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Three Part Question

In [adults treated for local anaesthetic toxicity] does [lipid emulsion compared to placebo] increase the risk of [pancreatitis]?

Clinical Scenario

A twenty-three year old patient has a number of blood tests carried out within the emergency department, you notice a raised serum amylase, two weeks ago he received lipid emulsion therapy for an accidental local anaesthetic overdose, are these events related?

Search Strategy

Using Ovid interface; Medline 1950 to June week 4 2010, Embase 1980 to 2010 week 26, Cochrane database of systematic reviews 2005 May 2010
[exp Anesthesia, Local/ OR (local adj1 anaesthe$).mp OR exp Anesthetics, Local/ OR exp bupivacaine$/ OR bupivacaine$.mp. OR lidocaine$/ OR lidocaine$.mp. OR exp prilocaine$/ OR prilocaine$.mp. OR exp lignocaine$/ OR lignocaine$.mp. OR exp marcaine$/ OR marcaine$.mp.] AND [exp Fat Emulsions, Intravenous/ OR IFE.mp OR intralipid.mp OR Intravenous lipid emulsion.mp] AND [exp pancreatitis/] LIMIT to English language and humans.

Search Outcome

6 results 1 of which was relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Rosenblatt M 2006 USA	56 year old male, 82kg, 170cm who suffered local anaesthetic toxicity while receiving bupivacaine 20ml 0.5% and mepivacaine 20ml 1.5%. Standard resuscitation combined with 100ml 20% Intralipid followed by 0.5ml kg /hr of Intralipid for 2 hours, was successful in reviving.	Case report	Evidence of pancreatitis.	No evidence of pancreatitis was noted.	It is not stated what evidence for pancreatitis was looked for. The follow up period was short only two weeks.

Comment(s)

When Lipid emulsion is used in the context of lipid rescue it is administered in a very large dose over a short period of time. This dictates it may not carry the same risks as when used for total parentral nutrition. The evidence suggests that pancreatitis is not a risk in the cases in which lipid emulsion has been used in this way. The only paper on the subject reports no signs of pancreatitis, although it does not list any specific tests that were carried out. Lipid rescue has not widely been reported on in the literature, only a limited number of case reports exist. For this reason no definitive answer can be given, only that with the available evidence pancreatitis does not seem to be an adverse affect at this dose.

Clinical Bottom Line

No evidence to suggest intravenous lipid emulsion used in this context causes pancreatitis.

References

1. Rosenblatt M et al Sucsessful use of a 20% lipid emulsion to resucitate a patient after a presumed bupivacaine related cardiac arrest. Anesthesiology. 2006 Jul;105(1):217-8.