Lipid emulsion

Lipid emulsion
A lipid emulsion (Intralipid) 20%
Names
Trade namesIntralipid, Nutrilipid, others
Other namesFat emulsion, lipid emulsion therapy, lipid resuscitation therapy
Clinical data
Main usesParenteral nutrition, certain overdoses[1][2]
WHO AWaReUnlinkedWikibase error: ⧼unlinkedwikibase-error-statements-entity-not-set⧽
Typical dose100 ml dose of 20% emulsion (overdose)[1]
External links
AHFS/Drugs.comFDA Professional Drug Information

Lipid emulsion, sold under the brand name Intralipid among others, is a oil based solution for intravenous use.[2] They are traditionally used as part of parenteral nutrition.[2] They are also used to treat a number of toxicities including local anesthetic, beta-blocker, calcium channel blocker, organophosphate, and antipsychotic.[1][2]

Side effects are generally few, though may include allergies, pancreatitis and adult respiratory distress syndrome.[1] Use may be complicated by certain fungal infections.[2] How it works in toxicity is not entirely clear.[1]

Lipid emulsions became available for medical use in 1961.[2] It use for toxicity began in 1998.[3] Different versions are made from different source.[1] Common sources include soy bean, coconut, olive, eggs, and fish.[1] In the United States it costs about 47 USD per 250 ml of 20% emulsion as of 2021.[4]

Medical uses

Nutrition

Intralipid and other balanced lipid emulsions provide essential fatty acids, linoleic acid (LA), an omega-6 fatty acid, alpha-linolenic acid (ALA), an omega-3 fatty acid. The emulsion is used as a component of intravenous nutrition for people who are unable to get nutrition via an oral diet.

Local anaesthetic toxicity

Lipid emulsions are effective in treating experimental models of severe cardiotoxicity from intravenous overdose of local anaesthetic drugs such as bupivacaine.[5][6][7][8]

They have been effective in people unresponsive to the usual resuscitation methods. They have subsequently been used off-label in the treatment of overdose from other fat-soluble medications.[9]

Vehicle for other medications

Propofol is dissolved in a lipid emulsion for intravenous use. Sometimes etomidate (the vehicle for etomidate is propylene glycol) is supplied using a lipid emulsion as a vehicle.

Dose

The dose for anesthetic toxicity in those over 70 kg is 100 mL bolus of 20% lipid emulsion followed by another 200 to 250 mL infusion over 15 to 20 minutes.[1] For those below 70 kg, a rapid 1.5 mL/kg bolus of 20% lipid emulsion followed by a 0.25 mL/kg/minute infusion for 30 minutes is recommended.[1][10]

History

Intravenous lipid emulsions have been used experimentally since at least the 19th century. An early product marketed in 1957 under the name Lipomul was briefly used in the United States but was subsequently withdrawn due to side effects.[11] Intralipid was invented by the Swedish physician and nutrition researcher Arvid Wretlind, and was approved for clinical use in Sweden in 1962.[12] In the United States, the Food and Drug Administration initially declined to approve the product due to prior experience with another fat emulsion. It was approved in the United States in 1972.

Research

Intralipid is also widely used in optical experiments to simulate the scattering properties of biological tissues.[13] Solutions of appropriate concentrations of intralipid can be prepared that closely mimic the response of human or animal tissue to light at wavelengths in the red and infrared ranges where tissue is highly scattering but has a rather low absorption coefficient.

Cardioprotective agent

Intralipid is currently being studied for its potential use as a cardioprotective agent, specifically as a treatment for ischemic reperfusion injury. The rapid return of myocardial blood supply is critical in order to save the ischemic heart, but it also has the potential to create injury due to oxidative damage (via reactive oxygen species) and calcium overload.[14] Myocardial damage with the resumption of blood flow after an ischemic event is termed “reperfusion injury”.

The mitochondrial permeability transition pore (mPTP) is normally closed during ischemia, but calcium overload and increased reactive oxygen species (ROS) with reperfusion open mPTP allowing hydrogen ions to flow from the mitochondrial matrix into the cytosol. The hydrogen flux disrupts the mitochondrial membrane potential and results in mitochondrial swelling, outer membrane rupture, and the release of pro-apoptotic factors.[14][15] These changes impair mitochondrial energy production and drive cardiac myocyte apoptosis.

Intralipid (5mL/kg) provided five minutes before reperfusion delays the opening of mPTP in vivo rat models, making it a potential cardioprotective agent[16] Lou et al. (2014) found that the cardioprotection aspect of Intralipid is initiated by the accumulation of acylcarnitines in the mitochondria and involves inhibition of the electron transport chain, an increase in ROS production during early (3 min) reperfusion, and activation of the reperfusion injury salvage kinase pathway (RISK).[14] The mitochondrial accumulation of acylcarnitines (primarily palmitoyl-carnitine) inhibits the electron transport chain at complex IV, generating protective ROS.[17] The effects of ROS are both “site” and “time” sensitive, meaning that both will ultimately determine whether the ROS are beneficial or detrimental.[17] The generated ROS, which are formed from electrons leaking from the electron transport chain of the mitochondria, first act directly on mPTP to limit opening.[18] ROS then activate signalling pathways that act on the mitochondria to decrease mPTP opening and mediate protection.[18] Activation of the RISK pathway by ROS increases the phosphorylation of other pathways, such as phosphatidylinositol 3-kinase/Akt and extracellular-regulated kinase (ERK) pathways,[16] both of which are found in pools localized at the mitochondria.[19] The Akt and ERK pathways converge to alter glycogen synthase kinase-3 beta (GSK-3β) activity. Specifically, Akt and ERK phosphorylate GSK-3β, inactivating the enzyme, and inhibiting the opening of mPTP.[16] The mechanism by which GSK-3β inhibits the opening of the mPTP is controversial. Nishihara et al. (2007) proposed that it is achieved through interaction of GSK-3β with ANT subunit of mPTP, inhibiting the Cyp-D–ANT interaction, resulting in the inability of the mPTP to open.[20]

In a study by Rahman et al. (2011) Intralipid-treated rat hearts were found to required more calcium to open mPTP during ischemia-reperfusion. The cardiomyocytes are therefore, better able to tolerate the calcium overload, and increase the threshold for opening of the mPTP with the addition of Intralipid.[16]

References

  1. 1 2 3 4 5 6 7 8 9 Sepulveda, EA; Pak, A (January 2021). "Lipid Emulsion Therapy". PMID 31751087. {{cite journal}}: Cite journal requires |journal= (help)
  2. 1 2 3 4 5 6 Spray, JW (2016). "Review of Intravenous Lipid Emulsion Therapy". Journal of infusion nursing : the official publication of the Infusion Nurses Society. 39 (6): 377–380. doi:10.1097/NAN.0000000000000194. PMID 27828934.
  3. ↑ Fettiplace, MR; Weinberg, G (September 2015). "Past, Present, and Future of Lipid Resuscitation Therapy". JPEN. Journal of parenteral and enteral nutrition. 39 (1 Suppl): 72S–83S. doi:10.1177/0148607115595979. PMID 26187938.
  4. ↑ "Intralipid Prices, Coupons & Patient Assistance Programs". Drugs.com. Archived from the original on 26 May 2021. Retrieved 14 April 2021.
  5. ↑ Picard J, Meek T (February 2006). "Lipid emulsion to treat overdose of local anaesthetic: the gift of the glob". Anaesthesia. 61 (2): 107–9. doi:10.1111/j.1365-2044.2005.04494.x. PMID 16430560.
  6. ↑ Weinberg GL, VadeBoncouer T, Ramaraju GA, Garcia-Amaro MF, Cwik MJ (April 1998). "Pretreatment or resuscitation with a lipid infusion shifts the dose-response to bupivacaine-induced asystole in rats". Anesthesiology. 88 (4): 1071–5. doi:10.1097/00000542-199804000-00028. PMID 9579517.
  7. ↑ Weinberg G, Ripper R, Feinstein DL, Hoffman W (2003). "Lipid emulsion infusion rescues dogs from bupivacaine-induced cardiac toxicity". Regional Anesthesia and Pain Medicine. 28 (3): 198–202. doi:10.1053/rapm.2003.50041. PMID 12772136.
  8. ↑ Weinberg G (2004). "Reply to Drs. Goor, Groban and Butterworth – Lipid rescue: Caveats and recommendations for the 'silver bullet' (letter)". Regional Anesthesia and Pain Medicine. 29: 74–75. doi:10.1097/00115550-200401000-00022.
  9. ↑ Mahoney D. "IV Fat Emulsion Beneficial for Some Drug Overdoses". Acep.org. Elsevier Global Medical News. Archived from the original on 18 September 2016. Retrieved 3 November 2013.
  10. ↑ Lavonas, EJ; Akpunonu, PD; Arens, AM; Babu, KM; Cao, D; Hoffman, RS; Hoyte, CO; Mazer-Amirshahi, ME; Stolbach, A; St-Onge, M; Thompson, TM; Wang, GS; Hoover, AV; Drennan, IR; American Heart, Association (17 October 2023). "2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation. 148 (16): e149–e184. doi:10.1161/CIR.0000000000001161. PMID 37721023.
  11. ↑ Hallberg D, Holm I, Obel AL, Schuberth O, Wretlind A (April 1967). "Fat emulsions for complete intravenous nutrition". Postgraduate Medical Journal. 43 (498): 307–16. doi:10.1136/pgmj.43.498.307. PMC 2466293. PMID 4962960.
  12. ↑ Isaksson B, Hambraeus L, Vinnars E, Samuelson G, Larsson J, Asp NG (2002). "In memory of Arvid Wretlind 1919 – 2002". Scandinavian Journal of Nutrition. 46 (3): 117–118. doi:10.1080/11026480260363233. Archived from the original on 24 September 2015.
  13. ↑ Driver I, Feather JW, King PR, Dawson JB (1989). "The optical properties of aqueous suspensions of Intralipid, a fat emulsion". Physics in Medicine and Biology. 34 (12): 1927–1930. Bibcode:1989PMB....34.1927D. doi:10.1088/0031-9155/34/12/015.
  14. 1 2 3 Li J, Iorga A, Sharma S, Youn JY, Partow-Navid R, Umar S, Cai H, Rahman S, Eghbali M (October 2012). "Intralipid, a clinically safe compound, protects the heart against ischemia-reperfusion injury more efficiently than cyclosporine-A". Anesthesiology. 117 (4): 836–46. doi:10.1097/ALN.0b013e3182655e73. PMC 3769111. PMID 22814384.
  15. ↑ Sanada S, Komuro I, Kitakaze M (November 2011). "Pathophysiology of myocardial reperfusion injury: preconditioning, postconditioning, and translational aspects of protective measures". American Journal of Physiology. Heart and Circulatory Physiology. 301 (5): H1723-41. doi:10.1152/ajpheart.00553.2011. PMID 21856909.
  16. 1 2 3 4 Rahman S, Li J, Bopassa JC, Umar S, Iorga A, Partownavid P, Eghbali M (August 2011). "Phosphorylation of GSK-3β mediates intralipid-induced cardioprotection against ischemia/reperfusion injury". Anesthesiology. 115 (2): 242–53. doi:10.1097/ALN.0b013e318223b8b9. PMC 3322241. PMID 21691195.
  17. 1 2 Lou PH, Lucchinetti E, Zhang L, Affolter A, Schaub MC, Gandhi M, Hersberger M, Warren BE, Lemieux H, Sobhi HF, Clanachan AS, Zaugg M (2014). "The mechanism of Intralipid®-mediated cardioprotection complex IV inhibition by the active metabolite, palmitoylcarnitine, generates reactive oxygen species and activates reperfusion injury salvage kinases". PLOS ONE. 9 (1): e87205. Bibcode:2014PLoSO...987205L. doi:10.1371/journal.pone.0087205. PMC 3907505. PMID 24498043.
  18. 1 2 Perrelli MG, Pagliaro P, Penna C (June 2011). "Ischemia/reperfusion injury and cardioprotective mechanisms: Role of mitochondria and reactive oxygen species". World Journal of Cardiology. 3 (6): 186–200. doi:10.4330/wjc.v3.i6.186. PMC 3139040. PMID 21772945.
  19. ↑ Martel C, Huynh L, Garnier A, Ventura-Clapier R, Brenner C (2012). "Inhibition of the Mitochondrial Permeability Transition for Cytoprotection: Direct versus Indirect Mechanisms". Biochemistry Research International. 2012: 1–13. doi:10.1155/2012/213403. PMC 3364550. PMID 22675634.
  20. ↑ Nishihara M, Miura T, Miki T, Tanno M, Yano T, Naitoh K, Ohori K, Hotta H, Terashima Y, Shimamoto K (November 2007). "Modulation of the mitochondrial permeability transition pore complex in GSK-3beta-mediated myocardial protection". Journal of Molecular and Cellular Cardiology. 43 (5): 564–70. doi:10.1016/j.yjmcc.2007.08.010. PMID 17931653.
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