Intravenous lipid emulsion in oral overdoses: what is the optimal dosing?

intralipid-161x3003.5 out of 5 stars

Confusion About Infusion: Rational Volume Limits for Intravenous lipid Emulsion during Treatment of Oral Overdoses. Fettiplace MR et al. Ann Emerg Med 28 Feb 2015 [Epub ahead of print]

Reference

As we discussed during our interview with Dr. Guy Weinberg on a recent TPR podcast, it seems intuitively obvious that the ideal dosing of lipid emulsion (LE) for treating oral overdoses may be different from the well-established protocol used to treat local anesthetic toxicity. As Fettiplace et al (et al includes Dr. Weinberg) point out:

This recommendation was based on guidelines for treatment of local anesthetic toxicity, in which absorption is quick and toxicity short lived. In contrast to local anesthetic toxicity, prolonged absorption during general overdose can result in extended toxicity, with a need for continuing medical support, including a protracted infusion of lipid emulsion.

This article is an attempt to arrive at a rational dosing schedule for LE in oral overdoses. The authors consider a number of factors:

  • High doses of lipid emulsion are associated with adverse effects, including acute respiratory distress syndrome
  • The FDA recommends a maximum dose of 12.5 mL/kg/day when LE is used for nutritional support
  • The antidotal action of LE may depend on both the “lipid sink” effect and direct cardiac inotropy
  • Both of the above effects require creation of a moderately lipemic plasma

Combining these considerations with pharmacologic calculations, the authors make the following dosing recommendations for use of  20% LE in oral overdoses:

  • give an initial bolus of 1.5 mL/kg,then an additional 0.25 mL/kg/min for 3 minutes
  • following by infusion of 0.025 mL/kg/min, which can continued for up to 6.5 hours
  • monitor serum triglyceride levels, aiming for 1000 mg/dL

Is this regimen optimal? It’s impossible to know at this point. But it’s a reasonable starting point while we await more evidence.
Related posts:

Excellent review of lipid rescue therapy

TPR Podcast #7: Interview with Guy Weinberg about lipid rescue therapy

Acute respiratory distress syndrome following intralipid emulsion therapy 

Complications associated with lipid emulsion therapy

Lipid rescue therapy can interfere with critical lab values

Case report: cocaine cardiotoxicity treated with intravenous lipid infusion

Lipid emulsion therapy for poisonings: a review

Lipid emulsion overdose

 

Spinal Cord Injury, Questions

1. What imaging do you use for patients with possible acute, traumatic spinal cord injury?

2. How do you treat neurogenic shock?

3. What is your management and disposition for elderly patients with vertebral compression fractures?

4. How do you clear a C-spine after a negative CT in a trauma patient who is awake, neuro intact, wearing a collar?


Preliminary Review – House Of Cards season 3


I'm just about to reach the halfway mark, but can't possibly wait till the end before writing something!



*SPOILER ALERT!**


*SPOILER ALERT!**


*SPOILER ALERT!**




After finally usurping the American presidency in season 2, the latest chapter focuses on the new challenges Frank Underwood faces as the leader of the free world. However, it has not escaped my attention that episode 1 was entirely devoted to one of my favourite characters - Douglas Stamper, played by Michael Kelly. Originally a more secondary figure, Stamper is now given abundant screen time, following a shocking accident which left little doubt that he had perished. Imagine my delight when it was revealed that he not only survived, but made a remarkable recovery after major surgery and aggressive rehabilitation.

His political career, on the other hand, suffers a huge blow. Previously Frank's right hand man, he is now sidelined and unable to return to the White House despite multiple pleas and a display of unwavering loyalty. But even the most stalwart servant has his limits. By episode 5, Stamper makes his counter move, and I can't wait to see how it's going to turn out.

The new American President has his hands full as well, making executive decisions on a drone strike in the Middle East, hosting a state dinner and trying to outwit a crafty Russian leader. And if these weren't difficult enough, he fails to secure the Democratic party's support for a 2016 run. I believe that bombshell dropped in episode 2. The writers really aren't holding back this season!

While the plot twists are highly entertaining, Frank's responses are what make this series so irresistible. It's easy to label him a villain - and who would blame you? After all, he did become the President through Machiavellian scheming, orchestrating the death of a hapless senator ( a role that launched Corey Stoll's career ) and personally shoving a nosy reporter in front of a subway train ( a moment many of us will never forget ). And yet, I find myself sympathizing with Frank; understanding his desperation; rooting for him to defeat his opponents. Because rising to the top of any hierarchy takes gumption, intelligence and fearlessness. And why shouldn't someone possessing these qualities be in charge of the United States?

But even Frank occasionally crumbles under pressure, which is where his wife comes in. Claire - played to perfection by Robin Wright - has ambitions of her own and takes bold measures to establish herself in the international political arena. And like her husband, she encounters her share of dissension and manages to claw her way through. The marital dynamic between Frank and Claire is both simple and complex. They've settled into a comfortable routine through the years, never arguing about bedroom arrangements or the open nature of their relationship. The complexity lies in their collaborative effort in maintaining political sovereignty - discussing power plays and boosting the other's morale when necessary.

One memorable scene from an early episode depicts Frank curled up on the floor in the Oval Office, sobbing silently after failed attempts to secure campaign funds for a presidential run as an independent candidate. Claire discovers him in this sorry state, says nothing, then proceeds to please him sexually. Cut to the next morning, and Frank is a changed man, full of new resolve to beat the odds after almost giving up the night before. I have never encountered a more vivid illustration of the saying "Behind every great man is a great woman."

The lead characters are what viewers tune in for, but the secondary players are no less worthy of our attention. Russian President Petrov - a salute to Putin - features prominently, as does Solicitor General Heather Dunbar. Both are thorns in Frank's side and seriously undermine his authority. There's really no way to predict the final outcome of these conflicts. I look forward to seeing who emerges the victor. :)

My brain isn't working very well post-call, so I'll try to post a more coherent entry once I finish all 13 episodes. So far, season 3 is turning out to be everything I hoped for - smart, twisted and deliciously sarcastic. Bonuses come in the form of jazz musician Peter Cincotti, who plays himself at the state dinner ( I've met him twice and he's a real sweetheart ), and an amusing epiphany involving President Underwood, a magazine review of a video game, and a job offer to pen a propagandistic book. Made me think hard about my own writing skills - why hasn't anyone harnessed my potential for political agendas yet? Probably because they know I'll refuse. ;)