14.800-903, Brazil
| | - Laura Caminitti Lima
- Department of Biological Sciences, São Paulo State University (UNESP), School of Pharmaceutical Sciences, Campus Araraquara, São Paulo State 14.800-903, Brazil
| | - Marlus Chorilli
- Department of Drugs and Medicines, São Paulo State University (UNESP), School of Pharmaceutical Sciences, Campus Araraquara, São Paulo State 14.800-903, Brazil.
| | - Tais Maria Bauab
- Department of Biological Sciences, São Paulo State University (UNESP), School of Pharmaceutical Sciences, Campus Araraquara, São Paulo State 14.800-903, Brazil.
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Epstein SE, Hopper K, Farrell KS. Manual plasma exchange to treat an accidental overdose of intravenous lipid emulsion in a dog with baclofen toxicosis. J Am Vet Med Assoc 2022; 260:650-656. [DOI: 10.2460/javma.21.03.0152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
CASE DESCRIPTION
An approximately 2-year-old sexually intact male German Shorthair Pointer was presented for treatment of baclofen toxicosis.
CLINICAL FINDINGS
The dog had signs of severe baclofen toxicosis (no gag reflex, intermittent vocalization, and stupor) and received intravenous lipid emulsion (142 mL/kg) as a constant rate infusion over 11 hours. Severe hypertriglyceridemia (29,221 mg/dL; reference interval, 19 to 133 mg/dL) developed, followed by cardiovascular depression (poor peripheral perfusion, hyperlactatemia, and hypertension), severe hypoglycemia (26 mg/dL), acute kidney injury (serum creatinine, 3.6 mg/dL), intravascular hemolysis, and coagulopathy (hypocoagulable thromboelastogram and marked bilateral epistaxis).
TREATMENT AND OUTCOME
Therapeutic plasma exchange was performed in 4 stages to treat the hypertriglyceridemia. For each stage, an approximately 500-mL aliquot of blood (22 mL/kg) was removed and centrifuged, and the patient’s RBCs and allogenic fresh-frozen plasma were returned to the dog. Approximately 1.2 times the dog’s plasma volume was exchanged, reducing the serum triglyceride concentration to 1,349 mg/dL and improving the dog’s cardiovascular function and coagulation. Hours after the procedure was completed, the dog regurgitated and developed acute respiratory distress as a result of presumptive aspiration pneumonia, and the owner elected to have the dog euthanized.
CLINICAL RELEVANCE
Veterinarians should be aware of possible complications associated with administration of intravenous lipid emulsion, and veterinary-specific guidelines for the maximum dose of intravenous lipid emulsion should be developed to help prevent adverse effects. TPE appears to be an effective method for treating iatrogenic hypertriglyceridemia in dogs.
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Affiliation(s)
- Steven E. Epstein
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, CA
| | - Kate Hopper
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, CA
| | - Kate S. Farrell
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, CA
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Hori K, Matsuura T, Tsujikawa S, Hino H, Kuno M, Oda Y, Nishikawa K, Mori T. Lipid emulsion facilitates reversal from volatile anesthetics in a rodent model. Clin Toxicol (Phila) 2022; 60:716-724. [PMID: 34985393 DOI: 10.1080/15563650.2021.2020280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Lipid emulsion infusion is a first-line therapy against the toxicity of local anesthetics and is a potential treatment for other drug overdoses, especially for highly lipophilic drugs. Considering the lipophilic property of volatile anesthetics, we hypothesized that lipid emulsion could reverse general anesthesia. METHODS Using adult rats, we tested the effect of lipid emulsion infusion on time to emergence after discontinuation of sevoflurane and isoflurane, and further evaluated restoration of righting reflex under continuous sevoflurane anesthesia. Electroencephalogram during lipid emulsion infusion was also investigated under continuous sevoflurane inhalation. The effect of lipid emulsion on sevoflurane-induced respiratory and hemodynamic depressions was evaluated by measuring respiratory rate, PaCO2 (arterial partial pressure of CO2), blood pressure, and heart rate. The binding property of lipid emulsion on sevoflurane and isoflurane was assessed using in vitro setting with a conical flask. RESULTS Lipid emulsion infusion significantly decreased time to emergence from sevoflurane anesthesia (131 ± 53 vs. 237 ± 69 s) and restored righting reflex during continuous sevoflurane inhalation, by comparing normal saline infusion. Consistent with the behavioral findings, the electroencephalogram under continuous sevoflurane showed decreased power of the δ bands at 5 min after the initiation of lipid emulsion infusion. In addition to reversing hypnosis, lipid emulsion recovered respiratory as well as hemodynamic depressions induced by sevoflurane. Decreased time to emergence was observed also in isoflurane anesthesia (203 ± 111 vs. 314 ± 154 s). To investigate the binding mechanism of lipid emulsion infusion, in vitro experiments revealed significantly decreased anesthetic concentrations of sevoflurane and isoflurane by mixing with lipid emulsion. CONCLUSIONS Lipid emulsion facilitated reversal from volatile anesthetics, as shown by several parameters. As lipid emulsion could bind to volatile anesthetics and simply decrease their effects, our findings suggest that lipid emulsion is a potentially useful agent to reverse general anesthesia.
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Affiliation(s)
- Kotaro Hori
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tadashi Matsuura
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shogo Tsujikawa
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hideki Hino
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Miyuki Kuno
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yutaka Oda
- Department of Anesthesiology, Osaka City Juso Hospital, Osaka, Japan
| | - Kiyonobu Nishikawa
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka, Japan.,Department of Anesthesiology, Shiraniwa Hospital, Nara, Japan
| | - Takashi Mori
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka, Japan
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Steele RW, Moran JH, Patton AL, Kokes CP, James LP, Storm EA, Schexnayder SM. The Spice of Death: Sudden Cardiac Arrest After Novel Psychoactive Substance Exposure. Pediatr Emerg Care 2022; 38:e63-e64. [PMID: 34534160 DOI: 10.1097/pec.0000000000002316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Novel psychoactive substances (NPSs), commonly referred to as "K2" or "spice," are a relatively new toxicology challenge for pediatricians. Adolescents often incorrectly believe that these drugs are safe and can be used without major adverse effects. Although recent legislation attempts to ensure that these drugs are not commercially available, many are able to be purchased online as "not fit for human consumption" or under various misnomers such "incense." In addition, there is a wide chemical variation among these substances, making regulation challenging. Standard urine drug screens test for tetrahydrocannabinol, which may not cross-react with synthetic substances, making NPS poisonings difficult to diagnose. We report a case of fatal cardiac arrest in a 16-year-old adolescent boy temporally associated with use of the NPS, 5F-ADB. The case illustrates the dangerous consequences that these unregulated substances pose to users, as well as the need for the consideration of comprehensive toxicological testing in patients with a history of substance use and sudden cardiac arrest, despite a negative drug screen.
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Badr M, Goulard M, Theret B, Roubertie A, Badiou S, Pifre R, Bres V, Cambonie G. Fatal accidental lipid overdose with intravenous composite lipid emulsion in a premature newborn: a case report. BMC Pediatr 2021; 21:584. [PMID: 34930217 PMCID: PMC8686371 DOI: 10.1186/s12887-021-03064-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 12/08/2021] [Indexed: 01/30/2023] Open
Abstract
Background Tenfold or more overdose of a drug or preparation is a dreadful adverse event in neonatology, often due to an error in programming the infusion pump flow rate. Lipid overdose is exceptional in this context and has never been reported during the administration of a composite intravenous lipid emulsion (ILE). Case presentation Twenty-four hours after birth, a 30 weeks’ gestation infant with a birthweight of 930 g inadvertently received 28 ml of a composite ILE over 4 h. The ILE contained 50% medium-chain triglycerides and 50% soybean oil, corresponding to 6 g/kg of lipids (25 mg/kg/min). The patient developed acute respiratory distress with echocardiographic markers of pulmonary hypertension and was treated with inhaled nitric oxide and high-frequency oscillatory ventilation. Serum triglyceride level peaked at 51.4 g/L, 17 h after the lipid overload. Triple-volume exchange transfusion was performed twice, decreasing the triglyceride concentration to < 10 g/L. The infant’s condition remained critical, with persistent bleeding and shock despite supportive treatment and peritoneal dialysis. Death occurred 69 h after the overdose in a context of refractory lactic acidosis. Conclusions Massive ILE overdose is life-threatening in the early neonatal period, particularly in premature and hypotrophic infants. This case highlights the vigilance required when ILEs are administered separately from other parenteral intakes. Exchange transfusion should be considered at the first signs of clinical or biological worsening to avoid progression to multiple organ failure. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-03064-6.
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Affiliation(s)
- Maliha Badr
- Department of Neonatal Medicine and Paediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France
| | - Marion Goulard
- Department of Neonatal Medicine and Paediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France
| | - Bénédicte Theret
- Department of Neonatal Medicine and Paediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France
| | - Agathe Roubertie
- Department of Neuropaediatrics, Gui de Chauliac Hospital, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Stéphanie Badiou
- Department of Biochemistry and Hormonology, Lapeyronie Hospital, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Roselyne Pifre
- Department of Neonatal Medicine and Paediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France
| | - Virginie Bres
- Department of Medical Pharmacology and Toxicology, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Gilles Cambonie
- Department of Neonatal Medicine and Paediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France. .,Pathogenesis and Control of Chronic Infection, INSERM UMR 1058, University of Montpellier, Montpellier, France.
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Pannu AK, Garg S, Bhalla A, Dhibar DP, Sharma N. Lipid emulsion for the treatment of acute organophosphate poisoning: an Open-Label randomized trial. Clin Toxicol (Phila) 2021; 60:602-608. [PMID: 34928182 DOI: 10.1080/15563650.2021.2013496] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Many organophosphate (OP) pesticides are lipid-soluble; therefore, intravenous lipid emulsion (ILE) has been evaluated as a possible treatment for acute poisoning. A single bolus dose of 100 ml of 20% ILE was found safe in a pilot observational study. This randomized trial aimed to assess the effectiveness and safety of an extended dose of ILE in acute OP poisoning. METHODS This was an investigator-initiated, parallel-group, open-label, randomized controlled trial conducted at PGIMER, Chandigarh (India), from January 2019 to June 2020, in patients aged above 13 years with acute OP poisoning. The primary efficacy outcome was to study the change in atropine dose requirement (total and over the first 24 h) for cholinergic crisis after giving an initial bolus dose of 100 ml of 20% ILE followed by an infusion of 100 ml of 20% ILE over 6 h in addition to the standard care. The secondary efficacy outcomes were to detect the effects on hemodynamic variables, length of hospital stay, and duration of mechanical ventilation required. The incidence of adverse events was evaluated. RESULTS A total of 45 patients were assigned to receive either ILE (intervention group, n = 23) or normal saline (control group, n = 22) in addition to standard treatment. Baseline variables in both groups were comparable. The median dose of atropine (in mg) in the first 24 h and at complete resolution in the ILE group were similar to the control group (124.0 versus 141.8, p-value 0.916; and 150.8 versus 175.0, p-value 0.935). Hemodynamic variables (systolic and diastolic blood pressures, mean arterial pressure, and pulse rate) over 24, 48, and 72 h of treatment, length of hospital stay, and duration of mechanical ventilation were also unaffected by ILE. Case fatality was 4 and not statistically different between intervention and control groups (1 versus 3, p-value 0.346). There was no excessive fever, dyspnea, elevation of serum amylase, or pancreatitis from ILE. CONCLUSION ILE has no apparent benefit in acute OP poisoning. However, an extended dose appears safe for the indication.
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Affiliation(s)
- Ashok Kumar Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sahil Garg
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashish Bhalla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Deba Prasad Dhibar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Navneet Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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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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Liu Y, Zhang J, Yu P, Niu J, Yu S. Mechanisms and Efficacy of Intravenous Lipid Emulsion Treatment for Systemic Toxicity From Local Anesthetics. Front Med (Lausanne) 2021; 8:756866. [PMID: 34820396 PMCID: PMC8606423 DOI: 10.3389/fmed.2021.756866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/07/2021] [Indexed: 11/13/2022] Open
Abstract
Local anesthetics are widely used clinically for perioperative analgesia to achieve comfort in medical treatment. However, when the concentration of local anesthetics in the blood exceeds the tolerance of the body, local anesthetic systemic toxicity (LAST) will occur. With the development and popularization of positioning technology under direct ultrasound, the risks and cases of LAST associated with direct entry of the anesthetic into the blood vessel have been reduced. Clinical occurrence of LAST usually presents as a series of severe toxic reactions such as myocardial depression, which is life-threatening. In addition to basic life support (airway management, advanced cardiac life support, etc.), intravenous lipid emulsion (ILE) has been introduced as a treatment option in recent years and has gradually become the first-line treatment for LAST. This review introduces the mechanisms of LAST and identifies the clinical symptoms displayed by the central nervous system and cardiovascular system. The paper features the multimodal mechanism of LAST reversal by ILE, describes research progress in the field, and identifies other anesthetics involved in the resuscitation process of LAST. Finally, the review presents key issues in lipid therapy. Although ILE has achieved notable success in the treatment of LAST, adverse reactions and contraindications also exist; therefore, ILE requires a high degree of attention during use. More in-depth research on the treatment mechanism of ILE, the resuscitation dosage and method of ILE, and the combined use with other resuscitation measures is needed to improve the efficacy and safety of clinical resuscitation after LAST in the future.
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Affiliation(s)
- Yang Liu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China.,Key Laboratory of Anesthesiology of Jiangxi Province, Nanchang, China
| | - Jing Zhang
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China.,Key Laboratory of Anesthesiology of Jiangxi Province, Nanchang, China
| | - Peng Yu
- Department of Endocrinology and Metabolism, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jiangfeng Niu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China.,Key Laboratory of Anesthesiology of Jiangxi Province, Nanchang, China
| | - Shuchun Yu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China.,Key Laboratory of Anesthesiology of Jiangxi Province, Nanchang, China
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McDaniel M, Flores KB, Akpa BS. Predicting Inter-individual Variability During Lipid Resuscitation of Bupivacaine Cardiotoxicity in Rats: A Virtual Population Modeling Study. Drugs R D 2021; 21:305-320. [PMID: 34279844 PMCID: PMC8363697 DOI: 10.1007/s40268-021-00353-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2021] [Indexed: 12/01/2022] Open
Abstract
Introduction Intravenous lipid emulsions (ILE) have been credited for successful resuscitation in drug intoxication cases where other cardiac life-support methods have failed. However, inter-individual variability can function as a confounder that challenges our ability to define the scope of efficacy for lipid interventions, particularly as relevant data are scarce. To address this challenge, we developed a quantitative systems pharmacology model to predict outcome variability and shed light on causal mechanisms in a virtual population of rats subjected to bupivacaine toxicity and ILE intervention. Materials and Methods We combined a physiologically based pharmacokinetic–pharmacodynamic model with data from a small study in Sprague-Dawley rats to characterize individual-specific cardiac responses to lipid infusion. We used the resulting individual parameter estimates to posit a population distribution of responses to lipid infusion. On that basis, we constructed a large virtual population of rats (N = 10,000) undergoing lipid therapy following bupivacaine cardiotoxicity. Results Using unsupervised clustering to assign resuscitation endpoints, our simulations predicted that treatment with a 30% lipid emulsion increases bupivacaine median lethal dose (LD50) by 46% when compared with a simulated control fluid. Prior experimental findings indicated an LD50 increase of 48%. Causal analysis of the population data suggested that muscle accumulation rather than liver accumulation of bupivacaine drives survival outcomes. Conclusion Our results represent a successful prediction of complex, dynamic physiological outcomes over a virtual population. Despite being informed by very limited data, our mechanistic model predicted a plausible range of treatment outcomes that accurately predicts changes in LD50 when extrapolated to putatively toxic doses of bupivacaine. Furthermore, causal analysis of the predicted survival outcomes indicated a critical synergy between scavenging and direct cardiotonic mechanisms of ILE action. Supplementary Information The online version contains supplementary material available at 10.1007/s40268-021-00353-4.
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Affiliation(s)
- Matthew McDaniel
- Department of Mathematics, North Carolina State University, Raleigh, NC, USA
| | - Kevin B Flores
- Department of Mathematics, North Carolina State University, Raleigh, NC, USA
| | - Belinda S Akpa
- Division of Biosciences, Oak Ridge National Laboratory, Oak Ridge, TN, USA. .,Department of Chemical and Biomolecular Engineering, University of Tennessee, Knoxville, TN, USA. .,Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, NC, USA.
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Villa López G, Valero Zanuy MA, González Barrios I, Maíz Jiménez M, Gomis Muñóz P, León Sanz M. Acute Hypertriglyceridemia in Patients with COVID-19 Receiving Parenteral Nutrition. Nutrients 2021; 13:2287. [PMID: 34371797 PMCID: PMC8308259 DOI: 10.3390/nu13072287] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/23/2021] [Accepted: 06/28/2021] [Indexed: 12/13/2022] Open
Abstract
Hypertriglyceridemia is a metabolic complication associated with parenteral nutrition (PN). It is unknown if patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19 are more at risk. Our aim was to describe the incidence, risk factors and clinical impact of hypertriglyceridemia in critically ill patients with ARDS-COVID-19 receiving PN. We designed a cohort study of patients with ARDS-COVID-19 infection that required admission to critical care units and nutritional support with PN. Individual PN prescriptions for macronutrients and insulin were provided. Lipid emulsion contained fish oil (SMOFlipid® or Lipoplus®). Hypertriglyceridemia was defined as plasma levels above 400 mg/dL. Eighty-seven patients, 66.6% men, 60.1 ± 10.8 years old, BMI 29.1 ± 5.6 kg/m2, 71% of whom received lopinavir/ritonavir, 56% received Propofol and 55% received Tocilizumab were included. The incidence of hypertriglyceridemia was 37 × 100 patient-days with PN. This complication was more frequent in obese patients (OR 3.34; 95% CI, 2.35-4.33) and in those treated with lopinavir/ritonavir (OR 4.98; 95% CI, 3.60-6.29) or Propofol (OR 2.45; 95% CI, 1.55-3.35). Total mortality was 33.3%, similar between the type of lipid emulsion (p = 0.478). On average, patients with hypertriglyceridemia had a longer requirement of PN compared to the group without elevated triglycerides (TG), probably because of their longer survival (p = 0.001). TG higher than 400 mg/dL was not a protective factor for mortality (OR 0.31; 95% CI, 0.01-1.30). In conclusion, the incidence of hypertriglyceridemia was 37 × 100 patient-days with PN. The risk of this complication is associated with obesity and the use of lopinavir/ritonavir or Propofol.
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Affiliation(s)
- Gema Villa López
- Clinical Nutrition Unit, Department of Endocrinology and Nutrition, Hospital Universitario 12 de Octubre, Avenida de Córdoba, s/n, 28041 Madrid, Spain; (G.V.L.); (M.A.V.Z.); (M.M.J.)
| | - Maria Angeles Valero Zanuy
- Clinical Nutrition Unit, Department of Endocrinology and Nutrition, Hospital Universitario 12 de Octubre, Avenida de Córdoba, s/n, 28041 Madrid, Spain; (G.V.L.); (M.A.V.Z.); (M.M.J.)
| | - Ivan González Barrios
- Department of Pharmacy, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (I.G.B.); (P.G.M.)
| | - Maria Maíz Jiménez
- Clinical Nutrition Unit, Department of Endocrinology and Nutrition, Hospital Universitario 12 de Octubre, Avenida de Córdoba, s/n, 28041 Madrid, Spain; (G.V.L.); (M.A.V.Z.); (M.M.J.)
| | - Pilar Gomis Muñóz
- Department of Pharmacy, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (I.G.B.); (P.G.M.)
| | - Miguel León Sanz
- Clinical Nutrition Unit, Department of Endocrinology and Nutrition, Hospital Universitario 12 de Octubre, Avenida de Córdoba, s/n, 28041 Madrid, Spain; (G.V.L.); (M.A.V.Z.); (M.M.J.)
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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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Reisinger A, Vogt S, Essl A, Rauch I, Bangerl F, Eller P, Hackl G. Lessons of the month 3: Intravenous poppers abuse: case report, management and possible complications. Clin Med (Lond) 2021; 20:221-223. [PMID: 32188665 DOI: 10.7861/clinmed.2019-0469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Poppers are nitrite-containing liquids, which are inhaled for their aphrodisiac and hallucinogenic effects. Despite some cases of severe poisonings, poppers are often perceived as harmless by consumers. Inhalation and ingestion of poppers are well known, but, according to our literature review, intravenous abuse has not been reported before. CASE PRESENTATION A 34-year-old man injected poppers intravenously for recreational purposes. He then suffered from dyspnoea and general discomfort. Upon arrival of emergency medical services, the patient was dyspnoeic with blue-grey skin colour and oxygen saturation was 82% on ambient air. Non-invasive ventilation was necessary, and he was transferred to the intensive care unit. Toluidine blue was administered because of a methaemoglobinaemia of 40% and methaemoglobin levels dropped to 0.4%. He was discharged home after a 24-hour observation. We additionally analysed the contents of the poppers bottle: isopropyl nitrite, isopropanol and acetone were detected. Possible complications and the treatment regarding intravenous administration of poppers are discussed. CONCLUSION We present the first published case of intravenous poppers abuse. Our patient suffered from methaemoglobinaemia and was rapidly discharged after treatment with toluidine blue. No specific treatment regarding the contents of the poppers bottle, apart from isopropyl nitrite, was necessary.
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Affiliation(s)
- Alexander Reisinger
- Medical University of Graz, Graz, Austria and Austrian Red Cross, Graz, Austria
| | | | | | | | | | | | - Gerald Hackl
- Medical University of Graz, Graz, Austria and Austrian Red Cross, Graz, Austria
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Swartz S, Dummann K, Guell C, Lubinsky M, Kozeniecki M. Back pain associated with centrally administered parenteral nutrition. Nutr Clin Pract 2021; 37:199-202. [PMID: 33955609 DOI: 10.1002/ncp.10664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Parenteral nutrition (PN) is well recognized for its ability to provide nutrition to patients without the ability to digest enterally; however, PN must also be seen as a medication with associated adverse drug events similar to any other pharmacological agent that is administered to patients. Here we present a case report of localized lower back pain with central PN infusion. The initial areas of concern were the intravenous lipid emulsion, peripherally inserted central catheter placement, osmolarity of the formula, and the additives. The patient's back pain was ultimately felt to be an adverse reaction to the multivitamin component of the infusion based on an elimination trial of the PN components.
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Affiliation(s)
- Sheila Swartz
- Section of Hospital Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kacy Dummann
- Nutrition Services Department, Froedtert Hospital, Milwaukee, Wisconsin, USA
| | - Caitlin Guell
- Nutrition Services Department, Froedtert Hospital, Milwaukee, Wisconsin, USA
| | - Mark Lubinsky
- Nutrition Services Department, Froedtert Hospital, Milwaukee, Wisconsin, USA
| | - Michelle Kozeniecki
- Nutrition Services Department, Froedtert Hospital, Milwaukee, Wisconsin, USA
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van Nispen J, Voigt M, Song E, Armstrong A, Fedorova M, Murali V, Krebs J, Samaddar A, Manithody C, Jain A. Parenteral Nutrition and Cardiotoxicity. Cardiovasc Toxicol 2021; 21:265-271. [PMID: 33554318 DOI: 10.1007/s12012-021-09638-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/27/2021] [Indexed: 12/30/2022]
Abstract
Parenteral nutrition (PN) is a life-saving nutritional therapy for those situations when patients are unable to receive enteral nutrition. However, despite a multitude of benefits offered by PN, it is associated with a variety of side effects, most notably parenteral nutrition-associated liver disease (PNALD). Adverse effects of PN on other organ systems, such as brain and cardiovascular system, have been poorly studied. There have been several case reports, studies, and a recent animal study highlighting cardiotoxic effects of PN; however, much remains unclear about the underlying mechanisms causing cardiac damage. In this review, we propose a series of potential mechanisms behind PN-associated heart injury, and we provide an overview of therapeutic strategies and recent scientific advances.
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Affiliation(s)
- Johan van Nispen
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO, 63103, USA.
- Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO, 63103, USA.
| | - Marcus Voigt
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO, 63103, USA
- Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO, 63103, USA
| | - Eric Song
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO, 63103, USA
| | - Austin Armstrong
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO, 63103, USA
| | - Margarita Fedorova
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO, 63103, USA
| | - Vidul Murali
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO, 63103, USA
| | - Joseph Krebs
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO, 63103, USA
| | - Ashish Samaddar
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO, 63103, USA
| | | | - Ajay Jain
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO, 63103, USA
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Fukushima K, Omura K, Goshi S, Okada A, Tanaka M, Tsujimoto T, Iriyama K, Sugioka N. Individualization of the infusion rate of a soybean oil-based intravenous lipid emulsion for inpatients, based on baseline triglyceride concentrations: A population pharmacokinetic approach. JPEN J Parenter Enteral Nutr 2021; 46:104-113. [PMID: 33769561 PMCID: PMC9290941 DOI: 10.1002/jpen.2111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 02/24/2021] [Accepted: 03/14/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND A rapid infusion rate for intravenous lipid emulsion (ILE) can cause adverse effects; therefore, safe and efficient infusion rates are desired. This study aimed to develop a triglyceride (TG) kinetic model after soybean oil-based ILE (SO-ILE) administration and individualize the infusion rate via a population pharmacokinetic approach. METHODS Eighty-three inpatients were enrolled in this prospective observational study. A TG kinetic model was applied to the observations based on population pharmacokinetics using a nonlinear mixed-effect model. The patients' characteristics and laboratory parameters were evaluated to identify predictors of TG kinetics, and the maximum acceptable infusion rate was defined as that for which the maximum TG concentration did not exceed 400 mg/dl in 90% of patients. RESULTS No adverse events associated with SO-ILE administration were observed. The developed TG kinetic model explained the observed TG concentrations and identified the baseline TG concentration and body weight as predictors of TG kinetics. The estimated maximum acceptable infusion rates greatly varied among individuals, ranging from <0.01 to 0.3 g/kg/h. CONCLUSION The present study suggested the necessity and demonstrated the feasibility of individualizing the infusion rates of SO-ILE, using a population pharmacokinetic approach.
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Affiliation(s)
- Keizo Fukushima
- Department of Clinical Pharmacokinetics, Faculty of Pharmaceutical Sciences, Kobe Gakuin University, Kobe, Japan
| | - Kenji Omura
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Satoshi Goshi
- Department of Gastroenterology and Hepatology, Joetsu General Hospital, Niigata, Japan
| | - Akira Okada
- Department of Clinical Pharmacokinetics, Faculty of Pharmaceutical Sciences, Kobe Gakuin University, Kobe, Japan.,Department of Regulatory Science, Faculty of Pharmacy, Musashino University, Tokyo, Japan
| | - Motomu Tanaka
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Takae Tsujimoto
- Department of Pathophysiology, Faculty of Pharmaceutical Sciences, Kobe Gakuin University, Kobe, Japan
| | - Keiji Iriyama
- Department of Surgery, Nagashima Central Hospital, Mie, Japan
| | - Nobuyuki Sugioka
- Department of Clinical Pharmacokinetics, Faculty of Pharmaceutical Sciences, Kobe Gakuin University, Kobe, Japan
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49
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Fletcher DJ, Boller M. Fluid Therapy During Cardiopulmonary Resuscitation. Front Vet Sci 2021; 7:625361. [PMID: 33585610 PMCID: PMC7876065 DOI: 10.3389/fvets.2020.625361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/31/2020] [Indexed: 11/16/2022] Open
Abstract
Cardiopulmonary arrest (CPA), the acute cessation of blood flow and ventilation, is fatal if left untreated. Cardiopulmonary resuscitation (CPR) is targeted at restoring oxygen delivery to tissues to mitigate ischemic injury and to provide energy substrate to the tissues in order to achieve return of spontaneous circulation (ROSC). In addition to basic life support (BLS), targeted at replacing the mechanical aspects of circulation and ventilation, adjunctive advanced life support (ALS) interventions, such as intravenous fluid therapy, can improve the likelihood of ROSC depending on the specific characteristics of the patient. In hypovolemic patients with CPA, intravenous fluid boluses to improve preload and cardiac output are likely beneficial, and the use of hypertonic saline may confer additional neuroprotective effects. However, in euvolemic patients, isotonic or hypertonic crystalloid boluses may be detrimental due to decreased tissue blood flow caused by compromised tissue perfusion pressures. Synthetic colloids have not been shown to be beneficial in patients in CPA, and given their documented potential for harm, they are not recommended. Patients with documented electrolyte abnormalities such as hypokalemia or hyperkalemia benefit from therapy targeted at those disturbances, and patients with CPA induced by lipid soluble toxins may benefit from intravenous lipid emulsion therapy. Patients with prolonged CPA that have developed significant acidemia may benefit from intravenous buffer therapy, but patients with acute CPA may be harmed by buffers. In general, ALS fluid therapies should be used only if specific indications are present in the individual patient.
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Affiliation(s)
- Daniel J Fletcher
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Manuel Boller
- Faculty of Veterinary and Agricultural Sciences, Melbourne Veterinary School, University of Melbourne, Werribee, VIC, Australia
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50
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Elgazzar FM, Elgohary MS, Basiouny SM, Lashin HI. Intravenous lipid emulsion as an adjuvant therapy of acute clozapine poisoning. Hum Exp Toxicol 2021; 40:1053-1063. [DOI: 10.1177/0960327120983873] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Introduction: Clozapine is a frequently prescribed atypical antipsychotic drug. Various case reports documented the successful recovery of acute antipsychotics toxicity in association with the administration of intralipid emulsion (ILE). Aim: This study aimed to assess the adjuvant therapeutic role of SMOF Lipid administration on the outcomes of acute clozapine poisoning. Methods: Forty patients with acute clozapine poisoning were randomly allocated into two equal groups. The control group received the standard supportive treatment only, whereas the intervention group received the standard supportive treatment plus SMOF Lipid 20% infusion. All patients were subjected to history taking, full clinical examination, and laboratory investigations. The study outcomes were evaluated. Results: The mean Glasgow Coma Scale (GCS) at 6 hours (13.1 ± 2.3 vs 9.2 ± 2, p < 0.001) and 12 hours (14.3 ± 1.5 vs 9.6 ± 2, p < 0.001) after admission was significantly higher in the intervention group compared to the control group. The intervention group showed a significantly lower frequency of prolonged QTc interval 12 hours after admission (p = 0.003), as well as a significantly shorter hospital stay (p < 0.001). Conclusions: SMOF Lipid infusion seemed to have improved GCS, the prolonged QTc interval, and shortened the length of hospital stay. Furthermore, there were no adverse effects related to its administration.
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Affiliation(s)
- Fatma M Elgazzar
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mona S Elgohary
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Sara M Basiouny
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Heba I Lashin
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
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