Saturday, 5 May 2018

Intralipid emulsion treatment as an antidote in lipophilic drug intoxications- Worst paper of the decade?


This case series from Turkey published in the American Journal of Emergency Medicine is a fabulous example of intoxicated peer review (perhaps they needed the intralipid?)

It is awful from the first sentence.

Intravenous lipid emulsion (ILE) is a lifesaving treatment of lipophilic drug intoxications.

Of course, this is not referenced.  

There is no definitive high-quality evidence demonstrating a reduction in mortality from intralipid. There best evidence is mostly case series. (Although I did find an RCT of 34 cats poisoned by permethrin!)

So, getting past the first sentence is problematic… but I’ll continue.

The authors report a case series of 10 patients admitted to their ED who had allegedly taken overdoses of mostly amitriptyline but also some metoprolol, nifedipine, quetiapine, lamotrigine, sertraline, fluoxetine, alprazolam and of course Bonsai.

Bonsai?

This term is not explained in the manuscript. Gut if you google Bonsai, you get some beautiful images of small trees. If you dig a bit further, you come to discover it is a popular synthetic cannabinoid in Turkey. Who would have known?

Another tangent… back to the paper.

The authors describe each patient in some detail, but don’t really mention if any standard treatment was given. It looks like only one of the patients with TCA overdose ever got sodium bicarbonate except one who (I think) died.

She did not answer cardiopulmonary resuscitation, and she was admitted as exitus.

What should we conclude?

In the end they gave intralipid to 10 patients who may or may not have needed it. They may or may not have derived benefit or harm from this therapy. We’re not sure…

The authors conclude

According to these results, it was found that ILE treatment is a lifesaving agent in lipophilic drug intoxications and can be used in unconscious patients who have cardiac and/or neurologic symptoms, but no history of a specific drug ingestion.

I conclude the authors and the peer reviewers were probably on the bonsai… and I’m not talking small trees.


Covering:

Image result for bonsai

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