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• W1564695877 abstract "We read with interest the case report by Dean et al. regarding their successful treatment of a patient presenting with propranolol overdose [1]. They reported the use of 20% Intralipid™ (Fresenius Kabi Ltd, Runcorn, Cheshire, UK) for severe propranolol overdose presenting with clinical signs and investigative findings that appeared refractory to conventional treatments. Their use of Intralipid is supported by an increasing body of scientific work in rodent and rabbit models [2, 3]. Recently, another case report has highlighted the effectiveness of Intralipid in nebivolol toxicity [4] and we are also aware of a contemporaneous internet posting linking successful treatment of propranolol and clonidine toxicity with Intralipid [5]. We believe that log P values may eventually be used to predict the clinical efficacy of intravenous lipid emulsion for lipophilic drugs taken in overdose [6]. The log P refers to the logarithm of the partition coefficient P and represents the degree to which a drug is lipid soluble. The lipid sink theory requires the toxic drug to be lipid soluble and certainly intravenous lipid emulsion has been shown to reduce the toxic effects of many other lipophilic drugs with high log P values such as amiodarone, clomipramine and amitriptyline [7]. The log P of propranolol is 3 [8], which is very similar to that of nebivolol, and therefore we would have expected intravenous lipid emulsion to have been effective in this case of propranolol overdose. Conversely, experimental work examining the use of intravenous lipid emulsion on the toxic effects of the beta-blocker metoprolol, which possesses a log P of 1.9 (over 10 times less lipid soluble than propranolol), did not demonstrate any significant difference when compared to 0.9% saline solution [9]. We appreciate that case reports describing mixed overdoses can be difficult to interpret because it is difficult to delineate the relative toxic effects of drugs in combination. Hence, although overdoses involving the use of intravenous lipid emulsion treatment for metoprolol and other lipophilic drugs have been encouraging [10], we eagerly await the first case to be reported demonstrating the efficacy of intravenous lipid emulsion for metoprolol overdose in isolation. Finally, we endorse Dean et al.’s statement with regard to the consideration of intravenous lipid emulsion in ‘patients who have responded poorly to conventional therapy’. However, we believe that earlier administration of intravenous lipid emulsion in this patient, immediately following standard resuscitative procedures (i.e. oxygen therapy, intravenous fluid therapy, etc.), may have prevented this patient from deteriorating into pulseless electrical activity cardiac arrest. Perhaps, intravenous lipid emulsion may one day be administered before or concomitantly with many of the conventional treatments for severe beta-blocker overdose that were expertly demonstrated in the management of this patient. No external funding and no competing interests declared. Previously posted at the Anaesthesia Correspondence website: http://www.anaesthesiacorrespondence.com." @default.
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• W1564695877 date "2011-02-14" @default.
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• W1564695877 title "Logging the potential for intravenous lipid emulsion in propranolol and other lipophilic drug overdoses" @default.
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• W1564695877 doi "https://doi.org/10.1111/j.1365-2044.2011.06635.x" @default.
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