Bedside Snapshot
- Use It For
- Local anesthetic systemic toxicity (LAST) rescue; off-label rescue in life-threatening lipophilic drug poisoning after standard care fails
- Adult Dose
- Bolus: 1.5 mL/kg of 20% IV over 2–3 min; repeat if the response is unsatisfactory
- Infusion: 0.25 mL/kg/min after the bolus, until stable and for at least 10 min after; double if hypotension persists
- Pediatric Dose
- Adult mL/kg extrapolated (no separate pediatric LAST dose found): 1.5 mL/kg IV, then 0.25 mL/kg/min; total 10–12 mL/kg per protocol. Off-label; medical direction
- Onset / Duration
- IV: bolus over 2–3 min; onset and duration not established; infusion continued per protocol
- Do Not Give / Hold If
- Do not delay lipid in arrest for lab results. Egg, soy or peanut allergy: risk-benefit, not a hold. Stop routine lipid at 10–12 mL/kg total. After stabilization, triglycerides above 400 mg/dL (PN label): reassess
- Watch For
- Pancreatitis (abdominal pain, rising lipase); lab interference (lipemic samples); fat overload and hypoxemia; bronchospasm (rare)
- Reversal / Rescue
- No antidote; lipid is the rescue with modified ACLS. Limit epinephrine to 1 mcg/kg; avoid vasopressin, calcium channel blockers, beta-blockers and more local anesthetic. Benzodiazepines for seizures; early ECMO referral
- Must Remember
- Start early and track the total: the rate (mL/hr) and the running mL/kg total are the errors to prevent; draw labs before the bolus when it does not delay treatment
Indications
Emergency & Prehospital
- Local anesthetic systemic toxicity (LAST): Seizures, arrhythmias or cardiovascular collapse after local anesthetic injection or absorption. ASRA and AAGBI guidance put lipid emulsion in LAST management. AHA 2023 calls it efficacious in life-threatening LAST, especially with bupivacaine (off-label use).
- Severe lipophilic drug poisoning, refractory to standard care: A last-resort option in life-threatening toxicity, per toxicology protocol. Off-label. The evidence is largely case reports.
ED / ICU / Transport
- Arrest from LAST: Lipid goes alongside modified ACLS, never instead of it. Watch the epinephrine limits under Interactions.
- Lidocaine or bupivacaine toxicity in the ED or OR: once you recognize LAST, you run the same protocol.
Other Uses
- Parenteral nutrition (FDA-labeled): Its only labeled use is as a calorie and essential fatty acid source. LAST and every other rescue use is off-label.
Dosing & Administration
Doses vary by protocol; follow local protocols and medical direction.
Available Forms
- Intralipid 20% (Fresenius Kabi, US): 20 g/100 mL (0.2 g/mL) lipid, in 100, 250 and 500 mL single-dose containers and a 1,000 mL pharmacy bulk package (label)
- EMS / transport: Carry only the 20% concentration. Read the label every time: 10% and 20% emulsions look alike.
High-Alert Medication: Three things go wrong here: the mL/hr rate, the running mL/kg total and the 20% strength. Use a pump. Have a second person check weight, concentration, bolus volume and mL/hr independently before the infusion starts.
Off-Label Rescue Dosing: The label covers parenteral nutrition, not LAST. The LAST protocol runs 0.25 mL/kg/min (15 mL/kg/hr), and the labeled adult PN maximum is 0.5 mL/kg/hr, so the protocol rate sits well past it. Keep the dose in mL/kg, keep a running total, and pass that total to the receiving team.
Adult Dosing
| Indication | Dose & Route | Repeat / Max | Notes |
|---|---|---|---|
| LAST, initial bolus | 1.5 mL/kg of 20% IV over 2–3 min (dosing weight per protocol) | Repeat 1.5 mL/kg if the response is unsatisfactory (protocols differ on the number of repeats) | High-alert Start immediately; do not wait for arrest or for labs. |
| LAST, infusion | 0.25 mL/kg/min IV immediately after the bolus, until hemodynamically stable and for at least 10 min after | Max 10 mL/kg (ACMT protocol) to about 12 mL/kg (ASRA, AAGBI) total. For persistent hypotension, double the rate to 0.5 mL/kg/min (protocol-dependent) | High-alert Record BP and HR every 15 min. ASRA 2020 checklist: continue at least 10 min after circulatory stability (secondary summary; see editorFlags). ACMT variant (2025 review): reduce to 0.025 mL/kg/min after about 3 min if improved. This is one protocol, not the default; do not step down on a timer alone. |
| Lipophilic drug poisoning (off-label) | Same 1.5 mL/kg bolus and 0.25 mL/kg/min infusion, per toxicology protocol | Per protocol; total lipid limit 10–12 mL/kg; no further doses once the limit is reached without medical direction | High-alert Evidence is limited to case series and reports; use only when standard care has failed. 2025 AHA Part 10: may be considered (COR 2b) for refractory beta-blocker or calcium channel blocker shock; may be reasonable for life-threatening sodium channel blocker poisoning refractory to standard care. |
Pediatric Dosing
| Indication | Dose (per kg) & Route | Max Single / Max Total | Notes |
|---|---|---|---|
| LAST, bolus and infusion | 1.5 mL/kg IV over 2–3 min, then 0.25 mL/kg/min (adult mL/kg protocol, extrapolated) | Single bolus 1.5 mL/kg; total 10–12 mL/kg per protocol (no separate pediatric maximum in the sources checked) | Off-label. The label caps pediatric PN infusions at 0.75 mL/kg/hr for all ages through 17 years (DailyMed), far below the LAST rate; follow pediatric toxicology and medical direction. |
| Neonates and infants | Not established for LAST | — | The label warns of fat overload and pediatric ARDS in neonatal PN; use only under specialist direction. |
Pediatric Note: The primary sources gave no pediatric LAST dose apart from the adult weight-based protocol. Only one pediatric source was reviewed: a 2013 review of 14 published case reports. It covers several drug toxicities rather than LAST alone (Presley and Chyka). See weight-based dosing and medical direction.
Preparation & Administration
- Dilution: none; give undiluted 20% emulsion
- Push rate: bolus over 2–3 min; infusion by pump at the calculated mL/hr (0.25 mL/kg/min = 15 mL/kg/hr)
- Line: a dedicated or clearly labeled line; do not add other drugs to the emulsion
- Blood samples: draw labs before the bolus when this does not delay treatment (see Monitoring)
- Pump: required for the infusion; calculate the mL/hr before starting
Contraindications & Precautions
Contraindications
- Known hypersensitivity to egg, soybean or peanut protein, or any ingredient (product label). In life-threatening LAST, this is a risk-benefit decision. It is not a hold.
- Severe disorders of lipid metabolism with serum triglycerides above 1,000 mg/dL (product label, for nutrition use)
- No absolute contraindication in life-threatening LAST: The labeled contraindications apply to nutrition use. In toxicity, the decision follows protocol and medical direction.
Precautions
- Pancreatitis: High triglycerides can trigger acute pancreatitis. The label lists this as a clinical consequence.
- Fat and volume overload: A high cumulative volume (the 10–12 mL/kg total limit) raises the risk.
- Extracorporeal circuits: Lipid can clog VA-ECMO filters. That has been reported with beta-blocker or calcium channel blocker toxicity.
- Pulmonary: Bronchospasm and ARDS have been reported. Watch oxygenation.
Hold / Reassess If
- Circulatory collapse or arrest: Never delay the bolus or ongoing lipid for a lab result.
- After stabilization, triglycerides above 400 mg/dL (adults, PN label): Reassess the infusion with medical direction. The label says to stop.
- Total dose at 10 mL/kg (ACMT) to about 12 mL/kg (ASRA, AAGBI): Stop routine lipid unless medical direction decides otherwise.
- Hemodynamics: Reassess BP and HR every 15 min. If MAP falls despite lipid, that calls for ACLS. It does not call for more lipid alone.
- Abdominal pain or raised amylase or lipase: Stop. Check triglycerides and work up for pancreatitis.
No Boxed Warning, but Hard Limits: The product label carries no boxed warning. Two rules still apply: the total-dose limit, and the 400 mg/dL triglyceride reassessment after stabilization. Neither one delays a life-saving bolus in LAST.
Adverse Effects & Toxicity
Common
- Laboratory interference: Lipemic serum changes several assays. The label names hemoglobin, LDH, bilirubin and oxygen saturation.
- Hyperamylasemia: Seen in prospective and retrospective data.
- Hypertriglyceridemia: Expected with a high total dose. If the course runs long, check the levels.
Serious / Life-Threatening
| Effect | Recognition | Management |
|---|---|---|
| Acute pancreatitis | Epigastric pain, raised lipase or amylase, high triglycerides | Stop infusion; triglycerides and pancreatitis care |
| Fat overload | Rising triglycerides, hypoxia, fat embolism signs | Stop lipid; support oxygenation and ventilation |
| Bronchospasm | Wheezing, rising airway pressure | Stop lipid; standard bronchospasm care |
| ARDS | Hypoxemia with bilateral infiltrates (case reports) | Lung-protective ventilation; ICU care |
Overdose & Toxicity Management
- Signs: Lipid excess shows up as rising triglycerides, pancreatitis, hypoxemia or lab errors. None of these means the treatment failed.
- LAST seizures: Benzodiazepines are first-line for LAST seizures (ASRA). See midazolam or lorazepam. Propofol does not replace lipid for seizures (see Interactions).
- Airway: Secure the airway early and give high-flow oxygen. Airway support and early lipid are both priorities (ASRA).
- Lipid complications: Stop the infusion. Check triglycerides. Treat per complication.
- Antidote: None. Lipid is the rescue itself. For the poison, follow the toxicology protocol.
Monitoring
| Parameter | When / How Often | Target / Act If |
|---|---|---|
| Clinical | Every 15 min during infusion | BP, HR and rhythm; if worse, continue ACLS and protocol steps |
| Laboratory: triglycerides | Before the course if possible, then as the course runs long | Above 400 mg/dL (adults, PN label): reassess after stabilization; never delay the bolus or lipid in arrest for this result |
| Laboratory: pre-lipid draw | Before the bolus, when it does not delay treatment | Lipid interferes with many assays; if the sample is lipemic, centrifuge and send for re-testing |
| Laboratory: lipase or amylase | If abdominal pain or hyperamylasemia | Rising values with pain: stop lipid and treat as pancreatitis |
| Oxygenation | Continuous pulse oximetry and EtCO₂ | Falling SpO₂ or rising EtCO₂: support airway and ventilation |
| Volume | Running total at each handoff | Approaching 10 mL/kg (ACMT) or 12 mL/kg (ASRA, AAGBI): call medical direction before further lipid |
| Recurrence after recovery | Observe for a prolonged period after the last seizure or instability | At least 2 h after seizures; 4–6 h after cardiovascular instability (ASRA, as cited in a 2021 review) |
Draw the labs the infusion will skew (hemoglobin, LDH, bilirubin, saturation) at least 6 hours after it stops. Otherwise, read them with the lipemia in mind (label).
Interactions & Compatibility
Clinically Significant Interactions
| Drug / Class | Effect | What To Do |
|---|---|---|
| Epinephrine | Hyperlactatemia and acidosis may reduce lipid response (animal data) | ASRA limits epinephrine to 1 mcg/kg during LAST; start small |
| Vasopressin | Hyperlactatemia and acidosis may inhibit lipid-mediated resuscitation (animal data) | Avoid during LAST (ASRA) |
| Calcium channel blockers | Myocardial depression and hypotension | Avoid during LAST (ASRA) |
| Beta-blockers | Bradycardia and myocardial depression | Avoid during LAST (ASRA) |
| Further local anesthetics | Additive cardiotoxicity and CNS toxicity | Avoid during LAST (ASRA) |
| Propofol | Not a lipid substitute: it does not reverse LAST, causes hypotension, and adds lipid load | Do not use as a lipid substitute; avoid in hemodynamic instability (ASRA). Benzodiazepines are first-line for seizures |
| Parenteral nutrition lipids | Additive triglyceride load | Reduce or hold other lipids while on rescue doses; dietitian involved |
IV Compatibility
- Do not mix other drugs into the emulsion. Use a dedicated or clearly labeled line.
- Look-alike: Propofol and clevidipine are milky-white too. Label them separately.
Check an institutional compatibility resource.
Special Populations
- Pediatrics: Off-label. Work from the Pediatric Dosing table. The PN label limits children's infusion rates and warns about fat overload in neonates.
- Neonates: The PN label warns of fat overload, pediatric ARDS and jaundice. Avoid for LAST outside specialist direction.
- Pregnancy: No pregnancy-specific LAST data turned up in the sources checked. Standard lipid dosing applies. In obstetric arrest, follow AHA pregnancy guidance alongside lipid: manual left uterine displacement and an early decision on perimortem delivery.
- Lactation: No specific adjustment is established.
- Older Adults: No specific adjustment is established. Cardiac disease raises the risk of volume overload.
- Renal Impairment: No specific adjustment is established in the sources checked.
- Hepatic Impairment: The label lists hepatic risks of PN. Monitor closely. No dose change is established.
- Obesity / Dosing Weight: The protocol runs on weight in mL/kg. The sources checked do not settle actual, ideal or lean weight. So follow local protocol, state the weight used and show the mL total. A secondary summary of the ASRA checklist gives a 100 mL bolus for patients over 70 kg. A 70 kg adult at 1.5 mL/kg is 105 mL.
Field & Transport Considerations
- Scope: Varies by state and agency protocol. Paramedics and critical-care transport teams usually carry the bolus and infusion.
- Storage & Stability: Follow the product label. Do not use it if the emulsion has separated or looks abnormal.
- Carried Concentration: 20% only. Confirm concentration and volume on the container.
- Infusions in Transport: Set the pump's mL/hr before departure. Plan the supply. A 70 kg adult needs 105 mL for a 1.5 mL/kg bolus. Total supply runs up to 700 mL at 10 mL/kg, or 840 mL at 12 mL/kg.
- Handoff Essentials: time started, total mL/kg given, current mL/hr, last triglyceride result, response of BP, HR and rhythm
Clinical Pearls
Give It Early: Case series show improvement in LAST often comes within seconds to minutes of starting lipid. Don't wait for arrest.
Draw Labs First: Lipid makes many lab results unreadable. Draw before the bolus, if that doesn't delay treatment. A lipemic sample has to be re-tested.
Off-Label Rate vs PN Label: The labeled adult PN infusion maximum is 0.5 mL/kg/hr. LAST runs at 0.25 mL/kg/min (15 mL/kg/hr). That 30-fold gap comes from toxicology protocol, not from the label.
Exam Discriminator: The AHA 2023 focused update, as a 2025 review quotes it, says lipid “can be efficacious” in life-threatening local anesthetic toxicity, especially bupivacaine. Routine use is not advised for beta-blocker or calcium channel blocker poisoning. For refractory sodium channel blocker poisoning, it may be reasonable.
Propofol Is Not a Lipid Substitute: Propofol does not reverse LAST, and it can worsen hypotension. For LAST seizures, benzodiazepines are first-line (ASRA). Lipid is what treats the collapse.
Pharmacology
Mechanism of Action
- Proposed lipid sink: The lipophilic drug partitions into the infused lipid phase. That lowers free drug at the heart and brain.
- Proposed direct effects: Fatty acids may support contractility through myocardial and metabolic effects. The evidence comes from animal and case data.
- Clinical consequence: Hemodynamics and consciousness recover in LAST case series. There are no controlled human trials.
Onset, peak and duration after infusion were not established in the sources checked. This page doesn't state them.
- Metabolism: Lipid is handled like dietary fat. Clearance depends on lipoprotein lipase activity and falls in severe hypertriglyceridemia.
- Protein binding / Vd: not applicable
Names & Classification
- Generic Name
- Lipid injectable emulsion, 20%
- Brand Names
- Intralipid (US, Fresenius Kabi)
- Pharmacologic Class
- Parenteral lipid emulsion
- Therapeutic Class
- Parenteral nutrition; off-label toxicity rescue
- Controlled Substance
- Not controlled
- ISMP High-Alert
- Yes: ISMP high-alert medication (parenteral nutrition preparations, ISMP acute-care list); the rate and total-volume risks are covered in Dosing
- Look-Alike / Sound-Alike
- No name pair commonly reported; milky-white look-alikes (propofol, clevidipine)
References
- Fresenius Kabi USA. (2025). INTRALIPID (lipid injectable emulsion 20%): prescribing information. DailyMed, label revised 08/2025. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=61e025f1-a38e-4af2-9e18-13ea12977cf5
- Lavonas EJ, Akpunonu PD, Arens AM, et al. (2023). 2023 AHA focused update on cardiac arrest or life-threatening toxicity due to poisoning. Circulation. https://doi.org/10.1161/CIR.0000000000001161
- American Heart Association. (2025). Part 10: Adult and Pediatric Special Circumstances of Resuscitation: 2025 AHA Guidelines for CPR and ECC. Circulation, S578–S672. https://doi.org/10.1161/CIR.0000000000001380
- Neal JM, et al. (2018). The third American Society of Regional Anesthesia and Pain Medicine practice advisory on local anesthetic systemic toxicity: executive summary 2017. Reg Anesth Pain Med. 43(2):113–123. https://doi.org/10.1097/AAP.0000000000000720
- Presley JD, Chyka PA. (2013). Intravenous lipid emulsion to reverse acute drug toxicity in pediatric patients. Ann Pharmacother. 47(5):735–743. https://doi.org/10.1345/aph.1R666
- Use of intravenous lipid emulsions in drug-induced toxicities: a 2025 narrative review. (2025). Ann Intensive Care, article 181. https://doi.org/10.1186/s13613-025-01601-5
- Liu Y, Zhang J, Yu P, Niu J, Yu S. (2021). Mechanisms and efficacy of intravenous lipid emulsion treatment for systemic toxicity from local anesthetics. Front Med; article 756866. Reviews the ASRA 2020 checklist and AAGBI guidance. https://doi.org/10.3389/fmed.2021.756866
Medical Disclaimer
- For Educational Purposes Only: This content is intended for educational reference and should not be used for clinical decision-making.
- Not a Substitute for Professional Judgment: Always consult your local protocols, institutional guidelines, and supervising physicians.
- Verify Before Acting: Users are responsible for verifying information through authoritative sources before any clinical application.
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