Lipid Injectable Emulsions Research Articles

Parenteral Nutrition Lipid Injectable Emulsion Products Shortage Considerations.

Parenteral Nutrition Lipid Injectable Emulsion Products Shortage Considerations.

Erratum.

Driscoll DF. Pharmaceutical and clinical aspects of lipid injectable emulsions [published online October 13, 2016]. JPEN J Parenter Enteral Nutr. (Original DOI: 10.1177/0148607116673187 ).

Pharmaceutical and Clinical Aspects of Lipid Injectable Emulsions.

The first clinically successful lipid injectable emulsion was marketed in 1961, consisting of soybean oil triglycerides in sterile water for injection. Since that time, numerous products have entered the market, with the main difference being changes in the oil composition with triglycerides of plant and marine oil origin. With this change, the fatty acid profiles are unique, coming from medium- and long-chain triglycerides. The fatty acids can be saturated or unsaturated, having different pharmaceutical and metabolic activities that affect the safety and efficacy of these unique pharmaceutical dosage forms.

PFAT5 and the Evolution of Lipid Admixture Stability.

PFAT5 is defined by United States Pharmacopeia Chapter 729 as follows: the "percentage of fat residing in globules larger than 5 µm (PFAT5) for a given lipid injectable emulsion [is] not to exceed 0.05%." The unstable aggregates are trapped in lungs, liver, and the reticuloendothelial system. Large particles will accumulate in pulmonary capillaries, which are between 4 and 9 µm in diameter. Over the years, there has been an evolution of methods to characterize and define intravenous fat emulsion (IVFE) stability when combined as a total nutrient admixture (TNA). Many studies have claimed IVFE stability measuring mean particle size, zeta potential, and visual checks. Interestingly, none of the studies that claimed the TNA as stable identified an unstable one through testing. This report reviews those parameters and shows they were not a valid measure of lipid stability. The PFAT5 parameter has emerged as the only validated measure of lipid stability. There are clinical consequences of using lipids that exceed the PFAT5 limit. This parameter is applicable to both manufactured and compounded lipid preparations. The clinician should be aware of the limitations of much of the literature concerning the lipid stability assessment. More stability studies are needed using PFAT5 to identify the actual limits of TNA compounding.

Effect of high-pressure homogenization preparation on mean globule size and large-diameter tail of oil-in-water injectable emulsions

The effect of different high pressure homogenization energy input parameters on mean diameter droplet size (MDS) and droplets with > 5 μm of lipid injectable emulsions were evaluated. All emulsions were prepared at different water bath temperatures or at different rotation speeds and rotor-stator system times, and using different homogenization pressures and numbers of high-pressure system recirculations. The MDS and polydispersity index (PI) value of the emulsions were determined using the dynamic light scattering (DLS) method, and large-diameter tail assessments were performed using the light-obscuration/single particle optical sensing (LO/SPOS) method. Using 1000 bar homogenization pressure and seven recirculations, the energy input parameters related to the rotor-stator system will not have an effect on the final particle size results. When rotor-stator system energy input parameters are fixed, homogenization pressure and recirculation will affect mean particle size and large diameter droplet. Particle size will decrease with increasing homogenization pressure from 400 bar to 1300 bar when homogenization recirculation is fixed; when the homogenization pressure is fixed at 1000 bar, the particle size of both MDS and percent of fat droplets exceeding 5 μm (PFAT5) will decrease with increasing homogenization recirculations, MDS dropped to 173 nm after five cycles and maintained this level, volume-weighted PFAT5 will drop to 0.038% after three cycles, so the “plateau” of MDS will come up later than that of PFAT5, and the optimal particle size is produced when both of them remained at plateau. Excess homogenization recirculation such as nine times under the 1000 bar may lead to PFAT5 increase to 0.060% rather than a decrease; therefore, the high-pressure homogenization procedure is the key factor affecting the particle size distribution of emulsions. Varying storage conditions (4–25°C) also influenced particle size, especially the PFAT5.

Droplet-size distribution and stability of commercial injectable lipid emulsions containing fish oil

The droplet size of commercial fish oil-containing injectable lipid emulsions, including conformance to United States Pharmacopeia (USP) standards on fat-globule size, was investigated. A total of 18 batches of three multichamber parenteral products containing the emulsion SMOFlipid as a component were analyzed. Samples from multiple lots of the products were evaluated to determine compliance with standards on the volume-weighted percentage of fat exceeding 0.05% (PFAT(5)) specified in USP chapter 729 to ensure the physical stability of i.v. lipid emulsions. The products were also analyzed to determine the effects of various storage times (3, 6, 9, and 12 months) and storage temperatures (25, 30, and 40 °C) on product stability. Larger-size lipid particles were quantified via single-particle optical sensing (SPOS). The emulsion's droplet-size distribution was determined via laser light scattering. SPOS and light-scattering analysis demonstrated mean PFAT(5) values well below USP-specified globule-size limits for all the tested products under all study conditions. In addition, emulsion aging at any storage temperature in the range studied did not result in a significant increase of PFAT(5) values, and mean droplet-size values did not change significantly during storage of up to 12 months at temperatures of 25-40 °C. PFAT(5) values were below the USP upper limits in SMOFlipid samples from multiple lots of three multichamber products after up to 12 months of storage at 25 or 30 °C or 6 months of storage at 40 °C.

Injectable Lipid Emulsions—Advancements, Opportunities and Challenges

Injectable lipid emulsions, for decades, have been clinically used as an energy source for hospitalized patients by providing essential fatty acids and vitamins. Recent interest in utilizing lipid emulsions for delivering lipid soluble therapeutic agents, intravenously, has been continuously growing due to the biocompatible nature of the lipid-based delivery systems. Advancements in the area of novel lipids (olive oil and fish oil) have opened a new area for future clinical application of lipid-based injectable delivery systems that may provide a better safety profile over traditionally used long- and medium-chain triglycerides to critically ill patients. Formulation components and process parameters play critical role in the success of lipid injectable emulsions as drug delivery vehicles and hence need to be well integrated in the formulation development strategies. Physico-chemical properties of active therapeutic agents significantly impact pharmacokinetics and tissue disposition following intravenous administration of drug-containing lipid emulsion and hence need special attention while selecting such delivery vehicles. In summary, this review provides a broad overview of recent advancements in the field of novel lipids, opportunities for intravenous drug delivery, and challenges associated with injectable lipid emulsions.

Lipid globule size in total nutrient admixtures prepared in three-chamber plastic bags

The stability of injectable lipid emulsions in three-chamber plastic (3CP) bags, applying the globule-size limits established by United States Pharmacopeia ( USP ) chapter 729, was studied. A total of five premixed total nutrient admixture (TNA) products packaged in 3CP bags from two different lipid manufacturers containing either 20% soybean oil or a mixture of soybean oil and medium-chain-triglyceride oil as injectable lipid emulsions were tested. Two low-osmolarity 3CP bags and three high-osmolarity 3CP bags were studied. All products were tested with the addition of trace elements and multivitamins. All additive conditions (with and without electrolytes) were tested in triplicate at time 0 (immediately after mixing) and at 6, 24, 30, and 48 hours after mixing; the bags were stored at 24-26 degrees C. All additives were equally distributed in each bag for comparative testing, applying both globule sizing methods outlined in USP chapter 729. Of the bags tested, all bags from one manufacturer were coarse emulsions, showing signs of significant growth in the large-diameter tail when mixed as a TNA formulation and failing the limits set by method II of USP chapter 729 from the outset and throughout the study, while the bags from the other manufacturer were fine emulsions and met these limits. Of the bags that failed, significant instability was noted in one series containing additional electrolytes. Injectable lipid emulsions provided in 3CP bags that did not meet the globule-size limits of USP chapter 729 produced coarser TNA formulations than emulsions that met the USP limits.

Droplet-size distribution and stability of lipid injectable emulsions

The droplet-size distribution (DSD) and stability of multiple lots of lipid injectable emulsions were studied. A total of 234 commercial batches of Intralipid (Fresenius Kabi, Uppsala, Sweden) were characterized, and the influence of the emulsions' oil content on samples packaged in single- and three-chamber bags was tested. Larger-sized lipid particles were quantified using a single-particle optical sensing device. For this test, a 1-mL sample of each product was analyzed using a dilution factor of 90-400, depending on oil concentration. Analyses were performed in triplicate. Measurements were also performed in single-bag products after up to six months of storage at 23-27 degrees C and 40 degrees C. DSD measurements were determined by laser light scattering. Droplet sizes were determined using laser diffraction, with aliquots of emulsions carefully dispersed step by step applying gentle agitation. Standard deviation analyses were performed using analysis of variance. The volume-weighted percentage of fat droplets greater than 5 mum (PFAT(5)) values of all samples were below the large-globule size limit (0.05%) established by the United States Pharmacopeia for lipid injectable emulsions. Container volume did not significantly influence globule size, though a slight tendency for larger bag volumes to have larger PFAT(5) values was apparent. PFAT(5) and mean volume diameter values increased with oil concentration in the emulsion. Storage time and temperature had no significant effect on PFAT(5) and mean droplet-size values. Multiple lots of a lipid emulsion were found to have acceptable PFAT(5) and mean droplet-size values, regardless of oil content, container size, or storage time and tempearture.

The pharmacopeial evolution of intralipid injectable emulsion in plastic containers: From a coarse to a fine dispersion

On December 1, 2007, the United States Pharmacopeia (USP) adopted Chapter 〈729〉 entitled Globule Size Distribution in Lipid Injectable Emulsions that contains two globule sizing methods and criteria to measure the mean droplet diameter (MDD) and the large-diameter tail of the globule size distribution to meet pharmacopeial specifications. The first of these measures, as the intensity-weighted MDD expressed in nanometers, must be less than 500nm. The second measure, as the volume-weighted percentage of fat greater than 5μm or PFAT5, must be less than 0.05%. These limits were first suggested in 2001 based on an analysis of 16 lipid injectable emulsions available worldwide. In 2004, the packaging of the innovator lipid emulsion product Intralipid™ was changed from conventional glass bottles to plastic containers in the U.S. A subsequent analysis of the emulsion in its new container showed it to be more coarse than its previous glass counterpart and now failed the PFAT5 limit. In 2007, it was announced that Intralipid™ in plastic containers was reformulated to meet the pharmacopeial limits. To track the time course of its transition from a coarse to a fine dispersion, 31 lots of Intralipid with expiration dates spanning five years were investigated.

Globule-size distribution in injectable 20% lipid emulsions: Compliance with USP requirements

The compliance of injectable 20% lipid emulsions with the globule-size limits in chapter 729 of the U.S. Pharmacopeia (USP) was examined. As established in chapter 729, dynamic light scattering was applied to determine mean droplet diameter (MDD), with an upper limit of 500 nm. Light obscuration was used to determine the size of fat globules found in the large-diameter tail, expressed as the volume-weighted percent fat exceeding 5 microm (PFAT(5)), with an upper limit of 0.05%. Compliance of seven different emulsions, six of which were stored in plastic bags, with USP limits was assessed. To avoid reaching coincidence limits during the application of method II from overly concentrated emulsion samples, a variable dilution scheme was used to optimize the globule-size measurements for each emulsion. One-way analysis of variance of globule-size distribution (GSD) data was conducted if any results of method I or II exceeded the respective upper limits. Most injectable lipid emulsions complied with limits established by USP chapter 729, with the exception of those of one manufacturer, which failed limits as proposed for to meet the PFAT(5) three of the emulsions tested. In contrast, all others studied (one packaged in glass and three packaged in plastic) met both criteria. Among seven injectable lipid emulsions tested for GSD, all met USP chapter 729 MDD requirements and three, all from the same manufacturer and packaged in plastic, did not meet PFAT(5) requirements.

Étude de facteurs influençant l'apparition de bulles d'air dans la ligne d'administration de nutrition parentérale aux domiciles des patients. Influences respectives du couple pompe–tubulure et de la teneur en lipides dans le mélange nutritif

Patients followed at home parenteral nutrition (HPN) in our adult and paediatric centers, complain regularly with noise pollution generated by the “bubble air” alarms, and patients do not seem to be exposed in the same way. The aim of this study was to determine the precise impact of two factors empirically suspected to play a role into the bubble air genesis: pumping technology used (with a compartment or linear with fingers) and the presence of injectable lipid emulsion (ILE). Six pumps from three different models (two linear with fingers mechanism and one with compartment) were used and infusions of mixtures with different lipid proportions were realized. For each infusion, volume of emitted gas was measured and number of “bubble air” alarms counted. A significant difference between three pump models is highlighted without a strong proof that only pumping technology is alone in charge. ILE decrease the volume of gas emitted proportionally to its concentration. Emitted gas are dissolved gas. This identification of two factors supporting “bubble air” alarms should allow several adaptations into practices which contribute to improve patient's quality of life.

Physicochemical stability of lipid injectable emulsions: Correlating changes in large globule distributions with phase separation behavior

Single particle optical sensing (SPOS) and visual inspection were used to characterize a series of lipid injectable emulsions ( n = 21) featuring three lipid types, two electrolyte conditions, and three pH levels (7.0, 4.75, and 2.5). Seven of the twenty-one sample conditions exhibited phase separation instability by visual inspection within 98 h of emulsion preparation. The phase instability was driven by electrolyte type and pH, and “cracking” phenomena were independent of lipid type despite the base lipids ranging almost two orders of magnitude in PFAT 5 levels. Logistic regression analysis showed that the PFAT 5 level determined 1 h after admixture preparation was not correlated with phase separation behavior. However, PFAT 5 measured at later times showed much improved correlations with emulsion instability. PFAT 5 was highly correlated with neighboring cumulative distributions termed PFAT X where X = 2–10 μm. Although the admixtures studied were not clinically relevant, the data demonstrate some limitations of developing empirical correlations between single-point SPOS measurements and emulsion instability. An alternative limit test for emulsion stability based on the rate of change in the large globule counts is proposed to mitigate inherent deficiencies in the current USP Chapter 〈729〉 limit test based on single-point determination of PFAT 5 values.

Physical Stability of 20% Lipid Injectable Emulsions via Simulated Syringe Infusion: Effects of Glass vs Plastic Product Packaging

The United States Pharmacopeia (USP) has proposed large-globule-size limits to ensure the physical stability of lipid injectable emulsions, expressed as the percent fat >5 microm, or PFAT(5), not exceeding 0.05%. Visibly obvious phase separation as free oil has been shown to occur in some samples if PFAT(5) is >0.4%. We recently found that lipids, newly packaged in plastic (P), exceed the proposed USP limits and seem to produce less stable total nutrient admixtures compared with those made from conventional glass (G), which do meet proposed USP standards. We tested the possible stability differences between 20% lipid injectable emulsions in either P or G in a simulated neonatal syringe infusion study. Eighteen individual syringes were prepared from each 20% lipid injectable emulsion product (n = 36) and attached to a syringe pump set at an infusion rate of 0.5 mL/hour. The starting PFAT(5) levels were measured at time 0 and after 24 hours of infusion, using a laser-based light obscuration technique as described by the USP Chapter <729>. The data were assessed by a 2-way analysis of variance (ANOVA) with Container (G vs P) and Time as the independent variables and PFAT as the dependent variable. At time 0, the starting PFAT(5) level for lipids packaged in G was 0.006% +/- 0.001% vs 0.162% +/- 0.026% for P, whereas at the end of the infusion they were 0.013% +/- 0.003% and 0.328% +/- 0.046%, respectively. Significant differences were noted overall between groups for Container, Time, and Container-Time interaction (all p < .001). Bonferroni tests showed significant differences in PFAT(5) levels between Containers at time 0 (T-0; p < .001) and T-0 vs T-24 for P-based lipids (p < .001), whereas no such differences were noted for Time for the G-based lipids. Similar results were noted for PFAT(10) levels. We confirm that presently available lipid injectable emulsions packaged in newly introduced plastic containers exceed the proposed USP <729> PFAT(5) limits and subsequently become significantly less stable during a simulated syringe-based infusion. Although modest growth (p = NS) in large-diameter fat globules was observed for the glass-based lipids, they remained within proposed USP globule size limits throughout the study. Glass-based lipids seem to be a more stable dosage form and potentially a safer way to deliver lipids via syringe infusion to critically ill neonates.

Stability of total nutrient admixtures with lipid injectable emulsions in glass versus plastic packaging

The physical stability of two emulsions compounded as part of a total nutrient admixture (TNA) was studied in lipids packaged in either glass or plastic containers. Five weight-based adult TNA formulations that were designed to meet the full nutritional needs of adults with body weights between 40 and 80 kg were studied. Triplicate preparations of each TNA were assessed over 30 hours at room temperature by applying currently proposed United States Pharmacopeia (USP) criteria for mean droplet diameter, large-diameter tail, and globule-size distribution (GSD) for lipid injectable emulsions. In accordance with conditions set forth in USP chapter 729, the higher levels of volume-weighted percent of fat exceeding 5 microm (PFAT(5)) should not exceed 0.05% of the total lipid concentration. Significant differences were noted among TNA admixtures based on whether the lipid emulsion product was manufactured in glass or plastic. The plastic-contained TNAs failed the proposed USP methods for large-diameter fat globules in all formulations from the outset, and 60% had significant growth in large-diameter fat globules over time. In contrast, glass-contained TNAs were stable throughout and in all cases would have passed proposed USP limits. Certain lipid injectable emulsions packaged in plastic containers have baseline abnormal GSD profiles compared with those packaged in glass containers. When used to compound TNAs, the abnormal profile worsens and produces less stable TNAs than those compounded with lipid injectable emulsions packaged in glass containers.

Pathological Consequences From the Infusion of Unstable Lipid Emulsion Admixtures in Guinea Pigs

The pathophysiologic effects of infusing unstable lipid emulsions are unclear, but these were shown to cause reticuloendothelial system (RES) dysfunction in animals and humans. We investigated the effects of unstable lipid emulsions in RES organs defined by 2 levels of the percent fat &gt;5μ m (percentage of fat, PFAT &gt; 5 μm) in a guinea pig model. Two identical injectable lipid emulsions with differing (stable vs unstable) PFAT &gt;5 μm levels were infused for over 24 h into 2 groups of animals (n = 5/group). The PFAT &gt;5 μm concentration was measured before and at the end of the infusion to ascertain the dose range of enlarged fat globules in each group. Animals were killed and specimens from the upper, middle, and lower lung and a single liver sample were examined histologically and for micromolar concentrations of malondialdehyde (MDA) per g (μmol–1 g) of wet tissue. The PFAT &gt;5 μm concentrations preinfusion were 0.004 ± 0.001 and 2.418 ± 0.273 for the stable and unstable injectable lipid emulsions, respectively. At 24 hours, the PFAT &gt;5 μm level increased in both the groups (stable: 0.161± 0.008; unstable: 7.861 ± 0.291). MDA concentrations were significantly higher in the lungs of animals receiving the unstable (47.2± 26.2 μmol–1 g) vs stable (32.4 ± 11.2 μmol–1 g) injectable lipid emulsions (p = .033), but were not different for the liver specimens (stable: 16.9 ± 7.6 μmol–1 g vs unstable: 17.7 ± 2.2μ mol–1 g, p = .944). These preliminary data suggest that infusion of unstable injectable lipid emulsions has pathologic consequences showing greater evidence of oxidative stress in the lungs. (Clin Nutr. 2005;24:105–113.)

Establishing a stability window for medium- and long-chain-triglyceride lipid-based total nutrient admixtures using USP standards

The stability window of medium-chain triglyceride (MCT) and long-chain-triglyceride (LCT) lipid-based total nutrient admixtures (TNAs) was studied. Sixteen different admixtures were selected for study. Of these, eight base macronutrient concentrations representing low and high concentrations were selected, along with low and high concentrations of electrolytes. All TNAs studied contained 2 mg of elemental iron as part of the trace-element formulation, an amount previously shown to produce unstable TNAs with pure LCT-based lipid injectable emulsions. All admixtures were prepared in triplicate and analyzed over five time intervals: time 1 (immediately after preparation), time 2 (after four days of storage at 6 +/- 2 degrees C), and times 3, 4, and 5, corresponding to 6, 24, and 30 hours of storage at 25 +/- 2 degrees C, respectively, after time 2. Stability was measured by comparing results with USP standards for fat globule size in lipid injectable emulsions. A total of 48 admixtures were studied. Samples at each time interval showed an inconsistent but general increase in the number of globules with a diameter of >1.8 microm over time. All admixtures met both the proposed pharmacopoeial criteria for stability with respect to mean droplet size and volume-weighted proportion of fat globules with a diameter of >5 microm. A wide range of macronutrients and micronutrients were tested in a series of MCT-LCT-based TNAs and found to be stable. The use of MCTs and LCTs in lipid injectable emulsions confers greater stability to TNAs than has been achieved with pure LCT-based formulations.

Lipid Injectable Emulsions: Pharmacopeial and Safety Issues

Lipid injectable emulsions have been routinely used in patients worldwide for over 40 years as a nutritional supplement in patients requiring parenteral nutrition. They can be given as a separate infusion or added into total parenteral nutrition admixtures. Despite such broad use, no pharmacopeial standards exist with respect to the optimal pharmaceutical characteristics of the formulation. Several attempts to establish standard physical and chemical attributes have been attempted by various pharmacopeias around the world, but without success largely due to technical issues regarding the creation of globule size limits. Recently, the United States Pharmacopeia has revised its previous efforts and developed two methods and criteria (under Chapter <729>) to measure the mean droplet size (Method I), and the large-diameter tail > 5 mum (Method II) of the globule size distribution to verify the stability of lipid injectable emulsions. Importantly, it is the latter size limits of Method II that have the greatest implications for infusion safety. The major safety issues involving lipid injectable emulsions include impairments in plasma clearance in susceptible patients, and the infusion of an unstable emulsion containing large quantities of potentially embolic fat globules. Recent animal studies investigating the toxicity from the infusion of unstable lipid injectable emulsions have shown evidence of oxidative stress and tissue damage to the liver when recommended globule size limits determined by Method II of the USP are exceeded. Adoption of Chapter <729> of the USP seems appropriate at this time.

Lipid Injectable Emulsions: 2006

Lipid injectable emulsions are an essential source of fatty acids, as well as a daily source of calories. They have been used in the clinical setting for almost 40 years, but despite this, there are no established official standards governing pharmaceutical quality. After 15 years of development, the United States Pharmacopeia (USP), which writes such standards for all FDA-approved pharmaceuticals, is poised to adopt an official monograph for lipid injectable emulsions that sets pharmaceutical requirements on all manufacturers placing limits on pH, free fatty acid concentrations and globule size (both mean droplet size and the population of large fat globules larger than 5 micrometers). Recent animal data has shown pathophysiologic changes in vital organs for lipids that fall outside the USP-proposed globule size limits. From a clinical perspective, newer lipid injectable emulsions show great promise in certain patient settings, most notably in the intensive care unit in both adults and infants. The clinical use of alternative oils, such as medium-chain triglycerides, fish oil and olive oil show benefits over conventional soybean oil formulations. In adults, for example, the administration of omega-fatty acids via soybean oil-based lipids produces a heightened inflammatory response via production of 2-series prostaglandins, whereas substitution of a portion of the lipid with omega-3 fatty acids via fish oil can favorably dampen the inflammatory response. In infants, for example, substitution of soybean oil with fish oil has recently been shown to reverse parenteral nutrition-associated liver disease. These advances should lead to safer infusion therapy in patients receiving lipid injectable emulsions.

Pathological consequences to reticuloendothelial system organs following infusion of unstable all-in-one mixtures in rats

Recent evidence of lung injury from the infusion of unstable lipid injectable emulsions as all-in-one mixtures (AIOs) was shown in a guinea pig infusion model. We extended this research to a Sprague-Dawley rat infusion model, focusing our analyses on the dose of large-diameter fat globules (expressed as the volume-weighted percent of fat larger than 5 or 10 microm, PFAT5 or PFAT10) from the dispersed phase of emulsion mixtures of varying levels of stability, and the potential injurious effects on major tissues of the reticuloendothelial system (i.e., lungs and liver). Two identical infusion experiments (n=13 rats/study), involving stable (s-AIO) vs. unstable (u-AIO) mixtures were separately conducted, and differed in two respects: (1) duration of AIO infusion (24 h vs. 72 h) and, (2) starting PFAT5 levels for the u-AIO (24- vs. 72-h PFAT5: 0.682+/-0.055% vs. 0.117+/-0.024%, respectively). In both experiments, s-AIOs vs. u-AIOs were infused, and evidence of hepatic oxidative stress was noted by significantly higher tissue concentrations of malondialdehyde (MDA) during infusion of u-AIOs. The higher concentrations of MDA in the livers of animals receiving the u-AIOs were also accompanied by significantly higher plasma concentrations of AST in both infusion experiments suggesting injury. Levels of cytokines (IL-1beta, TNFalpha) in the lungs and livers in both infusion studies were variable. These results demonstrate the infusion of u-AIOs with starting PFAT5 levels of approximately 0.1% show evidence of pathological consequences to the liver and lungs, and therefore, such unstable AIO mixtures should probably be avoided in the clinical setting.