Utilization of lipid emulsion therapy in fatal overdose cases: an observational study

Figures & data

Figure 1. Case selection flow diagram.

Figure 2. Annual trends in intravenous lipid emulsion use in cases of fatal poisoning. The graph demonstrates the number RCF category 1 or 2 fatal cases in which intravenous lipid emulsion therapy was used, represented as a percentage of all RCF category 1 or 2 cases in that year.

Figure 3. Timing of intravenous lipid emulsion administration. Some cases have more than one timing situation because of multiple administrations of intravenous lipid emulsion.

Table 1. List of the most common substances involved in the exposure.

Substance	Number of Cases	Percent (n/459)	Number (%) with ROSC
Calcium channel blockers	183	40	8 (4.4%)
Beta-adrenergic antagonists	102	22	5 (4.9%)
Bupropion^a	53	12	5 (9.4%)
Tricyclic antidepressants^a	48	10	2 (4.2%)
Citalopram/Escitalopram	36	8	0
Quetiapine	26	6	1 (3.8%)
Flecainide	21	5	5 (23.8%)
Local anesthetics—parenteral^a	8	2	1 (12.5%)
Local anesthetics—oral	5	1	0

Many cases involve more than one substance.

^aUse of ILE supported by Lipid Work Group for a selection of these substances in certain clinical conditions [5].

Table 2. Detailed information on the use of intravenous lipid emulsion (ILE) for patients with local anesthetic systemic toxicity (LAST).^a

Year	Age	Sex	Primary toxin	Dose (mg)	Onset of clinical symptoms	Other toxins	Clinical effects	ILE %	Bolus dose	Infusion dose and duration	Total ILE dose in mg per kg	Delay from exposure to ILE	ILE Timing	Other treatment received before ILE	Response to ILE	Other notes
2011	50	M	Bupivacaine infiltration	150	Immediate	Fentanyl and midazolam	Asystole, cardiac arrest	20	2 X 250 mL	0.25 mL/kg	Unable to calculate	Immediate	Cardiac arrest	CPR, intubation, epinephrine, vasopressin, atropine, dopamine, procainamide, 9 L fluids	None	Therapies likely given all at same time, clearly no response to boluses and infusion
2012	63	M	Bupivacaine intrascalene nerve block	UNK	20 min	UNK	Cardiac arrest (ventricular fibrillation)	UNK	Not reported	2 h total	Unable to calculate	Not reported	Cardiac arrest	Defibrillation, epinephrine, amiodarone, intubation	ROSC	Also received amiodarone infusion and therapeutic hypothermia for 24 h. Was declared brain dead after rewarming
2013	66	F	Lidocaine injection	UNK	UNK	None	LOC, bradycardia, PEA	20	1.5 mL/kg	None	1.5 mL/kg	Not reported	Cardiac arrest	Bicarbonate bolus, calcium, epinephrine, norepinephrine	None	arrested × 3
2013	77	F	Lidocaine injection	40-100	UNK	None	LOC, possible seizure, wide complex bradycardia, asystole	UNK	Not reported	Not reported	Unable to calculate	∼30 min	Cardiac arrest	Dextrose, calcium, bicarbonate	None	Had a potassium of 6 mEq/L and was supposed to receive insulin and dextrose but received lidocaine instead
2015	85	F	Lidocaine 1%, bupivicaine 0.5%	100 50	Immediate	None	Cardiac arrest, hypotension, bradycardia	20	500 mL	UNK	500 mL	<24 hours	Last resort	CPR, norepinephrine, epinephrine, sodium bicarbonate, insulin, and dextrose	Not reported	Therapeutic error in hospital. Unclear whether bolus only or bolus plus infusion given; ILE gave concurrently with bicarbonate boluses
2015	50	UNK	Bupivacaine	UNK, pump failure	UNK	Hydromorphone	Seizures, cardiac arrest	UNK	Not reported	Not reported	Unable to calculate	Not reported	First line	None	Not reported	Patient with chronic pain and bupivacaine pump that was not turned off during MRI. Converted to a- fib, then asystole, then v-fib, then life support withdrawn day 2
2013	40	F	Lidocaine	2000	UNK	UNK	Asystolic cardiac arrest	UNK	Not reported	Not reported	Unable to calculate	Not reported	Cocktail	Epinephrine, vasopressin, methylene blue	None	1-h CPR prehospital then 2-h ACLS in ED
2013	83	F	Lidocaine 2% SC	300	2 min	None	Cardiac arrest	UNK	UNK	none	not reported	∼32 min	Last resort	CPR	None	Given as last resort prior to the termination of care. The hospital did not stock a lipid emulsion medication and it was obtained from a neighboring facility.

^aFor all cases the relative contribution to fatality (RCF) was recorded as 1, undoubtedly responsible

UNK: Unknown; SC: subcutaneously; ROSC: return of spontaneous circulation; CPR: cardiopulmonary resuscitation; ACLS: advanced cardiac life support; a-fib: atrial fibrillation; v-fib: ventricular fibrillation.

Gosselin S, Hoegberg LC, Hoffman RS, et al. Evidence-based recommendations on the use of intravenous lipid emulsion therapy in poisoning. Clin Toxicol. 2016;54:899–923.

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