Lipid Emulsion 20%
Intralipid
Lipid resuscitation agent
Theory: 'Lipid sink' sequesters lipophilic drugs (especially LAs), shifts to better Ca²⁺ handling, fatty acid metabolic support.
Indications
- •LAST (cardiotoxicity from local anesthetic)
- •Lipophilic drug overdose (TCA, calcium-channel blocker, β-blocker, bupropion — controversial)
Dosing
| Context | Adult | Pediatric |
|---|---|---|
| LAST bolus | 1.5 mL/kg IV over 1 min, repeat 1–2× if no response | — |
| LAST infusion | 0.25 mL/kg/min for 10 min after stability; max ~12 mL/kg total | — |
Pharmacokinetics
Onset 1–3 min.
Side effects
- !Pancreatitis (high cumulative dose)
- !Fat overload syndrome (rare with single resuscitation event)
- !Lab interference (lipemic samples)
- !ECMO circuit fouling (use only if no alternatives)
Contraindications
- ×Severe egg allergy (formulation contains egg phospholipid)
Clinical pearls
- ★ASRA recommends earliest lipid use, before resuscitation seems failing.
- ★Document via LipidRescue.org registry.
- ★Don't substitute propofol — its vehicle is a 10% lipid emulsion (half the lipid of 20% Intralipid) and it adds cardiac depression.
Other drugs in Others
- Dantrolene
Blocks RYR1 (ryanodine receptor) → ↓ Ca²⁺ release from sarcoplasmic reticulum → muscle relaxation. The only drug for malignant hyperthermia.
- Hydroxocobalamin
Vitamin B12a precursor; cyanide binds to cobalt center of hydroxocobalamin → forms cyanocobalamin (B12) → renal excretion. Also scavenges nitric oxide → vasoconstriction.
- Octreotide
Long-acting somatostatin analogue → suppresses splanchnic blood flow, GI/pancreatic secretions, GH, glucagon, insulin, and serotonin/vasoactive-peptide release.
- Alvimopan
Blocks GI mu-opioid receptors WITHOUT crossing the blood-brain barrier → reverses opioid-induced gut slowing while preserving central analgesia. Accelerates return of bowel function.
- Phentolamine
Competitive, reversible α1 + α2 blockade → vasodilation. Short-acting.
- Inhaled Nitric Oxide
Inhaled NO diffuses to pulmonary vascular smooth muscle → ↑ cGMP → SELECTIVE pulmonary vasodilation only in VENTILATED lung units (improves V/Q matching). Inactivated by hemoglobin before reaching systemic circulation → no systemic hypotension.
- Digoxin Immune Fab
Suggested reading
- •ASRA LAST checklist, 2020
- •FDA package insert
- •Miller's Anesthesia, 9e
