Article, Emergency Medicine

Lipid emulsion therapy given intraosseously in massive verapamil overdose

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Lipid emulsion therapy given intraosseou”>Case Report

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American Journal of Emergency Medicine

journal homepage: www. elsevier. com/ locate/ajem

American Journal of Emergency Medicine 33 (2015) 1844.e1

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Lipid emulsion therapy given intraosseously in massive verapamil overdose?

Abstract

Intravenous fat emulsion (IFE) therapy has been widely used in the emergency department (ED) for treating various medication overdoses. The standard recommended route to administer IFE therapy is intrave- nously through a peripheral or central vein. No reports of intraosseous (IO) administration in humans could be found in the literature after a brief search. We report of a patient emergently receiving IFE through the IO route. A 24-year-old woman presented to ED after a massive deliberate verapamil overdose. A decision was then made to start both vasopressors and 20% IFE therapy. Central access was established, and a norepinephrine drip was started. Intravenous fat emulsion was to be started, but peripheral access was lost at that time and not able to be reestablished. An IO line was then placed without difficulty in the left prox- imal tibia using an EZ-IO system. Approximately half way during the bolus administration, the intravenous pump began to alarm that the infusion was not flowing adequately. At this point, peripheral access was obtained, and IFE infusion was moved to that site. We believe that this is the first re- port of IFE administered via the IO route in a human. This case report illus- trates a novel way of administering IFE therapy in an emergency situation where intravenous access may be difficult to obtain.

Intravenous fat emulsion (IFE) therapy has been widely used in the emergency department (ED) for treating various medication overdoses [1]. The standard recommended route to administer IFE therapy is intravenously through a peripheral or central vein [2]. Fettiplace et al [3] reported on the success of intraosseous (IO) administration of IFE to reverse bupivacaine tox- icity in rats. No reports of IO administration in humans could be found in the literature after a brief search. We report of a patient emergently receiving IFE through the IO route. We also discuss the difficulties we encountered in ad- ministering the medication through this route.

A 24-year-old woman presented to ED after a deliberate overdose. The patient reported taking approximately 30 tablets of 240-mg extended-release verapamil along with a smaller but unknown quantity of 80-mg immediate-release verapamil. The ingestion occurred 1 to 2 hours before her arrival.

Consistently, since her arrival in ED, the patient’s heart rate remained in the 80s, but she was persistently hypotensive. The systolic blood pressure quickly dropped as low as 65/30 mm Hg. After initial treatment for calcium channel blocker overdose including glucagon, High dose insulin (100 U), and Calcium gluconate, there was no change in blood pressure. A decision was then made to start both vasopressors and 20% IFE therapy. Central ac- cess was established, and a norepinephrine drip was started, which was eventually titrated up to 20 mcg per minute. Intravenous fat emulsion

was delivered to the ED, but peripheral access was lost at that time and not able to be reestablished. Intravenous fat emulsion was not able to be administered via central line given possible interaction with other medica- tions. An IO line was then placed without difficulty in the left proximal tibia using an EZ-IO system (Morrisville, NC). Good flow was noted through IO line, and it was flushed with 2% lidocaine before use.

Intravenous fat emulsion 20% was then started through IO. The pa-

tient was noted to report some pain with the infusion of the 120-mL bolus. Approximately half way during the bolus administration, the intravenous pump (Alaris; San Diego, CA) began to alarm that the infu- sion was not flowing adequately. The pharmacist at the bedside noted that the pump could not administer the bolus rate through the required filter and then through the IO line. At this point, peripheral access was ob- tained, and IFE infusion was moved to that site. The patient was admitted to the intensive care unit and died 2 days later.

Current literature on IFE therapy via the IO route is limited to rats in bupivacaine-induced toxicity. We believe this is the first report of IFE administered via the IO route in a human. This case report illustrates a novel way of administering IFE therapy in an emergency situation where intravenous access may be difficult to obtain. We also see the potential complications that may arise in future administration of this medication intraosseously. One possibility for failure through this route could be viscosity of the medication, but given its success in the animal model, that may not be true. One suggestion we would offer to future prac- titioners attempting this route would be to slow down bolus rate of infusion.

Christopher S. Sampson, MD? Starr-Mar’ee Bedy PharmD, BCPS Department of Emergency Medicine University of Missouri-Columbia, Columbia, MO

?Corresponding author. One Hospital Drive, DC 029.1

Columbia, MO 65212

E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.04.061

References

  1. Cao D, Heard K, Foran M, Koyfman A. Intravenous lipid emulsion in the Emergency Department: A Systematic Review of Recent Literature. J Emerg Med 2015;48:387-97.
  2. Intralipid 20% [package insert]. Uppsala, Sweden: Fesenius Kabi; 2006.
  3. Fettiplace MR, Ripper R, Lis K, Feinstein DL, Rubinstein I, Weinberg G. Intraosseous Lipid Emulsion: An Effective Alternative to IV Delivery in Emergency Situations. Crit Care Med 2014;42:e157-60.

    ? No conflicts of interest.

    0735-6757/(C) 2015

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