title: Lipid emulsion use precluding renal replacement therapy.
abstract: BACKGROUND
  Intralipid emulsion (ILE) is a nutritional fatty acid supplementation that is emerging as a potential therapy for local anesthetic systemic toxicity and is also being considered as a therapy for other lipophilic medication intoxications. Isolated reports of pulmonary edema or severe lipemia exist as a complication of therapy.
  
  
  METHODS
  A 26-year-old hypertensive, male, kidney transplant recipient presented to an outside emergency department (ED) after an intentional overdose of his medications (ie, amlodipine, metoprolol, lisinopril). At presentation, he had hypotension and bradycardia that was unresponsive to treatment with intravenous saline, calcium, glucagon, and vasopressors. After failure of conventional therapy, an initial bolus of ILE (20%) was given with some improvement in his heart rate, and the dose was repeated. A continuous intravenous infusion of ILE therapy was started. The patient deteriorated, with development of both acute respiratory and renal failure. Continuous venovenous hemofiltration (CVVHF) was attempted to remove volume and correct metabolic abnormalities. Lipemic blood was immediately observed in the CVVHF filter. After 15 min, the transmembrane pressures of the filter began to rise in the absence of observed clotting of the blood and the filter then became completely obstructed. An attempt was made to remove the lipid by plasmapheresis to restart CVVHF, but the patient continued to deteriorate despite maximal vasopressor support. The patient's family decided to withdraw care and the patient expired. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians treat patients with toxic ingestions on a regular basis. Being aware of possible complications of experimental antidote therapy, like ILE, can improve the treatment approach and outcomes for these patients.
authors.affiliation: Division of Nephrology, University of Mississippi Medical Center, Jackson, Mississippi.
authors.forename: Betzaida
authors.initials: B
authors.lastname: Rodríguez
authors.affiliation: Division of Pulmonary and Critical Care, University of Mississippi Medical Center, Jackson, Mississippi.
authors.forename: Andrew
authors.initials: A
authors.lastname: Wilhelm
authors.affiliation: Division of Nephrology, University of Mississippi Medical Center, Jackson, Mississippi.
authors.forename: Kenneth E
authors.initials: KE
authors.lastname: Kokko
mesh_terms: D000328:Adult; D000959:Antihypertensive Agents / Q000506:poisoning; D062787:Drug Overdose / Q000628:therapy*; D005217:Fat Emulsions, Intravenous / Q000009:adverse effects*; D017809:Fatal Outcome; D006440:Hemofiltration / Q000379:methods*; D006801:Humans; D006949:Hyperlipidemias / Q000209:etiology*; D006973:Hypertension / Q000188:drug therapy; D016030:Kidney Transplantation; D008297:Male
chemical_list: D000959:Antihypertensive Agents; D005217:Fat Emulsions, Intravenous
keywords: CRRT; lipid emulsion; renal insufficiency; toxicology