In this episode, I’ll discuss how to make sure your hospital is prepared to administer lipid rescue therapy
Intravenous lipid emulsion (ILE) or “lipid rescue” therapy is used in local anesthetic systemic toxicity (LAST) and enteral drug toxicity. Anesthesia, toxicology, and ACLS guidelines recommend intravenous fat emulsion with various levels of evidence.
Because this intervention is rarely used and is only called for in stressful cardiac arrest situations, consider taking steps to prepare your hospital to be able to successfully deliver this intervention when it matters most.
Storage
It is critical to have the fat emulsion stored on the unit it is likely to be used in. I like to place 1 bag of 20% IV fat emulsion in each area where nerve blocks are used or where patients may be treated for drug toxicity. This may include:
1. All intensive care units
2. Pre-operative areas
3. Emergency Department
4. Post-Anesthesia Care Units
Include with the IV lipid emulsion several 60 mL syringes and large bore needles to facilitate giving the bolus rapidly.
Dosing
The dosing of fat emulsion is different for local anesthetic systemic toxicity (LAST) vs enteral drug toxicity.
For both indications, a bolus dose of 1.5 mL/kg 20% ILE is recommended. For LAST, this is followed by an infusion of 0.25 mL/kg/min. For enteral drug toxicity, after 3 minutes at 0.25 mL/kg/min the rate of ILE infusion is reduced by 90% to 0.025 mL/kg/min.
In the perioperative units, include copies of the ASRA recommendations for the use of IV fat emulsion in local anesthetic systemic toxicity.
In the ICU and ED areas, include copies of the American College of Medical Toxicology recommendations for the use of IV fat emulsion in enteral drug toxicity.
Administration
All published recommendations on the rate of administration of intravenous lipid emulsion suffer from a lack of practicality when it comes to actually administering ILE in a real-world toxicology scenario.
The problem is the disconnect between the recommended administration rate and the maximum administration rate possible on an IV infusion pump. I’ve yet to see a “smart” pump that is able to deliver a medication faster than 999 mL/hr (16.67 mL/min). But in any patient over 66 kg, the necessary infusion rate to deliver 0.25 mL/kg/min exceeds 999 mL/hr.
This leaves the clinician with the choice of hanging an ILE infusion in multiple IV sites. Unfortunately the logistics (establishing/tying up a 2nd line, getting an extra ILE bag, etc…) make this impractical.
I would like future guidelines to take into account the limitations of available “smart” pump technology.
For treatment of LAST, I would just set the smart pump with 20% ILE at 999 mL/hr.
For treatment of enteral drug toxicity, the same total 20% ILE dose that 0.25 mL/kg/min over 3 minutes provides can be infused as follows using conventional “smart” pumps:
~ 70 kg patient = 20% IV lipid emulsion at 999 mL/hr for 3 minutes
~ 90 kg patient = 20% IV lipid emulsion at 999 mL/hr for 4 minutes
~ 110 kg patient = 20% IV lipid emulsion at 999 mL/hr for 5 minutes
After the high-dose infusion is complete, the rate can be dropped to 0.025 mL/kg/min as the guidelines recommend for the remainder of treatment.
Remember, no matter what dose of ILE is used, one 250 mL bag will not last long. As soon as the bolus is given and the infusion is started, I request that another 2 bags of 20% ILE be brought to the bedside immediately.
Members of my Hospital Pharmacy Academy have access to my complete Lipid Rescue training that covers the background of ILE therapy in-depth for both LAST and enteral drug toxicity. You can sign up at pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
Leave a Reply