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Müller MM, Caspar L, Sazpinar O, Hofmaenner DA, Erlebach R, Andermatt R, Ganter CC, Schuepbach RA, Wendel-Garcia PD, David S. Metabolic disturbances potentially attributable to clogging during continuous renal replacement therapy. Intensive Care Med Exp 2023; 11:99. [PMID: 38127207 PMCID: PMC10739685 DOI: 10.1186/s40635-023-00581-9] [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: 09/10/2023] [Accepted: 12/12/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Clogging is characterized by a progressive impairment of transmembrane patency in renal replacement devices and occurs due to obstruction of pores by unknown molecules. If citrate-based anti-coagulation is used, clogging can manifest as a metabolic alkalosis accompanied by hypernatremia and hypercalcemia, primarily a consequence of Na3Citrate infusion. An increased incidence of clogging has been observed during the COVID-19 pandemic. However, precise factors contributing to the formation remain uncertain. This investigation aimed to analyze its incidence and assessed time-varying trajectories of associated factors in critically ill patients on continuous renal replacement therapy (CRRT). METHODS In this retrospective, single-center data analysis, we evaluated COVID-19 patients undergoing CRRT and admitted to critical care between March 2020 and December 2021. We assessed the proportional incidence of clogging surrogates in the overall population and subgroups based on the specific CRRT devices employed at our institution, including multiFiltrate (Fresenius Medical Care) and Prismaflex System (Baxter). Moderate and severe clogging were defined as Na > 145 or ≥ 150 mmol/l and HCO3- > 28.0 or ≥ 30 mmol/l, respectively, with a total albumin-corrected calcium > 2.54 mmol/l. A mixed effect model was introduced to investigate factors associated with development of clogging. RESULTS Fifty-three patients with 240 CRRT runs were analyzed. Moderate and severe clogging occurred in 15% (8/53) and 19% (10/53) of patients, respectively. Twenty-seven percent (37/136) of CRRTs conducted with a multiFiltrate device met the criteria for clogging, whereas no clogging could be observed in patients dialyzed with the Prismaflex System. Occurrence of clogging was associated with elevated triglyceride plasma levels at filter start (p = 0.013), amount of enteral nutrition (p = 0.002) and an increasing white blood cell count over time (p = 0.002). CONCLUSIONS Clogging seems to be a frequently observed phenomenon in critically ill COVID-19 patients. The presence of hypertriglyceridemia, combined with systemic inflammation, may facilitate the development of an impermeable secondary membrane within filters, thereby contributing to compromised membrane patency.
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Affiliation(s)
- Mattia M Müller
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Larina Caspar
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Onur Sazpinar
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Daniel A Hofmaenner
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Rolf Erlebach
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Rea Andermatt
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Christoph C Ganter
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Reto A Schuepbach
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Pedro D Wendel-Garcia
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
- Department of Nephrology, Hannover Medical School, Hanover, Germany.
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2
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Basta MN. Local anaesthetic systemic toxicity complicating intraoperative intercostal nerve blocks: What do clinicians need to know to prevent similar occurrence? J Perioper Pract 2023; 33:390-395. [PMID: 37525402 DOI: 10.1177/17504589231180769] [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] [Indexed: 08/02/2023]
Abstract
Local anaesthetic systemic toxicity is a life-threatening adverse event that may occur after administration of local anaesthetics through a variety of routes. Local anaesthetic systemic toxicity is always a potential complication and may occur with all local anaesthetics and in any route of administration. Local anaesthetic systemic toxicity primarily affects the central nervous system and the cardiovascular system and may be fatal. The following is a case of local anaesthetic systemic toxicity complicating surgeon-performed intraoperative intercostal nerve blocks at multiple levels, with a mixture of liposomal bupivacaine and bupivacaine hydrochloride in a patient who underwent video-assisted segmental lung resection for lung cancer under general anaesthesia. Local anaesthetic systemic toxicity presented with seizures and hypotension. The patient was successfully managed and fully recovered. This case illustrates the importance of awareness regarding the prevention, diagnosis and treatment of local anaesthetic systemic toxicity among medical professionals who administer local anaesthetics.
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Affiliation(s)
- Mafdy N Basta
- Department of Anesthesiology & Perioperative Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
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3
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Sohn JT. Lipid emulsion dosage used for resuscitation after drug toxicity. Am J Emerg Med 2022; 59:168-169. [PMID: 35868991 DOI: 10.1016/j.ajem.2022.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 07/13/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 beon-gil, Jinju-si, Gyeongsangnam-do 52727, Republic of Korea; Institute of Health Sciences, Gyeongsang National University, Jinju-si 52727, Republic of Korea.
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4
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Osman AF, Prasad RM, Marein S, O'Brien C. Multi-organ dysfunction as a presentation of calcium channel blocker intoxication. BMJ Case Rep 2022; 15:15/1/e245711. [PMID: 35039350 PMCID: PMC8768057 DOI: 10.1136/bcr-2021-245711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
SummaryWe report the case of a 73-year-old woman who intentionally ingested 400 mg of amlodipine in a suicidal attempt who initially presented with hypotension which persisted despite aggressive therapy with fluid resuscitation, multiple pressor support, high-dose insulin therapy and calcium infusion. Her haemodynamic instability evolved to include bradycardia requiring atropine and transcutaneous pacing. Eventually she required salvage therapy with intravenous lipid emulsion (ILE) therapy . Despite all aggressive therapy, she developed multi-organ failure resulting in death. The literature on high-dose insulin euglycaemic therapy (HIET) and ILE therapy shows mixed results with some showing significant improvement in haemodynamic status. In our case, it had no significant positive impact on the outcome.
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Affiliation(s)
| | | | - Shawn Marein
- Department of Pulmonary & Critical care, Sparrow Health System, Lansing, Michigan, USA
| | - Corey O'Brien
- Department of Pulmonary & Critical care, Sparrow Health System, Lansing, Michigan, USA
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Rotella JA, Greene SL, Koutsogiannis Z, Graudins A, Hung Leang Y, Kuan K, Baxter H, Bourke E, Wong A. Treatment for beta-blocker poisoning: a systematic review. Clin Toxicol (Phila) 2020; 58:943-983. [DOI: 10.1080/15563650.2020.1752918] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Joe-Anthony Rotella
- Victorian Poisons Information Centre, Austin Health, Victoria, Australia
- Department of Emergency Medicine, Northern Health, Epping, Victoria
| | - Shaun L. Greene
- Victorian Poisons Information Centre, Austin Health, Victoria, Australia
- Department of Medicine, Faculty of Medicine, University of Melbourne, Victoria, Australia
| | - Zeff Koutsogiannis
- Victorian Poisons Information Centre, Austin Health, Victoria, Australia
- Department of Emergency Medicine, Northern Health, Epping, Victoria
| | - Andis Graudins
- Victorian Poisons Information Centre, Austin Health, Victoria, Australia
- Monash Toxicology and Emergency Department, Monash Health, Victoria, Australia
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia
| | - Yit Hung Leang
- Victorian Poisons Information Centre, Austin Health, Victoria, Australia
| | - Kelvin Kuan
- Department of Emergency Medicine, Changi General Hospital, Singapore, Singapore
| | - Helen Baxter
- Austin Health Library, Austin Health, Victoria, Australia
| | - Elyssia Bourke
- Victorian Poisons Information Centre, Austin Health, Victoria, Australia
| | - Anselm Wong
- Victorian Poisons Information Centre, Austin Health, Victoria, Australia
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia
- Department of Medicine and Radiology, Centre for Integrated Critical Care, Melbourne Medical School, University of Melbourne, Victoria, Australia
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6
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Bupropion Overdose Complicated by Cardiogenic Shock Requiring Vasopressor Support and Lipid Emulsion Therapy. J Emerg Med 2020; 58:e47-e50. [PMID: 31911020 DOI: 10.1016/j.jemermed.2019.11.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 11/08/2019] [Accepted: 11/23/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Bupropion overdose is a commonly encountered presentation in the emergency department (ED). While the majority of cases resolve with supportive care, serious adverse effects, including seizures, cardiogenic shock, and death, can occur. Intravenous lipid emulsion (ILE) therapy has been utilized for a multitude of poisonings with varying levels of success. Although a number of cases suggest the value of ILE therapy in cases of bupropion overdose, more recent data propose that its role may be overstated. CASE REPORT A young woman presented to the ED with altered mental status complicated by seizure after bupropion overdose. She subsequently developed cardiogenic shock requiring vasopressor support. Bedside echocardiogram revealed a decreased left ventricular ejection fraction (LVEF). She received ILE therapy with significant improvement in both hemodynamic status and LVEF by bedside ultrasound. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although the majority of patients presenting with bupropion overdose improve with supportive care, life-threatening sequelae are possible. ILE therapy has shown promise in a variety of different overdose situations, although the evidence in cases of bupropion poisoning has been varied, and it has traditionally been utilized as a last-line rescue modality. Based on hemodynamic parameters and bedside ultrasound, this case suggests that early initiation of ILE therapy should be considered in these cases, as the potential benefits likely outweigh the theoretical risks.
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Higgins AM, LaPoint RJ, Vest MT. Intravenous lipid emulsion agglutination to Central venous catheter after treatment for intentional polysubstance overdose. Clin Toxicol (Phila) 2019; 58:428-429. [PMID: 31416360 DOI: 10.1080/15563650.2019.1650937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Amber M Higgins
- Departments of Emergency Medicine and Family Medicine, Christiana Care Health Care System, Delaware, DE, USA
| | - Randi J LaPoint
- Department of Pathology and Laboratory Medicine, Christiana Care Health Care System, Delaware, DE, USA
| | - Michael T Vest
- Section of Critical Care Medicine, Department of Medicine, Christiana Care Health Care System, Delaware, DE, USA
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Paneta M, Waring WS. Literature review of the evidence regarding intravenous lipid administration in drug-induced cardiotoxicity. Expert Rev Clin Pharmacol 2019; 12:591-602. [PMID: 31106655 DOI: 10.1080/17512433.2019.1621163] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Intravenous lipid emulsion (ILE) administration is capable of reversing the acute cardiac and neurological toxicity caused by local anesthetic agents. In recent years, ILE has also been explored as a potential antidote for cardiotoxicity caused by non-anesthetic agents too. Areas covered: The potential mechanisms, safety, and efficacy of this approach are considered. Data were sought from published reports listed in PubMed and EMBASE, and abstracts of meetings of the North American Congress of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxicologists. There were reports involving 298 patients where ILE has been administered for severe drug toxicity. Clinical improvement was observed in 57 of 59 patients with local anesthetic toxicity (96.6%); there were 239 patients where toxicity was due to non-anesthetic agents, and ILE apparently improved clinical outcome in 215 (72.1%). Expert opinion: Response rates were similar between ILE treated toxicity caused by lipid soluble and non-lipid soluble drugs. Potential adverse effects of ILE include interference with laboratory assays, acute pancreatitis, and adult respiratory distress syndrome, although the rate of occurrence is difficult to ascertain.
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Affiliation(s)
- Maria Paneta
- a Acute Medical Unit , York Teaching Hospital NHS Foundation Trust , York , UK
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9
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Practical guide for the management of systemic toxicity caused by local anesthetics. J Anesth 2018; 33:1-8. [PMID: 30417244 DOI: 10.1007/s00540-018-2542-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 08/04/2018] [Indexed: 10/27/2022]
Abstract
Systemic toxicity from local anesthetics can occur in any of the wide range of situations in which these agents are used. This practical guide is created to generate a shared awareness of the prevention, diagnosis, and treatment of local anesthetic systemic toxicity among all medical professionals who perform nerve blocks. Systemic toxicity of local anesthetic is induced by an increase of its protein-unbound plasma concentration. Initial symptoms are characterized by central nervous system signs such as excitation, convulsions, followed by loss of consciousness and respiratory arrest. These symptoms are often accompanied with cardiovascular signs such as hypertension, tachycardia and premature ventricular contractions. Further increase of plasma concentration of local anesthetic induces bradycardia, conduction disturbances, circulatory collapse and asystole. The incidence of local anesthetic systemic toxicity is 1-11 cases per 10,000. Infants, patients with decreased liver function and low cardiac output are vulnerable to systemic toxicity. When performing regional anesthesia, the guideline-directed monitoring, securing a venous line, preparation of medication to treat convulsions and lipid emulsions are required. For prevention of local anesthetic systemic toxicity, small-dose, divided administration, using agents with low toxicity such as ropivacaine and levobupivacaine, performing an aspiration test are recommended. If systemic toxicity is suspected, halt administration of local anesthetic, request assistance, secure venous line, airway, administration of 100% oxygen and if necessary tracheal intubation and artificial respiration should be immediately performed. Benzodiazepines are recommended to treat convulsions. Administration of 20% lipid emulsion according to the protocol is recommended to treat severe hypotension and arrhythmia.
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10
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Petersen KM, Bøgevig S, Petersen TS, Jensen TB, Dalhoff KP, Henriksen T, Poulsen HE, Christensen MB. Hemodynamic Effects of Intravenous, High-Dose Lipid Emulsion With and Without Metoprolol Infusion in Healthy Volunteers: A Randomized Clinical Trial. Clin Pharmacol Ther 2018; 105:1009-1017. [PMID: 30412277 DOI: 10.1002/cpt.1281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 10/15/2018] [Indexed: 11/09/2022]
Abstract
In a double-blinded, randomized, crossover trial, we investigated the hemodynamic effects of high-dose intravenous lipid emulsion (ILE) with/without metoprolol. Ten healthy volunteers each completed 4 trial days (placebo + ILE; metoprolol + placebo; metoprolol + ILE; placebo + placebo) in random order. Metoprolol was administered as an initial bolus (10 mg), followed by an infusion (50 mg) from 5 to 30 minutes. ILE was administered as a bolus at 12.5 minutes (2.5 mL/kg), followed by a 15-minute infusion (0.25 mL/kg per minute). On metoprolol + ILE days (compared with metoprolol + placebo) after 120 minutes, mean heart rates were significantly higher (difference, 5.5 beats per minute (bpm); 95% confidence interval (CI), 3.0-8.1 bpm; P < 0.001), and average relative cardiac output was higher (difference, 10 percentage points; 95% CI, 5-15 percentage points; P < 0.001). The hemodynamic effect of ILE developed gradually. ILE had no effect on plasma metoprolol or major adverse events. In conclusion, high-dose ILE has relatively marginal and delayed hemodynamic effects that may have limited clinical relevance in the short-term clinical toxicological setting.
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Affiliation(s)
- Kasper Meidahl Petersen
- Department and laboratory of Clinical Pharmacology, Bispebjerg, and Frederiksberg University Hospital, Copenhagen, Denmark
| | - Søren Bøgevig
- Department and laboratory of Clinical Pharmacology, Bispebjerg, and Frederiksberg University Hospital, Copenhagen, Denmark
| | - Tonny Studsgaard Petersen
- Department and laboratory of Clinical Pharmacology, Bispebjerg, and Frederiksberg University Hospital, Copenhagen, Denmark
| | - Thomas Bo Jensen
- Department and laboratory of Clinical Pharmacology, Bispebjerg, and Frederiksberg University Hospital, Copenhagen, Denmark
| | - Kim Peder Dalhoff
- Department and laboratory of Clinical Pharmacology, Bispebjerg, and Frederiksberg University Hospital, Copenhagen, Denmark
| | - Trine Henriksen
- Department and laboratory of Clinical Pharmacology, Bispebjerg, and Frederiksberg University Hospital, Copenhagen, Denmark
| | - Henrik Enghusen Poulsen
- Department and laboratory of Clinical Pharmacology, Bispebjerg, and Frederiksberg University Hospital, Copenhagen, Denmark
| | - Mikkel Bring Christensen
- Department and laboratory of Clinical Pharmacology, Bispebjerg, and Frederiksberg University Hospital, Copenhagen, Denmark
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11
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Abstract
PURPOSE OF REVIEW Enthusiasm for regional anesthesia has been driven by multimodal benefits to patient outcomes. Despite widespread awareness and improved techniques (including the increasing use of ultrasound guidance for block placement), intravascular sequestration and the attendant risk of local anesthetic systemic toxicity (LAST) remains. Intravenous lipid emulsion (ILE) for the treatment of LAST has been endorsed by anesthetic regulatory societies on the basis of animal study and human case report data. The accumulated mass of reporting now permits objective interrogation of published literature. RECENT FINDINGS Although incompletely elucidated the mechanism of action for ILE in LAST seemingly involves beneficial effects on initial drug distribution (i.e., pharmacokinetic effects) and positive cardiotonic and vasoactive effects (i.e., pharmacokinetic effects) acting in concert. Recent systematic review by collaborating international toxicologic societies have provided reserved endorsement for ILE in bupivacaine-induced toxicity, weak support for ILE use in toxicity from other local anesthetics, and largely neutral recommendation for all other drug poisonings. Work since publication of these recommendations has concluded that there is a positive effect on survival for ILE when animal models of LAST are meta-analyzed and evidence of a positive pharmacokinetic effect for lipid in human models of LAST. SUMMARY Lipid emulsion remains first-line therapy (in conjunction with standard resuscitative measures) in LAST. Increasing conjecture as to the clinical efficacy of ILE in LAST, however, calls for high-quality human data to refine clinical recommendations.
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12
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McLaughlin DC, Fang DC, Nolot BA, Guru PK. Hypertriglyceridemia Causing Continuous Renal Replacement Therapy Dysfunction in a Patient with End-stage Liver Disease. Indian J Nephrol 2018; 28:303-306. [PMID: 30158750 PMCID: PMC6094843 DOI: 10.4103/ijn.ijn_201_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hypertriglyceridemia is infrequently reported as a cause of suboptimal delivery of dialytic therapy in critically ill patients. We report the case of a critically ill liver transplant patient in the Intensive Care Unit who was found to have recurrent filter clotting during continuous renal replacement therapy (CRRT). The patient had increased serum triglycerides (TGs), which was identified approximately 2 weeks into hospitalization and initially believed to be due to prolonged propofol use. The patient's elevated TGs ultimately caused her blood to become lipemic, causing the dialytic circuit to become nonfunctional and placed the patient in imminent danger due to hyperkalemia and metabolic acidosis. Therapeutic plasma exchange was emergently used to lower TG levels, and renal replacement therapy was resumed without any other issues. The patient's persistent hypertriglyceridemia was attributed to a combination of adverse effect of medications and liver graft failure. The high TG level and abnormal liver functions improved after a repeat liver transplantation.
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Affiliation(s)
| | - D C Fang
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Florida, USA
| | - B A Nolot
- Department of Nursing, Apheresis, Mayo Clinic, Florida, USA
| | - P K Guru
- Department of Critical Care, Mayo Clinic, Florida, USA
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13
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Baker KA, Austin EB, Wang GS. Antidotes: Familiar Friends and New Approaches for the Treatment of Select Pediatric Toxicological Exposures. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2017. [DOI: 10.1016/j.cpem.2017.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sin JH, Tom A, Toyoda A, Roy N, Hayes BD. High-dose intravenous lipid emulsion affecting successful initiation of continuous venovenous hemofiltration and extracorporeal membrane oxygenation. Clin Toxicol (Phila) 2017; 56:149-150. [PMID: 28681624 DOI: 10.1080/15563650.2017.1341633] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Jonathan H Sin
- a Department of Pharmacy , Massachusetts General Hospital , Boston , MA , USA
| | - Andrew Tom
- a Department of Pharmacy , Massachusetts General Hospital , Boston , MA , USA
| | - Alexander Toyoda
- a Department of Pharmacy , Massachusetts General Hospital , Boston , MA , USA
| | - Nathalie Roy
- b Division of Cardiac Surgery, Massachusetts General Hospital , Boston , MA , USA
| | - Bryan D Hayes
- a Department of Pharmacy , Massachusetts General Hospital , Boston , MA , USA.,c Department of Emergency Medicine , Harvard Medical School , Boston , MA , USA
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16
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Agulnik A, Kelly DP, Bruccoleri R, Yuskaitis C, Ebrahimi-Fakhari D, Sahin M, Burns MM, Kohane DS. Combination Clearance Therapy and Barbiturate Coma for Severe Carbamazepine Overdose. Pediatrics 2017; 139:peds.2016-1560. [PMID: 28557718 PMCID: PMC9923579 DOI: 10.1542/peds.2016-1560] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2016] [Indexed: 11/24/2022] Open
Abstract
A 15-year-old female subject presented comatose, in respiratory failure and shock, after the intentional ingestion of ∼280 extended-release 200-mg carbamazepine tablets with a peak serum concentration of 138 µg/mL (583.74 µmol/L). The patient developed clinical seizures and an EEG pattern of stimulus-induced rhythmic, periodic, or ictal discharges, suggestive of significant cortical dysfunction. Due to the extremely high drug serum concentration and clinical instability, a combination of therapies was used, including lipid emulsion therapy, plasmapheresis, hemodialysis, continuous venovenous hemodiafiltration, and endoscopic intestinal decontamination. The patient's elevated serum lactate level with a high mixed venous saturation suggested possible mitochondrial dysfunction, prompting treatment with barbiturate coma to reduce cerebral metabolic demand. The serum carbamazepine concentration declined steadily, with resolution of lactic acidosis, no long-term end-organ damage, and return to baseline neurologic function. The patient was eventually discharged in her usual state of health. In the laboratory, we demonstrated in vitro that the active metabolite of carbamazepine hyperpolarized the mitochondrial membrane potential, supporting the hypothesis that the drug caused mitochondrial dysfunction. We thus successfully treated a life-threatening carbamazepine overdose with a combination of modalities. Future studies are required to validate this aggressive approach. The occurrence of mitochondrial dysfunction must be confirmed in patients with carbamazepine toxicity and the need to treat it validated.
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Affiliation(s)
- Asya Agulnik
- Department of Global Pediatric Medicine and Division of Critical Care, St. Jude Children's Research Hospital, Memphis, Tennessee; and
| | | | | | | | | | - Mustafa Sahin
- Neurology, Boston Children’s Hospital, Boston, Massachusetts
| | | | - Daniel S. Kohane
- Divisions of Medicine Critical Care,,Address correspondence to Daniel S. Kohane, MD, PhD, Division of Critical Care Medicine, Boston Children’s Hospital, Bader 634, 300 Longwood Ave, Boston, MA 02115. E-mail:
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Corwin DJ, Topjian A, Banwell BL, Osterhoudt K. Adverse events associated with a large dose of intravenous lipid emulsion for suspected local anesthetic toxicity. Clin Toxicol (Phila) 2017; 55:603-607. [DOI: 10.1080/15563650.2017.1294693] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Daniel J. Corwin
- Division of Emergency Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alexis Topjian
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Brenda L. Banwell
- Division of Neurology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kevin Osterhoudt
- Division of Emergency Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- The Poison Control Center, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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What is this chocolate milk in my circuit? A cause of acute clotting of a continuous renal replacement circuit: Answers. Pediatr Nephrol 2016; 31:2253-2255. [PMID: 26817475 PMCID: PMC6033319 DOI: 10.1007/s00467-016-3318-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 12/10/2015] [Accepted: 12/11/2015] [Indexed: 10/22/2022]
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19
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Forsberg M, Forsberg S, Edman G, Höjer J. No support for lipid rescue in oral poisoning: A systematic review and analysis of 160 published cases. Hum Exp Toxicol 2016; 36:461-466. [DOI: 10.1177/0960327116679715] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Lipid rescue is used as treatment of various poisonings despite weak scientific evidence. Some experimental studies have indicated a positive effect, but others have not. Clinical studies are lacking, wherefore a systematic review of virtually all published human case reports is presented. The case reports were searched for in PubMed and Web of Science and examined by two experts according to an assessment form grading the probability for a causal connection between lipid rescue and improved symptoms. A total of 160 cases were finally included, of which 30 had no positive effect of lipid rescue. Among the 130 included cases with alleged positive effect, 94 were oral poisonings and 36 were cases with local anesthetic systemic toxicity (LAST). The experts’ assessment resulted in a “certain” causal connection in three cases with LAST but not in oral poisoning. Moreover, the mean assessment score among the oral poisonings was significantly worse than the corresponding score in the cases with LAST. The average log p-value of the main toxins among the oral poisonings was significantly lower than the corresponding p-value in the cases with LAST. Among the oral poisonings, 91% had received some other resuscitative treatment more or less simultaneously with lipid rescue. Considering the findings of this study and the increasingly reported adverse effects of lipid rescue, it’s reasonable to strictly limit its use in clinical practice. We would not recommend it in oral poisonings.
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Affiliation(s)
- M Forsberg
- Department of Surgery, Norrtälje Sjukhus, TioHundra AB, Sweden
| | - S Forsberg
- Department of Anaesthesiology and Intensive Care, Norrtälje Sjukhus, TioHundra AB, Sweden
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Swedish Poisons Information Centre, Stockholm, Sweden
| | - G Edman
- Department of Psychiatry, Norrtälje sjukhus, TioHundra AB, Sweden
| | - J Höjer
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Swedish Poisons Information Centre, Stockholm, Sweden
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Rosenberg PH. Current evidence is not in support of lipid rescue therapy in local anaesthetic systemic toxicity. Acta Anaesthesiol Scand 2016; 60:1029-32. [PMID: 27465522 DOI: 10.1111/aas.12743] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- P. H. Rosenberg
- Department of Anaesthesiology and Intensive Care; University of Helsinki; Helsinki Finland
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21
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Lam SH, Majlesi N, Vilke GM. Use of Intravenous Fat Emulsion in the Emergency Department for the Critically Ill Poisoned Patient. J Emerg Med 2016; 51:203-14. [DOI: 10.1016/j.jemermed.2016.02.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 02/05/2016] [Indexed: 11/25/2022]
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22
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Höjer J, Jacobsen D, Neuvonen PJ, Rosenberg PH. Lipid Rescue - Efficacy and Safety Still Unproven. Basic Clin Pharmacol Toxicol 2016; 119:345-8. [DOI: 10.1111/bcpt.12607] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 04/08/2016] [Indexed: 12/12/2022]
Affiliation(s)
- Jonas Höjer
- Swedish Poisons Information Center; Karolinska Institute; Stockholm Sweden
| | - Dag Jacobsen
- Department of Acute Medicine; Oslo University Hospital; Oslo Norway
| | - Pertti J. Neuvonen
- Department of Clinical Pharmacology; Helsinki University Hospital and University of Helsinki; Helsinki Finland
| | - Per H. Rosenberg
- Department of Anaesthesiology and Intensive Care Medicine; Helsinki University Hospital and University of Helsinki; Helsinki Finland
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23
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Hayes BD, Gosselin S, Calello DP, Nacca N, Rollins CJ, Abourbih D, Morris M, Nesbitt-Miller A, Morais JA, Lavergne V. Systematic review of clinical adverse events reported after acute intravenous lipid emulsion administration. Clin Toxicol (Phila) 2016; 54:365-404. [PMID: 27035513 DOI: 10.3109/15563650.2016.1151528] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Intravenous lipid emulsions (ILEs) were initially developed to provide parenteral nutrition. In recent years, ILE has emerged as a treatment for poisoning by local anesthetics and various other drugs. The dosing regimen for the clinical toxicology indications differs significantly from those used for parenteral nutrition. The evidence on the efficacy of ILE to reverse acute toxicity of diverse substances consists mainly of case reports and animal experiments. Adverse events to ILE are important to consider when clinicians need to make a risk/benefit analysis for this therapy. METHODS Multiple publication databases were searched to identify reports of adverse effects associated with acute ILE administration for either treatment of acute poisoning or parenteral nutrition. Articles were selected based on pre-defined criteria to reflect acute use of ILE. Experimental studies and reports of adverse effects as a complication of long-term therapy exceeding 14 days were excluded. RESULTS The search identified 789 full-text articles, of which 114 met the study criteria. 27 were animal studies, and 87 were human studies. The adverse effects associated with acute ILE administration included acute kidney injury, cardiac arrest, ventilation perfusion mismatch, acute lung injury, venous thromboembolism, hypersensitivity, fat embolism, fat overload syndrome, pancreatitis, extracorporeal circulation machine circuit obstruction, allergic reaction, and increased susceptibility to infection. CONCLUSION The emerging use of ILE administration in clinical toxicology warrants careful attention to its potential adverse effects. The dosing regimen and context of administration leading to the adverse events documented in this review are not generalizable to all clinical toxicology scenarios. Adverse effects seem to be proportional to the rate of infusion as well as total dose received. Further safety studies in humans and reporting of adverse events associated with ILE administration at the doses advocated in current clinical toxicology literature are needed.
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Affiliation(s)
- Bryan D Hayes
- a Department of Pharmacy , University of Maryland Medical Center and Department of Emergency Medicine, University of Maryland School of Medicine , Baltimore , MD , USA
| | - Sophie Gosselin
- b Department of Medicine, McGill Faculty of Medicine, Emergency Medicine , McGill University Health Centre , Montréal , Canada ;,c Province of Alberta Drug Information Services , Alberta , Canada ;,d Centre antipoison du Québec , Québec , Canada
| | - Diane P Calello
- e Medical Toxicology, Department of Emergency Medicine , Morristown Medical Center, Emergency Medical Associates , Morristown , NJ , USA
| | - Nicholas Nacca
- f Department of Surgery, Division of Emergency Medicine , University of Vermont , Burlington , VT , USA
| | - Carol J Rollins
- g Banner-University Medical Center Tucson, University of Arizona College of Pharmacy , Tucson , AZ , USA
| | - Daniel Abourbih
- h Department of Medicine, Division of Emergency Medicine , University of Toronto , Toronto , Canada
| | - Martin Morris
- i Life Sciences Library , McGill University , Montréal , Canada
| | | | - José A Morais
- j Division of Geriatric Medicine , McGill University , Montréal , Québec , Canada
| | - Valéry Lavergne
- k Department of Medical Biology , Sacré-Coeur Hospital, University of Montréal , Montréal , Canada
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24
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Affiliation(s)
- Michael R Fettiplace
- Department of Anesthesiology, University of Illinois Hospital and Health Sciences System, Chicago, IL; Research and Development Service, Jesse Brown Veterans Affairs Medical Center, Chicago, IL
| | - Guy Weinberg
- Department of Anesthesiology, University of Illinois Hospital and Health Sciences System, Chicago, IL; Research and Development Service, Jesse Brown Veterans Affairs Medical Center, Chicago, IL
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25
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Levine M, Hoffman RS, Lavergne V, Stork CM, Graudins A, Chuang R, Stellpflug SJ, Morris M, Miller-Nesbitt A, Gosselin S. Systematic review of the effect of intravenous lipid emulsion therapy for non-local anesthetics toxicity. Clin Toxicol (Phila) 2016; 54:194-221. [DOI: 10.3109/15563650.2015.1126286] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Michael Levine
- Department of Emergency Medicine, Section of Medical Toxicology, University of Southern California, Los Angeles, CA, USA
| | - Robert S. Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, NY, USA
| | - Valéry Lavergne
- Department of Medical Biology, Sacré-Coeur Hospital, University of Montreal, Montreal, Canada
| | - Christine M. Stork
- Department of Emergency Medicine, Upstate Medical University, New York and Upstate New York Poison Center, New York, NY, USA
| | - Andis Graudins
- Department of Medicine, School of Clinical Sciences at Monash Health, Clinical Toxicology Service at Monash Health and Monash Emergency Translational Research Group, Monash University, Clayton, Victoria, Australia
| | - Ryan Chuang
- Department of Emergency Medicine, University of Calgary, Poison and Drug Information Service, Calgary, Canada
| | | | - Martin Morris
- Schulich Library of Science and Engineering, McGill University, Montreal, Canada; and
| | - Andrea Miller-Nesbitt
- Schulich Library of Science and Engineering, McGill University, Montreal, Canada; and
| | - Sophie Gosselin
- Department of Emergency Medicine, McGill University Health Centre & Department of Medicine, McGill University, Montreal, Canada
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26
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Fettiplace MR, Weinberg G. Past, Present, and Future of Lipid Resuscitation Therapy. JPEN J Parenter Enteral Nutr 2015; 39:72S-83S. [DOI: 10.1177/0148607115595979] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 06/22/2015] [Indexed: 01/18/2023]
Affiliation(s)
- Michael R. Fettiplace
- Department of Anesthesiology, University of Illinois College of Medicine, Chicago, Illinois
- Research & Development Service, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois
- Neuroscience Program, University of Illinois at Chicago, Chicago, Illinois
| | - Guy Weinberg
- Department of Anesthesiology, University of Illinois College of Medicine, Chicago, Illinois
- Research & Development Service, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois
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27
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Fettiplace MR, Akpa BS, Rubinstein I, Weinberg G. Confusion About Infusion: Rational Volume Limits for Intravenous Lipid Emulsion During Treatment of Oral Overdoses. Ann Emerg Med 2015; 66:185-8. [PMID: 25737211 DOI: 10.1016/j.annemergmed.2015.01.020] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Indexed: 01/25/2023]
Affiliation(s)
- Michael R Fettiplace
- Department of Anesthesiology, University of Illinois College of Medicine, Chicago, IL; Research and Development Service, Jesse Brown Veterans Affairs Medical Center, Chicago, IL.
| | - Belinda S Akpa
- Department of Chemical Engineering, University of Illinois at Chicago, Chicago, IL
| | - Israel Rubinstein
- Section of Pulmonary, Critical Care, Sleep and Allergy Medicine, Department of Medicine, University of Illinois College of Medicine, Chicago, IL; Research and Development Service, Jesse Brown Veterans Affairs Medical Center, Chicago, IL
| | - Guy Weinberg
- Department of Anesthesiology, University of Illinois College of Medicine, Chicago, IL; Research and Development Service, Jesse Brown Veterans Affairs Medical Center, Chicago, IL
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