![]() ![]() This website serves as a forum for discussing lipid therapy and related topics and contains useful links to relevant literature. Additional cases, along with descriptions of the use of lipid in treating many other types of drug toxicity, are posted at the educational website *. More cases of lipid resuscitation from local anesthetic toxicity can be found in recent reviews of the topic 4, 10. ![]() Braun, Melsungen, Germany) a mixture of long and medium chain fatty acid triglycerides. Though Intralipid (Fresenius Kabi, Uppsala, Sweden) has been the predominant lipid emulsion brand used in instances of lipid resuscitation reported in the medical literature, successful treatment of severe toxicity has also been reported with other formulations including Liposyn III (Hospira, Lake Forest, IL) and Medialipid (B. Successful treatment of severe cardiac toxicity has been reported in children, including two neonates, including a two day old 9 the oldest patient reported in a successful lipid resuscitation was a 92 year old woman in asystole following an infraclavicular block with ropivavcaine. This similarly contributes to the debate regarding the mechanisms underlying lipid resuscitation, since the metabolic hypothesis would not hold in the case of neurotoxicity because the central nervous system does not normally depend on lipid substrates (see the section on ‘Mechanisms’). Lipid infusion can also reverse neurological signs and symptoms of LAST, including seizures and altered mental status, suggesting that the benefit is not limited to the cardiovascular system 7, 8. These reports contribute directly to the controversy surrounding optimal timing of the lipid emulsion infusion that is addressed below. Several other recent cases seem to support this notion. This observation suggests that early lipid infusion might provide an advantage, presumably by interrupting the vicious cycle of low-output, tissue acidosis and worsening toxicity, thereby preventing progression to a low-output state or frank cardiac arrest. McCutchen and Gerancher 6 reported that in a patient with seizures and ventricular tachycardia following a combined femoral catheter (ropivacaine) and sciatic (bupivacaine) block, the use of lipid emulsion early in the sequence of rapidly worsening toxicity appeared to attenuate or prevent progression of local anesthetic cardiac toxicity. An additional feature common to many of the early case reports of lipid therapy for severe LAST was the presence of underlying heart disease, suggesting that coronary ischemia, baseline conduction defects or cardiomyopathy could lower the threshold for LAST, thereby defining one subgroup of vulnerable patients. This case is now recognized as typical of many lipid resuscitation cases and exemplifies key features repeated in virtually every subsequent report of reversal by lipid infusion of LAST- related cardiac arrest: 1) the event was witnessed (meaning, little to no associated asphyxia or delay in treatment) 2) the patient failed to recover with epinephrine, vasopressin and anti-arrhythmic medications and 3) spontaneous circulation was re-established shortly after lipid infusion. He subsequently recovered completely with no neurological deficit or cardiovascular sequelae. The patient failed to respond to standard resuscitative efforts for approximately 20 minutes but achieved normal vital signs shortly after receiving a 100 mL bolus of lipid emulsion. A middle aged man developed cardiac arrest shortly after a peripheral nerve block combining mepivacaine and bupivacaine. Rosenblatt et al 5 reported the first clinical application of lipid emulsion therapy in treating LAST. ![]()
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