Lipid Emulsion (ILE) protocol
20% intravenous lipid emulsion as an antidote for lipophilic toxicoses including local anesthetic systemic toxicity (lidocaine, bupivacaine), calcium-channel and beta-blocker overdose, permethrin and pyrethrin toxicosis in cats, ivermectin and macrocyclic lactone toxicity (particularly MDR1-deficient breeds), baclofen toxicosis, and other lipophilic agents. Mechanism is the lipid-sink effect: the emulsion sequesters fat-soluble toxins away from their sites of action.
- 20% lipid emulsion ONLY. 10% emulsion delivers half the effective dose at double the carrier- fluid load and is not appropriate for toxicology reversal. Read the bag: Intralipid 20%, SMOFlipid 20%, Liposyn 20%, or veterinary-equivalent.
- Draw essential labs BEFORE starting. Lipemia interferes with most subsequent biochemistry panels (glucose, electrolytes, liver enzymes) for hours after the infusion. Baseline CBC, chemistry, and any indication-specific labs (cardiac troponin in CCB overdose, etc.) should be drawn first.
- Concurrent propofol confounds lipid status. Propofol vehicle is the same emulsion; calculating total lipid load on a propofol-sedated patient requires accounting for both sources.
- Dedicated IV line preferred. Lipid emulsion is incompatible with calcium-containing solutions and sodium bicarbonate (precipitation). If a Y-site is unavoidable, flush thoroughly before and after. Discard remaining bag after 24 hours (sterility).
- Fat overload syndrome at high cumulative doses or in pancreatitis-prone breeds (Miniature Schnauzers especially): hyperlipidemia, hepatosplenomegaly, coagulopathy, hemolysis. Limit total daily dose to 10 mL/kg/day where possible.
Standard sequence: loading bolus over 2–3 min → maintenance CRI at 0.25 mL/kg/min × 30–60 min → reassess → optional re-bolus if cardiovascular response inadequate. Cumulative dose ceiling 10 mL/kg/day. Continue supportive care (IV fluids, vasopressors, antiarrhythmics as indicated) alongside ILE; the lipid sink is supportive, not definitive.
Enter a patient weight to see the result.
Protocol detail
Standard ASRA-adapted veterinary protocol:
- Loading bolus 1.5 mL/kg of 20% lipid emulsion IV over 2–3 minutes. Faster (1 min) is appropriate in cardiac arrest from LA toxicity; slower is preferred otherwise.
- Maintenance CRI 0.25 mL/kg/min for 30–60 minutes. The 30-min duration is standard; extend to 60 min in refractory cases where cardiovascular function has not stabilized, subject to the daily-dose cap.
- Re-bolus 1.5 mL/kg may be repeated if cardiovascular response is inadequate at any point. Counts toward the daily cap.
- Total cumulative ceiling 10 mL/kg/day (vet conservative; human ASRA uses 12 mL/kg). The calculator flags when CRI duration or re-bolus would exceed this ceiling.
Mechanism — "lipid sink": The 20% emulsion creates a lipophilic plasma compartment that sequesters fat-soluble toxins, drawing them away from cardiac sodium channels, CNS receptors, and other sites of action. Onset within minutes of bolus; benefit depends on the proportion of toxin that partitions into the emulsion. ILE is supportive, not definitive. Pair with standard toxicology measures (decontamination, vasopressors, antiarrhythmics, intubation if needed).
Sources
- Plumb's Veterinary Drugs, Intravenous Lipid Emulsion monograph (current edition).
- Fernandez AL, Lee JA, Rahilly L, et al. The use of intravenous lipid emulsion as an antidote in veterinary toxicology. J Vet Emerg Crit Care. 2011;21(4):309–320.
- Neal JM, Barrington MJ, Fettiplace MR, et al. The Third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Local Anesthetic Systemic Toxicity: Executive Summary 2017. Reg Anesth Pain Med. 2018;43(2):113–123.
- Hayes WK, Brown SR, Hodgson HA, et al. Intravenous lipid emulsion therapy for permethrin toxicosis in cats. J Vet Emerg Crit Care. 2020;30(5):608–614.