1
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Sohn JT. Lipid emulsion resuscitation for intractable calcium channel blocker toxicity in pediatric patients. Turk J Pediatr 2024; 66:383-384. [PMID: 39024594 DOI: 10.24953/turkjpediatr.2024.4657] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Accepted: 05/24/2024] [Indexed: 07/20/2024]
Affiliation(s)
- Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Gangnam-ro, Jinju-si, Republic of Korea
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2
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Lee S, Park KE, Hwang Y, Bae S, Ok SH, Ahn SH, Sim G, Kim HJ, Park S, Sohn JT. Lipid Emulsions Inhibit Labetalol-Induced Vasodilation in the Isolated Rat Aorta. Int J Mol Sci 2024; 25:7243. [PMID: 39000349 PMCID: PMC11241312 DOI: 10.3390/ijms25137243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 06/19/2024] [Accepted: 06/28/2024] [Indexed: 07/16/2024] Open
Abstract
Lipid emulsions are used as adjuvant drugs to alleviate intractable cardiovascular collapse induced by drug toxicity. We aimed to examine the effect of lipid emulsions on labetalol-induced vasodilation and the underlying mechanism in the isolated rat aorta. We studied the effects of endothelial denudation, NW-nitro-l-arginine methyl ester (l-NAME), calmidazolium, methylene blue, 1H-[1,2,4]oxadiazolo[4,3-a] quinoxalin-1-one (ODQ), and lipid emulsions on labetalol-induced vasodilation. We also evaluated the effects of lipid emulsions on cyclic guanosine monophosphate (cGMP) formation, endothelial nitric oxide synthase (eNOS) phosphorylation, and endothelial calcium levels induced by labetalol. Labetalol-induced vasodilation was higher in endothelium-intact aortas than that in endothelium-denuded aortas. l-NAME, calmidazolium, methylene blue, and ODQ inhibited labetalol-induced vasodilation in endothelium-intact aortas. Lipid emulsions inhibited labetalol-induced vasodilation in endothelium-intact and endothelium-denuded aortas. l-NAME, ODQ, and lipid emulsions inhibited labetalol-induced cGMP formation in endothelium-intact aortas. Lipid emulsions reversed the stimulatory and inhibitory eNOS (Ser1177 and Thr495) phosphorylation induced by labetalol in human umbilical vein endothelial cells and inhibited the labetalol-induced endothelial calcium increase. Moreover, it decreased labetalol concentration. These results suggest that lipid emulsions inhibit vasodilation induced by toxic doses of labetalol, which is mediated by the inhibition of endothelial nitric oxide release and reduction of labetalol concentration.
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Affiliation(s)
- Soohee Lee
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Changwon Hospital, Changwon-si 51472, Gyeongsangnam-do, Republic of Korea (S.-H.O.)
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
- Institute of Medical Science, Gyeongsang National University, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
| | - Kyeong-Eon Park
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 Beon-gil, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea (Y.H.)
| | - Yeran Hwang
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 Beon-gil, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea (Y.H.)
| | - Sungil Bae
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 Beon-gil, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
| | - Seong-Ho Ok
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Changwon Hospital, Changwon-si 51472, Gyeongsangnam-do, Republic of Korea (S.-H.O.)
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
- Institute of Medical Science, Gyeongsang National University, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
| | - Seung-Hyun Ahn
- Institute of Medical Science, Gyeongsang National University, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 Beon-gil, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
| | - Gyujin Sim
- Institute of Medical Science, Gyeongsang National University, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 Beon-gil, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
| | - Hyun-Jin Kim
- Division of Applied Life Science (BK21 Four), Gyeonsang National University, Jinju-si 52828, Gyeongsangnam-do, Republic of Korea
- Department of Food Science and Technology, Institute of Agriculture and Life Science, Gyeongsang National University, Jinju-si 52828, Gyeongsangnam-do, Republic of Korea
| | - Seunghyeon Park
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 Beon-gil, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
| | - Ju-Tae Sohn
- Institute of Medical Science, Gyeongsang National University, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 Beon-gil, Jinju-si 52727, Gyeongsangnam-do, Republic of Korea (Y.H.)
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Hwang Y, Sohn JT. Recurrence of Symptoms or Re-elevation of Drug Concentration After Termination of Lipid Emulsion Treatment for Drug Toxicity: Analysis of Case Reports and Systematic Review. Am J Ther 2024; 31:e338-e342. [PMID: 38219233 DOI: 10.1097/mjt.0000000000001687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Affiliation(s)
- Yeran Hwang
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju-si, Republic of Korea
| | - Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju-si, Republic of Korea
- Institute of Medical Science, Gyeongsang National University, Jinju-si, Republic of Korea
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Hwang Y, Sohn JT. Effect of lipid emulsion on neuropsychiatric drug-induced toxicity: A narrative review. Medicine (Baltimore) 2024; 103:e37612. [PMID: 38489675 PMCID: PMC10939703 DOI: 10.1097/md.0000000000037612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 02/13/2024] [Accepted: 02/23/2024] [Indexed: 03/17/2024] Open
Abstract
Lipid emulsion has been shown to effectively relieve refractory cardiovascular collapse resulting from toxic levels of nonlocal anesthetics. The goal of this study was to examine the effect of lipid emulsions on neuropsychiatric drug-induced toxicity using relevant case reports of human patients, with a particular focus on the Glasgow Coma Scale (GCS) score and corrected QT interval, to analyze drugs that frequently require lipid emulsion treatment. The following keywords were used to retrieve relevant case reports from PubMed: "antidepressant or antipsychotic drug or amitriptyline or bupropion or citalopram or desipramine or dosulepin or dothiepin or doxepin or escitalopram or fluoxetine or haloperidol or olanzapine or phenothiazine or quetiapine or risperidone or trazodone" and "lipid emulsion or Intralipid." Lipid emulsion treatment reversed the corrected QT interval prolongation and decreases in Glasgow Coma Scale scores caused by toxic doses of neuropsychiatric drugs, especially lipid-soluble drugs such as amitriptyline, trazodone, quetiapine, lamotrigine, and citalopram. The log P (octanol/water partition coefficient) of the group which required more than 3 lipid emulsion treatments was higher than that that of the group which required less than 3 lipid emulsion treatments. The main rationale to administer lipid emulsion as an adjuvant was as follows: hemodynamic depression intractable to supportive treatment (88.3%) > lipophilic drugs (8.3%) > suspected overdose or no spontaneous breathing (1.6%). Adjuvant lipid emulsion treatment contributed to the recovery of 98.30% of patients with neuropsychiatric drug-induced toxicity. However, further analyses using many case reports are needed to clarify the effects of lipid emulsion resuscitation.
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Affiliation(s)
- Yeran Hwang
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju-si, Republic of Korea
| | - Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju-si, Republic of Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju-si, Republic of Korea
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5
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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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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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Sohn JT. Lipid Emulsion-Mediated Improvement of Hemodynamic Depression Caused by Amlodipine Toxicity. Pediatr Emerg Care 2023; 39:205-206. [PMID: 36083186 DOI: 10.1097/pec.0000000000002842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju-si, Republic of Korea; and Institute of Health Sciences, Gyeongsang National University, Jinju-si, Republic of Korea
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Katlan B, Kesici S, Bayrakci B. Intravenous Lipid Emulsion Treatment for Calcium-Channel Blocker Intoxication: Pediatric Case Series and Review of the Literature. Pediatr Emerg Care 2023; 39:120-124. [PMID: 35344530 DOI: 10.1097/pec.0000000000002703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Calcium-channel blocker (CCBs) intoxication remains the most lethal among all other drug overdoses (Arroyo and Kao. Pediatr Emerg Care 2009;25:533-538). This study aimed to describe the use and efficacy of intravenous lipid emulsion treatment in our CCB overdose patients in tandem with a comprehensive literature investigation. CASE REPORTS Hereby we report 4 adolescent patients who arrived to the pediatric emergency department after intentional CCB ingestions. All patients were hospitalized in pediatric intensive care unit because of hypotension, and they were initially treated with fluid boluses, glucagon, calcium infusion, vasopressors, inotropes and insulin. Intravenous lipid emulsion (dose: 20% lipid emulsion given as a 1.5-mL/kg bolus followed by 0.25-0.5 mL/kg/min for 30-60 minutes) treatment was given to all patients unresponsive to initial treatments. Hemodynamic instability improved immediately after intravenous lipid emulsion treatment. All patients were discharged with complete recovery at the sixth day of pediatric intensive care unit admission. CONCLUSIONS Intravenous lipid emulsion therapy stands as a salvage treatment for CCB intoxications with cardiovascular failure unresponsive to standard supportive treatments.
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Affiliation(s)
- Banu Katlan
- From the Departmant of Intensive Care Medicine, Life Support Center, Hacettepe University Ihsan Doğramaci Children's Hospital, Ankara, Turkey
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Sohn JT. Half-Life of Lipid Emulsions Used in Lipid Emulsion Treatment for Drug Toxicity. J Emerg Med 2023; 64:253-254. [PMID: 36906377 DOI: 10.1016/j.jemermed.2022.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 12/13/2022] [Indexed: 03/11/2023]
Affiliation(s)
- Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, and Institute of Health Sciences, Gyeonsang National University, Republic of Korea
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Banerjee S, Zargari M, Medzikovic L, Russino H, Mikhael M, Koons N, Grogan T, Rahman S, Eghbali M, Umar S. Intralipid® improves left ventricular function in rats with lipopolysaccharide-induced endotoxaemia by a Src-STAT3-mediated mechanism. Br J Anaesth 2023; 130:e183-e187. [PMID: 36462942 PMCID: PMC10170391 DOI: 10.1016/j.bja.2022.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/07/2022] [Accepted: 10/11/2022] [Indexed: 12/03/2022] Open
Affiliation(s)
- Somanshu Banerjee
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Michael Zargari
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Lejla Medzikovic
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Hanzi Russino
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Matthew Mikhael
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Natalie Koons
- University of New England School of Osteopathic Medicine, Biddeford, ME, USA
| | - Tristan Grogan
- Department of Medicine Statistics Core, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Siamak Rahman
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Mansoureh Eghbali
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Soban Umar
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.
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Larson CP, Youssefzadeh K, Moon JS. The Bupivacaine Story: A Tribute to George A. Albright, MD (1931-2020). Anesth Analg 2022; 135:1115-1119. [PMID: 35924832 DOI: 10.1213/ane.0000000000006161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In 1979, George A. Albright, MD (1931-2020) published a controversial editorial in Anesthesiology that raised the question of bupivacaine cardiotoxicity. In it, he presented several cases of rapid cardiovascular collapse after administration of the highly lipophilic local anesthetic and called for further investigation. Although the scientific community initially resisted Dr Albright's idea, his editorial would ultimately lead to several important advancements in anesthesiology. In 1983, the US Food and Drug Administration issued a black box warning that recommended against the use of 0.75% bupivacaine in obstetric anesthesia. This warning would remain in place until 1999. In addition, Dr Albright's article led to the following changes: laboratory research that proved the cardiotoxicity of bupivacaine; the development of safer, stereoselective agents like ropivacaine; and the acceptance of lipid emulsion as a treatment for local anesthetic toxicity. In this article, C. Philip Larson, Jr, MDCM, Editor-in-Chief of Anesthesiology at the time of publication of Albright's manuscript, provides a unique perspective on the bupivacaine story.
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Affiliation(s)
- C Philip Larson
- From the Departments of Anesthesia and Neurosurgery, Stanford University, Stanford, California.,Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Kevin Youssefzadeh
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Jane S Moon
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
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Sohn JT. Commentary: Case report: Successful intravenous lipid emulsion therapy for canine amphetamine toxicosis. Front Vet Sci 2022; 9:1011210. [PMID: 36187822 PMCID: PMC9525104 DOI: 10.3389/fvets.2022.1011210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 08/30/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju-si, South Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju-si, South Korea
- *Correspondence: Ju-Tae Sohn
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13
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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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Long B, Chavez S, Gottlieb M, Montrief T, Brady WJ. Local anesthetic systemic toxicity: A narrative review for emergency clinicians. Am J Emerg Med 2022; 59:42-48. [PMID: 35777259 DOI: 10.1016/j.ajem.2022.06.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/31/2022] [Accepted: 06/05/2022] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Emergency clinicians utilize local anesthetics for a variety of procedures in the emergency department (ED) setting. Local anesthetic systemic toxicity (LAST) is a potentially deadly complication. OBJECTIVE This narrative review provides emergency clinicians with the most current evidence regarding the pathophysiology, evaluation, and management of patients with LAST. DISCUSSION LAST is an uncommon but potentially life-threatening complication of local anesthetic use that may be encountered in the ED. Patients at extremes of age or with organ dysfunction are at higher risk. Inadvertent intra-arterial or intravenous injection, as well as repeated doses and higher doses of local anesthetics are associated with greater risk of developing LAST. Neurologic and cardiovascular manifestations can occur. Early recognition and intervention, including supportive care and intravenous lipid emulsion 20%, are the mainstays of treatment. Using ultrasound guidance, aspirating prior to injection, and utilizing the minimal local anesthetic dose needed are techniques that can reduce the risk of LAST. CONCLUSIONS This focused review provides an update for the emergency clinician to manage patients with LAST.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, USA.
| | - Summer Chavez
- Department of Emergency Medicine, UT Health Houston, Houston, TX, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Tim Montrief
- Department of Emergency Medicine, Jackson Memorial Health System, Miami, FL, USA
| | - William J Brady
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA.
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Zaballos M, Fernández I, Rodríguez L, García S, Varela O, Quintela O, Anadón MJ, Almendral J. Effects of intravenous lipid emulsions on the reversal of pacing-induced ventricular arrhythmias and electrophysiological alterations in an animal model of ropivacaine toxicity. Clin Toxicol (Phila) 2022; 60:902-911. [PMID: 35658706 DOI: 10.1080/15563650.2022.2080075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Ropivacaine is considered to have a wider margin of cardiovascular safety. However, several reports of ventricular arrhythmias (VA) due to ropivacaine toxicity have been documented. Intravenous lipid emulsions (ILEs) have recently been used successfully in the treatment of local anesthetic intoxication. The main objective of the present study was to evaluate the efficacy of the ILEs in the prevention of pacing-induced-VA and electrophysiological alterations in an animal model of ropivacaine toxicity. METHODS Nineteen pigs were anesthetized and instrumentalized. A baseline programmed electrical ventricular stimulation protocol (PEVSP) to induce VA was performed. Ropivacaine (5 mg·kg-1 + 100 μg·kg-1·min-1) followed by normal saline infusion (control group n = 8) or intralipid 20% (1.5 mL·kg-1 + 0.25 mL·kg-1·min-1) for the ILE group (n = 8), were administered three minutes after the ropivacaine bolus. PEVSP was repeated 25 min after the onset of ropivacaine infusion. Pacing-induced VA and electrophysiological abnormalities were assessed in both groups. A sham-control group (n = 3) without ropivacaine infusion was included. RESULTS Most of the electrophysiological parameters evaluated were affected by ropivacaine: PR interval by 28% (p = 0.001), AV interval by 40% (p = 0.001), sinus QRS by 101% (p = 0.001), paced QRS at a rate of 150 bpm by 258% (p = 0.001), and at 120 bpm by 241% (p = 0.001). Seven animals (87.5%) in the control group and eight animals (100%) in the ILE group developed sustained-VA (p = 0.30). Successful resuscitation occurred in 100% of animals in the ILE group vs. 57% of animals in the control group, p = 0.038. Pacing-induced-VA terminated at the first defibrillation attempt in 75% of the animals in the ILE group vs. 0% in the control group, p = 0.01. CONCLUSION Ropivacaine strongly altered the parameters of ventricular conduction, thus facilitating the induction of VA. ILEs did not prevent pacing-induced VA. However, facilitated resuscitation and termination of VA were delivered at the first defibrillation attempt compared to the control group.
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Affiliation(s)
- Matilde Zaballos
- Department of Forensic Medicine, Psychiatry and Pathology, Department of Anaesthesiology, Faculty of Medicine, Complutense University, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Ignacio Fernández
- Department of Anesthesiology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Lucia Rodríguez
- Department of Anesthesiology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Sergio García
- Department of Anesthesiology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Olalla Varela
- Department of Anesthesiology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Oscar Quintela
- Department of Forensic Medicine, Psychiatry and Pathology, Faculty of Medicine, Complutense University, Madrid, Spain
| | - María-José Anadón
- Head Department of Forensic Medicine, Psychiatry and Pathology, Faculty of Medicine, National Institute of Toxicology and Forensic Science, Complutense University, Madrid, Spain
| | - Jesús Almendral
- Electrophysiology Arrhythmia Unit, Hospital Monteprincipe Grupo HM Hospitales, University CEU-San Pablo, Madrid, Spain
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16
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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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17
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Sohn JT. Lipid emulsion treatment of cardiotoxicity caused by calcium channel blocker and beta-blocker. Am J Emerg Med 2022; 58:331-332. [PMID: 35346530 DOI: 10.1016/j.ajem.2022.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 03/19/2022] [Indexed: 11/15/2022] 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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18
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Stewart R, Newman V, Harvey M, Tang M, Wu Z, Cave G. Lipid emulsion mitigates intravenous amiodarone toxicity in a rat model. TOXICOLOGY COMMUNICATIONS 2022. [DOI: 10.1080/24734306.2022.2031565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Rachael Stewart
- Registrar, Intensive Care Unit, Canterbury District Health Board, Christchurch, New Zealand
| | - Verity Newman
- ACCS CT1 Anaesthetics, Royal Cornwall Hospital Trust, Cornwall, England
| | - Martyn Harvey
- Waikato DHB Emergency Department, Emergency Physician and Director of Research, Hamilton, New Zealand
| | - Mingtan Tang
- School of Pharmacy, University of Auckland, Auckland, New Zealand
| | - Zimei Wu
- School of Pharmacy, University of Auckland, Auckland, New Zealand
| | - Grant Cave
- Intensive Care Physician, Hawkes Bay District Health Board, Hastings, New Zealand
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19
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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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20
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Karamlou M, Asaria I, Barron J, Boutros P, Fisher V, Grandinetti R, Johnson J, Richard E, Susko D, Urrutia C, Woolsey B, Baumann R, Cottle J, Sweaney R, Wenzel M, Nusstein J, Hall D. Complications After Dental Sedation: A Myotonic Mystery Case Report. Anesth Prog 2022; 69:26-31. [PMID: 36534775 PMCID: PMC9773408 DOI: 10.2344/anpr-69-02-09] [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: 06/24/2021] [Accepted: 03/18/2022] [Indexed: 12/23/2022] Open
Abstract
Myotonic dystrophy (dystrophia myotonica; DM) is an uncommon progressive hereditary muscle disorder that can present with variable severity at birth, in early childhood, or most commonly as an adult. Patients with DM, especially type 1 (DM1), are extremely sensitive to the respiratory depressant effects of sedative-hypnotics, anxiolytics, and opioid agonists. This case report describes a 37-year-old male patient with previously undiagnosed DM1 who received dental care under minimal sedation using intravenous midazolam. During the case, the patient experienced 2 brief episodes of hypoxemia, the second of which required emergency intubation after propofol and succinylcholine and resulted in extended hospital admission. A lipid emulsion (Liposyn II 20%) infusion was given approximately 2 hours after the last local anesthetic injection due to slight ST elevation and suspicion of local anesthetic toxicity (LAST). Months after treatment, the patient suffered a fall resulting in a fatal traumatic brain injury. Complications noted in this case report were primarily attributed to the unknown diagnosis of DM1, although additional precipitating factors were likely present. This report also provides a basic review of the literature and clinical guidelines for managing myotonic dystrophy patients for dental care with local anesthesia, sedation, or general anesthesia.
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Affiliation(s)
- Milad Karamlou
- Former Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Iman Asaria
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Jaime Barron
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Petra Boutros
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Vincent Fisher
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Rachel Grandinetti
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Julian Johnson
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Emily Richard
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - David Susko
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Cristobal Urrutia
- Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Bryce Woolsey
- Chief Resident, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Ronald Baumann
- Former Assistant Professor and Attending, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - James Cottle
- Assistant Professor and Attending, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Richard Sweaney
- Assistant Professor and Attending, The Ohio State University College of Dentistry General Practice Residency Program, Columbus, Ohio
| | - Mark Wenzel
- Program Director and Hospital Attending, The Ohio State University College of Dentistry General Practice Residency Program and Wexner Medical Center, Columbus, Ohio
| | - John Nusstein
- Professor and Chair Division of Endodontics, The Ohio State University College of Dentistry, Columbus, Ohio
| | - David Hall
- Associate Professor and Hospital Attending, The Ohio State University College of Dentistry General Practice Residency Program and Wexner Medical Center, Columbus, Ohio
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21
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Sohn JT. Putative Mechanisms Associated With Lipid Emulsion Treatment for Cardiac Toxicity Caused by Yew Intoxication. Pediatr Emerg Care 2022; 38:e438. [PMID: 32649486 DOI: 10.1097/pec.0000000000002196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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23
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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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24
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Dontukurthy S, Tobias JD. Update on Local Anesthetic Toxicity, Prevention and Treatment During Regional Anesthesia in Infants and Children. J Pediatr Pharmacol Ther 2021; 26:445-454. [PMID: 34239395 DOI: 10.5863/1551-6776-26.5.445] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 09/17/2020] [Indexed: 01/29/2023]
Abstract
Local anesthetic agents play a key role in the treatment and prevention of pain in children. Although generally safe and effective, as with any pharmacologic agent, adverse effects may occur with the administration of these medications. Systemic absorption or inadvertent systemic injection during bolus dosing or continuous infusion can result in local anesthetic systemic toxicity with life-threatening neurological and cardiac complications. The following article reviews the pharmacology of local anesthetic agents, outlines previous reports of systemic toxicity during regional anesthesia, and discusses prevention and treatment algorithms.
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25
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First Case of Acute Poisoning with Amiodarone and Flecainide in Attempted Suicide Successfully Managed with Lipid Emulsion Therapy in the Emergency Department: Case Report and Literature Review. Healthcare (Basel) 2021; 9:healthcare9060671. [PMID: 34199756 PMCID: PMC8226996 DOI: 10.3390/healthcare9060671] [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: 05/13/2021] [Revised: 05/31/2021] [Accepted: 06/01/2021] [Indexed: 11/17/2022] Open
Abstract
Acute antiarrhythmics poisoning represents a challenge in the Emergency Department (ED). These patients often develop malignant arrhythmias in need of exceptional therapeutic measures in the ICU. We report a 47-year-old patient admitted to the ED 5 h after the ingestion of a large dose of amiodarone and flecainide in a suicide attempt. During their ED stay, the patient developed signs of cardiotoxicity evidenced by electrocardiogram and ventricular arrhythmias. The toxicological results showed a level of 4.8 mg/L amiodarone and 2.98 mg/L flecainide. He was successfully treated in the ED using a large dose of sodium bicarbonate and lipid emulsion therapy. After hospital admission, he remained stable, with no need for exceptional therapeutic measures such as mechanical circulatory support, cardiac pacing or ECMO. We emphasize the importance of an early start of pharmacological therapies in the ED, which might improve the outcome in antiarrhythmic acute poisoning.
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26
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Hwang Y, Sohn JT. Lipid emulsion treatment of hydroxychloroquine toxicity. Mod Rheumatol 2021; 31:924-925. [PMID: 34060429 DOI: 10.1080/14397595.2020.1836790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Yeran Hwang
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju, Gyeongsangnam-do, Korea
| | - Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju, Gyeongsangnam-do, Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju, Korea
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27
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Flecainide Toxicity Secondary to Accidental Overdose: A Pediatric Case Report of Two Brothers. Case Rep Crit Care 2021; 2021:6633859. [PMID: 34094603 PMCID: PMC8140826 DOI: 10.1155/2021/6633859] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 04/15/2021] [Accepted: 05/03/2021] [Indexed: 11/17/2022] Open
Abstract
Flecainide is a class 1C antiarrhythmic with a narrow therapeutic window and thereby a high-risk medication for causing acute toxicity. Dysrhythmias secondary to flecainide ingestion are often refractory to antiarrhythmics and cardioversion, and patients commonly require extracorporeal support. We review the successful resuscitation of two brothers aged 2 and 4 who presented two years apart with unstable wide-complex tachyarrhythmia suspicious for severe flecainide toxicity. Each patient received sodium bicarbonate and 20% intravenous lipid emulsion with a full recovery. While extracorporeal support is often required following flecainide ingestion, we present two cases where it was avoided due to aggressive multimodal management with sodium bicarbonate, electrolyte repletion, and 20% intravenous lipid emulsion. In addition, avoidance of agitation-induced tachycardia may be beneficial.
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28
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Cobey FC, Kawabori M, Schumann R, Couper G, Bonney I, Fettiplace MR, Weinberg G. Intravenous Lipid Emulsion During Heart Transplantation. J Cardiothorac Vasc Anesth 2021; 35:3139-3141. [PMID: 33771441 DOI: 10.1053/j.jvca.2021.02.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 02/15/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Frederick C Cobey
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA.
| | - Masashi Kawabori
- CardioVascular Center, Cardiac Surgery, Tufts Medical Center, Boston, MA
| | - Roman Schumann
- Department of Anesthesiology, VA Boston Healthcare System, West Roxbury, MA
| | - Gregory Couper
- CardioVascular Center, Cardiac Surgery, Tufts Medical Center, Boston, MA
| | - Iwona Bonney
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Michael R Fettiplace
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Guy Weinberg
- Department of Anesthesiology, University of Illinois and Jesse Brown VA Medical Center, Chicago, IL
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29
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Lipid emulsion treatment as an antidote for chloroquine and hydroxychloroquine toxicity. Am J Emerg Med 2021; 42:258-259. [PMID: 33546954 DOI: 10.1016/j.ajem.2021.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/08/2021] [Accepted: 01/11/2021] [Indexed: 11/24/2022] Open
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30
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Sohn JT. Plasma clearance and lipaemic index of lipid emulsion used for lipid emulsion treatment. Ann Clin Biochem 2021; 58:547-548. [PMID: 33435698 DOI: 10.1177/0004563221990686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Gyeongsangnam-do, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju-si, Republic of Korea
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31
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Macfarlane AJR, Gitman M, Bornstein KJ, El-Boghdadly K, Weinberg G. Updates in our understanding of local anaesthetic systemic toxicity: a narrative review. Anaesthesia 2021; 76 Suppl 1:27-39. [PMID: 33426662 DOI: 10.1111/anae.15282] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2020] [Indexed: 12/21/2022]
Abstract
Despite advances in clinical practice, local anaesthetic systemic toxicity continues to occur with the therapeutic use of local anaesthesia. Patterns of presentation have evolved over recent years due in part to the increasing use of ultrasound which has been demonstrated to reduce risk. Onset of toxicity is increasingly delayed, a greater proportion of clinical reports are secondary to fascial plane blocks, and cases are increasing where non-anaesthetist providers are involved. The evolving clinical context presents a challenge for diagnosis and requires education of all physicians, nurses and allied health professionals about these changing patterns and risks. This review discusses: mechanisms; prevention; diagnosis; and treatment of local anaesthetic systemic toxicity. The local anaesthetic and dose used, site of injection and block conduct and technique are all important determinants of local anaesthetic systemic toxicity, as are various patient factors. Risk mitigation is discussed including the care of at-risk groups, such as: those at the extremes of age; patients with cardiac, hepatic and specific metabolic diseases; and those who are pregnant. Advances in the changing clinical landscape with novel applications and settings for the use of local anaesthesia are also described. Finally, we signpost future directions to potentially improve the management of local anaesthetic systemic toxicity. The utility of local anaesthetics remains unquestionable in clinical practice, and thus maximising the safe and appropriate use of these drugs should translate to improvements in patient care.
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Affiliation(s)
- A J R Macfarlane
- Department of Anaesthesia, Critical Care and Pain Medicine, Glasgow Royal Infirmary, Glasgow, UK.,2University of Glasgow, Glasgow, UK
| | - M Gitman
- Department of Anaesthesia, University of Illinois College of Medicine, Chicago, IL, USA
| | - K J Bornstein
- Department of Medical Education, University of Miami School of Medicine, Miami, FL, USA
| | - K El-Boghdadly
- Department of Anaesthesia and Peri-operative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
| | - G Weinberg
- Department of Anaesthesia, University of Illinois College of Medicine, Chicago, IL, USA.,Jesse Brown VA Medical Centre, Chicago, IL, USA
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32
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Huang L, Ren Q, Yu S, Shao Y, Chen Y, Huang X. Supplement of Lipid Emulsion to Epinephrine Improves Resuscitation Outcomes of Asphyxia-Induced Cardiac Arrest in Aged Rats. Clin Interv Aging 2020; 15:1701-1716. [PMID: 33061323 PMCID: PMC7519862 DOI: 10.2147/cia.s268768] [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: 06/21/2020] [Accepted: 08/12/2020] [Indexed: 11/23/2022] Open
Abstract
Objective The goal of the study was to investigate the efficacy of lipid supplement to epinephrine-based therapy in resuscitation of asphyxia-induced cardiac arrest in aged rats. Methods The study included two parts: in experiment A, rats underwent asphyxial cardiac arrest and cardiopulmonary resuscitation, randomized to receive epinephrine and normal saline (control group, n=22), epinephrine and intralipid 20% (long-chain triglycerides (LCT) group, n=22) or epinephrine and lipovenoes 20% (LCT/medium-chain triglcerides (MCT) group, n=22). Return of spontaneous circulation, recurrence of asystole after resuscitation, hemodynamic metrics, arterial blood gas values, neurological assessment score and indexes of pulmonary transudation were recorded. In experiment B, rats using the same model and resuscitation protocol were randomly divided into 21 groups: Control 0, Control 20, Control 40, Control 60, Control 80, Control 100, Control 120, LCT 0, LCT 20, LCT 40, LCT 60, LCT 80, LCT 100, LCT 120, LCT/MCT 0, LCT/MCT 20, LCT/MCT 40, LCT/MCT 60, LCT/MCT 80, LCT/MCT 100 and LCT 120 (n=10, the subscripts represent respective endpoint of observation in minutes). Myocardial bioenergetics were determined. Results In experiment A, the LCT and LCT/MCT groups had a shorter time to return of spontaneous circulation (ROSC) (P=0.001and P<0.001, respectively) and higher survival rate (P=0.033 and P=0.014, respectively) compared with the Control group. The LCT/MCT group had higher MAP (P<0.001 and P=0.001, respectively), HR (P<0.001 and P=0.004, respectively) and RPP (P<0.001 and P<0.001, respectively) compared with the Control and LCT groups, respectively. In experiment B, the LCT/MCT group had a higher energy charge compared with the control group at 20 (P<0.001) and 40 (P<0.001) minutes. The LCT group had higher energy charge compared with the Control group at 40 (P<0.001) and 60 (P<0.001) minutes. Conclusion The supplement of lipid emulsion to epinephrine improves resuscitation outcomes of asphyxia-induced cardiac arrest than epinephrine alone in our in vivo model of aged rat. LCT/MCT emulsion may be superior to LCT emulsion in epinephrine-based resuscitation.
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Affiliation(s)
- Lijun Huang
- Department of Anesthesiology, Ningbo Yinzhou People's Hospital, The Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang, People's Republic of China
| | - Qiusheng Ren
- Department of Anesthesiology, Ningbo Yinzhou People's Hospital, The Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang, People's Republic of China
| | - Shenghui Yu
- Department of Anesthesiology, Ningbo Yinzhou People's Hospital, The Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang, People's Republic of China
| | - Ya Shao
- Department of Anesthesiology, Ningbo Yinzhou People's Hospital, The Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang, People's Republic of China
| | - Yijun Chen
- Department of Anesthesiology, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, Zhejiang, People's Republic of China
| | - Xin Huang
- Department of Anesthesiology, Ningbo Yinzhou People's Hospital, The Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang, People's Republic of China
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Walters E, Wurster Ovalle V, Yin S, Dribin T. Republished: Infant with status epilepticus secondary to systemic lidocaine toxicity from topical application. Drug Ther Bull 2020; 58:141-143. [PMID: 32527849 DOI: 10.1136/dtb.2020.233119rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Erica Walters
- Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Shan Yin
- Drug and Poison Information Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Timothy Dribin
- Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Lee SH, Sohn JT. Lipid Emulsion Treatment of Cardiogenic Shock Induced by Toxic Dose of Bupropion. J Emerg Med 2020; 59:e33. [PMID: 32900462 DOI: 10.1016/j.jemermed.2020.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/16/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Soo Hee Lee
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Institute of Health Sciences, Gyeonsang National University, Jinju, Republic of Korea
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Arumugam S, Contino V, Kolli S. Local Anesthetic Systemic Toxicity (LAST) – a Review and Update. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00381-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Ghataoura R, Patil S. Flecainide toxicity: a presentation to the emergency department with literature review. BMJ Case Rep 2020; 13:13/2/e232691. [PMID: 32114494 DOI: 10.1136/bcr-2019-232691] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Flecainide toxicity can result in increased cardiovascular instability which can significantly alter patient outcome if not recognised early. In this case report, the management of a 68-year-old woman who took an unintentional overdose of flecainide is detailed. We look at the management she received in the emergency department and her successful recovery and follow-up since the admission. In addition, the case report outlines the ECG changes that are most commonly documented in flecainide overdose and reviews the frequently used treatment methods for the overdose as summarised in current literature.
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Affiliation(s)
- Rashpal Ghataoura
- Emergency Department, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Shashank Patil
- Emergency Department, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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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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Walters E, Wurster Ovalle V, Yin S, Dribin T. Infant with status epilepticus secondary to systemic lidocaine toxicity from topical application. BMJ Case Rep 2020; 13:13/1/e233119. [DOI: 10.1136/bcr-2019-233119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A previously healthy 11-month-old infant presented to the emergency department in status epilepticus. There was no clear trigger of her seizure activity which resolved with benzodiazepines and fosphenytoin. On further review, her parents disclosed that she had been prescribed topical 4% lidocaine cream for a groin rash and was ultimately diagnosed with lidocaine toxicity in the emergency department. She was monitored in the intensive care unit without cardiovascular abnormalities or recurrence of seizure activity. Emergency medicine providers must maintain a broader differential of status epileptics and be able to recognise and manage potential complications from systemic lidocaine toxicity.
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Lee SH, Ok SH, Kim JY, Subbarao RB, Bae SI, Hwang Y, Park KE, Kim JW, Sohn JT. Linolenic Acid Attenuates the Vasodilation Induced by Acetylcholine in Isolated Rat Aortae. Dose Response 2019; 17:1559325819894148. [PMID: 31839761 PMCID: PMC6902396 DOI: 10.1177/1559325819894148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/15/2019] [Accepted: 11/19/2019] [Indexed: 11/17/2022] Open
Abstract
This study aims to examine the effect of linolenic acid on the vasodilation or vasoconstriction induced by acetylcholine and bupivacaine in isolated rat aortae and its underlying mechanism. The effect of linolenic acid on the vasodilation induced by acetylcholine, the calcium ionophore A23187, sodium nitroprusside, and 8-bromoguanosine 3',5'-cyclic monophosphate sodium salt (bromo-cyclic guanosine monophosphate [bromo-cGMP]) in endothelium-intact and endothelium-denuded aortae was examined. Linolenic acid inhibited vasodilation induced by acetylcholine, calcium ionophore A23187, and sodium nitroprusside. However, this fatty acid increased bromo-cGMP-induced vasodilation in endothelium-denuded aortae. Linolenic acid increased bupivacaine-induced contraction in endothelium-intact aortae, whereas it decreased bupivacaine-induced contraction in endothelium-intact aortae with Nω-nitro-l-arginine methyl ester and endothelium-denuded aortae. Linolenic acid inhibited acetylcholine- and bupivacaine-induced phosphorylation of endothelial nitric oxide synthase. Sodium nitroprusside increased cGMP in endothelium-denuded aortic strips, whereas bupivacaine decreased cGMP in endothelium-intact aortic strips. Linolenic acid decreased cGMP levels produced by bupivacaine and sodium nitroprusside. Together, these results suggest that linolenic acid inhibits acetylcholine-induced relaxation by inhibiting a step just prior to nitric oxide-induced cGMP formation. In addition, linolenic acid-mediated inhibition of vasodilation induced by a toxic concentration (3 × 10-4 M) of bupivacaine seems to be partially associated with inhibition of the nitric oxide-cGMP pathway.
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Affiliation(s)
- Soo Hee Lee
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Seong-Ho Ok
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Ji-Yoon Kim
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Raghavendra Baregundi Subbarao
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Sung Il Bae
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Yeran Hwang
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Kyeong-Eon Park
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Jong Won Kim
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju-si, Gyeongsangnam-do, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju-si, Republic of Korea
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Local anesthetic systemic toxicity: proposed mechanisms for lipid resuscitation and methods of prevention. J Anesth 2019; 33:569-571. [DOI: 10.1007/s00540-019-02648-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 04/24/2019] [Indexed: 10/26/2022]
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Rhee SH, Park SH, Ryoo SH, Karm MH. Lipid emulsion therapy of local anesthetic systemic toxicity due to dental anesthesia. J Dent Anesth Pain Med 2019; 19:181-189. [PMID: 31501776 PMCID: PMC6726891 DOI: 10.17245/jdapm.2019.19.4.181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 11/15/2022] Open
Abstract
Local anesthetic systemic toxicity (LAST) refers to the complication affecting the central nervous system (CNS) and cardiovascular system (CVS) due to the overdose of local anesthesia. Its reported prevalence is 0.27/1000, and the representative symptoms range from dizziness to unconsciousness in the CNS and from arrhythmias to cardiac arrest in the CVS. Predisposing factors of LAST include extremes of age, pregnancy, renal disease, cardiac disease, hepatic dysfunction, and drug-associated factors. To prevent the LAST, it is necessary to recognize the risk factors for each patient, choose a safe drug and dose of local anesthesia, use vasoconstrictor , confirm aspiration and use incremental injection techniques. According to the treatment guidelines for LAST, immediate application of lipid emulsion plays an important role. Although lipid emulsion is commonly used for parenteral nutrition, it has recently been widely used as a non-specific antidote for various types of drug toxicity, such as LAST treatment. According to the recently published guidelines, 20% lipid emulsion is to be intravenously injected at 1.5 mL/kg. After bolus injection, 15 mL/kg/h of lipid emulsion is to be continuously injected for LAST. However, caution must be observed for >1000 mL of injection, which is the maximum dose. We reviewed the incidence, mechanism, prevention, and treatment guidelines, and a serious complication of LAST occurring due to dental anesthesia. Furthermore, we introduced lipid emulsion that has recently been in the spotlight as the therapeutic strategy for LAST.
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Affiliation(s)
- Seung-Hyun Rhee
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Korea
| | - Sang-Hun Park
- Department of Oral and Maxillofacial Surgery, Seoul National University Dental Hospital, Seoul, Korea
| | - Seung-Hwa Ryoo
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Korea
| | - Myong-Hwan Karm
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Korea
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Enhanced myocardial protection in cardiac donation after circulatory death using Intralipid® postconditioning in a porcine model. Can J Anaesth 2019; 66:672-685. [DOI: 10.1007/s12630-019-01322-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 10/23/2018] [Accepted: 12/14/2018] [Indexed: 01/07/2023] Open
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Abstract
Although the mechanism of action is not well known, intravenous lipid emulsion (ILE) has been shown to be effective in the treatment of lipophilic drug intoxications. It is thought that, ILE probably separates the lipophilic drugs from target tissue by creating a lipid-rich compartment in the plasma. The second theory is that ILE provides energy to myocardium with high-dose free fatty acids activating the voltage-gated calcium channels in the myocytes. In this study, effects of ILE treatment on digoxin overdose were searched in an animal model in terms of cardiac side effects and survival. Forty Sprague-Dawley rats were divided into five groups. As the pre-treatment, the groups were administered saline, ILE, DigiFab and DigiFab and ILE. Following that, digoxin was infused to all groups until death except the control group. First arrhythmia and cardiac arrest observation times were recorded. According to the results, there was no statistically significant difference among the group in terms of first arrhythmia time and cardiac arrest times. However, when the saline group compared with ILE-treated group separately, significant difference was observed. DigiFab, ILE or ILE-DigiFab treatment make no significant difference in terms of the first arrhythmia and cardiac arrest duration in digoxin-intoxicated rats. However, it is not possible to say that at the given doses, ILE treatment might be successful at least as a known antidote. The fact that the statistical significance between the two groups is not observed in the subgroup analysis, the study should be repeated with larger groups.
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Lee MJ, Min YG. Hemodynamic changes after infusion of intravenous lipid emulsion to treat refractory hypotension caused by glyphosate-surfactant herbicide poisoning: A case report. Medicine (Baltimore) 2019; 98:e14156. [PMID: 30653155 PMCID: PMC6370017 DOI: 10.1097/md.0000000000014156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 12/18/2018] [Accepted: 12/25/2018] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Glyphosate-surfactant herbicides (GlySH) are non-selective herbicides that are extensively used worldwide. A recent case report on GlySH poisoning suggested successful resuscitation upon using intravenous lipid emulsion (ILE) for refractory hypotension. The efficacy of ILE in GlySH poisoning remains unproven due to a lack of randomized controlled trials, and further evidence is required to clarify the mechanism by which ILE may reverse hypotension in GlySH poisoning. PATIENT CONCERNS A 46-year-old man presented to the emergency department 45 min following ingestion of approximately 200 cc of GlySH. On arrival, his vital signs were as follows: blood pressure, 82/50 mmHg and pulse, 85 beats/min. Hypotension did not respond to fluid resuscitation and norepinephrine infusion; his cardiac output (CO) was 4.5 L/min and systemic vascular resistance (SVR) was 604 dynes·s·cm with blood pressure of 63/35 mmHg. DIAGNOSIS GlySH poisoning presented with refractory hypotension. INTERVENTIONS A bolus (100 mL) of ILE was infused with subsequent infusion of 400 mL over 4 h. OUTCOMES A few minutes following the bolus of ILE, his blood pressure increased to 101/54 mmHg with CO of 6.5 L/min and SVR of 701 dynes·s·cm. Blood pressure, CO, and stroke volume increased gradually over next 8.5 h. His clinical status improved gradually, and norepinephrine could be tapered on hospital day (HD) 3. The patient was discharged at HD 10 without sequelae. LESSONS ILE could be used as a rescue treatment in case of a poor response to conventional fluid and vasopressor therapy. The underlying mechanism of rescue with ILE might be a positive inotropic effect.
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The Effects of Intravenous Lipid Emulsion Therapy in the Prevention of Depressive Effects of Propofol on Cardiovascular and Respiratory Systems: An Experimental Animal Study. ACTA ACUST UNITED AC 2018; 55:medicina55010001. [PMID: 30585197 PMCID: PMC6358815 DOI: 10.3390/medicina55010001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 11/27/2018] [Accepted: 12/20/2018] [Indexed: 11/18/2022]
Abstract
Background and objectives: Although there are several hypotheses about the mechanism of action, intravenous lipid emulsion (ILE) therapy has been shown to be effective in the treatment of toxicities due to local anaesthetics and many lipophilic drugs. In this study, we had hypothesized that ILE therapy might also be effective in preventing mortality and cardiorespiratory depressant effects due to propofol intoxication. Materials and methods: Twenty-eight Sprague-Dawley adult rats were randomly divided into four groups. Saline was administered to the subjects in the control group. The second group was administered propofol (PP group); the third group was administered ILE (ILE group), and the fourth group was administered propofol and ILE therapy together (ILE+PP group). Systolic blood pressure (SBP), diastolic blood pressure (DBP), respiratory rate (RR), heart rate (HR), and mortality were recorded at 10 time-points during a period of 60 min. A repeated measures linear mixed-effect model with unstructured covariance was used to compare the groups. Results: In the PP group; SBP, DBP, RR, and HR levels declined steadily; and all rats in this group died after the 60-min period. In the ILE+PP group, the initially reduced SBP, DBP, RR, and HR scores increased close to the levels observed in the control group. The SBP, DBP, RR, and HR values in the PP group were significantly lower compared to the other groups (p < 0.01). The mortality rate was 100% (with survival duration of 60 min) for the PP group; however, it was 0% for the remaining three groups. Conclusions: Our results suggest that the untoward effects of propofol including hypotension, bradycardia, and respiratory depression might be prevented with ILE therapy.
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McAllister RK, Lay JF, Culp WC. Letter to 'Practical use of C1 esterase inhibitor concentrate for clinical amniotic fluid embolism'. J Obstet Gynaecol Res 2018; 45:239. [PMID: 30251427 DOI: 10.1111/jog.13821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/29/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Russell K McAllister
- Department of Anesthesiology, Texas A&M College of Medicine, Temple, Texas, USA.,Department of Anesthesiology, Scott & White Medical Center, Temple, Texas, USA
| | - Jack F Lay
- Department of Anesthesiology, Texas A&M College of Medicine, Temple, Texas, USA.,Department of Anesthesiology, Scott & White Medical Center, Temple, Texas, USA
| | - William C Culp
- Department of Anesthesiology, Texas A&M College of Medicine, Temple, Texas, USA.,Department of Anesthesiology, Scott & White Medical Center, Temple, Texas, USA
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Abstract
The experimental use of lipid emulsion for local anesthetic toxicity was originally identified in 1998. It was then translated to clinical practice in 2006 and expanded to drugs other than local anesthetics in 2008. Our understanding of lipid resuscitation therapy has progressed considerably since the previous update from the American Society of Regional Anesthesia and Pain Medicine, and the scientific evidence has coalesced around specific discrete mechanisms. Intravenous lipid emulsion therapy provides a multimodal resuscitation benefit that includes both scavenging (eg, the lipid shuttle) and nonscavenging components. The intravascular lipid compartment scavenges drug from organs susceptible to toxicity and accelerates redistribution to organs where drug (eg, bupivacaine) is stored, detoxified, and later excreted. In addition, lipid exerts nonscavenging effects that include postconditioning (via activation of prosurvival kinases) along with cardiotonic and vasoconstrictive benefits. These effects protect tissue from ischemic damage and increase tissue perfusion during recovery from toxicity. Other mechanisms have diminished in favor based on lack of evidence; these include direct effects on channel currents (eg, calcium) and mass-effect overpowering a block in mitochondrial metabolism. In this narrative review, we discuss these proposed mechanisms and address questions left to answer in the field. Further work is needed, but the field has made considerable strides towards understanding the mechanisms.
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Low dose Intralipid resuscitation improves survival compared to ClinOleic in propranolol overdose in rats. PLoS One 2018; 13:e0202871. [PMID: 30161186 PMCID: PMC6116996 DOI: 10.1371/journal.pone.0202871] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 08/10/2018] [Indexed: 12/15/2022] Open
Abstract
Background Medication overdose is a prevalent issue and despite mixed reports of efficacy, the use of intravenous lipid emulsions, notably Intralipid®, for the management of toxicity from lipid-soluble drugs is becoming increasingly prevalent. Whether alternative lipid emulsion formulations have similar efficacy for resuscitation compared to Intralipid is not known. Here, we compared the efficacy of Intralipid and ClinOleic® for resuscitation following overdose with the lipid-soluble beta-adrenergic antagonist propranolol. Methods Male Sprague-Dawley rats (age 3–4 months) were anesthetized with isoflurane and instrumented for direct hemodynamic assessments. In Study One, rats (n = 22) were pre-treated with Intralipid 20% (n = 12) or ClinOleic 20% (n = 10) to determine whether the hemodynamic effects of propranolol could be prevented. In Study Two, rats were randomly assigned to Intralipid 20% (1, 2, or 3 mL/kg IV, n = 21) or ClinOleic 20% (1, 2, or 3 mL/kg IV, n = 20) resuscitation groups following propranolol overdose (15 mg/kg IV). In Study Three the effect of Intralipid 20% (1 mL/kg IV, n = 3) and ClinOleic 20% (1 mL/kg IV, n = 3) in the absence of propranolol was investigated. The primary endpoint in all studies was survival time (up to a maximum of 120 minutes), and secondary endpoints were time to achieve 50%, 75%, and 90% of baseline hemodynamic parameters. Results In Study One, pre-treatment with Intralipid prior to propranolol administration resulted in prolonged survival compared to pre-treatment with ClinOleic at low doses (1 mL/kg; P = 0.002), but provided no benefit at higher doses (3 mL/kg; P = 0.95). In Study Two, Intralipid conferred a survival advantage over ClinOleic, with 18/21 rats surviving 120 minutes in the Intralipid group and only 4/20 survivors in the ClinOleic group (P<0.0001). Median survival times (with interquartile ranges) for rats treated with Intralipid, and ClinOleic, and saline were 120 (80.5–120) min, 21.5 (3.25–74.5) min, and 1 (0.25–2.5) min respectively (P<0.001). Only 3/21 rats in the Intralipid group survived less than 30 minutes, whereas 12/20 ClinOleic treated rats had survival times of less than 30 minutes. The number of rats achieving 75%, and 90% of baseline mean arterial pressure was also greater in the Intralipid group (P<0.05 for both values). Treatment in Study Three did not alter survival times. Conclusions Low-dose Intralipid (1, 2, or 3 mL/kg IV) confers a survival advantage up to 120 minutes post-propranolol overdose (the end-point of the experiment) and better hemodynamic recovery compared to ClinOleic (1, 2, or 3 mL/kg IV) in rats with propranolol overdose. As health care centres choose alternate intravenous lipid emulsions, limited availability of Intralipid could impact efficacy and success of overdose treatment for lipid-soluble drugs.
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El-Boghdadly K, Pawa A, Chin KJ. Local anesthetic systemic toxicity: current perspectives. Local Reg Anesth 2018; 11:35-44. [PMID: 30122981 PMCID: PMC6087022 DOI: 10.2147/lra.s154512] [Citation(s) in RCA: 225] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Local anesthetic systemic toxicity (LAST) is a life-threatening adverse event that may occur after the administration of local anesthetic drugs through a variety of routes. Increasing use of local anesthetic techniques in various healthcare settings makes contemporary understanding of LAST highly relevant. Recent data have demonstrated that the underlying mechanisms of LAST are multifactorial, with diverse cellular effects in the central nervous system and cardiovascular system. Although neurological presentation is most common, LAST often presents atypically, and one-fifth of the reported cases present with isolated cardiovascular disturbance. There are several risk factors that are associated with the drug used and the administration technique. LAST can be mitigated by targeting the modifiable risk factors, including the use of ultrasound for regional anesthetic techniques and restricting drug dosage. There have been significant developments in our understanding of LAST treatment. Key advances include early administration of lipid emulsion therapy, prompt seizure management, and careful selection of cardiovascular supportive pharmacotherapy. Cognizance of the mechanisms, risk factors, prevention, and therapy of LAST is vital to any practitioner using local anesthetic drugs in their clinical practice.
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Affiliation(s)
- Kariem El-Boghdadly
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK, .,School of Medicine, King's College London, London, UK,
| | - Amit Pawa
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK,
| | - Ki Jinn Chin
- Department of Anesthesia, Toronto Western Hospital, University of Toronto, Ontario, Canada
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Lipid Emulsion Pretreatment Decreased the Maximum Total and Free Plasma Concentration of Levobupivacaine for Femoral and Sciatic Nerve Block in Below-Knee Fracture Surgery. Reg Anesth Pain Med 2018; 43:838-843. [DOI: 10.1097/aap.0000000000000834] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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