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A cohort study of unstable overdose patients treated with intravenous lipid emulsion therapy

  • Shazma Mithani (a1) (a2), Kathryn Dong (a1) (a2), Ashlea Wilmott (a3), Heather Podmoroff (a4), Nadim Lalani (a5), Rhonda J. Rosychuk (a6), Ryan Chuang (a3) (a7) (a4) and Mark C. Yarema (a1) (a3) (a8)...



Intravenous lipid emulsion (ILE) has been used increasingly over the last decade for a range of drug overdoses. Although the use of ILE in local anesthetic toxicity (LAST) is well established, the hemodynamic effectiveness of ILE in non-LAST poisonings is still unclear. Thus, the primary objective of this study was to examine a cohort of poisoned patients in whom ILE was administered.


Consecutive patients were identified by calls to a regional poison center from May 1, 2012 to May 30, 2014. Patients were enrolled if they ingested a drug, developed hemodynamic instability, failed conventional treatment, and received ILE therapy. Data were collected by medical record review. The primary outcome was the change in mean arterial pressure (MAP) in the first hour after ILE administration. Secondary outcomes included survival, length of stay, and the effect of drug class on patient outcome.


Thirty-six patients were enrolled. Agents ingested included calcium channel blockers and beta blockers (10/36, 27.8%), tricyclic antidepressants (5/36, 13.9%), bupropion (3/36, 8.3%), and antiepileptic agents (1/36, 2.8%). Seventeen patients (47.2%) ingested multiple agents. Twenty-five patients survived (69.0%). Overall, MAP increased by 13.79 mm Hg (95% CI 1.43–26.15); this did not meet our a priori definition of clinical significance.


Our study did not find a clinically important improvement in MAP after ILE administration. Until future research is done to more definitively study its efficacy, ILE should remain a potential treatment option for hemodynamically unstable overdose patients only after conventional therapy has failed.


Le recours à l’émulsion lipidique intraveineuse (ELI) a connu une augmentation au cours de la dernière décennie dans le traitement de divers types de surdosage. Si l’utilisation de l’ELI dans le traitement de la toxicité des anesthésiques locaux est bien établie, l’efficacité hémodynamique de l’ELI dans les cas d’intoxication causée par d’autres substances que les anesthésiques locaux, elle, est incertaine. L’étude décrite ici avait donc pour objectif principal d’examiner une cohorte de patients intoxiqués, traités par une ELI.


Le repérage des patients consécutifs s’est fait à l’aide des appels reçus dans un centre antipoisons régional, du 1er mai 2012 au 30 mai 2014. Ont été retenus ceux qui avaient pris des médicaments, présentaient de l’instabilité hémodynamique, n’avaient pas réagi au traitement habituel et avaient été traités par une ELI. La collecte de données a été réalisée à l’aide des dossiers médicaux. Le principal critère d’évaluation consistait en la mesure des variations de la pression artérielle moyenne (PAM) au cours de la première heure suivant l’administration de l’ELI; les critères secondaires d’évaluation comprenaient la survie, la durée du séjour et l’effet de la classe de médicaments sur l’évolution de l’état de santé.


Ont participle à l’étude 36 patients. Différents types de médicaments avaient été avalés, notamment des inhibiteurs calciques et des bêta-bloquants (10/36; 27,8 %), des antidépresseurs tricycliques (5/36; 13,9 %), du bupropion (3/36; 8,3 %) et des antiépileptiques (1/36; 2,8 %). Dix-sept patients (47,2 %) avaient pris un mélange de médicaments. Vingt-cinq patients ont survécu (69,0 %) au surdosage. La PAM a augmenté, dans l’ensemble, de 13,79 mm Hg (IC à 95 % : 1,43 - 26,15), mais l’écart ne respectait la définition de portée clinique, établie avant l’étude.


Les résultats de l’étude ne permettent pas de conclure à une amélioration importante de la PAM sur le plan clinique après l’administration de l’ELI. Aussi le traitement devrait-il rester une solution de rechange possible dans les seuls cas de surdosage accompagnés d’instabilité hémodynamique, après l’échec du traitement courant, jusqu’à ce que des recherches ultérieures examinent davantage en profondeur la question de l’efficacité de l’ELI.

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Corresponding author

Correspondence to: Dr. Shazma Mithani, Department of Emergency Medicine, Royal Alexandra Hospital, 10240 Kingsway Avenue, Community Services Building, Room 541, Edmonton, AB, Canada, T5H 3V9; email:


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1. Weinberg, GL, VadeBoncouer, T, Ramaraju, GA, et al. Pretreatment or resuscitation with a lipid infusion shifts the dose-response to bupivacaine-induced asystole in rats. Anesthesiology 1998;88(4):1071-1075.
2. Zausig, YA, Zink, W, Keil, M, et al. Lipid emulsion improves recovery from bupivacaine-induced cardiac arrest, but not from ropivacaine- or mepivacaine-induced cardiac arrest. Anesth Analg 2009;109(4):1323-1326.
3. Aprea, F, Vettorato, E, Corletto, F. Severe cardiovascular depression in a cat following a mandibular nerve block with bupivacaine. Vet Anaesth Analg 2011;38(6):614-618.
4. Bushey, BA, Auld, VH, Volk, JE, et al. Combined lipid emulsion and ACLS resuscitation following bupivacaine-and hypoxia-induced cardiovascular collapse in unanesthetized swine. AANAJ 2011;79(2):129-138.
5. Weinberg, G, Ripper, R, Feinstein, DL, et al. Lipid emulsion infusion rescues dogs from bupivacaine-induced cardiac toxicity. Reg Anesth Pain Med 2003;28(3):198-202.
6. Admani, B, Essajee, F. Successful resuscitation of a three month old child with intralipid infusion, presumed to have bupivacaine induced seizures and cardiovascular complications: case report. East Afr Med J 2010;87(8):354-356.
7. Bourne, E, Wright, C, Royse, C. A review of local anesthetic cardiotoxicity and treatment with lipid emulsion. Local Reg Anesth 2010;3:11-19.
8. Hoegberg, LCG, Bania, TC, Lavergne, V, et al. Systematic review of the effect of intravenous lipid emulsion therapy for local anesthetic toxicity. Clin Toxicol 2016, doi:10.3109/15563650.2015.1121270.
9. Neal, JM, Bernards, CM, Butterworth, JF, et al. ASRA practice advisory on local anesthetic systemic toxicity. Reg Anesth Pain Med 2010;35(2):152-161.
10. Kuo, I, Akpa, BS. Validity of the lipid sink as a mechanism for the reversal of local anesthetic systemic toxicity: a physiologically based pharmacokinetic model study. Anesthesiology 2013;118(6):1350-1361.
11. Weinberg, GL. Lipid resuscitation: more than a sink. Crit Care Med 2012;40(8):2521-2523.
12. French, D, Smollin, C, Ruan, W, et al. Partition constant and volume of distribution as predictors of clinical efficacy of lipid rescue for toxicological emergencies. Clin Toxicol 2011;49:801-809.
13. Weinberg, GL. Lipid emulsion infusion: resuscitation for local anesthetic and other drug overdose. Anesthesiology 2012;117(1):180-187.
14. Lee, SH, Sung, H, Ok, S, et al. Lipid emulsions enhance the norepinephrine-mediated reversal of local anesthetic-induced vasodilation at toxic doses. Yonsei Med J 2013;54(6):1524-1532.
15. Cave, G, Harvey, M. Lipid emulsion may augment early blood pressure recovery in a rabbit model of atenolol toxicity. J Med Toxicol 2009;5(1):50-51.
16. Browne, A, Harvey, M, Cave, G. Intravenous lipid emulsion does not augment blood pressure recovery in a rabbit model of metoprolol toxicity. J Med Toxicol 2010;6(4):373-378.
17. Harvey, M, Cave, G, Lahner, D, et al. Insulin versus Lipid Emulsion in a Rabbit Model of Severe Propranolol Toxicity: A Pilot Study. Crit Care Research and practice 2011;(2011):361737.
18. Hayes, CL, Knight, M. Calcium channel blocker toxicity in dogs and cats. The Veterinary clinics of North America Small animal practice 2012;42(2):263-277.
19. Bania, TC, Chu, J, Perez, E, et al. Hemodynamic effects of intravenous fat emulsion in an animal model of severe verapamil toxicity resuscitated with atropine, calcium, and saline. Academic emergency medicine 2007;14(2):105-111.
20. Heinonen, JA, Litonius, E, Backman, JT, et al. Intravenous lipid emulsion entraps amitriptyline into plasma and can lower its brain concentration - an experimental intoxication study in pigs. Basic & Clinical Pharmacology & Toxicology 2013;113(3):193-200.
21. Harvey, M, Cave, G. Intralipid outperforms sodium bicarbonate in a rabbit model of clomipramine toxicity. Ann Emerg Med 2007;49(2):178-185.
22. Patel, T, Tietze, D, Mehta, AN. Amlodipine overdose. Proceedings (Baylor University Medical Center) 2013;26(4):410-411.
23. Bologa, C, Lionte, C, Coman, A, et al. Lipid emulsion therapy in cardiodepressive syndrome after diltiazem overdose - case report. Am J Emerg Med 2013;31(7):1154.e3-1154.e4.
24. Liang, CW, Diamond, SJ, Hagg, DS. Lipid rescue of massive verapamil overdose: a case report. Journal of medical case reports 2011;5(1):399.
25. Akinci, E, Koylu, R. Verapamil Poisoning, the Importance of Intravenous Lipid Therapy: Case Report. Journal of Academic Emergency Medicine Case Reports 2013;4:130-132.
26. Engels, PT, Davidow, JS. Intravenous fat emulsion to reverse haemodynamic instability from intentional amitriptyline overdose. Resuscitation 2010;81(8):1037-1039.
27. Boegevig, S, Rothe, A, Tfelt-Hansen, J, et al. Successful reversal of life threatening cardiac effect following dosulepin overdose using intravenous lipid emulsion. Clinical toxicology 2011;49(4):337-339.
28. Hendron, D, Menagh, G, Sandilands, EA, et al. Tricyclic antidepressant overdose in a toddler treated with intravenous lipid emulsion. Pediatrics 2011;128(6):e1628-e1632.
29. Livshits, Z, Feng, Q, Chowdhury, F, et al. Life-threatening bupropion ingestion: is there a role for intravenous fat emulsion? Basic & Clinical Pharmacology & Toxicology 2011;109(5):418-422.
30. Jakkala-Saibaba, R, Morgan, PG, Morton, GL. Treatment of cocaine overdose with lipid emulsion. Anaesthesia 2011;66(12):1168-1170.
31. Finn, SDH, Uncles, DR, Willers, J, et al. Early treatment of a quetiapine and sertraline overdose with Intralipid. Anaesthesia 2009;64(2):191-194.
32. Cave, G, Harvey, M, Willers, J, et al. LIPAEMIC report: results of clinical use of intravenous lipid emulsion in drug toxicity reported to an online lipid registry. Journal of Medical Toxicology 2014;10(2):133-142.
33. Levine, M, Hoffman, RS, Lavergne, V, et al. Systematic review on the effect of intravenous lipid emulsion therapy for non-local anesthetics toxicity. Clinical Toxicology 2016; doi:10.3109/15563650.2015.1126286.
34. Kasi, VS, Estrada, CA, Wiese, W. Association of pancreatitis with administration of contrast medium and intravenous lipid emulsion in a patient with the acquired immunodeficiency syndrome. South Med J 2003;96(1):66-69.
35. Raasch, RH, Hak, LJ, Benaim, V, et al. Effect of intravenous fat emulsion on experimental acute pancreatitis. Journal of Parenteral Nutrition 1983;7(3):254-256.
36. Weinberg, G. Hyperamylasemia following lipid resuscitation: pancreas or parotid? Anesth Analg 2012;115(3):739.
37. Bass, J, Friedl, W, Jeranek, W. Intralipid causing adult respiratory distress syndrome. J Natl Med Assoc 1984;76(4):401-403.
38. Ali, J, Wood, L. The acute effects of intralipid on lung function. J Surg Res 1985;38(6):599-605.
39. Koch, T, Duncker, HP, Klein, A, et al. Modulation of pulmonary vascular resistance and edema formation by short-term infusion of a 10% fish oil emulsion. Infusionsther Transfusionsmed 1993;20(6):291-300.
40. Ishitsuka, Y, Moriuchi, H, Yang, C, et al. Effects of bolus injection of soybean-based fat emulsion and fatty acids on pulmonary gas exchange function. Biol Pharm Bull 2009;32(3):500-503.
41. Calmarza, P, Cordero, J. Lipemia interferences in routine clinical biochemical tests. Biochemia medica 2011;21(2):160-166.
42. Grunbaum, AM, Gilfix, BM, Gosselin, S, et al. Analytical interferences resulting from intravenous lipid emulsion. Clin Toxicol 2012;50(9):812-817.
43. Johnson-Arbor, K, Salinger, L, Luczycki, S. Prolonged Laboratory Interference After Administration of Intravenous Lipid Emulsion Therapy. J Med Toxicol 2015;11(2):223-226.
44. American College of Medical Toxicology. ACMT position statement: interim guidance for the use of lipid resuscitation therapy. J Med Toxicol 2011;7:81-82.
45. LipidRescue™ Resucitation for drug toxicity. Treatment Regimens. Available at: (accessed December 11, 2009).
46. Florian, JP, Pawelczyk, JA. Non-esterified fatty acids increase arterial pressure via central sympathetic activation in humans. Clin Sci 2010;118:61-69.
47. Pinheiro, J, Bates, D, DebRoy, S, et al. 2015. nlme: Linear and Nonlinear Mixed Effects Models. R package version, 3:1-122; Available at:
48. Niiya, T, Litonius, E, Petaja, L, et al. Intravenous lipid emulsion sequesters amiodarone in plasma and eliminates its hypotensive action in pigs. Ann Emerg Med 2010;56(4):402-408.
49. Geib, A, Liebelt, E, Manini, AF. Clinical experience with intravenous lipid emulsion for drug-induced cardiovascular collapse. J Med Toxicol 2012;8(1):10-14.
50. Levine, M, Skolnik, AB, Ruha, A, et al. Complications following antidotal use of intravenous lipid emulsion therapy. J Med Toxicol 2014;10:10-14.
51. Punja, M, Neill, SG, Wong, S. Caution with interpreting laboratory results after lipid rescue therapy. Am J Emerg Med 2013;31(10):1536.e1-1536.e2.
52. Kroll, MH. Evaluating interference caused by lipemia. Clin Chem 2004;50(11):1968-1969.
53. Reimold, EW. Studies of the toxicity of an intravenous fat emulsion. II. Blood chemical changes after administration of a soybean oil (FE-S15) in beagles. J Parenter Enteral Nutr 1979;3(5):335-340.
54. Miller, S, Greenberg, M. Failure of lipid emulsion therapy to treat a metformin overdose. Clin Toxicol 2011;49(6):538-539.
55. Litonius, E, Niiya, T, Neuvonen, PJ, et al. No antidotal effect of intravenous lipid emulsion in experimental amitriptyline intoxication despite significant entrapment of amitriptyline. Basic Clin Pharm Toxicol 2012;110(4):378-383.


A cohort study of unstable overdose patients treated with intravenous lipid emulsion therapy

  • Shazma Mithani (a1) (a2), Kathryn Dong (a1) (a2), Ashlea Wilmott (a3), Heather Podmoroff (a4), Nadim Lalani (a5), Rhonda J. Rosychuk (a6), Ryan Chuang (a3) (a7) (a4) and Mark C. Yarema (a1) (a3) (a8)...


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