Corwin Daniel J, Topjian Alexis, Banwell Brenda L, Osterhoudt Kevin
a Division of Emergency Medicine , The Children's Hospital of Philadelphia , Philadelphia , PA , USA.
b Department of Anesthesiology and Critical Care Medicine , The Children's Hospital of Philadelphia , Philadelphia , PA , USA.
Clin Toxicol (Phila). 2017 Jul;55(6):603-607. doi: 10.1080/15563650.2017.1294693. Epub 2017 Feb 26.
Intravenous lipid emulsion (ILE) has gained favor as a rescue treatment for cardiovascular collapse due to intravenous local anesthetic overdose, however, goals of ILE therapy are still being defined. We describe a case of a girl given 66 mL/kg of 20% lipid emulsion (ILE) in the treatment of presumed mepivacaine toxicity.
An 11-year-old girl weighing 55.6 kg developed pallor, rolling back of the eyes, and rhythmic muscle twitching after receiving a mandibular nerve block injection with a 1.8 mL ampule of 3% mepivacaine. With concern for persistent seizures she was given three 1 mL/kg boluses of ILE, followed by an infusion of 0.25 mL/kg/min. The total dose ultimately administered was 3670 mL (66 mL/kg) over 7 h. A serum triglyceride concentration, drawn 2 h after cessation of ILE infusion, was estimated to be 16,583 mg/dL (429 mmol/L) after several dilutions; her blood was grossly lipemic. Notable signs included hypersomnolence, tachypnea, and tachycardia. Other complications included apparent metabolic acidosis (serum bicarbonate of 5 mmol/L) with hyperlactatemia (lactate 7.0 mmol/L), difficulty with serum laboratory interpretation, and a non-contrast brain magnetic resonance imaging showing high signal in the dural venous sinuses. The lipemia cleared over three days and the patient recovered uneventfully. Case discussion: This case demonstrates a unique neurologic and metabolic toxicity associated with ILE given as an antidote in a high total dose, and highlights the need for cautious antidotal application of lipid emulsion infusions. Until more data is available, clinicians are advised to take great care if considering a dose in excess of 12.5 mL/kg/day, the maximum daily dosage recommended by the U.S. Food and Drug Administration for nutritional supplementation. Careful monitoring of total doses administered across institutions and hospital wards during transfers is paramount to avoid inadvertent overdose of antidotes.
静脉注射脂质乳剂（ILE）已成为因静脉局部麻醉药过量导致心血管虚脱的一种抢救治疗方法，然而，ILE治疗的目标仍在确定中。我们描述了一例在治疗疑似甲哌卡因中毒时给予66毫升/千克20%脂质乳剂（ILE）的女孩病例。
一名体重55.6千克的11岁女孩在接受下颌神经阻滞注射1.8毫升安瓿的3%甲哌卡因后出现面色苍白、眼球后翻和有节律的肌肉抽搐。因担心持续性癫痫发作，她接受了三次1毫升/千克的ILE推注，随后以0.25毫升/千克/分钟的速度输注。最终在7小时内给予的总剂量为3670毫升（66毫升/千克）。在ILE输注停止2小时后采集的血清甘油三酯浓度，经多次稀释后估计为16583毫克/分升（429毫摩尔/升）；她的血液明显呈脂血状。显著体征包括嗜睡、呼吸急促和心动过速。其他并发症包括明显的代谢性酸中毒（血清碳酸氢盐为5毫摩尔/升）伴高乳酸血症（乳酸7.0毫摩尔/升）、血清实验室检查结果解读困难以及非增强脑磁共振成像显示硬脑膜静脉窦高信号。脂血在三天内消退，患者顺利康复。病例讨论：本病例显示了在高总剂量下作为解毒剂使用ILE所导致的独特神经和代谢毒性，并强调了谨慎使用脂质乳剂输注作为解毒剂的必要性。在获得更多数据之前，建议临床医生在考虑超过12.5毫升/千克/天的剂量时要格外小心，这是美国食品药品监督管理局推荐的营养补充剂最大日剂量。在转运过程中，跨机构和医院病房仔细监测给药总量对于避免解毒剂意外过量至关重要。
