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Lipid emulsion or fat emulsion (the first brand name being Intralipid) is a fat emulsion for human use, approved in 1962 in Europe and invented by Professor Arvid Wretlind, Sweden. The FDA initially would not approve the product due to prior experience with another fat emulsion. It was approved in the United States in 1972. It is used as a component of parenteral nutrition for patients who are unable to get nutrition via an oral diet. It is an emulsion of soy bean oil, egg phospholipids and glycerin. It is available in a 10%, 20% and 30% concentration. The 30% concentration is not approved for direct intravenous infusion, but should be mixed with amino acids and dextrose as part of a total nutrient admixture.

Intralipid provides essential fatty acids, linoleic acid (LA), an omega-6 fatty acid, alpha-linolenic acid (ALA), an omega-3 fatty acid.

Some preparations of the anaesthetic drugs propofol and etomidate (the vehicle for etomidate is propylene glycol) are supplied using a lipid emulsion as a vehicle.

Medical uses

Antidote

Lipid emulsions are effective in treating experimental models of severe cardiotoxicity from intravenous overdose of local anaesthetic drugs such as bupivacaine.^[1]^[2]^[3]^[4]

They have been effective in people unresponsive to the usual resuscitation methods. It has subsequently been used off-label in the treatment of overdose from other fat-soluble medications.^[5]

Research

Intralipid is also widely used in optical experiments to simulate the scattering properties of biological tissues.^[6] Solutions of appropriate concentrations of intralipid can be prepared that closely mimic the response of human or animal tissue to light at wavelengths in the red and infrared ranges where tissue is highly scattering but has a rather low absorption coefficient.

Cardioprotective agent

Intralipid is currently being studied for its potential use as a cardioprotective agent, specifically as a treatment for ischemic reperfusion injury. The rapid return of myocardial blood supply is critical in order to save the ischemic heart, but it also has the potential to create injury due to oxidative damage (via reactive oxygen species) and calcium overload.^[7] Myocardial damage with the resumption of blood flow after an ischemic event is termed “reperfusion injury”.

The mitochondrial permeability transition pore (mPTP) is normally closed during ischemia, but calcium overload and increased reactive oxygen species (ROS) with reperfusion open mPTP allowing hydrogen ions to flow from the mitochondrial matrix into the cytosol. The hydrogen flux disrupts the mitochondrial membrane potential and results in mitochondrial swelling, outer membrane rupture, and the release of pro-apoptotic factors.^[7]^[8] These changes impair mitochondrial energy production and drive cardiac myocyte apoptosis.

Intralipid (5mL/kg) provided five minutes before reperfusion delays the opening of mPTP in vivo rat models, making it a potential cardioprotective agent^[9] Lou et al. (2014) found that the cardioprotection aspect of Intralipid is initiated by the accumulation of acylcarnitines in the mitochondria and involves inhibition of the electron transport chain, an increase in ROS production during early (3 min) reperfusion, and activation of the reperfusion injury salvage kinase pathway (RISK).^[7] The mitochondrial accumulation of acylcarnitines (primarily palmitoyl-carnitine) inhibits the electron transport chain at complex IV, generating protective ROS.^[10] The effects of ROS are both “site” and “time” sensitive, meaning that both will ultimately determine whether the ROS are beneficial or detrimental.^[10] The generated ROS, which are formed from electrons leaking from the electron transport chain of the mitochondria, first act directly on mPTP to limit opening.^[11] ROS then activate signalling pathways that act on the mitochondria to decrease mPTP opening and mediate protection.^[11] Activation of the RISK pathway by ROS increases the phosphorylation of other pathways, such as phosphatidylinositol 3-kinase/Akt and extracellular-regulated kinase (ERK) pathways,^[9] both of which are found in pools localized at the mitochondria.^[12] The Akt and ERK pathways converge to alter glycogen synthase kinase-3 beta (GSK-3β) activity. Specifically, Akt and ERK phosphorylate GSK-3β, inactivating the enzyme, and inhibiting the opening of mPTP.^[9] The mechanism by which GSK-3β inhibits the opening of the mPTP is controversial. Nishihara et al. (2007) proposed that it is achieved through interaction of GSK-3β with ANT subunit of mPTP, inhibiting the Cyp-D–ANT interaction, resulting in the inability of the mPTP to open.^[13]

In a study by Rahman et al. (2011) Intralipid-treated rat hearts were found to required more calcium to open mPTP during ischemia-reperfusion. The cardiomyocytes are therefore, better able to tolerate the calcium overload, and increase the threshold for opening of the mPTP with the addition of Intralipid.^[9]

References

^ Picard J, Meek T (February 2006). "Lipid emulsion to treat overdose of local anaesthetic: the gift of the glob". Anaesthesia 61 (2): 107–9. doi:10.1111/j.1365-2044.2005.04494.x. PMID 16430560.
^ Weinberg GL, VadeBoncouer T, Ramaraju GA, Garcia-Amaro MF, Cwik MJ (April 1998). "Pretreatment or resuscitation with a lipid infusion shifts the dose-response to bupivacaine-induced asystole in rats". Anesthesiology 88 (4): 1071–5. doi:10.1097/00000542-199804000-00028. PMID 9579517.
^ Weinberg G, Ripper R, Feinstein DL, Hoffman W (2003). "Lipid emulsion infusion rescues dogs from bupivacaine-induced cardiac toxicity". Reg Anesth Pain Med 28 (3): 198–202. doi:10.1053/rapm.2003.50041. PMID 12772136.
^ Weinberg G. Reply to Drs. Goor, Groban and Butterworth – Lipid rescue: Caveats and recommendations for the "silver bullet" (letter). Regional Anesthesia and Pain Medicine 2004; 29: 74.
^ Mahoney, Diana. "IV Fat Emulsion Beneficial for Some Drug Overdoses". Acep.org. Elsevier Global Medical News. Retrieved 3 November 2013.
^ Driver I, Feather J W, King P R, Dawson J B. The optical properties of aqueous suspensions of Intralipid, a fat emulsion. Physics in Medicine and Biology 1989, Vol.34 No. 12, 1927–1930.
^ ^a ^b ^c Li J., Iorga A., Sharma S., Youn J., Partow-Navid R., Umar S., … Eghbali M. (2013). Intralipid, a clinically safe compound, protects the heart against ischemia-reperfusion injury more efficiently than cyclosporine-A. Anesthesiology. 117(4): 836-846. DOI: 10.1097/ALN.0b013e3182655e73
^ Sanada, S., Komuro, I., & Kitakaze, M. (2011). Pathophysiology of myocardial reperfusion injury: preconditioning, postconditioning, and translational aspects or protective measures. Am J Physiol Heart Circ Physiol. 301. DOI: 10.1152/ajpheart.00553.2011.
^ ^a ^b ^c ^d Rahman S., Li J., Bopassa J.C., Soban Umar, Iorga A., Partownavid P., & Eghbali M. (2011). Phosphorylation of GSK-3β mediates Intralipid-induced cardioprotection against ischemia/reperfusion injury. Anesthesiology. 115(2): 242-253. DOI: 10.1097/ALN.0b013e318223b8b9
^ ^a ^b Lou P., Lucchinetti E., Zhang L., Affolter A., Schaub M.C., Gandhi M., … Zaugg M. (2014). The mechanism of intralipid®-mediated cardioprotection complex IV inhibition by the active metabolite, palmitoylcarnitine, generates reactive oxygen species and activates reperfusion injury salvage kinases. PLoS One. 9(1). DOI: 10.1371/journal.pone.0087205
^ ^a ^b Perrelli M., Pagliaro P., & Penna C. (2011). Ischemia/reperfusion injury and cardioprotective mechanisms: Role of mitochondria and reactive oxygen species. World J Cardiol. 3(6): 186-200. DOI: 10.4330/wjc.v3.i6.186
^ Martel C., Huynh L.H., Garnier A., Ventura-Clapier R., & Brenner C. (2012). Inhibition of the mitochondrial permeability transition for cytoprotection: Direct versus indirect mechanisms. Biochem Res Int. DOI: 10.1155/2012/213403
^ Nishihara, M., Miura, T., Miki, T., Tanno, M., Yano, T., Naitoh, K., et al. (2007). Modulation of the mitochondrial permeability transition pore complex in GSK-3β-mediated myocardial protection. J Mol Cell Cardiol. 43: 564-570

External links

Lipid rescue (intralipid as antidote)

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English Journal

Intravenous lipid emulsion entraps amitriptyline into plasma and can lower its brain concentration - an experimental intoxication study in pigs.

Heinonen JA, Litonius E, Backman JT, Neuvonen PJ, Rosenberg PH.SourceDepartment of Anaesthesiology and Intensive Care Medicine, University of Helsinki, Helsinki, Finland.
Basic & clinical pharmacology & toxicology.Basic Clin Pharmacol Toxicol.2013 Sep;113(3):193-200. doi: 10.1111/bcpt.12082. Epub 2013 May 29.
Intravenous lipid emulsion has been suggested as treatment for severe intoxications caused by lipophilic drugs, including tricyclic antidepressants. We investigated the effect of lipid infusion on plasma and tissue concentrations of amitriptyline and haemodynamic recovery, when lipid was given after
PMID 23639060

Thermal stability of intralipid optical phantoms.

Rowe PI, Künnemeyer R, McGlone A, Talele S, Martinsen P, Oliver R.SourceThe New Zealand Institute for Plant and Food Research Limited, Hamilton, New Zealand.
Applied spectroscopy.Appl Spectrosc.2013 Aug;67(8):993-6. doi: 10.1366/12-06971.
We investigated the stability of light transmission through Intralipid-based optical phantoms in the wavelength range of 400-950 nm at temperatures between 35 and 70 °C. Optical phantoms are materials commonly used to simulate the light scattering and absorption properties of biological materials.
PMID 23876738

β-Cell Lipotoxicity in Response to Free Fatty Acid Elevation in Prepubertal Youth: African American Versus Caucasian Contrast.

Michaliszyn SF, Bonadonna RC, Sjaarda LA, Lee S, Farchoukh L, Arslanian SA.SourceDivision of Weight Management, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Diabetes.Diabetes.2013 Aug;62(8):2917-22. doi: 10.2337/db12-1664. Epub 2013 Apr 4.
Prepubertal African American (AA) youth compared with their Caucasian (C) peers have higher insulin secretion, which correlates positively with free fatty acid (FFA) concentration. In our continued efforts to explain the racial disparity in insulinemia, and because FFAs modulate insulin secretion, w
PMID 23557704

Japanese Journal

Mechanisms Involved in Guiding the Preference for Fat Emulsion Differ Depending on the Concentration

SAKAMOTO Kazuhiro,MATSUURA Shigenobu,OKAFUJI Yoko [他],EGUCHI Ai,LEE Shinhye,ADACHI Shin-ichi,FUJITANI Mina,TSUZUKI Satoshi,INOUE Kazuo,FUSHIKI Tohru
Journal of Nutritional Science and Vitaminology 61(3), 247-254, 2015
… To address this issue, we examined the influences of the opioid system and olfactory and gustatory transductions on the intake and reinforcing effects of various concentrations of a dietary fat emulsion (Intralipid). …
NAID 130005089920

選択的可溶化法を用いた改良LDLコレステロール測定試薬の評価

渡邉勇気,佐藤伊都子,林伸英,藤岡由夫,河野誠司
医学検査 64(2), 210-215, 2015
選択的可溶化法を原理とする改良LDLコレステロール（LDL-C）測定試薬（メタボリードLDL-C）の基礎的検討を行い，高TG血症検体を用いて，従来試薬との比較検討を行った。基礎的検討の結果，同時再現性，日差再現性はそれぞれ変動係数（CV）が0.5～1.3%，0.4～0.6%であり，677 mg/dLまで原点を通る希釈直線性が得られた。添加回収試験では回収率が99～102%で，共存物質の影響は，ビリ …
NAID 130005068981

新PTドライ試薬の基礎的検討

黒木泰則,都竹亜紀子,田中稔,大江伸司,石井真由子,菊池匡芳
医学検査 63(1), 99-103, 2014
… The new reagent showed good reproducibility, especially when citrated plasma or whole blood was used as a sample, yielding interference results similar to those of bilirubin-F, bilirubin-C, hemolytic hemoglobin, and intralipid. …
NAID 130005057038