Intralipid – myth or miracle?

Intralipid is one of the most exciting recent developments in clinical toxicology (right up there with high-dose insulin euglycemic therapy, aka HIET). We are rightly skeptical of any new therapy, especially one that promises so much. Nevertheless, many of the animal studies and published case reports are quite dramatic.

For instance, this video shows the left ventricular pressure and electrocardiogram tracings of an intact, anesthetized rat during acute bupivacaine cardiotoxicity and successful recovery with a lipid emulsion infusion.

WARNING: you may develop optokinetic nystagmus watching this!

The Poison Review recently commented on the first published case describing the clinical use of intralipid in reversing propanolol toxicity. Importantly, some of the caveats in interpreting this type of report are highlighted. Nevertheless, it’s well worth remembering intralipid as a last-ditch measure for the resuscitation of a patients with cardiotoxicity induced by a lipophilic drug.

You can find out more about intralipid from its major proponents at lipidrescue.org. They suggest the use of intralipid when standard resuscitation methods fail to re-establish sufficient circulatory stability. Their suggested treatment protocol (with my comments in brackets) is as follows:

20% Intralipid

  • 1.5 mL/kg as an initial bolus
    (e.g. about 100 mL in a 70kg adult)
    followed by
  • 0.25 mL/kg/min for 30-60 minutes
    (e.g. about 600 mL over 30 minutes in a 70kg adult)
  • Bolus could be repeated 1-2 times for persistent asystole
    (e.g. at 5 minute intervals)
  • Infusion rate could be increased if blood pressure declines
    (e.g. double the infusion rate)

Most importantly, however, we must remember to do the basics right — maintain effective CPR throughout — and don’t give up! Good neurological outcomes can be achieved even with hours of CPR in the setting of cardiotoxic poisoning.


References

  • Cave G, Harvey M. Intravenous lipid emulsion as antidote beyond local anesthetic toxicity: a systematic review. Acad Emerg Med. 2009 Sep;16(9):815-24. PMID: 19845549.
  • Leskiw U, Weinberg GL. Lipid resuscitation for local anesthetic toxicity: is it really lifesaving? Curr Opin Anaesthesiol. 2009 Oct;22(5):667-71.  PMID: 19581805.
  • 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 Apr;51(4):412-5, 415.e1. Epub 2007 Sep 4. PMID: 17766009.

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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