{"id":1017,"date":"2014-07-01T00:37:12","date_gmt":"2014-07-01T00:37:12","guid":{"rendered":"http:\/\/phosdev.com\/todaysveterinarypractice\/?p=1017"},"modified":"2022-02-16T15:54:37","modified_gmt":"2022-02-16T15:54:37","slug":"therapeutic-updates-in-veterinary-toxicology","status":"publish","type":"post","link":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/toxicology\/therapeutic-updates-in-veterinary-toxicology\/","title":{"rendered":"Therapeutic Updates in Veterinary Toxicology"},"content":{"rendered":"<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2016\/06\/T1407F02.pdf\"><img decoding=\"async\" class=\"alignnone size-full wp-image-9886\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2011\/07\/pdf_button.png\" alt=\"pdf_button\" width=\"110\" height=\"27\" \/><\/a><\/p>\n<hr \/>\n<p><i>Justine A. Lee, DVM, Diplomate ACVECC &amp; ABT<\/i><\/p>\n<p>Dr. Lee presents recent updates to therapeutic approaches for treating poisoned pets, including use of correct emetic agents, indications for gastric lavage, monitoring for hypernatremia, and the role of intravenous lipid emulsion.<\/p>\n<hr \/>\n<p><span class=\"garamond-9-5\">A number of new or improved therapeutic approaches are being applied in the field of veterinary toxicology\u2014some extrapolated from human medicine and others based on anecdotal experience.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Most veterinarians feel comfortable treating the poisoned patient, and are familiar with the common toxicants accidentally ingested by dogs and cats. However, in order to improve the quality of care and overall success in treating critically ill, poisoned patients, veterinary professionals need to be familiar with recent developments in toxicology.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Some recent updates involve the following aspects of therapy for poisoned pets:<\/span><\/p>\n<ul>\n<li class=\"tabs-and-bullets\"><span class=\"garamond-9-5\">Use of correct emetic agents<\/span><\/li>\n<li class=\"tabs-and-bullets\"><span class=\"garamond-9-5\">Indications for gastric lavage<\/span><\/li>\n<li class=\"tabs-and-bullets\"><span class=\"garamond-9-5\">Monitoring for hypernatremia<\/span><\/li>\n<li class=\"tabs-and-bullets\"><span class=\"garamond-9-5\">Role of intravenous lipid emulsion.<\/span><\/li>\n<\/ul>\n<h2 class=\"left-justified\"><strong><span class=\"aquabold\">THE CORRECT EMETIC AGENT<\/span><\/strong><\/h2>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">In veterinary medicine, aggressive decontamination is the mainstay therapy for poisoned patients.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">If emesis is warranted, the use of appropriate, effective, safe emetic agents is imperative. Emetic agents typically work by causing local gastric irritation and\/or stimulating the central nervous system chemoreceptor trigger zone (CRTZ).<sup>1,2<\/sup><\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Emesis should <\/span><span class=\"garamon-italics\">not<\/span><span class=\"garamond-9-5\"> be induced:<\/span><\/p>\n<ul>\n<li class=\"tabs-and-bullets\"><span class=\"garamond-9-5\">In patients exhibiting clinical signs of poisoning, such as agitation, tachycardia, tremors, hypoglycemia, or sedation<\/span><\/li>\n<li class=\"tabs-and-bullets\"><span class=\"garamond-9-5\">If the patient has ingested a toxin for which emesis induction is contraindicated (eg, corrosives, hydrocarbons)<\/span><\/li>\n<li class=\"tabs-and-bullets\"><span class=\"garamond-9-5\">After 1 to 2 hours of toxin ingestion, if the toxicant is thought to have moved out of the stomach.<\/span><\/li>\n<\/ul>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">The only at-home emetic agent currently recommended for dogs is hydrogen peroxide;1 however, note that excessive use of hydrogen peroxide may cause severe hemorrhagic gastritis. Since there are no safe at-home emetic agents for cats, immediate veterinary attention is warranted for emesis induction.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Veterinary-prescribed emetic agents include apomorphine hydrochloride for dogs and alpha-2 agonist agents (eg, xylazine hydrochloride, dexmedetomidine) for cats.<sup>1,2<\/sup> <\/span><strong><span class=\"garamond-bold\">Table 1<\/span><\/strong><span class=\"garamond-9-5\"> provides recommendations for appropriate use of emetic agents.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Methods of emesis induction that are no longer recommended include digital induction, syrup of ipecac, salt, soap, and mustard powder. Side effects of these methods include oropharyngeal injury, protracted emesis or vomiting, hemorrhagic vomiting or diarrhea, lethargy, cardiotoxicity, and hypernatremia.<sup>1,2<\/sup><\/span><\/p>\n<table border=\"0\" width=\"100%\" cellspacing=\"1\" cellpadding=\"3\">\n<tbody>\n<tr align=\"center\" bgcolor=\"#ffffff\">\n<td class=\"aquabold\" colspan=\"4\"><strong>Table 1. Recommended Emetic Agents for Use in Dogs &amp; Cats<sup>1,2<\/sup><\/strong><\/td>\n<\/tr>\n<tr class=\"bold\">\n<td bgcolor=\"#d8efe1\" width=\"16%\"><strong>Emetic Agent<\/strong><\/td>\n<td align=\"center\" bgcolor=\"#c2e9d1\" width=\"20%\"><strong>Mechanism<\/strong><br \/>\n<strong> Of Action<\/strong><\/td>\n<td align=\"center\" bgcolor=\"#d8efe1\" width=\"20%\"><strong>Dose<\/strong><\/td>\n<td align=\"center\" bgcolor=\"#c2e9d1\" width=\"44%\"><strong>Complications<\/strong><\/td>\n<\/tr>\n<tr bgcolor=\"#ffffff\">\n<td class=\"font_purple\" colspan=\"4\">Dogs<\/td>\n<\/tr>\n<tr>\n<td bgcolor=\"#d8efe1\"><strong>Hydrogen peroxide<\/strong><\/td>\n<td bgcolor=\"#c2e9d1\">Local irritation of oropharynx and gastric lining<\/td>\n<td bgcolor=\"#d8efe1\">1\u20132 mL\/kg PO (3% solution)<\/td>\n<td bgcolor=\"#c2e9d1\">\u2022 Bloat<br \/>\n\u2022 Gastric ulceration<br \/>\n\u2022 Gastric dilatation-volvulus (rare)<br \/>\n\u2022 Hemorrhagic gastritis<br \/>\n\u2022 Protracted emesis<br \/>\n\u2022 Vasovagal response<\/td>\n<\/tr>\n<tr>\n<td bgcolor=\"#d8efe1\"><strong>Apomorphine hydrochloride<\/strong><\/td>\n<td bgcolor=\"#c2e9d1\">Centrally acting, stimulation of the CRTZ<\/td>\n<td bgcolor=\"#d8efe1\">0.03\u20130.04 mg\/kg IM, IV<br \/>\nor<br \/>\n0.25 mg\/kg tablet in subconjunctival sac<\/td>\n<td bgcolor=\"#c2e9d1\">\u2022 Corneal ulcers<br \/>\n\u2022 Excitement and\/or restlessness<br \/>\n\u2022 Ocular irritation (subconjunctival use)<br \/>\n\u2022 Prolonged emesis<br \/>\n\u2022 Respiratory depression<br \/>\n\u2022 Sedation<\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\" bgcolor=\"#ffffff\"><span class=\"font_purple\">Cats<\/span><\/td>\n<\/tr>\n<tr>\n<td bgcolor=\"#d8efe1\"><strong>Xylazine hydrochloride<\/strong><\/td>\n<td bgcolor=\"#c2e9d1\">Centrally acting, stimulation of the CRTZ<\/td>\n<td bgcolor=\"#d8efe1\">0.44 mg\/kg IM<\/td>\n<td bgcolor=\"#c2e9d1\">\u2022 Bradycardia<br \/>\n\u2022 Increased responsiveness to sharp auditory stimuli<br \/>\n\u2022 Increased urination<br \/>\n\u2022 Muscle tremors<br \/>\n\u2022 Respiratory depression<br \/>\n\u2022 Sedation<\/td>\n<\/tr>\n<tr>\n<td bgcolor=\"#d8efe1\"><strong>Dexmedetomidine<\/strong><\/td>\n<td bgcolor=\"#c2e9d1\">Centrally acting, stimulation of the CRTZ<\/td>\n<td bgcolor=\"#d8efe1\">1\u20132 mcg\/kg IV<br \/>\nor<br \/>\n40 mcg\/kg IM<\/td>\n<td bgcolor=\"#c2e9d1\">\u2022 Apnea, bradycardia, sedation<br \/>\n\u2022 Hyperglycemia<br \/>\n\u2022 Hypothermia<br \/>\n\u2022 Muscle tremors<br \/>\n\u2022 Reduced tear production<br \/>\n\u2022 Respiratory depression<br \/>\n\u2022 Transient hypertension<br \/>\n\u2022 Vasoconstriction<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h2><strong><span class=\"aquabold\">INDICATIONS FOR GASTRIC LAVAGE<\/span><\/strong><\/h2>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">Gastric lavage is indicated for poisoned patients in certain situations,<sup>1,2<\/sup> but veterinarians rarely perform gastric lavage as it is more labor intensive than induction of emesis.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Canine studies have shown that, when gastric lavage was performed within 15 minutes after toxicant ingestion, recovery of the ingested material was poor (38%; range, 2%\u201369%), and if performed 60 minutes after toxicant ingestion, only 13% of the ingested material was recovered.<sup>3<\/sup> Since patients often present more than 1 hour after toxin ingestion, the clinical usefulness of gastric lavage is questioned.<sup>4<\/sup><\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">With certain life-threatening toxicants (included in <\/span><strong><span class=\"garamond-bold\">Table 2<\/span><\/strong><span class=\"garamond-9-5\">), however, gastric lavage is highly recommended, especially when emesis induction is unproductive or contraindicated. These toxicants typically have a narrow margin of safety or result in severe clinical signs.<\/span><\/p>\n<p class=\"indent-125\"><strong><span class=\"garamond-bold\">Table 2<\/span><\/strong><span class=\"garamond-9-5\"> outlines the indications and contraindications for gastric lavage. Visit <\/span><span class=\"garamond-bold\">vetgirlontherun.com<\/span><span class=\"garamond-9-5\"> to view a video demonstrating how to perform gastric lavage.<\/span><\/p>\n<table border=\"0\" width=\"100%\" cellspacing=\"1\" cellpadding=\"5\">\n<tbody>\n<tr>\n<td class=\"aquabold\" align=\"center\"><strong>Table 2. Indications &amp; Contraindications for Use of Gastric Lavage<sup>1<\/sup><\/strong><\/td>\n<\/tr>\n<tr>\n<td><strong>INDICATIONS<\/strong><\/td>\n<\/tr>\n<tr bgcolor=\"#d8efe1\">\n<td>\n<ul>\n<li>Baclofen<\/li>\n<li>Cholecalciferol<\/li>\n<li>Deadly medications with a narrow safety margin (eg, calcium channel blockers, fluorouracil)<\/li>\n<li>Macrocyclic lactones (eg, ivermectin, moxidectin), especially in dogs with ABCB1 gene mutation<\/li>\n<li>Massive ingestions approaching LD50<\/li>\n<li>Materials that can form a bezoar or concretion in the stomach (eg, aspirin pills, prenatal vitamins, bone meal, iron tablets, unbaked bread dough)<\/li>\n<li>Organophosphates\/carbamates<\/li>\n<li>Patient with clinical signs (eg, decreased gag reflex due to excessive sedation) in which aspiration is of concern if emesis is performed<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td><strong>CONTRAINDICATIONS<\/strong><\/td>\n<\/tr>\n<tr bgcolor=\"#d8efe1\">\n<td>\n<ul>\n<li>Corrosive agent (eg, batteries, drain cleaners, oven cleaners, ultra bleach)<\/li>\n<li>Ingestion of sharp objects (eg, sewing needles, knives)<\/li>\n<li>Petroleum distillates or hydrocarbons (eg, gasoline, kerosene, motor oil), which may be easily aspirated due to their low viscosity<\/li>\n<li>Risk for sedation or anesthetic complications<\/li>\n<li>Unstable patients (patients in shock and at risk for complications from sedation)<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h2><strong><span class=\"aquabold\">MONITORING FOR HYPERNATREMIA<\/span><\/strong><\/h2>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">Hypernatremia has been anecdotally reported in poisoned patients secondary to activated charcoal (AC) administration.<sup>4<\/sup> While uncommon, secondary hypernatremia can be severe and mimic clinical signs of worsening toxicosis. Clinical signs of ataxia, head pressing, worsening lethargy, tremors, or obtundation may actually be due to hypernatremia rather than the toxicant.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">If any of these clinical signs develop, the best way to determine if a patient is hypernatremic is to immediately measure its serum sodium level. If the patient is receiving multiple doses of AC per day, daily sodium levels should always be measured.<\/span><\/p>\n<h3 class=\"left-justified\"><strong><span class=\"font_purple\">Differentiation Between Hypernatremia &amp; Poisoning<\/span><\/strong><\/h3>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">Based on my experience, hypernatremia is seen more frequently in patients poisoned by certain toxicants\u2014chocolate or bromethalin. Since both of these toxicants can result in clinical signs attributable to the central nervous system (eg, ataxia, agitation, tremors, seizures), it is clinically important to differentiate between hypernatremia and poisoning.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Poisoned patients can become hypernatremic due to:<\/span><\/p>\n<ul>\n<li class=\"tabs-and-bullets\"><span class=\"garamond-9-5\">Use of salt as an emetic agent (hence, it is no longer recommended as a safe emetic agent in dogs or cats)<\/span><\/li>\n<li class=\"tabs-and-bullets\"><span class=\"garamond-9-5\">Dehydration due to emesis induction, which prohibits patient\u2019s oral intake for several hours<\/span><\/li>\n<li class=\"tabs-and-bullets\"><span class=\"garamond-9-5\">Excessive free water loss secondary to panting (eg, secondary to stress while administering AC or excitement\/agitation induced by toxin)<\/span><\/li>\n<li class=\"tabs-and-bullets\"><span class=\"garamond-9-5\">Other ongoing free water losses due to the toxicant (eg, vomiting, diarrhea, polyuria, polydipsia)<\/span><\/li>\n<li class=\"tabs-and-bullets\"><span class=\"garamond-9-5\">Administration of AC\u2014especially when it contains a cathartic, such as sorbitol, that can result in excessive free water loss from the gastrointestinal (GI) tract, resulting in secondary hypernatremia.<\/span><\/li>\n<\/ul>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Risk factors for hypernatremia are listed in <\/span><strong><span class=\"garamond-bold\">Table 3<\/span><\/strong><span class=\"garamond-9-5\">.<\/span><\/p>\n<table border=\"0\" width=\"100%\" cellspacing=\"1\" cellpadding=\"5\">\n<tbody>\n<tr>\n<td class=\"aquabold\" align=\"center\"><strong>Table 3. Risk Factors for Development of Hypernatremia in Dogs &amp; Cats<\/strong><\/td>\n<\/tr>\n<tr bgcolor=\"#d8efe1\">\n<td>\n<ul>\n<li>Dehydration<\/li>\n<li>Vomiting or fasting; inability to drink<\/li>\n<li>Predisposition to hyperosmolality disorders, such as chronic kidney injury, endocrine diseases (eg, diabetes mellitus, diabetes insipidus), or psychogenic polydipsia<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h3><span class=\"font_purple\">Minimizing Risk for Hypernatremia<\/span><\/h3>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">Typically, a onetime co-administered dose of a cathartic, such as sorbitol, with AC is warranted in the poisoned patient to aid in fecal expulsion of the toxicant.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">For patients receiving multiple doses of AC, ideally sorbitol should only be given with the first dose; additional doses should not contain sorbitol. In addition:<\/span><\/p>\n<ul>\n<li class=\"tabs-and-bullets\"><span class=\"garamond-9-5\">Monitor serum sodium levels at least daily<\/span><\/li>\n<li class=\"tabs-and-bullets\"><span class=\"garamond-9-5\">Assess hydration status frequently<\/span><\/li>\n<li class=\"tabs-and-bullets\"><span class=\"garamond-9-5\">Provide appropriate fluid supplementation (IV or SC) to prevent dehydration and hypernatremia.<\/span><\/li>\n<\/ul>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">In poisoned patients receiving IV fluids that were previously in good health, 3 main parameters should be used to assess appropriate hydration:<\/span><\/p>\n<p><span class=\"garamond-bold\">1. Packed cell volume (PCV)\/total solids (TS): <\/span><span class=\"garamond-9-5\">Ideally, patients on IV fluids should be hemodiluted down to a PCV of 35% and TS of 5 g\/dL; evidence of normal PCV (45%) and TS (7 g\/dL) in a patient receiving IV fluids is inappropriate as it demonstrates lack of adequate hemodilution.<\/span><\/p>\n<p><span class=\"garamond-bold\">2. Weight gain: <\/span><span class=\"garamond-9-5\">Weight gain provides an easy way to assess hydration. The dehydration formula is:<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamon-italics\">Percent dehydration \u00d7 BWkg = Amount of mLs of IV fluid to replace.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Note: the amount of mLs of IV fluid to replace is the same as anticipated weight gain (converted to kg).<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">For example, if a 30-kg Labrador retriever is 5% dehydrated, expected weight gain is 1.5 kg (or 1500 mL) once the patient is hydrated (hydrated weight = 31.5 kg).<\/span><\/p>\n<p class=\"tabs-and-bullets\"><span class=\"garamond-bold\">3. Evidence of isosthenuria:<\/span><span class=\"garamond-9-5\"> With appropriate hemodilution, urine specific gravity (USG) is targeted at 1.015 to 1.018 in both cats and dogs. A USG greater than 1.025 may indicate dehydration.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Risk for hypernatremia can also be minimized by use of a potent antiemetic (eg, maropitant, ondansetron, dolasetron), which helps treat any ongoing nausea or persistent vomiting and allows rapid return to oral water intake.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">For poisoned animals being managed as outpatients that have received a dose of AC, use of a potent antiemetic and administration of SC fluids (approximately 40\u201350 mL\/kg of a balanced, isotonic crystalloid) prevents additional free water loss and replaces any fluid deficit, thereby helping to prevent hypernatremia and allowing rapid return to a hydrated state.<\/span><\/p>\n<h2 class=\"left-justified\"><strong><span class=\"aquabold\">ROLE OF INTRAVENOUS LIPID EMULSION<\/span><\/strong><\/h2>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">Intravenous lipid emulsions (ILE), also known as intravenous fat emulsions (IFE), have been used in human and veterinary medicine as part of total or partial parenteral nutrition for several decades. ILE also has been used as a vehicle for drug delivery for emulsions (eg, propofol) and, more recently, it has been recommended as a potential antidote for lipophilic drug toxicosis.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">The precise mechanism of action through which ILE increases the rate of recovery and reduces the severity of clinical signs in lipophilic drug toxicosis is unknown. See <\/span><strong><span class=\"garamond-bold\">Table 4<\/span><\/strong><span class=\"garamond-9-5\"> for hypotheses regarding how ILE works.<\/span><\/p>\n<table border=\"0\" width=\"100%\" cellspacing=\"1\" cellpadding=\"5\">\n<tbody>\n<tr>\n<td class=\"aquabold\" align=\"center\"><strong>Table 4. Hypotheses: How ILE Addresses Fat-Soluble Toxicants<sup>5<\/sup><\/strong><\/td>\n<\/tr>\n<tr bgcolor=\"#d8efe1\">\n<td>\n<ol>\n<li>Provides myocytes with energy substrates, thereby augmenting cardiac performance.<\/li>\n<li>Restores myocardial function by increasing intracellular calcium concentration, which increases contractility of the heart.<\/li>\n<li>Increases overall fatty acid pool, which overcomes inhibition of mitochondrial fatty acid metabolism (eg, bupivacaine toxicosis).<\/li>\n<li>Acts as a lipid sink by sequestration of lipophilic compounds into the newly created intravascular lipid compartment (a lipid or pharmacologic sink), resulting in decreased free drug concentration available to the tissues.<\/li>\n<\/ol>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h3><strong><span class=\"font_purple\">In the Literature<\/span><\/strong><\/h3>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">A state-of-the-art review by Fernandez, et al,<sup>5<\/sup> was recently published, introducing the first recommendations for use of ILE in veterinary medicine. <\/span><strong><span class=\"garamond-bold\">Table 5<\/span><\/strong><span class=\"garamond-9-5\"> lists the toxicants for which ILE therapy is thought to be helpful.<\/span><\/p>\n<table border=\"0\" width=\"100%\" cellspacing=\"1\" cellpadding=\"5\">\n<tbody>\n<tr>\n<td class=\"aquabold\" align=\"center\"><strong>Table 5. Toxicants That Have Been Successfully Treated with ILE Therapy<sup>4,6-13<\/sup><\/strong><\/td>\n<\/tr>\n<tr bgcolor=\"#d8efe1\">\n<td>\n<ul>\n<li>Baclofen\u2020<\/li>\n<li>Beta blockers\u2020<\/li>\n<li>Calcium channel blockers<\/li>\n<li>Cholecalciferol\u2020<\/li>\n<li>Ibuprofen<\/li>\n<li>Lidocaine<\/li>\n<li>Macrocyclic lactones\u2021<\/li>\n<li>Pyrethrins<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr bgcolor=\"#d8efe1\">\n<td bgcolor=\"#f1faf4\"><em>\u2020 The ASPCA Animal Poison Control Center has recommended ILE for these fat-soluble toxicants with a narrow safety margin.<br \/>\n\u2021 In one case report, ILE was not found to be beneficial for macrocyclic lactone toxicosis in multidrug resistant (MDR), also known as ABCB1-1delta, gene mutation dogs.<\/em><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h3><strong><span class=\"font_purple\">Indications<\/span><\/strong><\/h3>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">ILE therapy is generally considered relatively safe; however, its use for treatment of toxicities is considered extra-label, and rare side effects can occur, including fat-overload syndrome, cholesterol deposits into the cornea, and coagulopathy. Keep in mind that the use of ILE in human medicine is typically reserved for severe toxicosis and life-threatening clinical signs when conventional therapies have failed.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Current human medicine guidelines recommend that infusion of ILE should only be:<\/span><\/p>\n<ul>\n<li class=\"tabs-and-bullets\"><span class=\"garamond-9-5\">Attempted in patients who have suffered cardiac arrest<\/span><\/li>\n<li class=\"tabs-and-bullets\"><span class=\"garamond-9-5\">Used when standard resuscitation protocols have failed to establish adequate return to spontaneous circulation<\/span><\/li>\n<li class=\"tabs-and-bullets\"><span class=\"garamond-9-5\">Cardiopulmonary resuscitation should continue during ILE administration.<\/span><\/li>\n<\/ul>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">In veterinary medicine, ILE is generally initiated earlier in the course of treatment, and is warranted:<\/span><\/p>\n<ul>\n<li class=\"tabs-and-bullets\"><span class=\"garamond-9-5\">For toxicities associated with lipid-soluble compounds in which a high morbidity has been reported<\/span><\/li>\n<li class=\"tabs-and-bullets\"><span class=\"garamond-9-5\">In patients with clinical signs of toxicosis<\/span><\/li>\n<li class=\"tabs-and-bullets\"><span class=\"garamond-9-5\">When traditional therapies have failed or are cost-prohibitive.<\/span><\/li>\n<\/ul>\n<h3 class=\"left-justified\"><strong><span class=\"font_purple\">Administration<\/span><\/strong><\/h3>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">ILE (eg, Intralipid, baxter.com; Liposyn III, hospira.com) can be delivered through a sterile, peripheral catheter, and does not require placement of a central line for administration.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">ILE has a long storage half-life, and can be stored at room temperature until it is opened. Once opened, aseptic handling is imperative and refrigeration necessary; the remaining product should be discarded after 24 hours.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">For additional information about ILE, including current dosing recommendations in veterinary medicine, see <\/span><strong><span class=\"garamond-bold\">Table 6<\/span><\/strong><span class=\"garamond-9-5\">.<\/span><\/p>\n<table border=\"0\" width=\"100%\" cellspacing=\"1\" cellpadding=\"5\">\n<tbody>\n<tr>\n<td class=\"aquabold\" align=\"center\"><strong>Table 6. Suggested Dosing for ILE in Dogs &amp; Cats<sup>5<\/sup><\/strong><\/td>\n<\/tr>\n<tr bgcolor=\"#d8efe1\">\n<td>\n<ol>\n<li>Using a 20% solution, bolus 1.5\u20134 mL\/kg IV over 1 minute, followed by a constant rate infusion of 0.25 mL\/kg\/min for 30\u201360 min.<\/li>\n<li>If clinical signs are ongoing, continue:\n<ul>\n<li>Intermittent bolus dosing, 1.5 mL\/kg Q 4\u20136 H for 24 H, or<\/li>\n<li>Constant rate infusion, 0.5 mL\/kg\/H, until clinical signs improve.<\/li>\n<\/ul>\n<\/li>\n<li>If clinical signs do not improve after 24 H, discontinue ILE.<\/li>\n<\/ol>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h2><strong><span class=\"aquabold\">CONCLUSION<\/span><\/strong><\/h2>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">The use of new and updated approaches to therapy in veterinary toxicology may dramatically improve the overall outcome in toxicities that have been previously associated with a high morbidity, mortality, and cost. However, extra-label use should be judicious, and appropriate case selection, along with continuous supportive care, is imperative in critically ill, poisoned patients.<\/span><\/p>\n<p class=\"left-justified\"><span class=\"helvetica-9-pt\">AC = activated charcoal; BWkg = body weight in kg; CRTZ = chemoreceptor trigger zone; GI = gastrointestinal; IFE = intravenous fat emulsion; ILE = intravenous lipid emulsion; LD50 = lethal dose (dose required to kill 50% of the test population); PCV = packed cell volume; TS = total solids; USG = urine specific gravity<\/span><\/p>\n<h3 class=\"references\"><strong>References<\/strong><\/h3>\n<ol>\n<li class=\"references\">Lee JA. Decontamination of the poisoned patient. In Osweiler GD, Hovda LR, Brutlag AG, Lee JA, (eds): <span class=\"refersitalics\">Blackwell\u2019s Five-Minute Veterinary Consult Clinical Companion: <em>Small Animal Toxicology, <\/em>1st ed. Iowa City: Wiley-Blackwell, 2010, pp 5-19.<\/span><\/li>\n<li class=\"references\">Peterson ME. Toxicological decontamination. In Peterson ME, Talcott PA (eds): <em><span class=\"refersitalics\">Small Animal Toxicology<\/span>, <\/em>2nd ed. St. Louis: Elsevier Saunders, 2006, pp 127-141.<\/li>\n<li class=\"references\">Benson BE, Hoppu K, Troutman WG, et al. Position paper update: Gastric lavage for gastrointestinal decontamination. <span class=\"refersitalics\"><em>Clin Toxicol<\/em> 2013; 51(3):140-146.<\/span><\/li>\n<li class=\"references\">Personal communication, Justine Lee, DVM, Diplomate ACVECC &amp; ABT.<\/li>\n<li class=\"references\">Fernandez AL, Lee JA, Rahilly L, et al. The use of intravenous lipid emulsion as an antidote in veterinary toxicology. <em><span class=\"refersitalics\">J Vet Emerg Crit Care<\/span><\/em> 2011; 21(4):309-320.<\/li>\n<li class=\"references\">Crandell DE, Weinberg GL. Moxidectin toxicosis in a puppy successfully treated with intravenous lipids. <span class=\"refersitalics\"><em>J Vet Emerg Crit Care<\/em> 2009; 19(2):181-186.<\/span><\/li>\n<li class=\"references\">Wright HM, Chen AV, Talcott PA, et al. Intravenous fat emulsion as treatment for ivermectin toxicosis in three dogs homozygous for the ABCB1-1delta gene mutation. <span class=\"refersitalics\">J <em>Vet Emerg Crit Care<\/em> 2011; 21(6):666-672.<\/span><\/li>\n<li class=\"references\">Clarke DL, Lee JA, Murphy LA, Reineke EL. Use of novel intravenous lipid therapy to treat ivermectin toxicosis in a border collie. <em><span class=\"refersitalics\">JAVMA<\/span><\/em> 2011; 239(10):1328-1333.<\/li>\n<li class=\"references\">Bruenisholz H, Kupper J, Muentener CR, et al. Treatment of ivermectin overdose in a miniature Shetland pony using intravenous administration of a lipid emulsion. <span class=\"refersitalics\"><em>J Vet Intern Med<\/em> 2012; 26(2):407-411.<\/span><\/li>\n<li class=\"references\">O\u2019Brien TQ, Clark-Price SC, Evans EE, et al. Infusion of a lipid emulsion to treat lidocaine intoxication in a cat. <em><span class=\"refersitalics\">JAVMA<\/span><\/em> 2010; 237(12):1455-1458.<\/li>\n<li class=\"references\">Baton BL, Simmonds EE, Lee JA, Alwood AJ. The use of high-dose insulin therapy and intravenous lipid emulsion to treat severe, refractory diltiazem toxicosis in a dog. <span class=\"refersitalics\"><em>J Vet Emerg Crit Care<\/em> 2013; 23(3):321-327.<\/span><\/li>\n<li class=\"references\">Haworth MD, Smart L. Use of intravenous lipid therapy in three cases of feline permethrin toxicosis. <span class=\"refersitalics\"><em>J Vet Emerg Crit Care<\/em> 2012; 22(6):697-702.<\/span><\/li>\n<li class=\"references\">Bolfer L, McMichael M, Ngwenyama TR, O\u2019Brien MA. Treatment of ibuprofen toxicosis in a dog with IV lipid emulsion. <em><span class=\"refersitalics\">JAAHA<\/span> <\/em>2014; 50(2):136-140.<\/li>\n<\/ol>\n<p><img decoding=\"async\" class=\"size-full wp-image-4673 alignleft\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/07\/justineleeDVM.png\" alt=\"Justine Lee DVM\" width=\"100\" height=\"115\" \/><span class=\"author-bio\"><strong>Justine A. Lee<\/strong>, DVM, Diplomate ACVECC &amp; ABT, is the CEO and founder of VetGirl (vetgirlontherun .com), a subscription-based podcast and webinar service that offers RACE-approved veterinary continuing education. She recently received the NAVC Speaker of the Year Award, and is the author and editor of several veterinary textbooks, book chapters, and scientific publications. She completed her veterinary training at Cornell University, Angell Animal Medical Center (Boston), and University of Pennsylvania.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Justine A.<\/p>\n","protected":false},"author":1,"featured_media":9405,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"iawp_total_views":1216,"footnotes":""},"categories":[367],"tags":[13],"class_list":["post-1017","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-july-august-2014","tag-peer-reviewed","clinical_topics-toxicology"],"acf":{"hide_sidebar":false,"hide_sidebar_ad":false,"hide_all_ads":false},"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v24.7 (Yoast SEO v27.3) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Therapeutic Updates in Veterinary Toxicology | Today&#039;s Veterinary Practice<\/title>\n<meta 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