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Lipid therapy for the treatment of a refractory amitriptyline overdose

Published online by Cambridge University Press:  11 May 2015

Mathew B. Kiberd  and
Samuel F. Minor
Mathew B. Kiberd
Affiliation:
Department of Medicine, Dalhousie University, Halifax, NS
Samuel F. Minor*
Affiliation:
Department of Medicine, Dalhousie University, Halifax, NS Department of Surgery, Dalhousie University, Halifax, NS
*
Department of Medicine, Dalhousie University, Rm 813 Victoria Bldg, 1278 Tower Road, Halifax, NS B3H 2Y9

Abstract

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Tricyclic antidepressant (TCA) overdose is a leading cause of death among intentional overdoses. Intravenous lipid emulsion therapy is an emerging antidote for local anesthetic toxicity, and there is animal evidence that lipid therapy may be efficacious in TCA overdose. Furthermore, case reports in humans have described the use of lipid therapy to reverse the toxicity of other lipophilic drugs. Here we report a 25-year-old female presenting with coma and hemodynamic instability following intentional ingestion of amitriptyline. She had multiple episodes of pulseless wide-complex tachycardia despite conventional treatment with chest compressions, cardioversion, lidocaine, epinephrine, norepinephrine, magnesium sulphate, sodium bicarbonate, activated charcoal, and whole bowel irrigation. Twenty percent lipid emulsion was administered intravenously (an initial 150 mL bolus, followed by an infusion at 16 mL/h and a second bolus of 40 mL) over 39 hours (total dose 814 mL) yet resulted in no dramatic changes in hemodynamics or level of consciousness. However, there was a decrease in the frequency of wide-complex tachycardia during the lipid emulsion infusion and a recurrence of wide-complex tachycardia shortly after the infusion was stopped. The patient was discharged from the intensive care unit 11 days later with no lasting physiologic sequelae.

Keywords

amitriptylineintravenous fat emulsionstricyclic antidepressive agents
Type
Case Report • Rapport de cas
Information
Canadian Journal of Emergency Medicine , Volume 14 , Issue 3 , March 2012 , pp. 193 - 197
Copyright
Copyright © Canadian Association of Emergency Physicians 2012

References

REFERENCES

1.Bebarta, VS, Waksman, JC. Amitriptyline-induced brugada pattern fails to respond to sodium bicarbonate. Clin Toxicol (Phila) 2007;45:186–8, doi:10.1080/15563650600981186.CrossRefGoogle ScholarPubMed
2.Picard, J, Ward, SC, Zumpe, R, et al. Guidelines and the adoption of ‘lipid rescue’ therapy for local anaesthetic toxicity. Anaesthesia 2009;64:122–5, doi:10.1111/j.1365-2044.2008.05816.x.CrossRefGoogle ScholarPubMed
3.Cave, G, Harvey, M. Lipid emulsion therapy in lipophilic drug toxicity. Ann Emerg Med 2008;51:449–50; author reply 450, doi:10.1016/j.annemergmed.2007.10.014.CrossRefGoogle ScholarPubMed
4.Cave, G, Harvey, MG, Castle, CD. Intralipid ameliorates thiopentone induced respiratory depression in rats: investigative pilot study. Emerg Med Australas 2005;17:180–1, doi:10.1111/j.1742-6723.2005.00714.x.CrossRefGoogle ScholarPubMed
5.Corman, SL, Skledar, SJ. Use of lipid emulsion to reverse local anesthetic-induced toxicity. Ann Pharmacother 2007;41: 1873–7, doi:10.1345/aph.1K244.CrossRefGoogle ScholarPubMed
6.Picard, J, Harrop-Griffiths, W. Lipid emulsion to treat drug overdose: past, present and future. Anaesthesia 2009;64:119–21, doi:10.1111/j.1365-2044.2008.05830.x.Google Scholar
7.Picard, J, Meek, T, Weinberg, G, et al. Lipid emulsion for local anaesthetic toxicity. Anaesthesia 2006;61:1116–7, doi:10.1111/j.1365-2044.2006.04841.x.Google Scholar
8.Weinberg, G. Lipid rescue resuscitation from local anaesthetic cardiac toxicity. Toxicol Rev 2006;25:139–45, doi:10.2165/00139709-200625030-00001.Google Scholar
9.Weinberg, G. Lipid infusion resuscitation for local anesthetic toxicity: proof of clinical efficacy. Anesthesiology 2006;105:7–8, doi:10.1097/00000542-200607000-00005.Google Scholar
10.Weinberg, G, Ripper, R, Feinstein, DL, et al. Lipid emulsion infusion rescues dogs from bupivacaine-induced cardiac toxicity. Reg Anesth Pain Med 2003;28:198–202.Google Scholar
11.Harvey, M, Cave, G. Intralipid outperforms sodium bicarbonate in a rabbit model of clomipramine toxicity. Ann Emerg Med 2007;49:178“85, doi:10.1016/j.annemergmed.2006.07.016.CrossRefGoogle Scholar
12.Sirianni, AJ, Osterhoudt, KC, Calello, DP, et al. Use of lipid emulsion in the resuscitation of a patient with prolonged cardiovascular collapse after overdose of bupropion and lamotrigine. Ann Emerg Med 2008;51:412–5.Google Scholar
13.Finn, SD, Uncles, DR, Willers, J, et al. Early treatment of a quetiapine and sertraline overdose with intralipid. Anaesthesia 2009;64:191–4, doi:10.1111/j.1365-2044.2008.05744.x.CrossRefGoogle ScholarPubMed
14.Zuidema, X, Dunser, MW, Wenzel, V, et al. Terlipressin as an adjunct vasopressor in refractory hypotension after tricyclic antidepressant intoxication. Resuscitation 2007;72:319–23, doi:10.1016/j.resuscitation.2006.07.005.Google Scholar
15.Hutchinson, M, Traub, S. Tricyclic antidepressant poisoning. In: Ewald, MB, editor. UpToDate. Waltham (MA): 2011.Google Scholar
16.Weinberg, GL. In defence of lipid resuscitation. Anaesthesia 2006;61:807–8, doi:10.1111/j.1365-2044.2006.04723.x.Google Scholar
17.Weinberg, GL, Di Gregorio, G, Ripper, R, et al. Resuscitation with lipid versus epinephrine in a rat model of bupivacaine overdose. Anesthesiology 2008;108:907–13, doi:10.1097/ALN.0b013e31816d91d2.Google Scholar
18.Weinberg, GL, Ripper, R, Murphy, P, et al. Lipid infusion accelerates removal of bupivacaine and recovery from bupivacaine toxicity in the isolated rat heart. Reg AnesthPain Med 2006;31:296–303.CrossRefGoogle ScholarPubMed
19.Weinberg, GL. Lipid infusion therapy: translation to clinical practice. Anesth Analg 2008;106:1340–2, doi:10.1213/ane.0-b013e31816a6c09.Google Scholar
20.Tebbutt, S, Harvey, M, Nicholson, T, et al. Intralipid prolongs survival in a rat model of verapamil toxicity. Acad Emerg Med 2006;13:134–9, doi:10.1111/j.1553-2712.2006.tb01661.x.Google Scholar
21.Yoav, G, Odelia, G, Shaltiel, C. A lipid emulsion reduces mortality from clomipramine overdose in rats. Vet Hum Toxicol 2002;44:30.Google ScholarPubMed
22.Bania, TC, Chu, J, Perez, E, et al. Hemodynamic effects of intravenous fat emulsion in an animal model of severe verapamil toxicity resuscitated with atropine, calcium, and saline. Acad Emerg Med 2007;14:10511, doi:10.1111/j.1553-2712.2007.tb01752.x.Google Scholar
23.Kline, JA, Raymond, RM, Leonova, ED, et al. Insulin improves heart function and metabolism during non-ischemic cardiogenic shock in awake canines. Cardiovasc Res 1997;34:289–98, doi:10.1016/S0008-6363(97)00022-9.Google Scholar
24.Doursout, MF, Joseph, PM, Liang, YY, et al. Role of propofol and its solvent, intralipid, in nitric oxide-induced peripheral vasodilatation in dogs. Br J Anaesth 2002;89:492–8.CrossRefGoogle ScholarPubMed
25.Marwick, PC, Levin, AI, Coetzee, AR. Recurrence of cardiotoxicity after lipid rescue from bupivacaine-induced cardiac arrest. Anesth Analg 2009;108:1344–6, doi:10.1213/ane.0b013e3181979e17.CrossRefGoogle ScholarPubMed