Another successful use of lipid rescue..
There is another nice success of lipid administration in the literature, this time in the articles in press section of The Journal of Emergency Medicine. The offending drug was a TCA, dothiepin, and the patient came in very sick.
The time course of the patient care is pretty compelling case for the cause and effect relationship of the lipid making the patient better, and it seems like an appropriate usage of the rescue therapy.
I have a couple of issues with how this case and discussion were presented. The first is that there was scant discussion of lipid solubility, what that means, and the maybe more concise parameters of the octanol/water coefficients of log P and log D. It’s possible that they were severely limited on writing space, as often happens in case reports, so they can get an easy pass on this one. The second issue, and this one is the slightly more annoying one, is that at multiple points in the case presentation and discussion they reference giving sodium bicarbonate, and each time they insinuate that the only reason for its administration is for the bicarbonate portion of it to alkalinize the patient. They don’t reference the huge QRS (they include an ECG, and the QRS is really big) and they don’t make reference to attempting to narrow the QRS with the sodium portion of the sodium bicarb. Sodium bicarb in this setting certainly can transiently correct some acidemia, and that’s helpful because of the protein-binding implications (as the blood pH goes down, the protein binding goes down, leading to more free TCA circulating in the patient), but immediately after administration the more important effect is the QRS narrowing.