Post Your Cases > Intralipid for combined Propranalol/Clonidine OD

This was a interesting case regarding a 48 yo female with a history of depression and OD's in the past. Brought into the ER with decreased LOC and ingestion of a large number of pills. Most concerning was the combination of propranalol and clonidine resulting in both alpha/beta blockade. Quantity of drugs unknown. GCS initially 10 on arrival. Pt intubated and ventilated due to severity of OD. Soon after dropped both HR and BP. HR = 60 BP 70 systolic. No response to copious fluids. HR responded to glucagon however pressure continued to drop. Started in pressors including max epi and vasopressin. No response to Narcan. Then started on high dose insulin receiving ~120 units humulin/hr and D50. Pt continued to get progressively more acidotic over next 90 minutes. Given intralipid and moved to ICU. Unsure if pt received 2nd dose of intralipid in ICU. Within 1 hr, BP 120/80 and pt becoming more arousable. Eventually shipped to psych with no additional problems.

Thoughts: Likely not secondary to high dose insulin as had been receiving for substantial period of time. ?Propranalol/clonidine wearing off vs. intralipid rescue...
November 8, 2010 | Unregistered CommenterDr. Andrew Smith
Andrew, thanks for the very interesting post. I think you know what I think happened. Given the pharmacokinetics of propranolol and clonidine, I doubt they were wearing off just as the patient seemed to be going downhill (that's how I would interpret the worsening acidosis). I would be interested in Dr. David Uncles input given his recent abstract showing improved outcomes (shorter ICU stay and fewer intubations) in mixed drug OD treated with lipid. Thanks again for the post. If you have good data wrt timecourse, GCS and treatment you might consider writing this up.
November 8, 2010 | Registered Commenter[Guy Weinberg]
This is very timely.
Please see the letter reporting the response to intralipid in a patient who took propranolol, 7g, in this month's (i.e.November 2010's) Anaesthesia. Propranolol is one of the more lipophilic Beta blockers. The clonidine is an interesting combination and I don't quite know the significance. But interesting nonetheless.
November 9, 2010 | Unregistered CommenterDavid Uncles
I believe that the anesthesia resident that was working is now is year 3 and writing this case up. She has been speaking with pharmacy and are planning some experiments that might contribute to the overall knowledge. Could you email me with your emails. Sound like you folks have a lot of experience with this and we would certainly like to have a discussion.

Cheers
Andrew
November 9, 2010 | Unregistered CommenterAndrew