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Intravenous lipid emulsion for intentional Chloroquine poisoning

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Haesendonck Ruben at Ziekenhuis Oost Limburg
Haesendonck Ruben
Sabrina de Winter
Sabrina de Winter
Sabrina de Winter
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Sandra JJ Verelst at KU Leuven
Sandra JJ Verelst
Marc Sabbe at Universitair Ziekenhuis Leuven
Marc Sabbe
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Clinical Toxicology
ISSN: 1556-3650 (Print) 1556-9519 (Online) Journal homepage: http://www.tandfonline.com/loi/ictx20
Intravenous lipid emulsion for intentional
Chloroquine poisoning
Ruben Haesendonck, Sabrina de Winter, Sandra Verelst & Marc B Sabbe
To cite this article: Ruben Haesendonck, Sabrina de Winter, Sandra Verelst & Marc B Sabbe
(2012) Intravenous lipid emulsion for intentional Chloroquine poisoning, Clinical Toxicology,
50:3, 223-223, DOI: 10.3109/15563650.2011.653488
To link to this article: http://dx.doi.org/10.3109/15563650.2011.653488
Published online: 29 Feb 2012.
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223
Intravenous lipid emulsion for intentional
Chloroquine poisoning
To the Editor:
Intravenous lipid emulsion (ILE) has successfully been used in
local anesthetic toxicity and in poisonings with several other li-
pophilic drugs.
1 There is evidence supporting the use of ILE for
cardiotoxic effects due to poisonings with lipophilic agents. Until
now, data on the use of ILE for Chloroquine poisoning has been
limited. Chloroquine poisoning is exceptional, but with potentially
fatal consequences.
2 Two cases were described with little or no
bene t attributed to ILE.
3 In one case ILE therapy was initiated
more than 11 h post-ingestion. The other case describes ingestion
of 20 g of Hydroxychloroquine, a dose that greatly diminishes any
chance of survival. The lipophilic character of Chloroquine implies
the ef cacy of ILE for this type of poisoning.
We treated a 24-year-old male for voluntary ingestion of sev-
eral drugs including a high dose of Chloroquine. The ambulance
crew found him unconscious on the  oor. Ingestion of 58 tablets
of Chloroquine 250 mg, 20 tablets of Midazolam 7.5 mg, 5 tab-
lets of Domperidon 10 mg and 10 tablets of Ondansetron 4 mg
were suspected, and the time of ingestion was unknown. Clinical
exam revealed a Glasgow Coma Scale (GCS) of 6/15 (E1V1M4),
normal breathing, a junctional rhythm and a blood pressure of
70/40 mmHg. A rapid evolution to ventricular  brillation (VF)
occurred and resuscitation was initiated. The evacuation of the
patient out of his  at required  re  ghter assistance, resulting in
a long “ at the scene time ” of approximately 1 h, during which
standard advanced life support (ALS) was continued using a Lund
University cardiac arrest system (LUCAS) device.
At arrival in the emergency department (ED), pulseless electri-
cal activity (PEA) was observed. Active charcoal was given through
a gastric tube. Infusion of 500 ml Human Albumin 5% was started
in addition to standard volume resuscitation and ILE treatment
was also initiated. A bolus of Intralipid 20% was administered
in the dosage of 1.5 ml/kg followed by a continuous infusion of
0.25 ml/kg/min.
We observed an evolution of PEA to a shockable rhythm for
which a DC shock of 200 J was administered. Conversion to
sinus rhythm was reached for the  rst time. Blood pressure rose to
120/90 mmHg. After about 10 minutes, however, a recurrent ven-
tricular tachycardia (VT) occurred for which again a DC shock of
200 J was given, with no response.
At this point an arterial blood sample demonstrated an inad-
equate oxygenation despite 100% oxygen administration. Given
the prolonged resuscitation with only short-term bene cial he-
modynamic effect, a veno-arterial extracorporeal membrane
oxygenation (ECMO) was installed. Hereafter he was delivered to
the intensive care unit. Over the following days the hemodynamic
situation stabilized gradually, but the patient was declared brain
dead after 5 days.
Chloroquine is a highly lipophilic substance having a lipid/
aqueous partition coef cient (log P 4.3) that is comparable to that of
local anesthetics, thus ILE seemed justi ed because standard resus-
citation was insuf cient.4 Moreover, Chloroquine has an extremely
high volume of distribution, due to ion trapping (pKa ⫽ 10.3).
Stabilization of hemodynamic parameters and conversion to
sinus rhythm occurred within minutes after initiation of ILE
therapy. The irreversible neurologic damage was a result of the
prolonged resuscitation.
There was no interference with the ECMO therapy. Blood
sample analysis, however, did pose a problem, speci cally for
determining the coagulation parameters.
ILE therapy for poisonings with lipophilic substances, other
than local anesthetics, is still under debate. However, we strongly
support the use in distinct cases of life-threatening poisonings
with lipophilic drugs, such as Chloroquine. This case adds to
the increasing series of case reports on ILE therapy for speci c
poisonings.
Ruben Haesendonck
Faculty of Medicine, Catholic University of Leuven,
Department of Emergency Medicine,University Hospitals,
Herestraat 49, Leuven, Belgium
Sabrina De Winter
Pharmacy Department, University Hospitals, Herestraat 49,
Leuven, Belgium
Sandra Verelst and Marc B. Sabbe
Department of Emergency Medicine, University
Hospitals, Herestraat 49, Leuven, Belgium
References
Jamaty C, Bailey B, Larocque A, Notebaert E, Sanogo K, Chauny JM. 1.
Lipid emulsion in the treatment of acute poisoning: A systemic review
of human and animal studies. Clin Tox 2010;48:1 – 27.
Clemessy JL, Taboulet P, Hoffman JR, Hantson P, Barriot P, Bismuth 2.
C, Baud FJ. Treatment of acute chloroquine poisoning: a 5-year
experience. Crit Care Med 1996;24:1189 – 1195.
Wong OF, Chan YC, Lam SK, Fung HT, Ho JKY. From 2 cases, ILE is 3.
not effective in reversing the cardiotoxic effects of hydroxychloroquine
and chloroquine overdose. Hong Kong J Emerg Med 2011; 18:
243 – 248.
French D, Smollin C, Ruan W, Wong A, Drasner K, Wu AHB. Partition 4.
constant and volume of distribution as predictors of clinical ef cacy
of lipid rescue for toxicological emergencies. Clin Tox 2011;49:
801 – 809.
Clinical Toxicology (2012), 50, 223
Copyright © 2012 Infor ma Healthcare USA, Inc.
ISSN: 1556-3650 print / 1556-9519 online
DOI : 10. 3109/15563 650 .2011.6534 88
LETTER TO THE EDITOR
Received 16 December 2011; accepted 21 December 2011.
Address correspondence to Prof. Marc B Sabbe, MD PhD, University
Hospitals, Dept of Emergency Medicine, Herestraat 49, Leuven, 3000
Belgium. E-mail: marc.sabbe@uzleuven.be
Downloaded by [107.175.216.135] at 12:51 19 December 2015
... 114 Owing to the lipophilicity of aminoquinolines, there are several reports of successful outcomes following ILE use. 22,46,118,119 Recommended ILE treatment is 1.5 mL/kg lean body mass (~100mL in adults) as bolus over two to three minutes followed by 200 mL over 10-15 minutes. 22 If benefit is seen in vital signs and/or ECG parameter normalization, slower continuous infusion of ~0.25 mL/kg/min can be administered until resolution of toxicity. ...
... 22 Protracted ILE has been associated with dysfunction of ECMO circuits, though this is unlikely in short-term ILE use (<24 hours continuous infusion), and case reports have described safe concomitant use of both modalities. 118,120 Serum triglyceride levels may be monitored to guide ILE extent of infusion, with ~1000 mg/dL as a lipid volume limit of efficacy. 121 ...
Acute chloroquine and hydroxychloroquine toxicity: A review for emergency clinicians
Article
  • Jul 2020
  • AM J EMERG MED
Background Acute chloroquine and hydroxychloroquine toxicity is characterized by a combination of direct cardiovascular effects and electrolyte derangements with resultant dysrhythmias and is associated with significant morbidity and mortality. Objective This review describes acute chloroquine and hydroxychloroquine toxicity, outlines the complex pathophysiologic derangements, and addresses the emergency department (ED) management of this patient population. Discussion Chloroquine and hydroxychloroquine are aminoquinoline derivatives widely used in the treatment of rheumatologic diseases including systemic lupus erythematosus and rheumatoid arthritis as well as for malaria prophylaxis. In early 2020, anecdotal reports and preliminary data suggested utility of hydroxychloroquine in attenuating viral loads and symptoms in patients with SARS-CoV-2 infection. Aminoquinoline drugs pose unique and significant toxicological risks, both during their intended use as well as in unsupervised settings by laypersons. The therapeutic range for chloroquine is narrow. Acute severe toxicity is associated with 10–30% mortality owing to a combination of direct cardiovascular effects and electrolyte derangements with resultant dysrhythmias. Treatment in the ED is focused on decontamination, stabilization of cardiac dysrhythmias, hemodynamic support, electrolyte correction, and seizure prevention. Conclusions An understanding of the pathophysiology of acute chloroquine and hydroxychloroquine toxicity and available emergency treatments can assist emergency clinicians in reducing the immediate morbidity and mortality associated with this disease.
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... Due to the large volume of distribution of chloroquine, there is some thought that intralipid infusion may have benefit; however, this therapy has not been shown to be effective. 15 The couple reported that they each consumed a single "heaping" teaspoon of chloroquine; however, the precise amount of ingested product is unknown. Since the wife developed recurrent emesis, she likely absorbed less chloroquine, had lower peak serum concentrations, and was at lower risk for developing cardiac dysrhythmias. ...
Chloroquine Ingestion to Prevent SARS-CoV-2 Infection: A Report of Two Cases
Article
Full-text available
  • May 2021
Introduction: Amid the global pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), chloroquine and hydroxychloroquine were being studied as agents to prevent and treat coronavirus disease 2019. Information about these agents and their effects circulated throughout the general public media, raising the concern for self-directed consumption of both pharmaceutical and non-pharmaceutical products. Case report: We present two cases of chloroquine toxicity that occurred after ingestion of an aquarium disinfectant that contained chloroquine phosphate in a misguided attempt to prevent infection by SARS-CoV-2. One patient had repeated emesis and survived, while the other was unable to vomit, despite attempts, and suffered fatal cardiac dysrhythmias. Conclusion: These cases illustrate the spectrum of toxicity, varied presentations, and importance of early recognition and management of chloroquine poisoning. In addition, we can see the importance of sound medical guidance in an era of social confusion compounded by the extremes of public and social media.
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... Another report describes two fatal cases of hydroxychloroquine poisoning in which the use of ILE was not successful [32]. One report of chloroquine poisoning mentions the administration of ILE after a long (prehospital) reanimation, after which there was return of spontaneous circulation [33]. But subsequently extracorporeal membrane oxygenation was installed and 5 days later, the patient was declared brain dead. ...
Nearly Fatal Hydroxychloroquine Overdose Successfully Treated with Midazolam, Propofol, Sodium Bicarbonate, Norepinephrine, and Intravenous Lipid Emulsion
Article
Full-text available
  • Apr 2021
Background: In the context of the current COVID-19 pandemic, there has been renewed interest in the drug hydroxychloroquine. However, clinicians should be aware of the dangers of hydroxychloroquine intoxication, an insufficiently studied condition. Case Report. We present a case of autointoxication with 20 g hydroxychloroquine in a 35-year-old woman. Cardiac monitoring showed ventricular arrhythmias for which high-dose midazolam and propofol were initiated, resulting in a brief normalization of the cardiac rhythm. Because of the reoccurrence of these arrhythmias, intravenous lipid emulsion was administered with fast cardiac stabilization. Treatment with continuous norepinephrine, potassium chloride/phosphate, and sodium bicarbonate was initiated. On day 6, she was extubated and after 11 days, she was discharged from the hospital without complications. Conclusion: Since high-quality scientific evidence is lacking, treatment options are based on experience in chloroquine toxicity. Activated charcoal is advised if the patient presents early. Sedation with diazepam, early ventilation, and continuous epinephrine infusion are considered effective in treating severe intoxication. Caution is advised when substituting potassium. Despite the lack of formal evidence, sodium bicarbonate appears to be useful and safe in case of QRS widening. Intravenous lipid emulsion, with or without hemodialysis, remains controversial but appears to be safe. As a last resort, extracorporeal life support might be considered in case of persisting hemodynamic instability.
View
... Published reports of ILE therapy are constantly extending and have already included cases of several lipophilic drugs, such as antiarrhythmic agents [59][60][61][62][63] , the first-generation antihistamine diphenhydramine 64 , anti-malarial medications chloroquine and hydroxychloroquine 65,66 and a recent case of caffeine intoxication 67 . ...
Intravenous lipid emulsion as an antidote in clinical toxicology: a systematic review
Article
Full-text available
  • Jun 2020
  • EUR REV MED PHARMACO
OBJECTIVE: Intravenous lipid emulsions (ILE) were developed many decades ago to supply nutritional requirements to patients unable to obtain adequate enteral nutrition. The utility of ILE was extended to therapeutics, facilitating the delivery of drugs. More recently, the potential for ILE to act as an antidote for inversion of drug toxicity has been recognized. This review aims to summarize the literature on ILE therapy as an antidote. Suggested mechanisms of action, safety profile, and recommendations on the administration of ILE in cases of drug intoxication are highlighted. MATERIALS AND METHODS: A complete literature survey was performed using the PubMed database search to collect available information regarding mechanisms of ILE action as an antidote, ILE administration for drug toxicity, and presentation of adverse events. RESULTS: A total of 102 studies met the selection criteria for inclusion in the review. Mainly used for local anesthetics toxicity, ILE therapy has been expanded in clinical toxicology involving overdose treatment of drugs other than local anesthetics. Partitioning in a lipid phase of fat droplets is a mechanism named the lipid sink phenomenon that has primarily been described to explain this action of ILE and remains the most widely accepted. At the same time, recent research has also revealed several molecular mechanisms that may contribute to ILE efficacy. CONCLUSIONS: ILE therapy comprises a recognized approach in clinical toxicology. Due to the lack of randomized clinical trials, recommendations on administration are based on animal studies and published cases. Thus, the constantly increased knowledge about ILE therapy supports the need for a detailed appraisal.
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... One report presents temporary return of spontaneous circulation in cardiac arrest due to chloroquine poisoning after administering ILE 20% (1.5 ml/kg bolus followed by 0.25 ml/kg/min infusion) in one patient. 7 Two other patients were successfully treated with the same dosing regimen of ILE within two hours after suicide attempts with hydroxychloroquine. Both patients were concurrently treated with sodium bicarbonate and diazepam, and vasopressor agents were used in one of them. ...
Cardiac arrest following chloroquine overdose treated with bicarbonate and lipid emulsion
Article
Full-text available
  • Jun 2019
We describe a 27-year-old female with repeated episodes of pulseless electrical activity due to intoxication with a substance that was unidentified at presentation. Severe QRS widening was observed and empiric treatment with sodium bicarbonate and intravenous lipid emulsion was administered. In this case, intraosseous administration of lipid emulsion failed to improve haemodynamic parameters, suggesting that this dose remained in the bone marrow compartment. We recommend that physicians become aware of this possibility and to avoid intraosseous administration of lipid emulsion.
View
Massive Nonfatal Hydroxychloroquine Ingestion in a Pediatric Patient
Article
  • Jan 2022
  • J EMERG MED
Background Hydroxychloroquine overdose is rare but potentially lethal. Hydroxychloroquine overdose symptoms are characterized by central nervous system toxicity, cardiac toxicity, and hypokalemia. Recommended treatment consists of epinephrine, high-dose diazepam, and careful potassium repletion. Few pediatric hydroxychloroquine overdoses have been reported. Case Report We describe a 14-year-old girl who ingested 10 g (172 mg/kg) of hydroxychloroquine. She developed tachycardia, hypotension, and hypokalemia. She was intubated and treated with diazepam and epinephrine infusions and potassium supplementation. Her serum hydroxychloroquine concentration obtained 10 h after ingestion was 13,000 ng/mL (reference range 500–2000 ng/mL). The patient made a full medical recovery. Why Should an Emergency Physician Be Aware of This? Pediatric hydroxychloroquine overdoses are reported rarely, and the toxic and lethal doses of hydroxychloroquine ingestion have not been established. This case of a teenaged patient who ingested 10 g of hydroxychloroquine and survived provides additional information that may be used to help establish toxic and lethal doses of ingestion.
View
View
Literature review of the evidence regarding intravenous lipid administration in drug-induced cardiotoxicity
Article
  • May 2019
Introduction Intravenous lipid emulsion (ILE) administration is capable of reversing the acute cardiac and neurological toxicity caused by local anaesthetic agents. In recent years, ILE has also been explored as a potential antidote for cardiotoxicity caused by non-anaesthetic agents too. Areas covered The potential mechanisms, safety and efficacy of this approach are considered. Data were sought from published reports listed in PubMed and EMBASE, and abstracts of meetings of the North American Congress of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxicologists. There were reports involving 298 patients where ILE has been administered for severe drug toxicity. Clinical improvement was observed in 57 of 59 patients with local anaesthetic toxicity (96.6%); there were 239 patients where toxicity was due to non-anaesthetic agents, and ILE apparently improved clinical outcome in 215 (72.1%). Expert opinion Response rates were similar between ILE treated toxicity caused by lipid soluble and non-lipid soluble drugs. Potential adverse effects of ILE include interference with laboratory assays, acute pancreatitis, and adult respiratory distress syndrome, although the rate of occurrence is difficult to ascertain.
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Pharmacological and mechanical management of calcium channel blocker toxicity
Article
Full-text available
  • Aug 2018
Cardiovascular instability associated with calcium channel blocker toxicity comprises a small percentage of overdose presentations, yet they are associated with a high mortality rate. We detail the management of a 64-year-old man who took an intentional overdose of 840 mg nimodipine. We include the treatment he received and highlight the scarcity of evidence behind the use of gastric decontamination, calcium, glucagon, intravenous lipid emulsion, high-dose insulin therapy, sodium bicarbonate, vasopressors and methylene blue in calcium channel blocker toxicity. additionally, the article explores the use of electrical pacing and venoarterial extracorporeal membrane oxygenation (Va-eCMo). Following successful weaning of Va-eCMo, the patient was successfully extubated but remained neurologically impaired due to hypoxic-ischaemic brain injury, critical care polyneuropathy and renal failure requiring dialysis. He has cerebral performance category 3; he has mild cognitive impairment but able to perform some activities of daily living independently and communicate his thoughts and needs. He requires no respiratory or cardiovascular support.
View
Chloroquine and Quinine
Chapter
  • Jun 2017
Chloroquine is used to prevent and treat malaria in limited geographical areas (e.g., Central America and the Far East) and to manage immunological disorders such as systemic lupus erythematosus and rheumatoid arthritis. It represents the most severe and frequent cause of poisoning by any antimalarial drug.
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Treatment of acute chloroquine poisoning: A 5-year experience
Article
Full-text available
  • Jul 1996
  • CRIT CARE MED
To describe various aspects of prognostic and therapeutic importance in patients treated for acute chloroquine poisoning. Retrospective study. Toxicology intensive care unit (ICU) of a university hospital. None. One hundred sixty-seven consecutive patients with acute chloroquine overdose admitted to our toxicology ICU. The mean amount ingested by history was 4.5 +2- 2.8 g. and 43 (26%) of 167 patients ingested > 5 g. The mean blood chloroquine concentration on admission was 20.5 +/- 13.4 mumol/L The majority (87%) of our patients received at least one arm of a combination therapy regimen (epinephrine, mechanical ventilation, diazepam). cardiac arrest occurred in 25 patients before hospital arrival; In seven of these patients, cardiac arrest occurred immediately after injection of thiopental. The mortality rate was 8.4% overall, and was 9.3% in patients with massive ingestions (NS vs. the group as a whole). We did not find a meaningful correlation between the amount ingested as estimated by history and the peak blood chloroquine concentration; the latter was highly correlated with the mortality rate. The mortality rate in patients with acute chloroquine poisoning, including those patients sick enough to be referred to a specialty unit such as ours, can be limited to < or = 10%. This finding appears to be true even in patients with massive ingestions. We were not able to correlate mortality with amount ingested by history, although the mortality rate does correlate with blood chloroquine concentration. While early use of diazepam, epinephrine, and mechanical ventilation in most of our patients may have contributed to the excellent overall results, these elements, either singly or in combination, do not appear to have a truly antidotal effect in acute chloroquine poisoning. Thiopental, on the other hand, should be used with great caution, if at all, in such cases.
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Clinical Experience in the Use of Intravenous Lipid Emulsion in Hydroychloroquine and Chloroquine Overdose with Refractory Shock
Article
  • Jul 2011
Hydroxychloroquine overdose is a rare condition and often results in severe cardiovascular toxicities. We report 2 cases of fatal hydroxychloroquine overdose (1 patient had co-ingestion of chloroquine). Both patients developed refractory cardiovascular collapse and cardiac arrest soon after the drug overdose. Both of them were treated with high dose adrenaline and diazepam. However, they deteriorated rapidly despite the treatments. In view of similar toxicological profile of hydroxychloroquine to other lipophilic cardiotoxic medications, intravenous lipid emulsion was given as the last resort but both of them died eventually. Based on the clinical experience from these 2 cases, Intravenous lipid emulsion is not effective in reversing the cardiotoxic effects of hydroxychloroquine and chloroquine overdose.
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Partition constant and volume of distribution as predictors of clinical efficacy of lipid rescue for toxicologic emergencies
Article
  • Nov 2011
  • CLIN TOXICOL
Lipid infusion is useful in reversing cardiac toxicity of local anesthetics, and recent reports indicate it may be useful in resuscitation from toxicity induced by a variety of other drugs. While the mechanism behind the utility of lipid rescue remains to be fully elucidated, the predominant effect appears to be creation of a "lipid sink". Determine whether the extraction of drugs by lipid, and hence the clinical efficacy of lipid rescue in toxicological emergencies can be predicted by specific drug properties. Each drug investigated was added individually to human drug-free serum. Intralipid® was added to this drug-containing serum, shaken and then incubated at 37°C. The lipid was removed by ultracentrifugation and the concentration of drug remaining in the serum was measured by high-pressure liquid chromatography. In this in vitro model, the ability of lipid emulsion to bind a drug was largely dependent upon the drug's lipid partition constant. Additionally, using a multiple linear regression model, the prediction of binding could be improved by combining the lipid partition constant with the volume of distribution together accounting for approximately 88% of the variation in the decrease in serum drug concentration with the administration of lipid emulsion. The lipid partition constant and volume of distribution can likely be used to predict the efficacy of lipid infusion in reversing the cardiac toxicity induced by anesthetics or other medications.
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Lipid emulsions in the treatment of acute poisoning: A systematic review of human and animal studies
Article
  • Jan 2010
  • CLIN TOXICOL
To assess the evidence regarding the efficacy and safety of intravenous fat emulsion (IFE) in the management of poisoned patients. We performed a systematic review of the literature with no time or language restriction. The electronic databases were searched from their inception until June 1, 2009 (Medline, EMBASE, ISI web of science, Biological abstract, LILACS, ChemIndex, Toxnet, and Proquest). We also examined the references of identified articles and the gray literature. The target interventions eligible for inclusion were administration of any IFE before, during, or after poisoning in human or animals. All types of studies were reviewed. Eligibility for inclusion and study quality scores, based on criteria by Jadad and the STROBE statement, were evaluated by independent investigators. The primary outcome was mortality. Secondary outcomes included neurologic, hemodynamic, and electrocardiographic variables, as well as adverse effects. Of the 938 publications identified by the search strategies, 74 met the inclusion criteria. We identified 23 animal trials, 50 human, and 1 animal case reports. Overall, the quality of evidence was weak and significant heterogeneity prevented data pooling. Available data suggest some benefits of IFE in bupivacaine, verapamil, chlorpromazine, and some tricyclic antidepressants and beta-blockers toxicity. No trial assessed the safety of IFE in the treatment of acute poisoning. The evidence for the efficacy of IFE in reducing mortality and improving hemodynamic, electrocardiographic, and neurological parameters in the poisoned patients is solely based on animal studies and human case reports. The safety of IFE has not been established.
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From 2 cases, ILE is 3. not effective in reversing the cardiotoxic effects of hydroxychloroquine and chloroquine overdose
  • Jan 2011
  • 243-248
  • O F Wong
  • Y C Chan
  • S K Lam
  • H T Fung
  • Jky Ho
Wong OF, Chan YC, Lam SK, Fung HT, Ho JKY. From 2 cases, ILE is 3. not effective in reversing the cardiotoxic effects of hydroxychloroquine and chloroquine overdose. Hong Kong J Emerg Med 2011; 18: 243 -248.
ISSN: 1556-3650 print / 1556-9519 online DOI: 10.3109/15563650.2011.653488 LETTER TO THE EDITOR Received 16 Address correspondence to Prof E-mail: marc.sabbe@uzleuven.be Clinical Toxicology Downloaded from informahealthcare
  • Jan 2012
  • © Copyright
  • Informa Usa Healthcare
  • Inc
Copyright © 2012 Informa Healthcare USA, Inc. ISSN: 1556-3650 print / 1556-9519 online DOI: 10.3109/15563650.2011.653488 LETTER TO THE EDITOR Received 16 December 2011; accepted 21 December 2011. Address correspondence to Prof. Marc B Sabbe, MD PhD, University Hospitals, Dept of Emergency Medicine, Herestraat 49, Leuven, 3000 Belgium. E-mail: marc.sabbe@uzleuven.be Clinical Toxicology Downloaded from informahealthcare.com by Mcgill University on 10/30/14 For personal use only.
E-mail: marc.sabbe@uzleuven.be
  • Belgium
Belgium. E-mail: marc.sabbe@uzleuven.be
Partition 4. constant and volume of distribution as predictors of clinical effi cacy of lipid rescue for toxicological emergencies
  • Jan 2011
  • 801-809
  • D French
  • C Smollin
  • W Ruan
  • A Wong
  • K Drasner
  • Ahb Wu
French D, Smollin C, Ruan W, Wong A, Drasner K, Wu AHB. Partition 4. constant and volume of distribution as predictors of clinical effi cacy of lipid rescue for toxicological emergencies. Clin Tox 2011;49: 801 -809.