Last updated: 01/2020
Indications
- Local anesthetic toxicity/cardiac arrest unresponsive to conventional resuscitation.
- Rescue therapy for cardiac arrest or severe hemodynamic compromise due to lipid-soluble and sodium channel blocking drug toxicity unresponsive to conventional resuscitation (e.g., bupropion, lipid soluble beta-blockers and calcium channel blockers, tricyclic antidepressants, etc).
Dosage
Local Anesthetic Systemic Toxicity
- IV Direct: 1.5 mL/kg (300 mg/kg) lipid emulsion 20% over 1 to 3 minutes.
- Infusion: Follow immediately with 0.25 mL/kg/minute (50 mg/kg/minute) for 30 - 60 minutes. Dose can be increased to 0.5ml/kg/minute based on response.
Non-local Anesthetic Drug Toxicity
- IV Direct: 1.5 mL/kg (300 mg/kg) lipid emulsion 20% over 1 to 3 minutes. Bolus dose can be repeated 1-2 times at 5-minute intervals based on response.
- Infusion: Insufficient evidence to support infusions for this indication.
Administration
IV Direct: Administer undiluted over 1 to 3 minutes.
Infusion: 0.25 mL/kg/minute undiluted for 30 – 60 minutes. Rates as high as 0.5 mL/kg/minute have been used for life-threatening toxicity.
Therapeutic Endpoint: Intravenous lipid emulsion therapy should be discontinued once hemodynamic stability is achieved.
- A maximum of 10-12 mL/kg can be administered every 24 hours.
- If the dose exceeds a pump’s maximum infusion rate, administer the lipid infusion at the pump’s maximum infusion rate. Two pumps are not required.
- If infusions longer than 60 minutes appear necessary, consult the poison centre for direction.
- Lipid emulsion may be infused via peripheral, central, or intraosseous lines.
- DEHP-free tubing is not required, and the absence of this tubing should not delay therapy
Compatibility, Stability
- Do not add other drugs or intravenous nutrients to the lipid emulsion bag.
- Partially used containers of lipid emulsion must be discarded and should not be stored for later use.
- Lipid emulsion may be stored at room temperature. DO NOT FREEZE.
- In-line filters should not be used for the administration of lipid emulsion.
- Lipid emulsion should not be administered directly into an extracorporeal membrane oxygenation (ECMO) circuit. Separate IV line should be used.
- The integrity indicator (Oxalert) should be inspected before removing the lipid emulsion from the over-wrap. If the indicator is black the product should be discarded.
Potential Hazards of Administration
Relative contraindications:
- Allergy to eggs or soybeans, lipid metabolism and lipid storage disorders, severe sepsis, severe liver disease, acute pancreatitis, and acute myocardial infarction.
Adverse events in the rescue setting include:
- Lab interferences: transient disruption of lab values has been noted from the resulting hypertriglyceridemia, lasting 6-12 hours. All critical blood work should be drawn prior to lipid emulsion initiation.
- Fat overload syndrome: hypertriglyceridemia, fever, organomegaly, coagulopathy, altered mental status, and seizures
- Veno-occlusive: venous thromboembolism, priapism
- Cardiorespiratory: arrhythmia, acute lung injury, ARDS
- Gastrointestinal: pancreatitis, hepatic steatosis, acute renal failure
- Miscellaneous: sepsis, hyperphosphatemia
Miscellaneous
- Lipid emulsion contains approximately 15 mmol/L of phosphate and 300 microgram/L Vitamin K.
- Lipid emulsion is a category C substance in pregnancy; no safety data is available in this population. However, in refractory hemodynamic instability following toxicity from a lipid-soluble drug, lipid emulsion therapy can be considered as a rescue intervention