A historical perspective and review of the safety of lipid emulsion in pregnancy

Final Report on the Safety Assessment of Hydrogenated Cottonseed Oil, Cottonseed (Gossypium) Oil, Cottonseed Acid, Cottonseed Glyceride, and Hydrogenated Cottonseed Glyceride

Hydrogenated Cottonseed Oil, Cottonseed (Gossypium) Oil, Cottonseed Acid, Cottonseed Glyceride, and Hydrogenated Cottonseed Glyceride are cosmetic ingredients derived from Cottonseed Oil and used as skin-conditioning agents and surfactants. Non-oils known to be toxic that may be found in cottonseed oils include gossypol, aflatoxin, and cyclopropenoid fatty acids (CPFA). Toxic heavy metal and/or polychlorinated biphenyl (PCB) or other pesticide contamination is also possible. Cottonseed Oil was nontoxic in acute oral toxicity studies in rats. In a short-term study, rabbits that had been fed 2% Cottonseed Oil for 7 weeks had significantly lower blood chemistry parameters (compared to wheat bran controls) and significantly more stored hepatic vitamin A (compared to rabbits fed other fats). Cottonseed Oil controls used as vehicles in two parenteral studies produced negative results. Hydrogenated Cottonseed Oil tested in formulation did not produce dermal or ocular irritation in rabbits. An oral-dose reproductive study tested up to 30% Cottonseed Oil (with 1% CPFAs) and reported no adverse effects on sexual maturity and reproductive performance of the F0 generation; changes were noted in the F1 generation but reproductive capacity was not altered. Parenteral-dose reproductive studies reported no adverse effects. Cottonseed Oil was not mutagenic. Cottonseed Oil did not induce aberrant crypt foci when given orally to mice, but in other studies, it increased the incidence of spontaneous mammary tumors in rats and mice. Mice fed 20% Hydrogenated Cottonseed Oil during induction and promotion of photocarcinogenesis had significantly lower tumor incidence compared to mice fed 20 % sunflower oil. Hydrogenated Cottonseed Oil in formulation (up to 21 %) was neither an irritant nor sensitizer in clinical studies. Limited clinical data indicated that Cottonseed Oil does not contain allergic protein. Based on the available data, it was concluded that these ingredients may be used safely in cosmetic formulations if established limits on gossypol, heavy metals, and pesticide concentrations are not exceeded.

Systematic review of clinical adverse events reported after acute intravenous lipid emulsion administration

BACKGROUND

Intravenous lipid emulsions (ILEs) were initially developed to provide parenteral nutrition. In recent years, ILE has emerged as a treatment for poisoning by local anesthetics and various other drugs. The dosing regimen for the clinical toxicology indications differs significantly from those used for parenteral nutrition. The evidence on the efficacy of ILE to reverse acute toxicity of diverse substances consists mainly of case reports and animal experiments. Adverse events to ILE are important to consider when clinicians need to make a risk/benefit analysis for this therapy.

METHODS

Multiple publication databases were searched to identify reports of adverse effects associated with acute ILE administration for either treatment of acute poisoning or parenteral nutrition. Articles were selected based on pre-defined criteria to reflect acute use of ILE. Experimental studies and reports of adverse effects as a complication of long-term therapy exceeding 14 days were excluded.

RESULTS

The search identified 789 full-text articles, of which 114 met the study criteria. 27 were animal studies, and 87 were human studies. The adverse effects associated with acute ILE administration included acute kidney injury, cardiac arrest, ventilation perfusion mismatch, acute lung injury, venous thromboembolism, hypersensitivity, fat embolism, fat overload syndrome, pancreatitis, extracorporeal circulation machine circuit obstruction, allergic reaction, and increased susceptibility to infection.

CONCLUSION

The emerging use of ILE administration in clinical toxicology warrants careful attention to its potential adverse effects. The dosing regimen and context of administration leading to the adverse events documented in this review are not generalizable to all clinical toxicology scenarios. Adverse effects seem to be proportional to the rate of infusion as well as total dose received. Further safety studies in humans and reporting of adverse events associated with ILE administration at the doses advocated in current clinical toxicology literature are needed.

Pregnancy outcome in patients requiring parenteral nutrition

OBJECTIVE

The purpose of this retrospective study was to evaluate maternal and perinatal outcomes and complications of parenteral nutrition during pregnancy in our institution.

METHODS

This study was a review of medical records of all women who required parenteral nutrition during pregnancy at our institution from 1990-1997. The frequency of maternal and perinatal complications was calculated.

RESULTS

Twenty-six pregnancies required parenteral nutrition for the following indications: hyperemesis gravidarum (n = 16), cholecystitis/pancreatitis (n = 3), small bowel obstruction (n = 2), intracranial bleed (n = 2), ulcerative colitis (n = 1), and other (n = 2). The mean gestational age at initiation of therapy was 16.2 weeks and the mean duration of therapy was 30.6 days. Five pregnancies were terminated prior to fetal viability. Of the remaining pregnancies, obstetric complications occurred in 11, including two cases of idiopathic preterm labor resulting in preterm deliveries. Maternal complications resulting from the central venous catheters included four infections, two thromboses, one occlusion, one pneumothorax, and one catheter dislodgment. The complication rate for centrally inserted central catheters (50%) was significantly greater than the rate for peripherally inserted central catheters (9%).

CONCLUSIONS

Successful outcomes can be achieved in obstetric patients requiring parenteral nutrition. In this group of patients, the frequency of maternal complications secondary to centrally inserted central venous catheters was greater than that reported in nonpregnant patients. Peripherally inserted central catheters may be preferable when parenteral nutrition is required during pregnancy.

Clinical advances in the management of severe nausea and vomiting during pregnancy

The nutritional status of the woman with hyperemesis of pregnancy has been compromised by decreased food intake and increased nutrient loss. Depending on the severity of symptoms, interventions may begin with dietary and life-style alterations, proceed to oral nutritional supplementation or pharmacologic preparations, and continue on to intravenous vitamin-mineral therapy and either enteral tube feedings, parenteral nutrition, or both. These therapies, and the role of the nurse in initiating or supporting them, are described.