Low-dose lipid emulsion for pediatric vasoplegic shock due to quetiapine and fluvoxamine overdose: a case report

Abstract

Background: Intravenous lipid emulsion (ILE) therapy was originally used for treatment of for local anesthetic systemic toxicity. Over the last decade, it has been successfully used to treat severe toxicity of numerous lipophilic substances. The mechanism by which ILE therapy treats lipophilic drug toxicity was originally purported to be due to the lipid sink mechanism; however, further research suggests that several other factors likely play more substantial roles, including free fatty acid provision to cardiomyocytes, positive inotropic effect, ion channel modulation, and nitric oxide synthase inhibition. No standardized dosing recommendation exists for ILE treatment of pediatric lipophilic drug toxicity. Several case reports have documented successful resuscitation of such overdoses using much lower dosages of ILE than are used for local anesthetic toxicity. Case Description: We present a case of a 17-year-old male who presented to the emergency department (ED) with quetiapine and fluvoxamine overdose who rapidly progressed to refractory vasoplegic shock requiring ILE support. Following administration of low-dose ILE, the patient’s hemodynamic state substantially improved, and he survived to discharge with relatively minor comorbidities. Conclusions: This case highlights the successful use of low-dose ILE therapy for selective serotonin reuptake inhibitor (SSRI) and antipsychotic drug toxicity. Our experience suggests there may be a lower dosing range for ILE therapy that is safe and efficacious for the treatment of pediatric vasoplegic shock secondary to antipsychotic and SSRI toxicity.