UMEM Educational Pearls

Intravenous lipid emulsion (ILE) is use as a therapy of last resort in refractory cardiovascular shock from toxicity of select agents (e.g. calcium channel blockers, beta blockers and select Na-channel blocking agents). There are number of case reports/series that showed positive cardiovascular/hemodynamic response after ILE, which are prone to publication bias. Results from limited number of human trials  have shown mixed results.

A study reviewed fatal cases of poisoning that received ILE from the National Poison Data System to characterize the clinical response of ILE therapy.

Results

N=459 cases from 2010 to 2015.

Most common substance involved

 

N (%)

Number with ROSC (%)

Ca-channel blockers

183 (40)

8 (4.4)

Beta blockers

102 (22)

5 (4.9)

Bupropion*

53 (12)

5 (9.4)

TCAs*

48 (10)

2 (4.2)

Citalopram/escitalopram

36 (8)

0

Quetiapine

26 (6)

1 (3.8)

Flecainide

21 (5)

5 (23.8)

Local anesthetics – parenteral*

8 (2)

1 (12.5)

*Use of ILE supported by Lipid work group

Response rate

  • No response: 45%
  • Unknown response: 38%
  • Transient/minimal response: 7%
  • ROSC: 7%
  • Immediate worsening: 3%

Possible adverse reactions (n)

  • ARDS: 39
  • Lipemia: 3
  • Failure of CRRT filter: 2
  • Worsening/new seizure: 2
  • Asystole immediately after administration: 2
  • Fat embolism: 1

 

Conclusion

  • The number of failed cases of ILE therapy outnumbers the published cases of ILE success.
  • Currently, there is a lack of data that shows the efficacy of ILE therapy.

References

 2019 Mar;57(3):197-202. doi: 10.1080/15563650.2018.1504954. Epub 2018 Sep 27.

Utilization of lipid emulsion therapy in fatal overdose cases: an observational study.