Summary We describe the initial management and subsequent recovery of a 61 year‐old male patient following attempted suicide by oral ingestion of a potentially fatal overdose of quetiapine and sertraline. Intravenous Intralipid® was given soon after initiation of basic resuscitation. There was a rapid improvement in the patient’s level of consciousness. No other clinical signs of drug toxicity were observed. Intralipid may have reversed the deep coma associated with ingestion and prevented other manifestations of drug toxicity occurring, thus expediting this patient's recovery.

The use of intravenous lipid emulsion (ILE) as an antidote has prompted significant academic and clinical interest. Between August 2009 and August 2012, data from cases of ILE use in intoxicated patients in different hospitals on different continents were voluntarily entered into a registry based on the world wide web (www.lipidregistry.org). Here, we report data from this project. Participating centers were given access to the registry following institutional subscription. Specifically sought were details of the individual patients' presenting condition, indications for ILE use, ILE administration regimen, potential complications, and of clinical outcome. Forty-eight uses of ILE were reported from 61 participating centers. Ten cases of local anesthetic systemic toxicity were reported; all (10/10) survived. Thirtyeight cases of intoxication by other agents were reported [30 decreased conscious state, 8 cardiovascular collapse (3 deaths)]. There was an elevation in GCS (p<0.0001) and increased systolic blood pressure (p=0.012) from immediately prior to ILE administration to 30 min after use. One serious and two minor adverse effects of ILE use were recorded in 48 reported cases (one case of bronchospastic reaction, one case of hyperamylasemia and one case of interference with laboratory testing). In this series of cases reported to the registry, improvements were seen for GCS in patients with central nervous system toxicity and in systolic blood pressure in shocked patients over a short time frame after the injection of ILE. Few adverse effects were recorded. Clinical trials and the reporting of drug concentrations after ILE use are necessary to further elucidate the role of ILE in clinical toxicology.

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SummaryTo provide further evidence for the lipid sink theory, we have developed an in vitro model to assess the effect of Intralipid Ò 20%on methaemoglobin formation by drugs of varying lipid solubility. Progressively increasing Intralipid concentrations from 4 to 24 mg.ml )1 suppressed methaemoglobin formation by the lipid soluble drug glyceryl trinitrate in a dose-dependent manner (p < 0.001). Both dose and timing of administration of Intralipid to blood previously incubated with glyceryl trinitrate for 10 and 40 min resulted in significant suppression of methaemoglobin formation (p < 0.0001 and p < 0.05, respectively). Mathematical modelling demonstrated that the entire process of methaemoglobin formation by glyceryl trinitrate was slowed down in the presence of Intralipid. Intralipid did not significantly suppress methaemoglobin formation induced by 2-amino-5-hydroxytoluene (partially lipid soluble) or sodium nitrite (lipid insoluble; both p > 0.5). This work may assist determination of the suitability of drugs taken in overdose for which Intralipid might be deployed.

Our study provides a visual demonstration of the lipid sink effect. It supports the theory that lipid emulsion may reduce the amount of free drug present in plasma from concentrations associated with an invariably fatal outcome to those that are potentially survivable.

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Progressive encephalomyelitis with rigidity and myoclonus (PERM) is a rare autoimmune neurological condition. Antibodies targeting glycine receptors (GlyR) have been implicated in PERM. Because GlyR activity is enhanced by inhaled anesthetic drugs at clinically relevant concentrations, there is a theoretical possibility that these drugs may be less effective in the presence of GlyR antibodies. We describe a case of general anesthesia in a patient with PERM and GlyR antibodies. This patient did not demonstrate a clinically significant alteration in the behavioral effects of anesthesia using induction of anesthesia with sevoflurane and maintenance of anesthesia using sevoflurane and nitrous oxide.

BackgroundTeaching invasive techniques via simulation requires using phantoms. These teaching aids can be expensive, due in part to the cost of silicone material used. A progression of developments necessitated by lack of resources resulted in the creation of ADAMgel (Aqueous Dietary fibre Antifreeze Mix gel), a material that shows great promise for use in simulation phantoms.MethodologyWhile developing gelatine based ultrasound phantoms we accidentally discovered that the contrast medium routinely used with this medium the last 20 years (Ispagula husk – a dietary fibre laxative and food thickener) had some interesting properties. It transpired that if prepared at higher temperatures than employed in use as laxative at higher concentrations than used in food processing a gel formed which passed all the criteria for the perfect US medium.1,2 Searching for a suitable preservative among common substances found around the house we discovered preparation, if including antifreeze, is possible at a temperature higher than 100°C. This creates a stronger medium either by changing the already known temperature induced gel structure changes, or by liberating gel fractions known to have higher melting points.3 When using mono ethylene glycol (the commonest antifreeze) it forms a stable elastic polymer even without water.ResultsADAMgel can be prepared using ordinary kitchen utensils for <£2/kilo. It can be cast, folded, hot or cold pressed, layered, cut, moulded and made into thin films or strands. It is self-adherent and a model can be built incrementally incorporating other structures. It is selfrepairing and does not form needle tracts visible under ultrasound up to 18FG dilation. Diathermy or harmonic scalpel can both be used on it. In formal and informal feedback from anaesthetists and surgeons nobody has encountered a more realistic human tissue analogue.ConclusionADAMgel could make realistic phantoms for high fidelity simulation training more readily available.ReferencesBarnes L, Willers J, Hariharan S, Uncles D. Gauging the gel in Fybogel. Anaesthesia 2014;69:33Sultan S, Shorten G, Iohom G. Simulators for training in ultrasound guided procedures. Med Ultrasound 2013;5(2):125–131Farahnaky A, Askari H, Majzoobi M, Mesbahi G. The impact of concentration, temperature and pH on dynamic rheology of psyllium gels. J Food Eng 2010;100:294–301