Fat overload syndrome following intravenous lipid emulsion administration as antidote in suspected anesthetic intoxication: insights from a clinical and forensic case experience.

Q2 Medicine Clinica Terapeutica Pub Date : 2024-07-01 DOI:10.7417/CT.2024.5065
M Di Paolo, A Maiese, A Scatena, M Bonaso, I Marcacci, I Convertino, C Occhipinti, R Pieretti, M Tuccori
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Abstract

Abstract: Medication errors pose significant risks to patients' health, representing a relevant social and economic issue for the healthcare system. This study focuses on the life-threatening consequences of an overdose of intravenous lipid emulsion (ILE), used as an antidote for suspected bupivacaine intoxication in a young woman undergoing hip surgery. Shortly after administration of the local anesthetic, the woman experienced cardiac arrest and was admitted to the intensive care unit with severe respiratory failure, metabolic acidosis and deep coma. Despite medical intervention, her condition worsened, leading the medical team to administer ILE for suspected bupivacaine intoxication. The patient's condition did not improve and ultimately resulted in death. The autopsy highlighted a widespread presence of oily material in the vascular system, compatible with an overdose of ILE. At a checking, medical records reported a dose of ILE that was 4-fold higher than the recommended dose in this off-label indication. This case report highlights the important need for healthcare professionals to understand the risks of using ILE as an antidote. Adequate monitoring of these "sentinel events" and their critical evaluation can lead to the implementation of specific clinical risk management protocols to reduce the risk for the patient and contain healthcare costs.

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静脉注射脂质乳剂作为疑似麻醉剂中毒的解毒剂后出现脂肪过载综合征:从临床和法医案例中获得的启示。
摘要:用药错误对患者的健康构成重大风险,是医疗保健系统面临的一个相关社会和经济问题。本研究的重点是一名正在接受髋关节手术的年轻女性因静脉注射脂质乳剂(ILE)过量而导致的生命危险。在使用局麻药后不久,这名妇女出现心跳骤停,并因严重呼吸衰竭、代谢性酸中毒和深度昏迷而被送入重症监护室。尽管采取了医疗干预措施,但她的病情仍在恶化,医疗团队因此对其注射了 ILE,以治疗疑似布比卡因中毒。患者的病情没有好转,最终导致死亡。尸检结果表明,血管系统中广泛存在油性物质,与 ILE 用药过量相符。在一次检查中,医疗记录显示 ILE 的剂量比该非标签适应症的推荐剂量高出 4 倍。本病例报告强调,医护人员必须了解将 ILE 用作解毒剂的风险。对这些 "哨点事件 "进行充分监控和严格评估,可促成特定临床风险管理方案的实施,从而降低患者风险并控制医疗成本。
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来源期刊
Clinica Terapeutica
Clinica Terapeutica PHARMACOLOGY & PHARMACY-
CiteScore
2.50
自引率
0.00%
发文量
124
审稿时长
6-12 weeks
期刊介绍: La Clinica Terapeutica è una rivista di Clinica e Terapia in Medicina e Chirurgia, fondata nel 1951 dal Prof. Mariano Messini (1901-1980), Direttore dell''Istituto di Idrologia Medica dell''Università di Roma “La Sapienza”. La rivista è pubblicata come “periodico bimestrale” dalla Società Editrice Universo, casa editrice fondata nel 1945 dal Comm. Luigi Pellino. La Clinica Terapeutica è indicizzata su MEDLINE, INDEX MEDICUS, EMBASE/Excerpta Medica.
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