Michael Levine1, Robert S Hoffman2, Valéry Lavergne3, Christine M Stork4, Andis Graudins5, Ryan Chuang6, Samuel J Stellpflug7, Martin Morris8, Andrea Miller-Nesbitt8, Sophie Gosselin9. 1. a Department of Emergency Medicine , Section of Medical Toxicology, University of Southern California , Los Angeles , CA , USA ; 2. b Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine , New York University School of Medicine , New York , NY , USA ; 3. c Department of Medical Biology , Sacré-Coeur Hospital, University of Montreal , Montreal , Canada ; 4. d Department of Emergency Medicine , Upstate Medical University, New York and Upstate New York Poison Center , New York , NY , USA ; 5. e Department of Medicine , School of Clinical Sciences at Monash Health, Clinical Toxicology Service at Monash Health and Monash Emergency Translational Research Group, Monash University , Clayton , Victoria , Australia ; 6. f Department of Emergency Medicine , University of Calgary, Poison and Drug Information Service , Calgary , Canada ; 7. g Department of Emergency Medicine , Regions Hospital , Saint Paul , MN , USA ; 8. h Schulich Library of Science and Engineering , McGill University , Montreal , Canada ; and. 9. i Department of Emergency Medicine, McGill University Health Centre & Department of Medicine , McGill University , Montreal , Canada.
Abstract
BACKGROUND: The use of intravenous lipid emulsion (ILE) therapy for the treatment of lipophilic drug toxicity is increasing. Despite this, the evidence for its effect in non-local anesthetic toxicity remains sparse. Furthermore, many case reports describe ILE use for substances in which no clear efficacy data exists. The American Academy of Clinical Toxicology established a lipid emulsion workgroup. The aim of this group is to review the available evidence regarding the effect of ILE in non-LA drug poisoning and develop consensus-based recommendations on the use of this therapy. METHODS: A systematic review of the literature was performed to capture articles through 15 December 2014. Relevant articles were determined based upon a predefined methodology. Articles involving pre-treatment experiments, pharmacokinetic studies not involving toxicity, and studies not addressing antidotal use of ILE met pre-defined exclusion criteria. Agreement of at least two members of the subgroup was required before an article could be excluded. RESULTS: The final analysis included 203 articles: 141 for humans and 62 for animals. These include 40 animal experiments and 22 case reports involving animal toxicity. There were three human randomized control trials (RCT): one RCT examined ILE in TCA overdose, one RCT examined ILE in various overdoses, and one study examined ILE in reversal of sedation after therapeutic administration of inhaled anesthesia. One observational study examined ILE in glyphosate overdose. In addition, 137 human case reports or case series were identified. Intravenous lipid emulsion therapy was used in the management of overdose with 65 unique substances. CONCLUSIONS: Despite the use of ILE for multiple substances in the treatment of patients with poisoning and overdose, the effect of ILE in various non-local anesthetic poisonings is heterogenous, and the quality of evidence remains low to very low.
BACKGROUND: The use of intravenous lipid emulsion (ILE) therapy for the treatment of lipophilic drug toxicity is increasing. Despite this, the evidence for its effect in non-local anesthetic toxicity remains sparse. Furthermore, many case reports describe ILE use for substances in which no clear efficacy data exists. The American Academy of Clinical Toxicology established a lipid emulsion workgroup. The aim of this group is to review the available evidence regarding the effect of ILE in non-LA drug poisoning and develop consensus-based recommendations on the use of this therapy. METHODS: A systematic review of the literature was performed to capture articles through 15 December 2014. Relevant articles were determined based upon a predefined methodology. Articles involving pre-treatment experiments, pharmacokinetic studies not involving toxicity, and studies not addressing antidotal use of ILE met pre-defined exclusion criteria. Agreement of at least two members of the subgroup was required before an article could be excluded. RESULTS: The final analysis included 203 articles: 141 for humans and 62 for animals. These include 40 animal experiments and 22 case reports involving animal toxicity. There were three human randomized control trials (RCT): one RCT examined ILE in TCAoverdose, one RCT examined ILE in various overdoses, and one study examined ILE in reversal of sedation after therapeutic administration of inhaled anesthesia. One observational study examined ILE in glyphosate overdose. In addition, 137 human case reports or case series were identified. Intravenous lipid emulsion therapy was used in the management of overdose with 65 unique substances. CONCLUSIONS: Despite the use of ILE for multiple substances in the treatment of patients with poisoning and overdose, the effect of ILE in various non-local anesthetic poisonings is heterogenous, and the quality of evidence remains low to very low.
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Authors: Maude St-Onge; Kurt Anseeuw; Frank Lee Cantrell; Ian C Gilchrist; Philippe Hantson; Benoit Bailey; Valéry Lavergne; Sophie Gosselin; William Kerns; Martin Laliberté; Eric J Lavonas; David N Juurlink; John Muscedere; Chen-Chang Yang; Tasnim Sinuff; Michael Rieder; Bruno Mégarbane Journal: Crit Care Med Date: 2017-03 Impact factor: 7.598