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Intravenous lipid emulsion (ILE) therapy, also known as lipid resuscitation therapy, is the established standard treatment for local anesthetic systemic toxicity (LAST), including local anesthetic-mediated cardiac arrest. Professional societies such as the American Society of Regional Anesthesia (ASRA) recommend this therapy in the medical field. Although ILE therapy has been experimentally used to rescue lipophilic drug overdoses and toxicities, outcomes vary. ILE therapy is additionally recommended as an adjunct to advanced cardiac life support measures in cases of suspected LAST-induced cardiac arrest. ILE therapy extends beyond LAST to encompass other lipophilic agents, emerging as a potential rescue therapy in emergency rooms and critical care units for various acute toxicities and poisonings. The applicability of this therapy extends across numerous multidisciplinary healthcare professions, including physicians, advanced practice practitioners, nursing staff, and pharmacists, particularly those involved in anesthesiology, emergency medicine, medical toxicology, and critical care departments. Despite its growing recognition, further clinical studies are imperative to clarify its mechanism of action, optimal dosing, and the management of associated complications. This activity provides an overview of the indications and contraindications for ILE therapy—an invaluable agent in managing local anesthetic toxicity. This activity allows participating clinicians to acquire insights into the treatment of patients presenting with local anesthetic toxicity and related conditions via ILE therapy. Objectives: Identify appropriate indications for intravenous lipid emulsion therapy based on clinical presentation and local anesthetic systemic toxicity risk factors. Screen patients for contraindications and potential risks associated with intravenous lipid emulsion therapy, considering comorbidities and concurrent medications. Apply knowledge of lipid emulsion therapy in managing acute toxicities beyond local anesthetic systemic toxicity, considering lipophilic drug overdoses and poisonings. Collaborate with multidisciplinary healthcare professionals, including physicians, pharmacists, nurses, and toxicologists, for medication reconciliation and care coordination in complex cases requiring additional expertise in managing drug-related toxicities.

Apply knowledge of lipid emulsion therapy in managing acute toxicities beyond local anesthetic systemic toxicity, considering lipophilic drug overdoses and poisonings. Collaborate with multidisciplinary healthcare professionals, including physicians, pharmacists, nurses, and toxicologists, for medication reconciliation and care coordination in complex cases requiring additional expertise in managing drug-related toxicities. Access free multiple choice questions on this topic.

Higher ILE doses have correlated with hypertriglyceridemia, acute pancreatitis, lipid embolus, extracorporeal circulation machine circuit obstruction, acute kidney injury, cardiac arrest, acute lung injury, and increased susceptibility to infections. Higher infusion rates and higher total doses increase the likelihood of these events.[20] Clogging of dialysis filters by lipid molecules is also an issue of concern.[33] Fat overload syndrome is another well-known complication of ILE; initial reports of this condition appeared in the setting of parenteral nutrition. Characteristic symptoms include sudden elevation of triglyceride levels, fever, liver dysfunction, splenomegaly, pancreatitis, coagulopathy, and hemolysis. These symptoms improve as lipemia resolves.[34] In a severe case of ILE toxicity, clinicians observed somnolence and metabolic acidosis with elevated lactic acid levels after administration of 66 mL/kg, which is well above the recommended threshold.[35]

Since ILE therapy's initial proposal for bupivacaine toxicity, it is recognized as the standard treatment for LAST and is recommended for local anesthetic-mediated cardiac arrest.[9] Furthermore, ILE therapy has been used for experimental rescue treatment of other lipophilic drug overdoses, toxicities, and toxin antidotes, though with variable success. As such, ILE therapy is relevant to physicians, advanced practice practitioners, nursing staff, pharmacists, and other healthcare professionals across the interprofessional team, especially in anesthesiology, emergency medicine, medical toxicology, and critical care. Despite the increasing awareness of ILE therapy, more clinical studies and research are needed to explain better its mechanism of action, other appropriate indications, optimal dosing, and the management of associated complications. The decision to use ILE requires solid clinical judgment from the ordering clinician. The nursing staff responsible for administering the therapy must be well-versed in the administration protocol and potential adverse effects. Pharmacists play a crucial role in overseeing dosing, medication reconciliation, and collaborating with nursing staff on administration and monitoring adverse reactions, emphasizing the importance of pharmacist involvement in these aspects. The involvement of critical care and emergency clinicians is vital due to differing resuscitation protocols for LAST from standard ACLS protocol. Additionally, consultation with medical toxicologists may be necessary for drug-related toxicities. Pathologists and clinical biochemists are responsible for selecting the appropriate techniques to ensure accurate laboratory analysis, emphasizing their role in guaranteeing precise results. Overall, an interprofessional team approach and effective communication are crucial for optimizing outcomes associated with ILE therapy for LAST.