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23 February 2019

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Int J Med Sci 2018; 15(7):713-722. doi:10.7150/ijms.22643


Lipid Emulsion for Treating Local Anesthetic Systemic Toxicity

Seong-Ho Ok1,2*, Jeong-Min Hong3*, Soo Hee Lee1,2, Ju-Tae Sohn1,2✉

1. Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 Beon-gil, Jinju-si, Gyeongsangnam-do, 52727, Republic of Korea
2. Institute of Health Sciences, Gyeongsang National University, Jinju-si, 52727, Republic of Korea
3. Department of Anesthesia and Pain Medicine, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Republic of Korea
*These authors equally contributed to this study as co-first authors.


Lipid emulsion has been shown to be an effective treatment for systemic toxicity induced by local anesthetics, which is reflected in case reports. A systemic review and meta-analysis confirm the efficacy of this treatment. Investigators have suggested mechanisms associated with the lipid emulsion-mediated recovery of cardiovascular collapse caused by local anesthetic systemic toxicity; these mechanisms include lipid sink, a widely accepted theory in which highly soluble local anesthetics (particularly bupivacaine) are absorbed into the lipid phase of plasma from tissues (e.g., the heart) affected by local-anesthetic-induced toxicity; enhanced redistribution (lipid shuttle); fatty acid supply; reversal of mitochondrial dysfunction; inotropic effects; glycogen synthase kinase-3β phosphorylation associated with inhibition of the mitochondrial permeability transition pore opening; inhibition of nitric oxide release; and reversal of cardiac sodium channel blockade. The current review includes the following: 1) an introduction, 2) a list of the proposed mechanisms, 3) a discussion of the best lipid emulsion treatment for reversal of local anesthetic toxicity, 4) a description of the effect of epinephrine on lipid emulsion-mediated resuscitation, 5) a description of the recommended lipid emulsion treatment, and 6) a conclusion.

Keywords: lipid emulsion, local anesthetic systemic toxicity, lipid sink, lipid shuttle, bupivacaine

This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY-NC) license ( See for full terms and conditions.
How to cite this article:
Ok SH, Hong JM, Lee SH, Sohn JT. Lipid Emulsion for Treating Local Anesthetic Systemic Toxicity. Int J Med Sci 2018; 15(7):713-722. doi:10.7150/ijms.22643. Available from