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In this 216th episode I discuss case reports of using Lipid Emulsion Therapy for Amniotic Fluid Embolus. Big thanks to Dr. Adam Olson for bringing this to my attention!
CME: Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs here: https://earnc.me/sCY01P
References:
Eldor J and Kotlovker V. Intralipid for Amniotic Fluid Embolism (AFE)? Open Journal of Anesthesiology, 2012, 2, 127-133
Lynch W et al. Lipid Emulsion Rescue of Amniotic Fluid Embolism-Induced Cardiac Arrest: A Case Report. A&A Case Reports. 2017;8:64–66.
Gruzman I et al. INTRALIPID Rescue of Amniotic Fluid Embolism: from Theory to Existence. Journal of Health Science and Development. 2019: 2:1 (1-4).
Jed,
Thank you for reviewing this topic! A few weeks ago I helped my anesthesia team in caring for an Emergency Cesarean Section for a patient with known placenta increta. A general anesthesia was planned with MTP ordered and hysterectomy to follow. Approximately 20min after the baby was delivered the patient had a sudden drop in ETCO2, BP and SpO2. We suspected at the time she had an AFE, so we implemented the A-OK treatment immediately along with 100% FiO2. Atropine however was held since her HR was in the 130s. After about 15min of minimal-no improvement and multiple doses of epinephrine 100mcg, 1L crystalloid, additional IV access and arterial line placement I suggested we consider intralipid in light of the studies you mentioned in your podcast.
We administered a bolus of intralipid (30cc IVP drawn off the bag). Within roughly 60 seconds of the bolus, the patient had a rapid improvement in her ETCO2 (up to 35 from 15mmHg), SpO2 (up to 95% from 74%) and BP (up to 100/68 from 66/33). We continued the infusion of intralipid to finish off the 250mL bag and kept her on 100% FiO2 until she was consistently stable. We drew lab work to perform a TEG on her which showed stable clotting factors, so additional blood products were held. She remained intubated and transferred to ICU for further workup. In the ICU, TTE was negative in detecting any emboli and serum sample to detect amniotic fluid was also negative.
We are left to think this patient therefore had a Venous Air Embolism instead given her abrupt cardio-pulmonary compromise and the exposure of large vessels during her hysterectomy. Nonetheless, the intralipid seemed to provide a profound improvement in her hemodynamics and resolve her V/Q mismatch.
Given this patient’s dramatic improvement after giving intralipid I wanted to share with you my case and welcome your questions and feedback.
Thanks for sharing that case! Sounds like a great outcome that could have gone very differently.
Kristy,
Lipid emulsion has been shown to have inotropic properties in animal studies as well as anecdotal evidence in case reports such as our case that Dr. Wolpaw described in the podcast. In the case report, we describe multiple possible mechanisms by which lipid emulsion may have exerted a positive effect on the patient’s outcome. AFE is also frequently associated with pulmonary HTN and lipid emulsion has also been shown to attenuate and rescue pulmonary hypertension.
Much of our information is based on the animal studies noted in the references below. There is a wealth of information on the topic out there. I am hopeful that someone else will use lipid emulsion for AFE and show a definitive rescue that matches our case report. If it proves to be a reproducible and reliable treatment for AFE, it could definitely change the way that we respond to these cases that have such a high morbidity and mortality.
Thanks to Dr. Wolpaw for drawing additional attention to our case report. I would love to hear back if anyone else has any experiences in the use of lipid emulsion for treatment of AFE, successes or failures.
Fettiplace MR, Ripper R, Lis K, Lin B, Lang J, Zider B, Wang J, Rubinstein I, Weinberg G. Rapid cardiotonic effects of lipid emulsion infusion*. Crit Care Med. 2013 Aug;41(8):e156-62. doi: 10.1097/CCM.0b013e318287f874. PMID: 23531591.
Umar S, Nadadur RD, Li J, Maltese F, Partownavid P, van der Laarse A, Eghbali M. Intralipid prevents and rescues fatal pulmonary arterial hypertension and right ventricular failure in rats. Hypertension. 2011 Sep;58(3):512-8. doi: 10.1161/HYPERTENSIONAHA.110.168781. Epub 2011 Jul 11. PMID: 21747043; PMCID: PMC3339261.
Li J, Rahman S, Eghbali M. Inotropic effect of lipid emulsion: a new perspective*. Crit Care Med. 2013 Aug;41(8):2060-1. doi: 10.1097/CCM.0b013e31828ce934. PMID: 23863251.