Intravenous Fat Emulsion Research Articles

Systematic Review of Hypersensitivity to Parenteral Nutrition.

Hypersensitivity to the components of parenteral nutrition (PN) is a rare but important complication of PN. We performed a systematic review of hypersensitivity to PN to enable us to build an approach to the individual patient who presents with PN hypersensitivity. A systematic literature search was performed in Ovid Medline, CINAHL, Scopus, and Web of Science using terms for "hypersensitivity" AND "parenteral nutrition" and relevant synonyms. A total of 28 articles were analyzed, and 33 hypersensitivities to PN or components of PN were reported in these 28 articles. Reports of hypersensitivity and subsequent conclusions were based on the clinical observations made by each reporting author. These reactions were evenly split between pediatric and adult patients. Hypersensitivity to PN occurred on day of starting PN in 60.6% patients and after that time in 36.3% patients (range: 1-21 days). Of the hypersensitivities that occurred on day 1 of PN, 70% occurred in the first 30 minutes of initiation of PN. Cutaneous manifestations were the most common, followed by anaphylaxis, respiratory symptoms, and hemodynamic instability. The components most frequently identified as allergens were intravenous fat emulsion (48.4%), multivitamin solution (33.3%), and amino acid solution (9%). Based on this review, an algorithm was created to guide the practitioner on management of PN after the occurrence of such a reaction.

A quality improvement program with nutrition therapy: restriction of lipid emulsions in cardiac surgical patients.

To evaluate the effect of restriction of soybean-based intravenous fat emulsions (IVFEs) in clinical outcomes in cardiac surgical patients. This was a before-and-after interventional study comparing the clinical outcomes regarding the intervention of IVFEs restriction. Before August 2015, parenteral nutrition (PN) using a soy-based lipid emulsion was routinely implemented if patients failed to meet >60% of energy requirements in 48 h post cardiac surgery (Period A). Beginning in August 2015, a lipid restriction strategy was implemented in our cardiac surgery intensive care unit (CSICU) unless enteral route could not be established within 7 days (Period B). The ICU and hospital mortality, nosocomial infections during ICU stay, length of ICU and hospital stay, ICU and hospital cost, mechanical ventilation time and postoperative complications were compared between two periods. A total of 761 patients (370 patients in Period A and 391 patients in Period B) were ultimately enrolled in this study. There were no significant differences in demographic characteristics and intraoperative and postoperative parameters between the two groups. After the implementation of IVFEs restriction, the overall ICU mortality and hospital mortality were similar between two groups. Nosocomial infection rate was significantly reduced (3.84% vs. 7.84%, P=0.021). The mean length of ICU stay (3.15 vs. 3.74 days, P<0.001) and hospital stay (12.14 vs. 13.24 days, P<0.001) were significantly lower. The mean in-hospital cost (133,368 vs. 139,383 Yuan, P=0.037) was found to be reduced after implementation of IVFEs restriction. The duration of mechanical ventilation was shorter in the latter period (35.23±10.43 vs. 47.63±12.54 hours, P=0.011). IVFEs restriction was also associated with reduced cholestasis (2.81% vs. 6.76%, P=0.013). The implementation of soybean-based IVFEs restriction in cardiac surgical patients was associated with reduced postoperative nosocomial infection rate. It also led to reductions in the length of ICU/hospital stay, hospital costs and mechanical ventilation time and a lower incidence of cholestasis. Further studies are required to validate the conclusions.

Effect of Delaying Replacement of Parenteral Nutrition Intravenous Administration Sets: Preclinical Experiments and a Dynamic Laboratory Model of Microbial Colonization

Recommendations prescribe daily intravenous administration set (IVAS) replacement for parenteral nutrition (PN) comprising intravenous fat emulsions (IVFE) due to risk of micro-organism growth and resultant central-line associated bloodstream infections (CLABSIs), but system disconnection for this practice may allow contamination and CLABSIs. Laboratory experiments and model development were used to simulate PN administration after contamination from healthcare workers' hands. This study observed the growth of micro-organisms known to cause CLABSIs in a variety of PN and other IV fluids and developed a model to investigate the effect of delaying IVAS replacement on microbial growth for up to 7 days. Micro-organisms grew at different rates and were affected by solution type. In static experiments, growth was supported in IVFE and all-in-one PN, but suppressed in 50% glucose. Growth patterns were consistent over time for Staphylococcus epidermidis, Staphylococcus aureus, and Candida albicans in IVFE, all-in-one PN, and 0.9% sodium chloride in both static and dynamic experiments. C. albicans grew exponentially to clinically significant numbers in all-in-one PN and IVFE IVAS after 30 hours, but negligible growth of S. epidermidis or S. aureus occurred for 7 days. All-in-one PN and IVFE support the C. albicans growth after minimal initial contamination, with micro-organisms migrating from the fluid bag to the central venous access device. Improved aseptic nontouch technique during clinical practice is vital to prevent contamination. Daily IVAS replacement of for all-in-one PN and IVFE should continue until the safety of prolonging IVAS replacement is confirmed by randomized trials.

Lipid Injectable Emulsions: Infusion Confusion.

The commentary addresses discussion regarding the duration of infusion for lipid injectable emulsions (ILEs; previously known as intravenous fat emulsion) when administered separately from amino acids and dextrose (2:1) admixtures. The article by Mundi et al describes the administration time of ILEs administered separately as up to 24 hours, while previous American Society for Parenteral and Enteral Nutrition documents have outlined the infusion time not to exceed 12 hours.

Emergence of Mixed-Oil Fat Emulsions for Use in Parenteral Nutrition.

Since early work by Wretlind and Schuberth led to the development of a stable and safe intravenous fat emulsion (IFE) using soybean oil (SO) and egg phospholipid emulsifier, IFEs have become a crucial source of essential fatty acids and nonprotein energy in parenteral nutrition. However, largely due to their high ω-6 polyunsaturated fatty acid (PUFA) and phytosterol content, SO IFEs have been associated with complications, including a proinflammatory profile and hypertriglyceridemia, as well as intestinal failure-associated liver disease. Subsequent generations of IFEs have used other sources of triglycerides, including medium-chain triglycerides (MCTs), olive oil (OO), and fish oil (FO), to reduce the SO component. Although these IFEs showed some improvement in complications compared with SO IFE, the quest to develop an IFE with a better side effect profile and beneficial physiologic effects led to the development of a mixed-oil (MO) IFE (Smoflipid; 30% SO, 30% MCTs, 25% OO, and 15% FO) that was recently approved by the Food and Drug Administration. The use of a MO approach is theoretically and intuitively more physiologically similar to normal dietary human consumption. Although the data are from small, short-term trials, MO IFE results thus far have been promising, with some studies showing improved liver function tests, improvement in triglycerides, higher ω-3/ω-6 PUFA ratio, and higher α-tocopherol. Larger long-term studies are needed to ensure these theoretical benefits lead to significant improvement in clinical outcomes.

Will Availability of SMOF Lipid Emulsions for Parenteral Nutrition Change Surgical Nutrition Practice?

Purpose of Review Parenteral nutrition (PN) is a widely accepted form of nutrition administration in patients in whom enteral feeding is contraindicated or insufficient. This is true in surgical patient populations, as well. As a component of PN, intravenous fat emulsions (IVFEs) are essential for the administration of essential fatty acids (EFAs) and adequate energy intake. The oils that make up standard IVFE formulations have evolved over time.

Cardiopulmonary resuscitation under special pathophysiological conditions: an update of the American Heart Association cardiopulmonary resuscitation and cardiovascular emergency guidelines--2015

Background In clinical work, we often need to perform cardiopulmonary resuscitation in some patients with special pathophysiology. Objective By interpreting the 2015 American Heart Association cardiopulmonary resuscitation and cardiovascular emergency guidelines to update the relevant parts, improve the ability of patients with cardiopulmonary resuscitation. Content Cesarean section in pregnant women with cardiopulmonary resuscitation with attention to the failure of maternal recovery. Pulmonary embolism caused by cardiac arrest, suspected or confirmed cases of early thrombolysis can be carried out, and the diagnosis of cases can also be treated by surgical thrombectomy. Opioid overdose can lead to cardiac arrest, which can be treated with naloxone and cardiopulmonary resuscitation at the same time. Local anesthetics poisoning caused by cardiac arrest during cardiopulmonary resuscitation can be used simultaneously with the rescue of fat emulsion. Cardiopulmonary resuscitation in patients with sudden cardiac arrest during percutaneous coronary intervention. Trends The lack of relevant literature confirms that the pressure of the inferior vena cava in the lower abdomen of the maternal is reduced by hand to the left of the uterus to reduce hypotension. And there is no conclusion about the timing of cesarean section for women. The standard for the treatment of patients with cardiac arrest caused by suspected pulmonary embolism is still controversial. In some cases, intravenous fat emulsions may enhance the efficacy of epinephrine and vasopressin, which has been confirmed by animal studies, but not supported by experimental data. The above aspects are the direction of our future exploration. Key words: Cardiopulmonary resuscitation; Guideline update; Interpretation; Special pathological and physiological

Influence of Fish Oil-Containing Lipid Emulsions on Parenteral Nutrition-Associated Liver Disease in Neonates

This study is a comparative evaluation of the incidence of parenteral nutrition-associated liver disease (PNALD) when administering intravenous fat emulsions containing fish oil.

Emerging Clinical Benefits of New-Generation Fat Emulsions in Preterm Neonates.

Soybean oil-based intravenous fat emulsions (IVFEs) have been the predominant parenteral nutrition IVFE used in the United States for neonates over the past 45 years. Even though this emulsion has proven useful in supplying infants with energy for growth and essential fatty acids, there have been concerns over its composition in the development of several morbidities, ranging from sepsis to liver disease, bronchopulmonary dysplasia, and impaired neurodevelopment and growth. The exact mechanisms that drive these morbidities in preterm infants are multifactorial, but potential contributors include high ω-6 (n-6) fatty acid composition, low docosahexaenoic acid and antioxidant supplementation, and the presence of potentially harmful nonnutritive components (eg, phytosterols). To address these issues, new-generation IVFEs with various types and amounts of fat have been developed containing greater amounts of the medium-chain fatty acids, long-chain polyunsaturated fatty acid, docosahexaenoic acid, lower concentrations of ω-6 polyunsaturated fatty acids, supplemental vitamin E, and low or negligible amounts of phytosterols. This review examines the clinical outcomes associated with different morbidities of parenteral nutrition in neonates who have received either soybean oil-based or new-generation IVFEs and addresses whether the proposed benefits of new-generation IVFEs have improved outcomes in the neonatal population.

Review of Intravenous Lipid Emulsion Therapy.

Intravenous fat emulsion (IVFE) is an important source of calories and essential fatty acids for patients receiving parenteral nutrition (PN). Administered as an individual infusion or combined with PN, the fats provided by IVFE are vital for cellular structural function and metabolism. The affinity of some medications to lipids has led to the use of IVFE as a treatment for any lipophilic drug overdose. This article will explain the available formulations of IVFE, administration, and maintenance issues, as well as the risks and benefits for various applications.

Management of Parenteral Nutrition in Hospitalized Adult Patients

Despite the high prevalence of malnutrition in adult hospitalized patients, surveys continue to report that many clinicians are undertrained in clinical nutrition, making targeted nutrition education for clinicians essential for best patient care. Clinical practice models also continue to evolve, with more disciplines prescribing parenteral nutrition (PN) or managing the cases of patients who are receiving it, further adding to the need for proficiency in general PN skills. This tutorial focuses on the daily management of adult hospitalized patients already receiving PN and reviews the following topics: (1) PN basics, including the determination of energy and volume requirements; (2) PN macronutrient content (protein, dextrose, and intravenous fat emulsion); (3) PN micronutrient content (electrolytes, minerals, vitamins, and trace elements); (4) alteration of PN for special situations, such as obesity, hyperglycemia, hypertriglyceridemia, refeeding, and hepatic/renal disease; (5) daily monitoring and adjustment of PN formula; and (6) PN-related complications (PN-associated liver disease and catheter-related complications).

Case Study: Effect of an Olive Oil Based Intravenous Fat Emulsion Compared to a Soybean Oil Based Intravenous Fat Emulsion on Hyperkeratosis and Fatty Acid Profile

Describe the effect of two different formulations of IVFE on inflammatory response in a long-term HPN patient.

Potential Hepatotoxicities of Intravenous Fat Emulsions in Infants and Children.

Infants and children who depend on parenteral nutrition are among the most vulnerable to developing potentially devastating intestinal failure-associated liver disease. While the pathogenesis of intestinal failure-associated liver disease remains unclear, evidence for the contribution of fat emulsions to cholestasis and liver injury has rapidly increased in recent years. Data demonstrating the interaction among phytosterols, fatty acids, and antioxidants in cellular pathways that mediate bile flow and hepatic injury have led to the development of newer alternative fat emulsions. This article reviews recent studies that have provided insight into the potential hepatotoxicities of fat emulsions.

Home Parenteral Nutrition: Fat Emulsions and Potential Complications.

Since the first intravenous nutrition support attempt with olive oil in the 17th century, intravenous fat emulsions (IVFEs) have evolved to become an integral component in the management of patients receiving home parenteral nutrition (HPN). IVFEs serve as a calorie source and provide essential fatty acids (linoleic acid and α-linolenic acid) in patients unable to achieve adequate intake of these fatty acids through alternative means. However, IVFE use is also associated with multiple complications, including increased infection risk, liver disease, and systemic proinflammatory states. In the United States, most IVFEs are composed of 100% soybean oil; internationally multiple alternative IVFEs (using fish oil, olive oil, and long- and medium-chain triglycerides) are available or being developed. The hope is that these IVFEs will prevent, or decrease the risk of, some of the HPN-associated complications. The goal of this article is to review how IVFEs came into use, their composition and metabolism, options for IVFE delivery in HPN, benefits and risks of IVFE use, and strategies to minimize the risks associated with IVFE use in HPN patients.

Intravenous Fat Emulsion Formulations for the Adult and Pediatric Patient: Understanding the Differences.

Intravenous fat emulsions (IVFEs) provide essential fatty acids (EFAs) and are a dense source of energy in parenteral nutrition (PN). Parenterally administered lipid was introduced in the 17th century but plagued with side effects. The formulation of IVFEs later on made it a relatively safe component for administration to patients. Many ingredients are common to all IVFEs, yet the oil source(s) and its (their) percentage(s) makes them different from each other. The oil used dictates how IVFEs are metabolized and cleared from the body. The fatty acids (FAs) present in each type of oil provide unique beneficial and detrimental properties. This review provides an overview of IVFEs and discusses factors that would help clinicians choose the optimal product for their patients.

A Product Review of Alternative Oil-Based Intravenous Fat Emulsions.

Soybean oil-based intravenous fat emulsions have long been used as the primary product for delivery of lipid-based calories in parenteral nutrition formulations in the United States. Proinflammatory properties of these products may be related with poor clinical outcomes and have led investigators to develop newer generations of intravenous fat emulsions. These alternative formulations are derivatives of medium-chain triglycerides, olive oil, and fish oil in hopes to reduce the inflammatory response and potentially produce a clinically beneficial anti-inflammatory response. Although surrogate markers support this reduction in inflammatory response, clinical data and outcomes are still limited but potentially promising in the literature. This product review provides a general overview of the alternative-generation intravenous fat emulsion products and the literature supporting the potential transition to such products.

Repackaging of Intravenous Fat Emulsions: A Clinical Conundrum.

To accommodate small fluid volumes, repackaging of intravenous fat emulsions (IVFEs) is frequently performed in institutions providing parenteral nutrition to neonates and smaller pediatric patients. However, some consider this an unsafe practice. Concerns for potential administration errors leading to an overdose of IVFEs are weighed against the potential for microbial contamination from the repackaging process. The clinician providing pediatric nutrition support should tailor repackaging practices to ensure patient safety and quality. This discussion aims to describe the strengths and limitations surrounding IVFE repackaging to provide guidance regarding the practice.

Parenteral fish oil and liver function tests in hospitalized adult patients receiving parenteral nutrition: A propensity score-matched analysis

Intravenous fat emulsions are associated with liver disease and there is some evidence that the administration of intravenous fish oil (FO) may be useful in reversing it. The aim of our study was to assess whether there are differences in the changes of liver function tests (LFTs) in hospitalized adult patients with parenteral nutrition (PN) with FO and vegetal lipids vs patients without FO. The secondary aim was to study the relationship between impaired LFT and FO. This was a 4-year, propensity score-matched analysis including patients aged ≥18 years treated with PN for ≥10 days. The exclusion criteria were previous liver disease, biliary disorders or pancreatic cancer, and altered initial LFT values. Patients were classified into 2 groups: FO cohort (patients who received FO - in addition to vegetal oil - after the first week of PN) and the vegetal oil cohort (patients who received only vegetal oil). A propensity score matched cohort design was developed. Univariate analyses were used to study the changes in LFTs. To evaluate whether LFT alterations vary with FO administration, four stepwise multiple linear regression models were conducted. 52 patients were included, 52% men, median 66 (55-75) years and 69kg (61.7-78.8), with 18.5 (14-31.8) days of PN treatment. Maximum FO supplementation was 23%. During the first week with PN (none of the groups receiving FO), gammaglutamyl transferase (GGT), alkaline phosphatase (AP) and total bilirubin (BIL) increased significantly. Comparing LFT values at seven days of PN with at the end of PN treatment, the univariate analysis showed a better response for the FO group. The group without FO showed a significant increase for GGT and AP. In multivariate models, the percentage of FO administered was associated with a decrease in GGT, B=-0.33 [CI 95%=-0.54/-0.12], in AP, B=-0.12 [CI 95%=-0.20/-0.03] and ALT, B=-0.12 [CI 95%=-0.21/-0.024]. Lipid composition plays a significant role in LFT alteration associated with PN, and FO intravenous lipid emulsions (ILEs) minimize disturbance of LFTs in hospitalized adult patients.

Medication Safety

Medication Safety

Selected Medication Safety Risks to Manage in 2016-Part I Intravenous Fat Emulsion Needs a Filter.

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site (www.ismp.org), by calling 800-FAIL-SAFE, or via e-mail at ismpinfo@ismp.org. ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.