Canadian antidote guide

Lipid Emulsion

• Intralipid™ (product recommended by the Canadian poison centres)
• If not available:
  • Clinoleic™
  • Liposyn™
  • SMOFlipid™

Note:  Lipid emulsions are not recommended as a first line of treatment.

• Cardiovascular collapse (bradycardia, asystole, ventricular arrhythmias) following the administration of a local anesthetic, when resistant to first-line treatments.
• Alteration of consciousness, with our without seizures following the administration of a local anesthetic, when resistant to first-line treatments, we recommend to consult your poison centre.
• It should be noted that the evidence is potentially favourable, particularly in cases of bupivacaine poisoning.
• As a heroic measure, as a last resort if other therapies have failed, for severe shock or asystole due to sodium-channel blockers or a lipid-soluble drug poisoning or cases of shock not responding to other therapies.

• Potential for allergic reactions in patients with egg or soybean allergy
• Potential complications related to lipid overload:
  • Acute pancreatitis, acute respiratory distress syndrome
  • Especially if the dose is greater than the maximum recommended dose of 10 to 12 ml/kg/24h. Lipid emulsion administered by continuous IV infusion contributes to the risk of exceeding the maximum recommended dose.
• Potential complications related to vascular occlusion: deep vein thrombosis, phlebitis, fat embolism, CVVHF circuit and ECMO line interference
• Potential for increased absorption of fat-soluble toxin by the gastrointestinal tract (theoretical)
• Site of administration: local thrombophlebitis
• Interference with laboratory measurements of some analytes.

• Vital signs
• State of consciousness
• Triglycerides
• Lipase
• EKG

• Maximum dose reached (10 to 12 ml/kg)

Intravenous Route (IV)

• Direct IV
  • Administer by direct IV over 1 min.
  • May be infused via peripheral or central lines. DEHP tubing is not required and no in-line filter is required.

Intraosseous Route (IO)

• Possible alternative to IV route.

Subcutaneous Route (SC)

• Not a recommended route of administration.

Intramuscular Route (IM)

• Not a recommended route of administration.

Compatibility

Partial list only. Consult the pharmacist on duty at your health care facility.

• Compatible solutions: Do not dilute lipid emulsions.
• Y-site compatibility: No data available.
• Y-site incompatibility: No data available.

Stability

• Store at room temperature (20°C to 25°C)
• For single use only. Discard all unused portions.

• Product recommended by the Canadian poison centres:
  • Intralipid 20%, lipid emulsion for injection, bag of 250 ml or 500 ml, Fresenius Kabi (distributed by Baxter), DIN 02065673,
    • Soybean oil 20%.
• Alternatives if Intralipid™ out of stock:
  • Clinoleic 20%, lipid emulsion for injection, bag of 250 ml or 500 ml, Baxter, DIN 02344327, 
    • Soybean oil 4%; olive oil 16%.
  • SMOFlipid 20%, lipid emulsion for injection, latex-free, DEHP-free bag of 250 ml or 500 ml, Fresenius Kabi Canada, DIN 02396963, 
    • Soybean oil 6%; medium-chain triglycerides 6%; olive oil 5%; fish oil 3%.
    • Direct order: 1 877 953-9002.

• At least 1000 ml of 20% emulsion, preferably 20% Intralipid.

American College of Medical Toxicology. 2011. “ACMT Position Statement: Interim Guidance for the Use of Lipid Resuscitation Therapy.” Journal of Medical Toxicology: Official Journal of the American College of Medical Toxicology 7 (1):81–82.



Bailey, B. 2013. “Réflexions Sur L’utilisation de L'émulsion Lipidique Dans Le Traitement Des Intoxications.” Bulletin D’information Toxicologique 29 (2):62–71.



Brent, Jeffrey, and Michael Levine. 2016. “Lipid Resuscitation Therapy.” In Critical Care Toxicology, edited by Jeffrey Brent, Keith Burkhart, Paul Dargan, Benjamin Hatten, Bruno Megarbane, and Robert Palmer, 1–7. Springer International Publishing.



Fettiplace, Michael R., Belinda S. Akpa, Israel Rubinstein, and Guy Weinberg. 2015a. “Confusion About Infusion: Rational Volume Limits for Intravenous Lipid Emulsion During Treatment of Oral Overdoses.” Annals of Emergency Medicine 66 (2):185–88.



Fettiplace, Michael R., and Daniel J. McCabe. 2017. “Lipid Emulsion Improves Survival in Animal Models of Local Anesthetic Toxicity: A Meta-Analysis.” Clinical Toxicology 55 (7):617–23.



Gosselin, Sophie, Lotte C. G. Hoegberg, Robert S. Hoffman, Andis Graudins, Christine M. Stork, Simon H. L. Thomas, Samuel J. Stellpflug, et al. 2016. “Evidence-Based Recommendations on the Use of Intravenous Lipid Emulsion Therapy in Poisoning().” Clinical Toxicology 54 (10):899–923.



Grunbaum, Ami M., Brian M. Gilfix, Robert S. Hoffman, Valéry Lavergne, Martin Morris, Andrea Miller-Nesbitt, and Sophie Gosselin. 2016. “Review of the Effect of Intravenous Lipid Emulsion on Laboratory Analyses.” Clinical Toxicology 54 (2):92–102.



Hayes, Bryan D., Sophie Gosselin, Diane P. Calello, Nicholas Nacca, Carol J. Rollins, Daniel Abourbih, Martin Morris, et al. 2016. “Systematic Review of Clinical Adverse Events Reported after Acute Intravenous Lipid Emulsion Administration.” Clinical Toxicology 54 (5):365–404.



Hoegberg, Lotte C. G., Theodore C. Bania, Valéry Lavergne, Benoit Bailey, Alexis F. Turgeon, Simon H. L. Thomas, Martin Morris, et al. 2016. “Systematic Review of the Effect of Intravenous Lipid Emulsion Therapy for Local Anesthetic Toxicity.” Clinical Toxicology 54 (3):167–93.



Levine, Michael, Robert S. Hoffman, Valéry Lavergne, Christine M. Stork, Andis Graudins, Ryan Chuang, Samuel J. Stellpflug, et al. 2016. “Systematic Review of the Effect of Intravenous Lipid Emulsion Therapy for Non-Local Anesthetics Toxicity.” Clinical Toxicology 54 (3):194–221.



St-Onge, M., P-A Dubé, S. Gosselin, C. Guimont, J. Godwin, P. M. Archambault, J-M Chauny, et al. 2014. “Treatment for Calcium Channel Blocker Poisoning: A Systematic Review.” Clinical Toxicology 52 (9):926–44.



St-Onge, Maude, Kurt Anseeuw, Frank Lee Cantrell, Ian C. Gilchrist, Philippe Hantson, Benoit Bailey, Valéry Lavergne, et al. 2017. “Experts Consensus Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults.” Critical Care Medicine 45 (3):e306–15.



Zuckerman, Matthew, Howard A. Greller, and Kavita M. Babu. 2015. “A Review of the Toxicologic Implications of Obesity.” Journal of Medical Toxicology: Official Journal of the American College of Medical Toxicology 11 (3):342–54.