Intravenous lipid emulsion therapy for flecainide toxicity

Abstract

Intravenous lipid emulsion (ILE) is an accepted antidote for systemic local anesthetic toxicity and may be useful for other lipophilic drugs with cardiac toxicity. Flecainide is a class IC antiarrhythmic drug related to lidocaine. Flecainide is highly lipophilic with an octanol/water partition coefficient of 3.8 (similar to that of bupivacaine). In overdose, flecainide produces wide complex dysrhythmias and cardiogenic shock. We describe two patients with life-threatening flecainide overdoses which were refractory to standard treatment and which responded rapidly to ILE. Patient 1 was a 49-yearold man who had bradycardia (31 bpm) and hypotension (50 mmHg systolic) after taking 2400 mg of flecainide. His ECG showed a wide complex bradycardia (QRS 178 ms). Bradycardia and hypotension persisted despite atropine, glucagon, CPR, endotracheal intubation, epinephrine, dopamine, magnesium sulfate, and sodium bicarbonate. Patient 2 was a 69-year-old man who ingested 1 g of flecainide, 12 mg of clonazepam, and 1 mg of ropinirole. His ECG showed a rate of 76 bpm with QRS of 268 ms. His blood pressure fell to 66/29 mmHg. Both patients rapidly improved with ILE bolus and infusion. ILE appears useful in severe flecainide toxicity with cardiogenic shock that fails to respond to conventional therapy.

First Case of Acute Poisoning with Amiodarone and Flecainide in Attempted Suicide Successfully Managed with Lipid Emulsion Therapy in the Emergency Department: Case Report and Literature Review

“…LET was also used in one case of mixed poisoning including amiodarone, betablockers and calcium-channel blockers. In reviewed cases, LET was associated (in addition to treatment with high doses of sodium bicarbonate) with ACLS measures, CPR, pacing, CVVH and ECMO [6,7,26,28,31,34,35]. In a single case, in which the patient arrived at the ED 90 min after self-poisoning with a lower flecainide dose as compared with our patient, with a serum level of flecainide slightly over the therapeutic range, LET was involved as part of a pharmacological protocol that included atropine, MgSO4, Na bicarbonate for bradycardia, AV block and QTc prolongation.…”