Key points
- We recommend to consult your poison centre with the use of this antidote.
- Early administration of lipid emulsion could be considered in cases of toxicity related to the injection of a local anesthetic, particularly when bupivacaine is involved, for which more data are available.
- Because its efficacy remains poorly established, lipid emulsion should be reserved as a second-line treatment, after failure of standard treatment strategies, for cardiovascular toxicity associated with liposoluble toxins other than local anesthetics.
- Administration of lipid emulsion and subsequent lipemia can interfere with laboratory measurement of some analytes for several hours and may cause hemodialysis or ECMO circuit occlusion.
- If ECMO is started, it is recommended to stop the administration of the lipid emulsion.
- Treatment Algorithms for Cardiovascular Toxicity:
+ Synonyms and other terms
- Intralipid™ (product recommended by the Canadian poison centres)
- If not available:
- Clinoleic™
- Liposyn™
- SMOFlipid™
+ Indications
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.
- 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.
+ Dosage
+ Pediatric Dose
- 1.5 ml/kg by direct IV over 1 min.
- Can be repeated 1 or 2 times every 3 to 5 min, if shock/asystole persists (maximum total dose: 10 to 12 ml/kg).
+ Adult Dose
- 1.5 ml/kg by direct IV over 1 min.
- Can be repeated 1 or 2 times every 3 to 5 min, if shock/asystole persists (maximum total dose: 10 to 12 ml/kg).
+ Renal Impairment
No data suggests the need to modify the dose in the case of short-term use.
+ Hepatic Impairment
No data suggests the need to modify the dose in the case of short-term use.
+ Hemodialysis Patient
- No data suggests that the dose should be modified for short-term use.
- May cause hemodialysis circuit occlusion.
+ Pregnancy
- Safety has not been demonstrated.
- However, do not hesitate to use lipid emulsions during pregnancy if the anticipated toxic effects pose a significant risk of morbidity or mortality.
- No data suggests that the dose should be modified for short-term use.
+ Obese or Overweight Patient
No data suggests the need to modify the dose in the case of short-term use.
+ Adverse effects
- 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.
- Consult this article to learn more about laboratory interferences (Ami M Grunbaum et al_2016.pdf)
+ Monitoring
- Vital signs
- State of consciousness
- Triglycerides
- Lipase
- EKG
+ End of treatment
- Maximum dose reached (10 to 12 ml/kg)
+ Special Notes on Administration
Intravenous Route (IV)
- Direct IV
- Administer by direct IV over 1 min.
- May be infused via peripheral or central lines. DEHP-free 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.
+ Available products
- 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%.
- Intralipid 20%, lipid emulsion for injection, bag of 250 ml or 500 ml, Fresenius Kabi (distributed by Baxter), DIN 02065673,
- 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.
- Clinoleic 20%, lipid emulsion for injection, bag of 250 ml or 500 ml, Baxter, DIN 02344327,
+ Amount required to treat a person weighting 70kg during 24 hours
- At least 1000 ml of 20% emulsion, preferably 20% Intralipid.
+ References
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.
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