Journal Article

Fatal Fat Overload Syndrome Following Intravenous Lipid Emulsion Administration as Antidote in Suspected Anesthetic Intoxication: A Fatal Medication Error

Ferraro, S, Cappello, E, Valdiserra, G, Tuccori, N, Convertino, I, Bonaso, M

2023

Overview

Introduction: A medication error is an unintended failure in the drug treatment process that leads to, or has the potential to lead to, harm to the patient. These types of errors can occur for many reasons when a medicine is prescribed, dispensed, stored, prepared or administered and are the leading cause of preventable harm to patients, accounting for up to 56% of adverse drug reactions. (1) Aim: Describes the life-threatening consequences of overdose of ILE as an antidote for bupivacaine intoxication. Methods: Here, we present a clinical case, received at the Tuscan Pharmacovigilance Center, of a possible fatal overdose of intravenous lipid emulsion (ILE) used as an antidote for suspected anesthetic intoxication. Results: A 28-year-old woman, operated on the hip under loco-regional anesthesia with bupivacaine, experienced a cardiac arrest about half an hour after administration of the anesthetic. She was revived and admitted to intensive care with a picture of respiratory failure, deep coma and severe metabolic acidosis (with an excess of bases equal to - 7 and lactate equal to 4 mmol/l). Computed tomography (CT) of the brain showed no acute blood extravasations, nor focal lesions of the cerebral parenchyma, while CT of the chest showed probable cardiogenic alveolar interstitial edema with consolidations of parenchymal stasis, in the absence of signs of pulmonary embolism. Despite pharmacological and mechanical cardiorespiratory support, the patient's condition worsened, and the doctors decided to administer high doses of ILE in bolus and continuous infusion for suspected bupivacaine intoxication. The patient's condition remained serious and she died. The autopsy showed the ubiquitous presence of dense, oily, white-yellowish material within the vascular system, with optically empty halos in all examined organs that intervened or replaced the blood column of veins and capillaries. These findings are likely compatible with an intravenous administration of fatty substance. Conclusions: The high dose of ILE reported in the patient's medical record reveals a clear prescribing error by the physician, which led the patient to a potentially fatal fat overload syndrome. This type of error could be the result of misinterpretation of the guidelines or miscalculation of the patient's weight-based dose by the doctor. (2),(3),(4) Healthcare professionals must be aware of the potential risks associated with the use of ILE as an antidote, implementing effective management and monitoring strategies (e.g. warning labels over the product package with instructions about dose calculation) to minimize the incidence and impact of medication errors.

• Publisher: Springer Nature B.V
• Subject: Acidosis / Alveoli / Anesthesia / Antidotes / Autopsies / Autopsy / Blood / Bupivacaine / Capillaries / Computed tomography / Drug dosages / Edema / Embolism / Emulsions / Errors / Fatalities / Internet / Intoxication / Intravenous administration / Lipids / Medical errors / Medical personnel / Metabolic acidosis / Overdose / Overloading / Parenchyma / Patients / Pharmacists / Pharmacovigilance / Physicians / Regional anesthesia / Side effects / Toxicity / Vascular system / Warning labels