A BIG DAY FOR LIPID!!!!

Today the May issue of Anesthesia and Analgesia which features articles on lipid-based resuscitation was released on the web. There are three editorials, four case reports of lipid saves and a number of laboratory reports having to do with local anesthetic toxicity in one way or another. Rather than blather on about the various articles, I encourage you to read the amazing case reports first. Afterall, that's what we're here for: taking care of patients and improving the safety profile for the entire range of perioperative events. Then see what interests you most after that: editorials or lab reports. In addition to the well-written papers, I compliment the publisher for having a fantastic cover. It really says it all! 

First, an apology for the long delay since my last post. As many of you may know, my family has recently been struggling with serious medical issues that required my undivided attention. Fortunately, things have improved and I can now work on the website again. Meanwhile, the site has continued to grow and grow......

Hits: We experienced a very significant and sustained increase in the number 'unique' daily hits to lipidrescue.org. The first year after launch we had leveled off at approximately 60 different visitors per week day and 1000 visitors per month was typical. However, since Dr. Rowlingson's favorable review in the ASA Newsletter this past November, we regularly receive more than 300 hits per day from all over the world (yes, I know where you're coming from!) and occasionally more than 500 per day. Of these, 75% are new visitors and this number has been constant for the past two years. This is very heartening. Since we focus on education, I am particularly gratified to note that the second-most visited page (after 'Welcome') is 'Learning Links'. Fortunately, we'll soon see several significant additions to this page as well...(see Publications, below).

Youtube Posts: The two current strip charts of BP and ECG that I posted almost two years ago are admittedly getting a bit old, particularly since we have on hand so many high quality examples of instructive experiments. Last week I worked with Luke Edelman, our in-house video-editor and all-purpose incredible dude, to put together three more videos we've posted to Youtube. The original two were examples of lipid given either early (soon after the bupivacaine) or late (ie, a control that we chose to treat after collecting all required data, ~10 minutes after bupivacaine challenge...). The newest features include: a control experiment (no treatment other than chest compressionss and ventilation); saline (volume control); and lipid; all experiments are conducted on rats under  general anesthesia. Luke has also recently done voice-overs to replace the corny and annoying titles - & will post those soon. Let us know what you think.  

Publications:  As I suggested above, there will soon be a deluge of LipidRescue articles. The May issue of Anesthesia & Analgesia will focus on the topic with three editorials and four impressive case reports plus several articles on topics related to local anesthetic toxicity. I give credit to the Editor-in-Chief, Steve Shafer, for his tenacity and hard work - both required to pull all this together and no small feat at that. I believe the pay off is big: this issue will help raise awareness and thereby save lives in the process. The May issue of Anesthesiology will include a laboratory investigation comparing lipid to epinephrine in a rodent model of bupivacaine overdose. I am particularly proud of this work, the product of several years' work and a collaboration among so many talented people. Meanwhile, other manuscripts have been submitted and I'll preview them here once we receive word of their acceptance for publication.

Presentations: This has been a very busy year for LipidRescue. Our lab was represented at a number of scientific and clinical meetings, including the 2007 Spring ASRA and Annual ASA. Dr. Guido Di Gregorio also presented at NYSORA in December and gave a poster at the Critical Care Society meeting in February in Honolulu (tough assignment, Guido). Dr. Verna Baughman presented another poster on LipidRescue at the IARS in SF and Dr. Chad Kessler gave another poster at the International College of Emergency Medicine, also in SF. In a few weeks,  the findings of the ASRA Working Group on LA Toxicity will be presented and discussed at the Spring ASRA meeting in Cancun. All this is well and good, but my children are most impressed with the invitation to give a talk at the upcoming ASPCA Poison Control meeting; nothing rates like saving a puppy.  Finally, we've recently received confirmation of the acceptance of two sessions on lipid therapy for the upcoming Annual ASA meeting....more on those later.

Lots new to talk about.

First, I would say that the panel of Translational Research in Regional Anesthesia at ASA was very well received.

Then something quite amazing occured in SF. One day, within about 15 minutes I heard of two lipid saves from cardiac arrest, both involving non-LA drugs. First was a Flexiril overdose; this is a highly lipophilic drug with a pD >> bupivacaine. The next was a sentinel caase in that it was a cardiac arrest of unknown etiology, but suspected overdose (young psychiatric patient). The medical examiner has the case, so we don't know the results of the tox screen yet. Both cases rapidly regained normal vital signs. The first was a witnessed arrest in-house and did very well. The other had been down at the scene for a long time and did not recover consciousness, but was made a donor.

Two more amazing cases in the last week: both that you can read about at the "Post your cases" page. The haloperidol-related arrest: quick recovery with lipid, extubated doing well. Next, a puppy with an ivermectin overdose...this is neither a sodium channel blocker nor an I_kr blocker, so that says alot about the general applicability of LipidRescue.

Finally, I would like to personally thank Dr. John Rowlingson, one of my mentors at UVa, for the very thoughtful and positive review of LipidRescue in this month's ASA Newsletter.

More later,

Guy

I am very happy to record the publication of a remarkable case report. First author, Dr. A. Sirianni, was the attending anesthesiologist who recommended 20% lipid emulsion infusion for treatment of a young patient in cardiac arrest following an overdose of bupropion. She had been pulseless for more than an hour, and blood pressure and ECG werer unresponsive or minimally responsive to maximal adrenergic and bicarbonate therapy. Archie had been consulted for airway and access issues and in contemplating what else he could add, made the connection between an overdose with a drug having some sodium channel blocking properties, to the case report he'd read several months before by Meg Rosenblatt, who in turn had been familiar with lipidrescue and published the first report of its successful use. Back to Archie: he called home, got his wife to read Meg's case report, ran to the pharmacy to pick up the lipid, sprinted back to the ICU and made a suggestion. There'd been no substantive improvement in the patient's condition, so the Code Blue team was receptive. Within one minute of the lipid infusion, pulses returned, and CPR was stopped. The patient quickly regained normal vital signs and ECG. She has subsequently recovered without neurological deficit, is attending school, and I hear, getting good grades. Though I was not there, except in spirit, I still consider this by far the most exciting case I've ever had the privilege to be associated with- albeit by at least two degrees of (published) separation. It is truly amazing. Please read this article.....it's worth it. This is what I call real translational work. Wow. Good work Archie. You've definitely logged some heaven insurance.  

The Association of Anaesthetists of Great Britain and Ireland has just sent all its members guidelines for the treatment of severe systemic local anesthetic toxicity. A laminated copy of these newly established, official guidelines was  sent to each of the roughly 10,000 members of the organization. This is groundbreaking in that there has never been a well-defined consensus for treating this life-threatening complication until now. The need for such an approach was brought to public attention by the recent survey of Corcoran et al from Wake Forest, and published this year in Anesthesia and Analgesia. They found that among respondant American academic Anesthesia departments that there was no agreement on an approach to treating severe local anesthetic toxicity. Furthermore, the study found a low rate of awareness or, at leat willingness, to consider using lipid in this setting. This may be because the survey was conducted prior to the case of Rosenblatt et al which reported the first use of lipid to save a patient's life following cardiac arrest in the setting of a regional anesthetic (bupivacaine + mepivacaine). Subsequently, several more case reports have been published and awareness is likely to have improved since the survey and the corresponding paper. Nevertheless, there is still a need for general guidelines and a uniform, rational method for treating this problem will significantly improve the liklihood of recovery from or prevent progression to, anesthetic-induced cardiac arrest. The AAGBI guidelines incorporate lipidrescue as a cornerstone of the treatment, refer to this site, reference laboratory investigations on lipidrescue and therefore add to the general acceptance of the technique. Notably, the recent letter of  Picard et al, elaborates on the parallels of this process to that for dantrolene in treatment of MH. The several additional case reports (published and in the literature pipeline) will further validate lipidresuce, and presumably strengthen its acceptance in the medical community. Congratulations to AAGBI. I strongly believe that their forward thinking action will contribute to improved patient safety and hopefully save lives, too.