Use of Intralipid in Tricyclic overdose
Date First Published:
January 28, 2010
Last Updated:
June 8, 2010
Report by:
Dr Dianne Tabone, ST 4 Emergency Medicine (Royal Preston Hospital)
Search checked by:
Lee Helliwell, Royal Preston Hospital
Three-Part Question:
In [an adult with tricyclic antidepressant poisoning] is [intravenous lipid emulsion/Intralipid/Liposyn II] [beneficial in resistant hypotension and refractory arrhythmias]?
Clinical Scenario:
A patient with tricyclic antidepressant overdose is treated in the Emergency Department. He is hypotensive and drowsy and has prolonged QTc on electrocardiogram. Blood gas shows metabolic acidosis. He is given intravenous fluids and sodium bicarbonate boluses until his pH becomes 7.6. However, he remains hypotensive. His rhythm then changes to VT. You remember that intravascular lipid emulsion (intralipid) has been used for overdoses of lipid-soluble drugs and you wonder whether it could be effective in this patient.
Search Strategy:
MEDLINE 1966 to Week 2 January 2010
EMBASE 1980 to Week 2 January 2010
Google search
EMBASE 1980 to Week 2 January 2010
Google search
Search Details:
[{exp Antidepressive Agents, Tricyclic/ or tricyclic.mp} OR {clomipramine.mp. or exp Clomipramine/ } OR {exp Amitriptyline/ or amitriptyline.mp.} OR {nortryptiline.mp. or exp Nortriptyline/} OR dothiepin.mp. or exp Dothiepin/} OR {imipramine.mp. or exp Imipramine/} OR {doxepin.mp. or exp Doxepin/}] AND [{ intralipid.mp. or exp Fat Emulsions, Intravenous/ } OR {intravenous lipid emulsion.mp. or exp Fat Emulsions, Intravenous/ } OR {exp Fat Emulsions, Intravenous/ or liposyn$.mp.}]
The Cochrane library January 2010: (Intralipid, ti.ab OR lipsyn II.ti.ab,) AND (MeSH descriptor Antidepressive Agents, Tricyclic explode all trees) 0 results.
The Cochrane library January 2010: (Intralipid, ti.ab OR lipsyn II.ti.ab,) AND (MeSH descriptor Antidepressive Agents, Tricyclic explode all trees) 0 results.
Outcome:
Medline: six papers of which none were relevant. EMBASE: 16 papers of which none were relevant. Google: one systematic review and two case reports. The systematic review did not contain relevant human studies/reports. One of the case reports was published as an abstract at the North American Congress of Clinical Toxicology 2009, the other as a case report on the lipid rescue webpage.
Relevant Paper(s):
Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
---|---|---|---|---|---|
Successful resuscitation of a doxepin overdose using intravenous fat emulsion (IFE). Carr D, Boone A, Hoffman RS, Martin K, Ahluwalia N. 2009, Canada | 80 year-old man, ingested 1.5gr doxepin | Case report/abstract | Patient found with GCS 3, BP 56/34, HR 60. QRS 113ms. Patient intubated, treated with fluids, NaHCO3, dopamine, norepinephrine, vasopressin. Despite treatment, patient remained hypotensive and QRS widened further. | 225ml bolus of 20% Intravascular lipid emulsion, followed by infusion for a total of 100gr over 90 minutes. BP stabilized 2.5 hrs after starting infusion. | 1 case only. |
Case report on Lipid rescue website Brooks, C. 2009, | 53year old female with mixed overdose: amitryptiline, citalopram, fluoxetine,lorazepam and alcohol. | Case report on Lipidrescue website. | Patient arrived in ED with GCS 3, tachycardic, preserved BP, QRS 114ms. Patient intubated. | Intralipid started 3 hours after arrival in hospital. 1.5ml/Kg of 20% intralipid bolus over 1 minute, followed by an infusion of 0.25ml/kg/min for the following 2 hours. QRS duration decreased to 100ms 4 hours after arrival. 48 hour ICU | 1 case. Not formally published. Multiple drug ingestion. |
Author Commentary:
There are no human studies about use of intralipid in tricyclic antidepressant overdose. There is a small study3 in which humans were given therapeutic doses of tricyclic antidepressant and intralipid. In this study, patients treated with intralipid developed a non-significant increase in blood tricyclic level, which would support the hypothesis that intralipid attracts tricyclics away from tissues by creating an expanded lipid compartment. However, the pharmacology for therapeutic and toxic doses of tricyclics is different. The use of intralipid for tricyclic antidepressant overdose has been shown to be effective in four animal studies.4–7 Despite lack of clear evidence, Toxbase advises intralipid when there are life-threatening arrhythmias resistant other standard therapies.9 In the UK, intralipid is also recommended for treatment of severe local anaesthetic toxicity.10
Bottom Line:
There is no clear evidence about the effectiveness of Intralipid in tricyclic antidepressant overdose.
References:
- Carr D, Boone A, Hoffman RS, Martin K, Ahluwalia N.. Successful resuscitation of a doxepin overdose using intravenous fat emulsion (IFE).
- Brooks, C.. Case report on Lipid rescue website
- Minton N, Goode A, Henry J. . The effect of a lipid suspension on amitryptiline disposition.
- Harvey M, Cave G. . Intralipid outperforms sodium bicarbonate in a rabbit model of clomipramine toxicity.
- Yoav G, Odelia G, Shaltiel C. . A lipid emulsion reduces mortality from clomipramine overdose in rats.
- Bania T, Chu J. . Haemodynamic effect of Intralipid in amitryptiline toxicity.
- Harvey M, Cave G. . Correlation of plasma and peritoneal dialysate clomipramine concentration with haemodynamic recovery after Intralipid infusion in rabbits.
- Cave G, Harvey M. . Intravenous lipid emulsion as antidote beyond local anaesthetic toxicity: a systematic review.
- Toxbase. . [Online database]
- Association of Anaesthetists of Great Britain and Ireland (AAGBI). . Guidelines for the management of severe local anaesthetic toxicity.