Use of Intravenous Lipid Emulsion Therapy and Insulin in a Case of Tarka Intoxication.

INTRODUCTION: Tarka (trandolapril/verapamil hydrohloride extended-release) is a fixed-dose combination antihypertensive drug formed from verapamil hydrochloride and trandolapril. Toxicologic manifestations of Tarka overdose are altered mental status, bradycardia, hypotension, atrioventricular block (first-degree), hyperglycemia, metabolic acidosis, and shock. CASE PRESENTATION: We report a case of Tarka toxicity in a 2-year-old girl who presented with altered mental status, cardiogenic shock, hypotension, bradycardia, severe metabolic acidosis, hyperglycemia, and first-degree atrioventricular block. We started fluid resuscitation, epinephrine, norepinephrine, and insulin. Because of the patient's hyperlactatemia and hypotension despite standard therapies, we initiated intravenous lipid emulsion (ILE) therapy, after which her condition improved promptly. DISCUSSION: Tarka overdose may be life-threatening as it can cause cardiogenic shock. In our patient, the regression of lactate elevation in a short time with ILE therapy and the improvement of her general condition highlight the importance of ILE. CONCLUSIONS: ILE is an alternative treatment method for acute lipophilic drug intoxications, such as Tarka.

Hyperuricemia and intravenous fat emulsion are risk factors for gout flares during active gastrointestinal bleeding: a case control study.

OBJECTIVE: It is well-established that patients with a history of gout are more susceptible to experiencing gastrointestinal bleeding. Gout flare during active gastrointestinal bleeding poses a significant challenge due to the gastrointestinal side effects of anti-inflammatory therapy. This study sought to investigate the risk factors associated with gout flares during episodes of gastrointestinal bleeding. METHODS: We conducted a retrospective observational study involving 94 patients who experienced active gastrointestinal bleeding and had a history of gout. This study was conducted at Jinhua Municipal Central Hospital from January 2019 to October 2022. We collected and recorded demographic information and clinical characteristics. RESULTS: Among the gout flare patients, hyperuricemia and intravenous fat emulsion therapy were more prevalent compared to those who remained stable (81.6% vs. 57.8% and 46.9% vs. 24.4%, p < 0.05). Multivariate logistic regression analysis revealed that both hyperuricemia (odds ratio 2.741, 95% CI 1.014-7.413, p = 0.047) and intravenous fat emulsion therapy (odds ratio 2.645, 95% CI 1.046-6.686, p = 0.040) were independent predictors of gout flares. Furthermore, gout attacks occurred sooner in patients receiving intravenous fat emulsion therapy compared to those not receiving it (median: 4 days (interquartile range: 2) vs. median: 5 days (interquartile range: 2.25), p = 0.049). CONCLUSION: Our study revealed a high incidence of gout flares during episodes of active gastrointestinal bleeding, with patients undergoing intravenous fat emulsion therapy and those with hyperuricemia being at increased risk.

Comparison of two formulations of intravenous lipid emulsions in pediatric intestinal failure.

PURPOSE: The effect of different types of lipid emulsion may guide therapy of patients with intestinal failure (IF) to limit morbidity such as intestinal failure-associated liver disease (IFALD). METHODS: A retrospective chart review of pediatric patients with IF who received soybean oil lipid emulsion (SL) or mixed oil lipid emulsion (ML) was performed. Data over 1 year were collected. RESULTS: Forty-five patients received SL and 34 received ML. There were no differences in the incidence (82 versus 74%, P = 0.35) or resolution (86 versus 92%, P = 0.5) of IFALD between the cohorts. The median dose of ML was higher compared to SL (2 versus 1 g/kg/day, P < 0.001). If resolved, IFALD resolved rapidly in the ML cohort compared to the SL cohort (67 versus 37 days, P = 0.01). Weight gain was higher in the ML compared to the SL cohort at resolution of IFALD or 1 year from diagnosis of IF (P = 0.009). CONCLUSION: The administration of ML did not alter the incidence or resolution of IFALD compared to SL in pediatric IF. There was rapid resolution of IFALD and enhanced weight gain in the ML cohort compared to SL in pediatric IF.

Alpha-chloralose poisoning in 25 cats: clinical picture and evaluation of treatment with intravenous lipid emulsion.

OBJECTIVES: The aims of this study were to describe the clinical picture and progression in cats with alpha-chloralose (AC) intoxication and to determine if treatment with intravenous (IV) lipid emulsion (ILE) influenced either the serum concentration of AC or the clinical signs. METHODS: Cats with suspected AC poisoning admitted to a university small animal hospital were included. The cats were randomised into two groups: one receiving 20% ILE at a dose of 300 mg/kg as a 2 min bolus, followed by a 1500 mg/kg continuous rate infusion over 30 mins (IL+ group) and the other receiving IV fluid therapy with Ringer's acetate (IL- group). Serum samples were drawn at 0, 2, 12 and 24 h after admission. Samples were tested for AC with a novel validated, quantitative, ultra-high-performance liquid chromatography-tandem mass spectrometry method. Vital and predefined clinical signs were noted at the times of sampling and patients were scored using a previously described intoxication severity score. Telephone interviews were conducted after discharge to assess outcome. RESULTS: A total of 25 cats were enrolled: 13 cats in the IL+ group and 12 in the IL- group. The most common clinical signs at presentation were tremor (n = 22, 88.0%), cranial nerve deficits (n = 20, 80.0%) and bradycardia (n = 19, 76.0%). No significant difference in AC concentration or change in intoxication score over time was found between the IL+ and IL- groups at any time point (P >0.05). All cats recovered within 72 h. CONCLUSIONS AND RELEVANCE: ILE did not have any effect on the AC serum concentration or clinical signs in AC-poisoned cats. All cats survived until follow-up. In cats with an acute onset of the described neurological signs, AC intoxication is an important differential diagnosis with an excellent prognosis.

Effect of lipid emulsion on neuropsychiatric drug-induced toxicity: A narrative review.

Lipid emulsion has been shown to effectively relieve refractory cardiovascular collapse resulting from toxic levels of nonlocal anesthetics. The goal of this study was to examine the effect of lipid emulsions on neuropsychiatric drug-induced toxicity using relevant case reports of human patients, with a particular focus on the Glasgow Coma Scale (GCS) score and corrected QT interval, to analyze drugs that frequently require lipid emulsion treatment. The following keywords were used to retrieve relevant case reports from PubMed: "antidepressant or antipsychotic drug or amitriptyline or bupropion or citalopram or desipramine or dosulepin or dothiepin or doxepin or escitalopram or fluoxetine or haloperidol or olanzapine or phenothiazine or quetiapine or risperidone or trazodone" and "lipid emulsion or Intralipid." Lipid emulsion treatment reversed the corrected QT interval prolongation and decreases in Glasgow Coma Scale scores caused by toxic doses of neuropsychiatric drugs, especially lipid-soluble drugs such as amitriptyline, trazodone, quetiapine, lamotrigine, and citalopram. The log P (octanol/water partition coefficient) of the group which required more than 3 lipid emulsion treatments was higher than that that of the group which required less than 3 lipid emulsion treatments. The main rationale to administer lipid emulsion as an adjuvant was as follows: hemodynamic depression intractable to supportive treatment (88.3%) > lipophilic drugs (8.3%) > suspected overdose or no spontaneous breathing (1.6%). Adjuvant lipid emulsion treatment contributed to the recovery of 98.30% of patients with neuropsychiatric drug-induced toxicity. However, further analyses using many case reports are needed to clarify the effects of lipid emulsion resuscitation.

Effects of Intravenous Lipid Emulsion Administration in Acute Tramadol Poisoning: A Randomized Controlled Trial.

BACKGROUND: As the prevalence of tramadol toxicity is increasing, managing these patients with the aim of treatment and complete recovery has become a major challenge for health care professionals. OBJECTIVE: This study evaluated the short-term effects of IV lipid emulsion (ILE) administration in cases of tramadol poisoning. METHODS: In this double-blind, randomized controlled trial, 120 patients with pure tramadol poisoning and a Glasgow Coma (GCS) score ≤ 12 referred to a poisoning center in Tehran, Iran were selected and randomly assigned 1:1 to receive ILE 20% (intervention) or 0.9% saline (control) after admission and primary stabilization. The patient's vital signs, GCS score, hospitalization duration, and rate of seizure occurrence were recorded and compared between the two groups. RESULTS: Mean (SD) age of participants was 25.3 (5.4) years and 84 (70%) were male. Mean (SD) ingested dose of tramadol was 3118 (244) mg, which was not different between the groups. Compared with controls, the ILE group had a higher level of consciousness after treatment (median [interquartile range] GCS score 12 [10-13] vs. 10 [8-12]; p = 0.03). In addition, length of hospitalization (median [interquartile range] (2 [1-3] days vs. 4 [4-6] days; p < 0.01) and rate of seizure occurrence were lower in the intervention group (16/60 vs. 30/60; p < 0.01). CONCLUSIONS: In the setting of tramadol poisoning with a decreased level of consciousness and based on our study's findings, administration of ILE is suggested to help manage patients in hospital emergency departments. However, larger trials might be needed to confirm these findings before entering the guidelines.

[Research progress on the application of non-nutritional effects of fat emulsion in the treatment of poisoning].

Fat emulsion is a drug commonly used clinically for parenteral nutrition support in critically ill patients.With the development of the pharmaceutical industry, fat emulsion has formed a variety of different formulations, among which different types of fat emulsion have their own metabolic and body energy supply characteristics, and the application indications are also different. In addition to providing the supply of nutrients, the role of fat emulsion in anti-toxicity, immune regulation, anti-inflammatory, anti-shock, cardiopulmonary resuscitation and other aspects has gradually been discovered. This article reviews the existing evidence-based medical evidence and expounds the mechanism and therapeutic role of fat emulsion in the treatment of critically ill patients with poisoning. Its value in the treatment of critically ill patients with poisoning was discussed, and some references were provided for the application of non-nutritional functions of fat emulsion in the future.

Intravenous lipid emulsion for local anaesthetic systemic toxicity in pregnant women: a scoping review.

BACKGROUND: Local anaesthetic systemic toxicity (LAST) is a rare but life-threatening complication that can occur after local anaesthetic administration. Various clinical guidelines recommend an intravenous lipid emulsion as a treatment for local anaesthetic-induced cardiac arrest. However, its therapeutic application in pregnant patients has not yet been established. This scoping review aims to systematically identify and map the evidence on the efficacy and safety of intravenous lipid emulsion for treating LAST during pregnancy. METHOD: We searched electronic databases (Medline, Embase and Cochrane Central Register Controlled Trials) and a clinical registry (lipidrescue.org) from inception to Sep 30, 2022. No restriction was placed on the year of publication or the language. We included any study design containing primary data on obstetric patients with signs and symptoms of LAST. RESULTS: After eliminating duplicates, we screened 8,370 titles and abstracts, retrieving 41 full-text articles. We identified 22 women who developed LAST during pregnancy and childbirth, all presented as case reports or series. The most frequent causes of LAST were drug overdose and intravascular migration of the epidural catheter followed by wrong-route drug errors (i.e. intravenous anaesthetic administration). Of the 15 women who received lipid emulsions, all survived and none sustained lasting neurological or cardiovascular damage related to LAST. No adverse events or side effects following intravenous lipid emulsion administration were reported in mothers or neonates. Five of the seven women who did not receive lipid emulsions survived; however, the other two died. CONCLUSION: Studies on the efficacy and safety of lipids in pregnancy are scarce. Further studies with appropriate comparison groups are needed to provide more robust evidence. It will also be necessary to accumulate data-including adverse events-to enable clinicians to conduct risk-benefit analyses of lipids and to facilitate evidence-based decision-making for clinical practice.

Intravenous lipid emulsion for a life-threatening prothipendyl intoxication.

Prothipendyl, a lipophilic neuroleptic drug, requires a careful dosage regimen due to its potential side effects, including life-threatening arrhythmias.This report outlines a case of severe prothipendyl intoxication, its management and the successful utilisation of Intralipid, an intravenous lipid emulsion, in treating ventricular arrhythmia postmassive prothipendyl ingestion. Additionally, the mechanism of action of Intralipid and the rebound concentration of the lipophilic drug in such scenarios are discussed.

Intravenous lipid emulsion therapy in 2 dogs and 2 cats with vitamin D toxicosis.

Vitamin D toxicosis can lead to severe and prolonged hypercalcemia resulting in multi-organ damage and even death. Current treatment often involves prolonged hospitalization and may require medications with potential for adverse effects. The objective of this case series was to describe reductions in serum ionized calcium concentrations following intravenous lipid emulsion therapy in vitamin D toxicosis. Two dogs and 2 cats with vitamin D toxicosis were treated with intravenous lipid emulsion therapy in addition to standard treatment regimens. Ionized hypercalcemia was lower following intravenous lipid emulsion therapy despite a more than 24-hour delay in initiating treatment in 3 of the 4 patients, and no adverse reactions were observed. Additionally, 2 of the 4 animals in this case series had long-term monitoring of 25-hydroxyvitamin D concentrations that revealed persistent elevations at 6 d in a dog and 5 mo in a cat, despite earlier resolution of their ionized hypercalcemia. Key clinical message: This is the first documented serial report of reduction of serum ionized calcium concentrations after administration of intravenous lipid emulsion, in addition to other standard therapies, in 2 dogs and 2 cats with vitamin D toxicosis. Furthermore, a chronically elevated plasma 25-hydroxyvitamin D concentration was documented in 2 of the 4 patients, including the first report in a cat. In these 2 cases, ionized calcium concentrations normalized despite persistently elevated 25-hydroxyvitamin D concentrations.

Thérapie par émulsion lipidique intraveineuse chez 2 chiens et 2 chats atteints de toxicose à la vitamine D. La toxicose à la vitamine D peut entraîner une hypercalcémie grave et prolongée entraînant des lésions à plusieurs organes, voire la mort. Le traitement actuel implique souvent une hospitalisation prolongée et peut nécessiter des médicaments susceptibles d'entraîner des effets indésirables. L'objectif de cette série de cas était de décrire les réductions des concentrations sériques de calcium ionisé par suite d'un traitement par émulsion lipidique intraveineuse dans le traitement de la toxicose à la vitamine D. Deux chiens et 2 chats atteints d'une toxicose à la vitamine D ont été traités par émulsion lipidique intraveineuse en plus des protocoles thérapeutiques standards. L'hypercalcémie ionisée était plus faible après un traitement par émulsion lipidique intraveineuse malgré un retard de plus de 24 heures dans le début du traitement chez 3 des 4 patients, et aucun effet indésirable n'a été observé. De plus, 2 des 4 animaux de cette série de cas ont fait l'objet d'une surveillance à long terme des concentrations de 25-hydroxyvitamine D qui ont révélé des concentrations élevées persistantes à 6 jours chez un chien et à 5 mois chez un chat, malgré une résolution plus précoce de leur hypercalcémie ionisée.Message clinique clé :Il s'agit du premier rapport documenté d'une série de réduction des concentrations sériques de calcium ionisé après l'administration d'une émulsion lipidique intraveineuse, en plus d'autres traitements standards, chez 2 chiens et 2 chats atteints de toxicose à la vitamine D. De plus, une concentration plasmatique chroniquement élevée de 25-hydroxyvitamine D a été documentée chez 2 des 4 patients, y compris le premier rapport chez un chat. Dans ces 2 cas, les concentrations de calcium ionisé se sont normalisées malgré des concentrations constamment élevées de 25-hydroxyvitamine D.(Traduit par Dr Serge Messier).

Monitoring and management of hypertriglyceridemia in extremely low birth weight neonates receiving intravenous lipid emulsions: A national survey.

AIM: To assess the practice variation of defining, monitoring and managing hypertriglyceridemia (HTG) in extremely low birth weight neonates receiving intravenous lipid emulsions (IVLE). METHODS: An 8-question survey created via the web survey site Qualtrics was distributed to neonatologists, neonatal nurse practitioners and fellows within the Section of Neonatal-Perinatal Medicine email directory list in the United States and Canada. Survey results were obtained between August and September 2022. RESULTS: There were 249 respondents from approximately 4000 members within the Section of Neonatal-Perinatal Medicine. Responses were documented as a frequency (percentage) with a margin of error of plus or minus 6.2 %. Most respondents were neonatologists, individuals practicing for >10 years and reported a unit-based policy for IVLE initiation and advancement. The definitions of HTG varied among respondents, with the majority (42.7 %) reporting a defining threshold of >200 mg/dL. Nineteen percent of respondents reported not routinely monitoring serum triglyceride concentrations with variable triglyceride monitoring intervals reported by other survey respondents. Regarding elevated triglyceride concentrations, 19.0 % reported decreasing the IVLE rate and checking triglyceride concentrations until normalization; 14.6 % reported IVLE discontinuation and monitoring triglyceride concentrations until normalization; 61.9 % reported using a combination of the above practices; and 4.4 % reported individualized practices for IVLE management with elevated triglyceride concentrations. CONCLUSION: This survey demonstrates a high variation in defining, monitoring and managing HTG in extremely low birth weight neonates and emphasizes the need for studies to better guide this practice.

Lipid emulsion therapy during management of the critically-ill poisoned patient: a prospective cohort study.

BACKGROUND: Despite conflicting data, intravenous lipid emulsion has emerged as a potential antidote. The "lipid sink" theory suggests that following intravenous administration of lipid, lipophilic drugs are sequestered in the vascular compartment, thereby reducing their tissue concentrations. This study sought to determine if survival is associated with the intoxicant's degree of lipophilicity. METHODS: We reviewed all cases in the Toxicology Investigators Consortium's lipid sub-registry between May 2012 through December 2018. Information collected included demographics, exposure circumstances, clinical course, management, disposition, and outcome. The primary outcome was survival after lipid emulsion therapy. Survival was stratified by the log of the intoxicant's octanol-water partition coefficient. We also assessed the association between intoxicant lipophilicity and an increase in systolic blood pressure after lipid emulsion administration. RESULTS: We identified 134 patients, including 81 (60.4%) females. The median age was 40 years (interquartile range 21-75). One hundred and eight (80.6%) patients survived, including 45 (33.6%) with cardiac arrest during their intoxication. Eighty-two (61.2%) were hypotensive, and 98 (73.1%) received mechanical ventilation. There was no relationship between survival and the log of the partition coefficient of the intoxicant on linear analysis (P = 0.89) or polynomial model (P = 0.10). Systolic blood pressure increased in both groups. The median (interquartile range) systolic blood pressure before lipid administration was 68 (60-78) mmHg for those intoxicants with a log partition coefficient < 3.6 compared with 89 (76-104) mmHg after lipid administration. Among those drugs with a log partition coefficient > 3.6, the median (interquartile range) was 69 (60-84) mmHg before lipid and 89 (80-96) mmHg after lipid administration. CONCLUSION: Most patients in this cohort survived. Lipophilicity was not correlated with survival or the observed changes in blood pressure. The study did not address the efficacy of lipid emulsion.

Parenteral Nutrition in the Neonatal Intensive Care Unit: Intravenous Lipid Emulsions.

Intravenous lipid emulsions (ILEs) are a source of nonprotein calories and fatty acids and help promote growth in preterm infants and infants with intestinal failure. An ILE dose and oil source determines its fatty acid, phytosterol, and vitamin E delivery. These factors play a role in the infant's risk for essential fatty acid deficiency and cholestasis, and help modulate inflammation, immunity, and organ development. This article reviews different ILEs and their constituents and their relationship with neonatal health.

Lipid emulsions in parenteral nutrition: does it matter?

PURPOSE OF REVIEW: Recently, clinicians have shown interest in switching patients to nonsoybean-based intravenous lipid emulsion (ILE) formulas for parental nutrition (PN) due to adverse outcomes related to high Omega-6 content in soybean oil (SO) ILE's. This review summarizes recent literature on improved clinical outcomes with new Omega-6 lipid-sparing ILE's in PN management. RECENT FINDINGS: Although there is a paucity of large-scale studies directly comparing Omega-6 lipid sparing ILE's with SO-based lipid emulsion use in PN in ICU patients, there is strong translational and meta-analysis evidence to suggest that lipid formulations containing fish oil (FO) and/or olive oil (OO) have favorable effects on immune function and improve clinical outcomes in ICU populations. SUMMARY: More research is needed to directly compare omega-6-sparing PN formulas with FO and/or OO versus traditional SO ILE's. However, current evidence is promising for improved outcomes using newer ILE's including reduced infections, shorter lengths of stay, and reduced costs.

Successful management of minoxidil 5% toxicosis in 2 cats from the same household.

OBJECTIVE: To describe the successful management of 2 cats following ingestion of minoxidil 5%. SERIES SUMMARY: Two 2-year-old neutered male Savannah cats were presented following suspected minoxidil 5% ingestion. Both cats developed significant myocardial injury, and clinical signs were consistent with congestive heart failure, supported by cardiac troponin I concentrations, echocardiogram, and thoracic radiographs. They required vasopressor therapy and were decontaminated with intravenous lipid emulsion therapy. Following decontamination, both cats were successfully discontinued from vasopressor therapy, and their clinical signs resolved within 24 hours. The cats were successfully discharged without long-lasting cardiac compromise. Their echocardiograms and cardiac troponin concentration 7 weeks after discharge were within reference intervals. NEW OR UNIQUE INFORMATION: This is the first detailed report of the successful management of cats following minoxidil 5% ingestion.