Use of intravenous lipid emulsions in drug-induced toxicities: a 2025 narrative review

Intravenous lipid emulsions (ILE) were first proposed in 1998 as a treatment for bupivacaine-induced cardiac arrest. Since then, their use has expanded to include poisonings by various lipophilic drugs such as tricyclic antidepressants, calcium channel blockers, and antipsychotics. This 2025 narrative review explores the evolving pathophysiological mechanisms of ILE therapy, including the lipid sink and lipid shuttle theories, as well as non-scavenging cardiotonic effects such as membrane stabilization, mitochondrial support, and modulation of vascular tone. It summarizes recent findings from randomized controlled trials, cohort studies, animal models, and case registries. While clinical trials demonstrate potential benefits—particularly in tramadol, clozapine, and organophosphate poisonings—mortality reduction remains unproven, and evidence is limited by study heterogeneity and low methodological quality. Adverse effects, although rare, include acute pancreatitis, interference with laboratory testing, and fat overload syndrome, especially at high infusion volumes. Current guidelines recommend ILEs as a first-line treatment for local anesthetic systemic toxicity and as a second-line option in life-threatening poisonings involving other lipophilic agents. However, significant uncertainty remains regarding optimal indications, dosing strategies, and long-term safety. High-quality, multicenter studies and updated registries are needed to refine these recommendations and clarify the role of ILEs in clinical toxicology.