ACMT Position Statement: Interim Guidance for the Use of Lipid Resuscitation Therapy

Lipid resuscitation therapy (LRT) refers to the administration of a lipid emulsion with the intent of reducing the clinical manifestations of toxicity from excessive doses of certain medications. This therapy has shown very promising results in experimental (animal) models of poisoning by lipid-soluble cardiotoxic medications [1, 2]. The data deriving from experience with similarly poisoned humans is highly anecdotal, although they do suggest that LRT may be beneficial [1, 2]. The choice of whether, and when, to initiate LRT is one that is solely discretionary and is based on the clinical judgment of the treating physician. Given the uncertainty of its beneficial effect in human poisonings, it is the opinion of the American College of Medical Toxicology (ACMT) that there are no standard of care requirements to use, or to choose not to use, LRT. However, in circumstances where there is serious hemodynamic, or other, instability from a xenobiotic with a high degree of lipid solubility, LRT is viewed as a reasonable consideration for therapy, even if the patient is not in cardiac arrest.

The purpose of this document is to propose a treatment guideline if LRT is used as a component of the treatment of poisoned patients. If LRT is used, it should be instituted for patients with hemodynamic, or other (e.g., intractable seizures), instability, not responsive to standard resuscitation measures, such as fluid replacement, inotropes, and pressors, where appropriate. The decision to use LRT instead of, or in conjunction with, other therapies, such as euglycemic insulin therapy, is to be based on the clinical judgment of the treating physician. Where possible, it is recommended that these therapies be administered in consultation with a medical toxicologist.

Recommended Guideline

If the decision is made to initiate LRT, the following guideline is recommended. This suggested guideline is a modification of the ones posted on the LipidRescue.org [1], the UK Resuscitation Council [3], and the Association of Anaesthetists of Great Britain and Ireland [4]. However, it is completely appropriate if the treating physician, based on his/her clinical judgment, chooses to alter the manner in which LRT is administered.

1. Twenty percent lipid emulsion (e.g., Intralipid1) should be administered as a 1.5-ml/kg bolus. This can be accomplished by drawing the appropriate volume of 20% lipid emulsion into 50 ml syringes and administering it through an intravenous catheter. The bolus should be administered over 2–3 min.

2. The bolus should be followed immediately by an infusion of 20% lipid emulsion at a rate of 0.25 ml/kg/min. This can be accomplished by attaching the lipid emulsion bag to an intravenous pump. Blood pressure, heart rate, and other available hemodynamic parameters should be recorded at least every 15 min during the infusion.

3. For asystolic patients, or those with pulseless electrical activity, who do not respond to the bolus, the dose may be repeated.

4. If there is an initial response to the bolus followed by the re-emergence of hemodynamic instability, the infusion rate could be increased or, in severe cases, the bolus could be repeated.

5. Where possible, LRT should be terminated after 1 h, or less, if the patient’s clinical status permits. In cases where the patient’s stability is dependent on continued lipid infusion, longer periods of treatment may be appropriate.