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Atlantic Canada Poison Centre
Antidote Kit Manual

1-800-565-8161 or 902-470-8161 | atlanticcanadapoisoncentre.ca
Last updated: 01/2020
Pediatric Adult
Last updated: 01/2020
Antidote
Pediatric

Lipid Emulsion

Fat Emulsion, Intralipid 20%

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Antidote
Pediatric

Lipid Emulsion

Fat Emulsion, Intralipid 20%

WARNING: Warning: Evidence for the use of lipid emulsion therapy in the pediatric population for reversal of drug toxicity is limited.

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

PEDIATRIC DOSING NOT ESTABLISHED. Current recommendations follow the same dosing regimen as in adults:

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.
  • 1.2-micron filter (do not delay antidote therapy; administer without filter if not available).
  • 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

Agarwala, R., Ahmed, S. Z., & Wiegand, T. J. (2014). Prolonged use of intravenous lipid emulsion in a severe tricyclic antidepressant overdose. Journal of Medical Toxicology, 10 (2), 210-214.

Arora, N. P., Berk, W. A., Aaron, C. K., & Williams, K. A. (2013). Usefulness of intravenous lipid emulsion for cardiac toxicity from cocaine overdose. American Journal of Cardiology, 111, 445-447.

Bailey, B., Blais, R., Gaudreault, P., Gosselin, S., & Laliberte, M. (2009). Antidotes en toxicologie d'urgence (3rd ed.). Quebec, Canada: Centre antipoison du Quebec.

Bartos, M., & Knudson, K. (2013). Use of intravenous lipid emulsion in the resuscitation of a patient with cardiovascular collapse after a severe overdose of quetiapine. Clinical Toxicology (Philadelphia, Pa.), 51, 501-504.

Bucklin, M. H., Gorodetsky, R. M., & Wiegand, T. J. (2013). Prolonged lipemia and pancreatitis due to extended infusion of lipid emulsion in bupropion overdose. Clinical Toxicology (Philadelphia, Pa.), 51, 896-898.

Cave, G., & Harvey, M. (2009). Intravenous lipid emulsion as antidote beyond local anesthetic toxicity: A systematic review. Academic Emergency Medicine, 16, 815-824.

Doepker, B., Healy, W., Cortez, E., & Adkins, E. J. (2014). High-dose insulin and intravenous lipid emulsion therapy for cardiogenic shock by intentional calcium-channel blocker and beta-blocker overdose: A case series. The Journal of Emergency Medicine, 46(4), 486-490.

Downes, M. A., Calver, L. A., & Isbister, G. K. (2014).  Intralipid therapy does not improve level of consciousness in overdoses with sedating drugs: Case series . Emergency Medicine Australasia, 26 (3): 286-90

Harvey, M., & Cave, G. (2012). Case report: Successful lipid resuscitation in multi-drug overdose with predominant tricyclic antidepressant toxidrome. International Journal of Emergency Medicine, 5(1), 8-1380-5-8.

Hendron, D., Menagh, G., Sandilands, E. A., & Scullion, D. (2011). Tricyclic antidepressant overdose in a toddler treated with intravenous lipid emulsion. Pediatrics, 128, 1628-1632

IWK Regional Poison Centre. (2013). Sodium channel blockers (wide QRS): A brief overview for emergency departments. Unpublished manuscript.

IWK Regional Poison Centre. (2011). Beta-adrenergic antagonists (beta-blockers): A brief overview for emergency departments. Unpublished manuscript.

IWK Regional Poison Centre. (2011). Calcium channel blockers: A brief overview for emergency departments. Unpublished manuscript.

Martin, C., Gonzalez, H., Ruiz, S., Ribes, D., Franchitto, N., & Minville, V. (2014). Letter to editor: Acute respiratory distress syndrome following verapamil overdose treated with intravenous lipid emulsion: A rare life-threatening complication. Annales Francaises d’Anesthesie Et Reanimation, 33, e101-e102.

Martyn, H., & Grant, C. (2011). ACMT position statement: Interim guidance for the use of lipid resuscitation therapy. Journal of Medical Toxicology, 7, 81-82.

Meaney, C. J., Sareh, H., Hayes, B. D., & Gonzales, J. P. (2013). Case report: Intravenous lipid emulsion in the management of amlodipine overdose. Hospital Pharmacy, 48(10), 848-854.

Micromedex, T. H. A. (2014). Micromedex health care systems. Retrieved from http://www.micromedexsolutions.com

Olson, K. R. (2007). Poisoning & drug overdose (Sixth ed.). New York: McGraw Hill.

Presley, J. D., & Chyka, P. A. (2013). Intravenous lipid emulsion to reverse acute drug toxicity in pediatric patients. The Annals of Pharmacotherapy, 47(May), 735 - 743.

Punja, M., Neill, S. G., & Wong, S. (2013). Case report: Caution with interpreting laboratory results after lipid rescue therapy. American Journal of Emergency Medicine, 31, 1536.e1-1536.e2.

Shenoy, U., Paul, J., & Antony, D. (2014). Case report: Lipid resuscitation in pediatric patients-need for caution? Pediatric Anesthesia, 24, 332-334.

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Weinberg, G. L. (2012). Lipid emulsion infusion: Resuscitation for local anesthetic and other drug overdose. Anesthesiology, 117, 180-187.