Use Of Intravenous Fat Emulsions Research Articles

Use of Intravenous Fat Emulsion in the Emergency Department for the Critically Ill Poisoned Patient

BackgroundMultiple case reports of using intravenous fat emulsion (IFE) as an antidote for human poisoning from various xenobiotics have been published over the last decade. Given the rapidly evolving field, emergency physicians may be uncertain about the indications, timing, and dose for IFE treatment. MethodsA PubMed literature search was conducted from January 1996 to November 2015 and limited to human studies written in English and articles with relevant keywords. Guideline statements and nonsystematic reviews were excluded. Studies identified then underwent a structured review of their results. ResultsThere were 986 papers fulfilling the search criteria screened, and 85 appropriate articles were rigorously reviewed in detail. Recommendations were given on indications, timing, and dose of IFE. Most of these were based on case reports and anecdotal experience. DiscussionIn critically ill patients with refractory shock or cardiac arrest after a suspected overdose of local anesthetics or selected xenobiotics, IFE may be considered as a potentially beneficial adjunctive treatment. Despite an abundance of reports on the use of IFE on xenobiotics poisoning, the quality of evidence is suboptimal and fraught with reporting bias. ConclusionsIFE may be an effective antidote in poisonings from various xenobiotics. However, further research is needed to determine its optimal circumstances, timing, and dose of use.

Life-Threatening Diphenhydramine Toxicity Presenting With Seizures and a Wide Complex Tachycardia Improved With Intravenous Fat Emulsion

Diphenhydramine toxicity manifests with signs of anticholinergic toxicity; therapy is generally supportive. In rare cases, patients can also present with a wide complex tachycardia due to sodium channel blockade. Treatment involves sodium bicarbonate. Lidocaine and hypertonic saline are used for arrhythmias refractory to sodium bicarbonate. Although intravenous fat emulsion (IFE) therapy is proposed as an adjunctive therapy due to the lipophilicity of diphenhydramine (octanol/water partition coefficient of 3.3), successful use of IFE after a confirmed sole ingestion of diphenhydramine is not previously reported. We present the case of a 30-year-old woman presenting with seizures, a wide complex tachycardia, and cardiovascular collapse after an ingestion of diphenhydramine refractory to other therapies with rapid improvement after IFE administration.

Asystole Immediately Following Intravenous Fat Emulsion for Overdose

Use of intravenous fat emulsion (IFE) for the treatment of poisoned patients in extremis is increasing. Little literature exists describing failures and complications of IFE. We describe two cardiac arrests temporally associated with IFE. A 50-year-old woman presented after ingesting 80 total tablets of metoprolol 25mg and bupropion 150mg. Bradycardia and hypotension were refractory to calcium salts, catecholamines, and high dose insulin (HDI). With a pulse of 40/min and mean arterial pressure (MAP) of 30mmHg, 100mL of 20% IFE was given; within 30s, brady-asystolic arrest occurred. Pulses returned after 3min of CPR. The patient died on hospital day 4 of multisystem organ failure (MSOF). A 53-year-old man presented after ingesting of 3,600mg of diltiazem and 1,200mg of propranolol. Bradycardia and hypotension were refractory to calcium salts, catecholamines, HDI, bicarbonate, and atropine. With a pulse of 30/min and a MAP of 40mmHg, 150mL of 20% IFE was given; within 1min, a brady-asystolic arrest occurred. Pulses returned after 6min of CPR. The patient died on hospital day 7 of MSOF. Reported cases of IFE failures or potential complications are sparse. This report adds only case experience, not clarity. We report two cardiac arrests that were temporally associated with IFE.

Early Enteral Fat Supplement and Fish Oil Increases Fat Absorption in the Premature Infant with an Enterostomy

To test the hypothesis that in the premature infant with an enterostomy, early enteral supplementation with Microlipid (fat supplement) and fish oil increases enteral fat absorption and decreases the requirement for Intralipid (intravenous fat emulsion). Premature infants (<2 months old) with an enterostomy after surgical treatment for necrotizing enterocolitis or spontaneous intestinal perforation and tolerating enteral feeding at 20 mL/kg/day were randomized to usual care (control 18 infants) or early supplementing enteral fat and fish oil (treatment 18 infants). Intravenous fat emulsion was decreased as enteral fat intake was increased. Daily weight, ostomy output, and nutrition data were recorded. Weekly 24-hour ostomy effluent was collected until bowel reanastomosis, and fecal fat, fecal liquid, and dry feces were measured. Fat absorption (g/kg/d) was calculated by subtracting fecal fat from dietary fat. The fecal liquid and dry feces were reported as mg/g wet stool. Date were analyzed by using ANOVA and mixed-effects model. The interval from initial postoperative feeding to bowel reanastomosis varied from 2 to 10 weeks. The treatment group received more dietary fat and less intravenous fat emulsion and had higher enteral fat absorption, less fecal liquid, and drier feces than the control group. These effects were greater among infants with a high ostomy compared with those with a low ostomy. Enteral fat intake was significantly correlated with fat absorption. Early enteral fat supplement and fish oil increases fat absorption and decreases the requirement for intravenous fat emulsion. This approach could be used to promote bowel adaptation and reduce the use of intravenous fat emulsion in the premature infant with an enterostomy.

Response to: ‘Intravenous Fat Emulsion Therapy: Can It be Tried Without Sufficient First‐Line Treatment Modalities?’

We wish to thank Dr. Zamani for his comments and the opportunity to clarify the treatment of poisoned patients. While we agree that at this moment the use of intravenous fat emulsion (IFE) therapy for patients with life-threatening poisoning from cardiotoxic lipophilic drugs should be only considered after routine care is provided, we emphatically disagree with Dr. Zamani's definition of routine care. Although the use of calcium 1 and glucagon 2 is frequently recommended for calcium channel blocker and beta-adrenergic antagonist toxicity, there are no controlled trials that establish their optimal dosing. Furthermore, the use of either calcium and/or glucagon in bupropion toxicity is entirely unknown. The patient we described had failed acceptable initial doses of calcium and glucagon that would have been used for empiric treatment of cardiotoxic overdose and was receiving high doses of norepinephrine at the time IFE therapy was considered. Increasing norepinephrine further may have improved the blood pressure at the cost of end-organ vasoconstriction and subsequent ischaemia. Instead, we chose to administer IFE, based on published success 3 in hopes of sequestering a lipid-soluble toxin and obviating the need for another toxic drug (norepinephrine). Finally, most of the adverse effects associated with IFE, as noted in the article cited by Dr. Zamani, are with prolonged total parenteral nutrition and therefore cannot be extrapolated to short administration of lipid resuscitation therapy 4.

Effect of intravenous fat emulsion therapy on glyphosate-surfactant–induced cardiovascular collapse

Intravenous fat emulsion (IFE) therapy is an adjunct therapy administered to hemodynamically compromised patients with glyphosate-surfactant intoxication when they respond poorly to conventional therapies such as fluid resuscitation or vasopressors [1,2]. However, the use of IFE as an adjunct therapy in collapsed patients with glyphosate intoxication has not been reported previously. Here, we describe the case of a patient with glyphosate-surfactant–induced cardiovascular collapse who responded to IFE.

Intravenous fat emulsion: A potential novel antidote

Intravenous fat emulsions (IFE) are traditionally used as a component of parenteral nutrition therapy. Recently, IFE was used to resuscitate severe local anesthetic drug toxicity. This review focuses on the potential role of IFE in treatment of toxicity due to local anesthetics and other lipid-soluble drugs. The general properties of IFE, metabolic fate, and associated adverse events are described. Cases of local anesthetic toxicity treated with IFE are presented along with a discussion of the possible antidotal mechanisms. Initial investigations into the antidotal use of IFE for lipophilic central nervous and cardiovascular drug toxicity are also reviewed.

Parenteral use of medium-chain triglycerides: A reappraisal

Over the last two decades, the clinical use of intravenous fat emulsions for the nutritional support of hospitalized patients has become routine. During this time long-chain triglycerides (LCT) derived from soybean and/or safflower oils were the exclusive lipid source for these emulsions, providing both a safe calorically dense alternative to dextrose and essential fatty acids needed for biologic membranes and the maintenance of immune function. During the past decade, the availability of novel experimental triglycerides for parenteral use has generated interest in the use of these substrates for nutritional and metabolic support. Medium-chain triglycerides (MCT), long advocated as a superior substrate for parenteral use, possess many unique physiochemical and metabolic properties that make them theoretically advantageous over their LCT counterparts. Although not yet approved in the United States, preparations containing MCT have been widely available in Europe. Intravenous MCT preparations, either as physical mixtures or structured lipids, have been used clinically in patients with immunosuppresion, critical illness, liver and pulmonary disease and in premature infants. Despite great promise, the clinical data comparing the efficacy of MCT-based lipid emulsions to their LCT counterparts has been equivocal. This may be due in part to the limited nature of the published clinical trials. Measures of efficacy for parenteral or enteral nutritional products has taken on new meaning, in light of the reported experience using immunomodulatory nutrients. Current concerns about cost of medical care and resource use warrant careful deliberation about the utility of any new and expensive therapy. Until clinical data can fulfill expectations derived from animal studies, it is difficult to advocate the general use of MCT-based lipid emulsions. Future clinical studies with MCT-based emulsions should have clear outcome objectives sufficient to prove their theorized metabolic superiority.

Antifungal agents in neonatal systemic candidiasis.

Neonatal systemic candidiasis is increasingly being recognized as a cause of septicemia in the neonatal intensive care unit (2, 19, 26, 36, 59). Predisposing factors for candidemia and subsequently invasive infections include prematurity, prolonged exposure to broad-spectrum antibiotics, the use of intravenous fat emulsions, the presence of necrotizing enterocolitis, prolonged intravascular catheterization, and tracheal intubation (33, 49, 50, 51, 63). Moreover, the immune functions of the newborn, especially in the preterm infant, are suboptimal, manifested as a decreased T-cell and granulocyte function (6, 22, 65). Additionally, it has been shown that lung macrophages of newborns have reduced anti-Candida activity (16). Infection is preceded generally by colonization of the gastrointestinal tract and the skin shortly after delivery (1, 27). Clinical evidence suggests that heavy colonization at multiple sites is a predisposing factor for clinical disease (27, 41), although this is still controversial (40). Most fungal infections in newborns are caused by Candida albicans, Candida parapsilosis, and more rarely, Candida tropicalis (1, 20, 42, 48). The symptoms of systemic candidal infection in the newborn are not specific. In several studies deterioration of respiratory function and apnea were the most common presenting signs, occurring in 70% of infants (2, 10, 26). Temperature instability, irritability, abdominal distension, carbohydrate intolerance, rash, and lethargy were also commonly observed. Similar symptoms are noted in newborns with bacterial infections, which occur frequently or coincidentally with systemic candidiasis. Therefore, most fungemic newborns are presumptively treated for bacterial infection. Since the signs, symptoms, and results of hematologic studies for infants suspected of having candidiasis are not specific, positive cultures are the mainstay in the diagnosis of invasive candidiasis. However, in newborn patients most antifungal therapy is started when fungal elements are seen on Gram stain or yeasts are isolated from some body fluid. On occasion it is even begun empirically or on the basis of the presence of a suggestive rash. Amphotericin B with or without flucytosine is still the treatment of choice for newborns with systemic candidiasis. However, since the introduction of ketoconazole in 1981, fluconazole in 1990, and intraconazole in 1992, these antifungal azoles, which unlike amphotericin B can be given orally, there has been a tendency to use these drugs as alternative therapies. Physicians have been influenced by the efficacy, safety, and ease of the administration of the azoles, despite the lack of direct comparisons of the efficacies of these drugs and amphotericin B. Our purpose here is to present an overview of the available pharmacokinetic data for amphotericin B, flucytosine, and this new group of azole drugs in the newborn. Dosage recommendations, recommendations for dosage adjustments in the face of organ system failure, and recommendations for monitoring toxicity will be suggested.

Intravenous fat emulsions in clinical practice.

The use of intravenous fat emulsions has become an integral part of the provision of parenteral nutrition. In the past, this was achieved by the administration of lipids separately from the dextrose-amino acid base solution. More recently, lipids have been admixed along with the dextrose-amino acid formula as a total nutrient admixture (TNA). This article discusses the advantages and disadvantages of TNAs, the factors that affect the stability of emulsions, the potential for microbial growth in TNAs, and guidelines for the compounding of TNAs.

Nutrition, the gastrointestinal tract and the Acquired Immune Deficiency Syndrome. Facts and perspectives

Diarrhoea and malnutrition are common findings in patients with the Acquired Immune Deficiency Syndrome (AIDS). In this disease, enteropathy leads to fat and D-xylose malabsorption and chronic non-specific inflammation of the small bowel. Moreover, gastrointestinal infection can induce severe diarrhoea. Depletion in real body cell mass, body fat content, and weight loss have been observed. Nutritional therapy is mandatory when weight loss is 10% or greater. Enteral feeding is not easily achieved. Parenteral feeding including fat as a nonprotein calorie source improves general condition. The use of intravenous fat emulsions has been hypothesized to have several beneficial effects. Fluidisation of human immunodeficiency virus membranes by lipid emulsions through cholesterol extraction could decrease the infectivity of the virus. Long term intravenous nutrition may be more than a treatment for malabsorption and depletion; it may possibly have direct pharmacological effects.

Epidemiology, diagnosis, and management of Malassezia furfur systemic infection.

Malassezia furfur, a normal skin flora yeast, generally associated with very mild superficial skin infections, has become an opportunistic pathogen in patients with deep-line vascular catheters. The use of intravenous fat emulsions appears to have altered the microenvironment of the catheter and allowed colonization and subsequent infection. Dissemination of the organism appears to be limited to the lungs, which may have been previously altered by vascular lipid deposition. Because of the serious underlying disease(s) of patients with M. furfur catheter sepsis, it is difficult to determine the exact role of the organism in the overall status of the patients. At the very least, however, catheter removal or discontinuance of the fat emulsion therapy may be required. Antifungal therapy without either of these two steps has not been shown to be efficacious. Physicians must maintain a high index of suspicion of M. furfur catheter sepsis in the appropriate clinical setting, and laboratory investigators must be prepared to provide appropriate diagnostic methods.

Use of Intravenous Fat Emulsions During Total Parenteral Nutrition in Glucose‐Intolerant Patients

Nutrition in Clinical PracticeVolume 1, Issue 3 p. 136-139 Article Use of Intravenous Fat Emulsions During Total Parenteral Nutrition in Glucose-Intolerant Patients Jane E. Bradley, Department of Clinical PharmacySearch for more papers by this authorCynthia Brown, Pharmacy Resident V.A. Medical CenterSearch for more papers by this authorRex O. Brown, Clinical Pharmacy College of Pharmacy University of Tennessee, Memphis Memphis, TennesseeSearch for more papers by this author Jane E. Bradley, Department of Clinical PharmacySearch for more papers by this authorCynthia Brown, Pharmacy Resident V.A. Medical CenterSearch for more papers by this authorRex O. Brown, Clinical Pharmacy College of Pharmacy University of Tennessee, Memphis Memphis, TennesseeSearch for more papers by this author First published: 01 June 1986 https://doi.org/10.1177/088453368600100305Citations: 2AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat Citing Literature Volume1, Issue3June 1986Pages 136-139 RelatedInformation

Hematologic disorders following prolonged use of intravenous fat emulsions in children.

Abnormalities in hematologic parameters, associated with prolonged utilization of intravenous fat emulsion (IVFE), were observed in seven children on long-term cyclic total parenteral nutrition (TPN). All patients were receiving IVFE (Intralipid 20%) 1 to 2 g/kg/24 hr as part of TPN, during 3 to 18 months. Recurrent thrombocytopenia occurred in all seven patients. Platelet lifespan, as measured with 111 Indium was reduced. Sea-blue histiocytes containing granulations and hemophagocytosis were seen on bone marrow smears. Scans taken after injection of autologous erythrocytes labeled with technetium-99 showed bone marrow sequestration of these cells. Taken together, this constellation of hematologic abnormalities suggests that long-term IVFE administration induces hyperactivation of the monocyte-macrophage system.

Fatty Acid Changes in Plasma Lipids and Lymphocyte Phospholipids after Infusion of Intralipid to Newborn Infants

The fatty acid composition of the major plasma lipids and blood lymphocyte phospholipids was studied in four patients before and after 1 month of parenteral nutrition including 2 to 3 g/kg/day of Intralipid fat and in four matched controls before and after 1 month of breast-feeding. After treatment with Intralipid the concentration of polyunsaturated fatty acids including linoleic acid increased in all plasma lipids. The total concentration of polyunsaturated fatty acids in lymphocyte phospholipids did not change. The increase of linoleic acid and decrease of arachidonic acid in lymphocyte phospholipids were not statistically significant. In control infants the concentration of polyunsaturated fatty acids including linoleic and arachidonic acid in lymphocyte phospholipids increased after 1 month of breast-feeding to almost the same values as in the patients. The study indicates that at least in lymphocytes the incorporation of polyunsaturated fatty acids is actively regulated. The present way of administering Intralipid does not seem to cause any abnormal fatty acid pattern of the plasma and lymphocyte lipids. The use of intravenous fat emulsion with high content of linoleic acid in term newborns should thus not be expected to result in changes of the physical-chemical properties of membranes and membrane dysfunction.

Hyperalimentation Laboratory Support

The Committee on Nutrition, American Academy of Pediatrics has recently reported on the "Use of Intravenous Fat Emulsions in Pediatric Patients" (Pediatrics 68:738, 1981). The committee recommends restriction of the amount of fat emulsion given infants because of a lack of accurate and appropriate means of monitoring serum fatty acid and triglyceride concentrations. Such is not the case for triglycerides. The pediatric clinical chemistry laboratory has the ability to measure serum triglyceride concentrations to support hyperalimentation therapeutic monitoring.

Use of Intravenous Fat Emulsions in Pediatric Patients

Intravenous fat preparations are used in the nutrition of those requiring parenteral alimentation. Although parenteral nutrition is recognized as a limited substitute for oral alimentation, and should be used for as short a time as possible, widespread use has resulted in some adverse effects. Fat has the highest caloric density of any nutrient. In addition, intravenously infused fat emulsions exert negligible osmotic effects. Thus, for a number of years, the possibility of providing calories by the intravenous administration of fat emulsions has been an attractive one. In fact, one of the first attempts at intravenous nutrition was infusion of various nonemulsified oils.1 Approximately 30 years ago, a fat emulsion suitable for intravenous use was developed and used extensively. Although it was efficacious as an intravenous calorie source, it was unstable and the serious, short-term effects of this instability resulted in its withdrawal from the market in the late 1960s. Subsequently, advances in manufacturing technology allowed preparation of stable fat emulsions, and several such preparations are available today. All currently available emulsions are efficacious calorie sources; moreover, they appear to be extremely stable and have been associated with relatively few adverse effects.2-5 All allow delivery of lipid to patients requiring parenteral nutrition. In fact, they may make it possible to deliver adequate nutrients solely by peripheral vein, thus avoiding in many patients the use of central vein catheters and their associated complications.6 This possibility, plus the possibility of providing linoleic acid and thereby preventing essential fatty acid deficiency, which occurs with fat-free total parenteral nutrition,7,8 has generated considerable enthusiasm for these products.

Drug Therapy Reviews: Rational Use of Intravenous Fat Emulsions

Drug Therapy Reviews: Rational Use of Intravenous Fat Emulsions

Rational use of intravenous fat emulsions

The composition, effect on blood components, relative value compared with intravenous dextrose, clinical applications as a caloric and fatty acid source, adverse reactions, limitations, and administration of intravenous fat emulsions are reviewed. Fat emulsions provide essential fatty acids and calories and are primarily used to supplement of parenteral nutrition regimens. Their use as a major source of calories remains limited because of cost. However, the trend toward aligning intravenous nutrition to that of the normal diet and the increased demand for peripherally administered parenteral nutrition have increased demand for use. The advantages and disadvantages presented may be used by clinicians to assist in establishing the role of intravenous fat therapy in nutritional support services.

Effects of prolonged use of intravenous fat emulsion on jejunal mucosa: T. C. Iancu, Y. Bujanover, Z. Freier, et al. Isr J Med Sci 16:212, (March), 1980

Effects of prolonged use of intravenous fat emulsion on jejunal mucosa: T. C. Iancu, Y. Bujanover, Z. Freier, et al. Isr J Med Sci 16:212, (March), 1980