3. Case
• 58 yo M OR holding room - R torn rotator cuff
• PMHx: CAD, HTN, Angina
• PSHx: CABG 43 yo
• Meds: nitro prn, isosorbide mononitrate,
lisinopril, atenolol, clopidogrel, and asa
• Allergies: NKDA
• Pre-op ECG: RBBB, LAHB, old anterior wall MI
4. Case
• 120/80, 98% RA, HR: 60, T: 98.9, RR: 16
• O2 - 3 l/min NC, PIV – 20 gauge L hand
• 2 mg midazolam and 50 μg fentanyl
• 50-mm, 22-gauge stim needle - brachial
plexus
• 20ml bupivacaine, 0.5%
• 20ml mepivacaine, 1.5%
• No blood aspirated, no p/p
5. Case
• 30 s later - incoherent, tonic–clonic seizure
• What now?
• Oxygen, 50 mg propofol, seizure stopped
• 90 s later, seized again, 100 mg propofol
• ECG: asystole, no pulse, no BP
• What now?
6. Case
• ACLS
• Intubate
• 20 min - 3 mg epinephrine, 2 mg atropine,
300 mg amiodarone, 40 U vasopressin
– Monophasic defib 200, 300, 360 x2
– Primary rhythms- pulseless v-tach and asystole
8. Case
• 20 min - 100 ml of 20% Intralipid IV, 360 J D-fib
• Single sinus beat, 1 dose atropine/epinephrine
• Within 15 s, SR 90, detectable BP and pulse
• Intralipid infusion 0.5 ml/kg/min x2 h then d/c’d
• Remained in SR, extubated 2.5h
• Awake/responsive, RUE weakness c/w block
• Disposition?
9. Case
• Overnight obs
• No complitactions 2 weeks following
• Cath’d 2/2 incr. cardiac markers s/p arrest
• Total RCA occlusion and EF 32%
• Defibrillator placed and d/c’d home
10. Intralipid: Goals
• Brief History
• *Mechanism
• Complications
• LAST
• Other toxicities
• Evidence
• *Applications
• *Our ED
• *Dose
11. Brief History
• IV fat - soybean oil, egg yolk phospholipids,
glycerin, and water
• ’98 - bupivacaine OD in rat study with
soybean oil – poss tx for cardiac toxicity
• ‘03 – bupivacaine toxicity in dogs undergoing
internal cardiac massage – IL recovered
• ’06 - isolated rat heart – bupivacaine
removed faster from cardiac muscle – IL
15. LAST
• Local anesthetic systemic toxicity
• ’06 case report – 1st published human use
• Case reports – witnessed, standard ACLS
failed, ROSC s/p lipid, underlying heart dz
– Most reports with bupivacaine toxicity
18. Lidocaine
• Intra-lipid rescue for CNS toxicity after
Lidocaine local for excision of breast mass
– 35 yo F - breast mass excised, 40cc of 1% lido w/o
– PACU – jerking motions UE/LE
– MS waning, tachycardic 110s
– Bolus 120cc 20% intralipid over 15min
– A+Ox3 end of bolus
– Infusion 0.25cc/kg/min over 1 hour
– No post-ictal/further comp, d/c’d 5 hours later
19. Lidocaine
• Intractable cardiac arrest due to lidocaine
toxicity successfully resuscitated with lipid
emulsion
– Prolonged lidocaine toxicity – pt ressusitated
with intralipid
– Consider intralipid in ACLS for lidocaine toxicity
as well as other lipid soluble drug intoxications
20. Other Toxicities
• TCAs, BBs, CCBs
• Common theme – lipophillicity
• Case reports – bias
– RCT not ethical
21. Evidence
• Cochrane – nada
• BestBets:
– TCA OD - no clear evidence about effectiveness
of Intralipid in TCA OD
– BB OD – same
– Reference Toxbase – Intralipid rec in TCA and BB
OD with cv collapse not responsive to stnd tx
22. Literature Review
• Lipid emulsions in the treatment of acute
poisoning: a systematic review of human and
animal studies. (Clinical Toxicology 2010)
– 23 animal trials, 50 human and 1 animal case rep
– Conclusion
• Weak evidence
• Suggest some benefits - bupivacaine, verapamil,
chlorpromazine, some TCAs and BBs
• Safety not established
23. Case Report
• 17 yo F sz and cv collapse s/p 7.95 g
bupropion & 4 g of lamotrigine (2008)
– ACLS x 70min unsuccessful
– 100-mL IV 20% lipid emulsion administered
– 1 min later – ROSC
– Pt suffered ALI but recovered with near-normal
neurologic function
24. *Applications
• Highly lipid soluble:
bupivacaine, ropivacaine, verapamil, propran
olol, TCAs
• Moderate lipid soluble:
bupropion, organophosphates
• Others: other CCBs, BBs, and LAs
26. *Our ED
• Not currently stocked
• Pharmacy – call, bedside in minutes
• Potential stock in future
• Shortage, use for dietary therapy
27. *Dose
• 20% Lipid Emulsion (70 kg patient)
• Bolus 1.5 mL/kg IV over 1 min (100 mL)
– Repeat 1-2x for persistent CV collapse
• Infusion 0.25 mL/kg/min (18 mL/min)
– Double if BP remains low
• Infuse at least 10 min once stable
• Upper limit: 10-12 mL/kg over first 30 min
• lipidrescue.org
30. References
• 1. Weinberg GL, VadeBoncouer T, Ramaraju GA, Garcia-Amaro MF, Cwik MJ:
Pretreatment or resuscitation with a lipid infusion shifts the dose-response to
bupivacaine-induced asystole in rats. ANESTHESIOLOGY 1998; 88:1071–5
• 2. Weinberg GL, Ripper R, Murphy P, Edelman LB, Hoffman W, Strichartz G,
Feinstein DL: Lipid infusion accelerates removal of bupivacaine and recovery from
bupivacaine toxicity in the isolated rat heart. Reg Anesth Pain Med 2006; 31:296–
303
• 3. Weinberg G, Ripper R, Feinstein DL, Hoffman W: Lipid emulsion infusion rescues
dogs from bupivacaine-induced cardiac toxicity. Reg Anesth Pain Med 2003;
28:198–202
• 4. Rosenblatt MA, Abel M, Fischer GW, Itzkovich CJ, Eisenkraft JB: Successful use of
a 20% lipid emulsion to resuscitate a patient after a presumed bupivacaine-related
cardiac arrest. ANESTHESIOLOGY 2006; 105:217–8
• 5. Spence AG: Lipid reversal of central nervous system symptoms of bupivacaine
toxicity. ANESTHESIOLOGY 2007; 107:516–7
31. References
• 6. Rothschild L, Bern S, Oswald S, Weinberg G: Intravenous lipid emulsion in clinical
toxicology. Scand J Trauma Resusc Emerg Med 2010; 18:51
• 7. Sirianni AJ, Osterhoudt KC, Calello DP, Muller AA, Waterhouse MR, Goodkin MB,
Weinberg GL, Henretig FM: Use of lipid emulsion in the resuscitation of a patient
with prolonged cardiovascular collapse after overdose of bupropion and
lamotrigine. Ann Emerg Med 2008; 51:412–5, 415.e1
• 8. Weinberg G, Lin B, Zheng S, Di Gregorio G, Hiller D, Ripper R, Edelman L, Kelly K,
Feinstein D: Partitioning effect in lipid resuscitation: Further evidence for the lipid
sink. Crit Care Med 2010; 38:2268–9
• 9. http://bestbets.org/bets/bet.php?id=1939
• 10. http://bestbets.org/bets/bet.php?id=1934
• 11. Lipid Emulsion Infusion: Resuscitation for Local Anesthetic and Other Drug
Overdose. Anesthesiology: July 2012 - Volume 117 - Issue 1 - p 180–187. doi:
10.1097/ALN.0b013e31825ad8de
