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Abstract

Introduction: Lipid infusions as part of parenteral nutrition (PN) can adversely affect the liverfunction as measured by the observed rise in serum LFT’s during PNadministration. Using full dose of lipid infusions in patients with derangedLFT’s is not advisable by current consensus[l1]. In the event of sepsis, orsignificantly raised LFT’s, the lipid infusions are either reduced or completelyremoved from the PN regime to reduce the load on the liver. Any type of lipidinfusion is considered to be equally contraindicated in such conditions, asthere is currently an absence of information in the literature as to the impactof various lipid formulations on the LFT’s within the critically ill paediatricpopulation[l2]. Intralipid contains 20% soybean, Lipofundin50% soya oil and 50% medium chain triglycerides (MCT), and SMOF contains soya,MCT, olive oil, and fish oil.[l3] Hypothesis: To investigate the impact of SMOF, Lipofundin, and Intralipid infusions on LFT’s and outcomes of sepsis and death. Methods: This was a retrospective cohort study included all patients who received PN between 2007 and 2011 (study period) on the paediatric intensive care unit[l5] at the Harley Street Clinic. All patients who received PN were identified from the pharmacy records. Out of the 116 records identified, only 50 records were suitable or available for final analysis. [l6] Paper and electronic records of theses patients were scanned and observations relating to their period of PN administration were recorded. Changes in LFT’s (AST, ALT, GGT, and Bilirubin) were calculated from baseline and compared for patients who received different doses and types of lipids. Fisher’s t test was used to examine the differences between groups. K-Wallis test was used for the differences between more than 2 groups. Logistic regression was performed to investigate the effect of PN duration on sepsis. Results: A total of 50 patients [l7] (48% females; n=24) were included during the study period. The median age in months was 2 (IQR 0,12)[l8] in this population. The diagnoses varied but the majority were cardiac patients (41/29, 84%); 41% of the cardiac patients were HLHS (17/41). The median number of days on PN therapy was 13 (IQR 8, 28). Patients were grouped by the type of lipid they received: SMOF, Lipofundin, and Intralipid. The majority of patients received Lipofundin (58%; n=29) followed by SMOF (24%; n=12). One patient received no lipids.The median duration of PN in the intralipid, SMOF, and lipofundin groups were 8.5, 30.5, and 12days respectively (n=49, p=0.0056), and they received a median dose in g/kg of 2.5, 2.75, and 3 respectively (n=49, p=0.724). Death occurred in 2/8(25%), 3/12 (25%), and 4/27 (15%) in those who received intralipid, SMOF, and lipofundin respectively (n=48, p=0.67). Sepsis was present in 5/8(63%), 11/12(92%), and15/27(56%) in those who received intralipid, SMOF, and lipofundin respectively (n=31, p=0.08). Of the septic patients, sepsis occurred post PN initiation in 1/5(20%), 3/10(30%), and 4/15(27%) in those who received intralipid, SMOF, and lipofundin respectively (n=30, p=1.00)Logistic regression for the effect of duration of PN on sepsis shows a 3.4% rise in the odd ratio (OR) of developing sepsis post PN for each day on PN, (OR 1.0339, 95% CI [l9] 1.0108-1.0577, p=0.004). Likewise, patients on longer term PN were more likely to have sepsis (OR 1.094, CI 1.0140-1.2138, p=0.024).Regression analyses for changes in LFT’s for the different lipid doses have shown no relationship between the dose or type of lipids and LFT or bilirubin changes. In septic patients, the median changes in bilirubin from baseline and IQR’s were +1.5 (-28,12.5), -6 (-44,1) and -3.0 (-22, 1) for the intralipid, SMOF, and lipofundin groups (p=0.815 for the differences between the 3 groups). Conclusions: Patients who received SMOF had a similar death rate compared to those on other type of lipids despite their higher proportion with sepsis and their significantly prolonged time on PN. There was no relationship between the lipid dose and LFT’s suggesting that adequate doses of lipids in the presence of sepsis and raised LFT’s are not contraindicated. Although firm conclusions cannot be drawn, data from this study should prove useful in the assessment of SMOF use in septic and post surgical children and in the planning of a future large scale study.