State of the art review: Intravenous fat emulsions: Current applications, safety profile, and clinical implications

Incidence of Hypertriglyceridemia in Patients on Propofol, Clevidipine, or Both

BACKGROUND

Propofol and clevidipine (PC) are commonly used in the treatment of critically ill patients. While both medications are lipid emulsions, there is limited evidence concerning the incidence of hypertriglyceridemia (HTG) when these agents are used individually or concurrently.

OBJECTIVE

The objective of this study is to determine the effects of propofol, clevidipine, or concurrent PC on triglycerides (TGs) and related outcomes in critically ill adults.

METHODS

This was a retrospective cohort study conducted at an academic medical center. Patients were included if they received ≥24 hours of continuous propofol and/or clevidipine. Excluded were those without TG levels after ≥24 hours of infusion, baseline HTG, acute pancreatitis at admission, or receiving total parenteral nutrition with lipids. The primary outcome was incidence of HTG (defined as a TG level >400 mg/dL). Secondary outcomes included median and peak TG levels, hospital length of stay, intensive care unit length of stay, total lipid infused, time to peak TG level, peak lipase level, and development of pancreatitis.

RESULTS

In total, 190 patients were studied: 109 in the propofol group, 50 in the clevidipine group, and 31 in the PC group. Incidence of HTG was similar (19 [17.4%] vs 6 [12%] vs 4 [12.9%] patients, P = 0.6246). Peak and median TG levels were similar for propofol, clevidipine, and PC groups (216 mg/dL vs 189.5 mg/dL vs 205 mg/dL, P = 0.7069; 177 mg/dL vs 185.5 mg/dL vs 177 mg/dL, P = 0.6791).

CONCLUSIONS AND RELEVANCE

There was a similar incidence of HTG in all groups. The results of this study suggest that the concurrent use of PC should not modify the frequency of TG level monitoring.

n-3 Polyunsaturated Fatty Acid Supplementation Affects Oxidative Stress Marker Levels in Patients with Type II Intestinal Failure: A Randomized Double Blind Trial

Type II intestinal failure (IF-II) is a condition in which the gastrointestinal tract is compromised. Liver complications may occur because of the pathology and/or prolonged use of parenteral nutrition (PN); oxidative stress has been implicated as one of the causes. Lipid emulsions containing n-3 polyunsaturated fatty acids (PUFAs) have been proposed for the treatment. We aimed to evaluate the effect of 7-day n-3 PUFA supplementation on oxidative stress in IF-II patients receiving PN. This was a randomized, controlled, double-blinded, pilot trial of adult patients with IF-II, receiving either conventional PN (control) or PN enriched with n-3 PUFAs (intervention). Twenty patients were included (14 men, 49 ± 16.9 years), with the ANCOVA analysis the glucose (p = 0.003), and direct bilirubin (p = 0.001) levels reduced; whereas the high-density lipoprotein cholesterol (HDL-C) increased (p = 0.017). In the random-effect linear regression analysis, a reduction (p < 0.0001) in the malondialdehyde (MDA) level was found in the intervention group when the covariables age, HDL-C level, and alanine aminotransferase activity were considered. After 1 week of PN supplementation with n-3 PUFAs, the marker levels of some oxidative stress, blood lipids, and hepatic biomarkers improved in patients with IF-II.

Lipid emulsion for xenobiotic overdose: PRO

Infusion of lipid emulsion for drug overdose arose as a treatment for local anaesthetic systemic toxicity (LAST) initially based on laboratory results in animal models with the subsequent support of favourable case reports. Following successful translation to the clinic, practitioners also incorporated lipid emulsion as a treatment for non-local anaesthetic toxicities but without formal clinical trials. Recent clinical trials demonstrate a benefit of lipid emulsion in antipsychotic, pesticide, metoprolol and tramadol overdoses. Formal trials of lipid emulsion in LAST may never occur, but alternative analytic tools indicate strong support for its efficacy in this indication; for example, lipid emulsion has obviated the need for cardiopulmonary bypass in most cases of LAST. Herein, we describe the pre-clinical support for lipid emulsion, evaluate the most recent clinical studies of lipid emulsion for toxicity, identify a possible dose-based requirement for efficacy and discuss the limitations to uncontrolled studies in the field.

Lipid Emulsion to Treat Acute Poisonings: Mechanisms of Action, Indications, and Controversies

Biodetoxification using intravenous lipid emulsion (ILE) in acute poisoning is of growing interest. As well as for local anesthetics, ILE is currently used to reverse toxicity caused by a broad-spectrum of lipophilic drugs. Both pharmacokinetic and pharmacodynamic mechanisms have been postulated to explain its possible benefits, mainly combining a scavenging effect called "lipid sink" and cardiotonic activity. Additional mechanisms based on ILE-attributed vasoactive and cytoprotective properties are still under investigation. Here, we present a narrative review on lipid resuscitation, focusing on the recent literature with advances in understanding ILE-attributed mechanisms of action and evaluating the evidence supporting ILE administration that enabled the international recommendations. Many practical aspects are still controversial, including the optimal dose, the optimal administration timing, and the optimal duration of infusion for clinical efficacy, as well as the threshold dose for adverse effects. Present evidence supports the use of ILE as first-line therapy to reverse local anesthetic-related systemic toxicity and as adjunct therapy in lipophilic non-local anesthetic drug overdoses refractory to well-established antidotes and supportive care. However, the level of evidence is low to very low, as for most other commonly used antidotes. Our review presents the internationally accepted recommendations according to the clinical poisoning scenario and provides the precautions of use to optimize the expected efficacy of ILE and limit the inconveniences of its futile administration. Based on their absorptive properties, the next generation of scavenging agents is additionally presented. Although emerging research shows great potential, several challenges need to be overcome before parenteral detoxifying agents could be considered as an established treatment for severe poisonings.

Clinical Effects of Inadvertent Increased Lipid Infusion in Neonates: Two Case Reports

BACKGROUND

Utility of total parenteral nutrition (TPN) with an intravenous lipid emulsion (IVLE) component is common in the neonatal intensive care unit; however, there are inherent risks to TPN use. With IVLE administered separate from other TPN components, opportunities exist for additional error and subsequent potential harm.

CLINICAL FINDINGS

We present 2 cases in term infants where IVLE infusions were noted to be inadvertently administered at higher than prescribed rates, prompting concern for lipemia and end-organ damage due to hyperviscosity.

PRIMARY DIAGNOSIS

Both infants developed iatrogenic hypertriglyceridemia and hyponatremia.

INTERVENTION

Upon recognition of the error, IVLE was immediately discontinued in each case. Triglyceride levels were serially monitored until they reached a normal level. Electrolyte panels and hepatic function panels were also drawn to assess for electrolyte derangements and function. Radiologic studies were performed for evaluation of end-organ effects of hyperviscosity.

OUTCOMES

Triglyceride levels for both infants normalized within 7 hours. Both infants survived to discharge without any known effects related to the inadvertent excessive lipid infusion.

CONCLUSION

It is helpful to perform a root-cause analysis for these types of events; have the exact amount of lipids in the bag needed and no overfill; consider having lipids in 4-hour dosage aliquots; require 2 nurses to verify infusion rates hourly; and educational sessions and unit protocols for any infusion may reduce the risk of administration error.

Repurposing of parenterally administered active substances used to treat pain both systemically and locally

Pain is a constant in our lives. The efficacy of drug therapy administered by the parenteral route is often limited either by the physicochemical characteristics of the drug itself or its adsorption-distribution-metabolism-excretion (ADME) mechanisms. One promising alternative is the design of innovative drug delivery systems that can improve the pharmacokinetics |(PK) and/or reduce the toxicity of traditionally used drugs. In this review, we discuss several products that have been approved by the main regulatory agencies (i.e., nano- and microsystems, implants, and oil-based solutions), highlighting the newest technologies that govern both locally and systemically the delivery of drugs. Finally, we also discuss the risk assessment of the scale-up process required, given the impact that this approach could have on drug manufacturing. Teaser: The management of pain by way of the parenteral route can be improved using complex drug delivery systems (e.g., micro- and nanosystems) which require high-level assessment and shorten the regulatory pathway.

Case Report: Successful Intravenous Lipid Emulsion Therapy for Canine Amphetamine Toxicosis

A 4-year-old, female-spayed, mixed breed dog, weighing 24.2 kg, was presented for acute ingestion of ~12.3 mg/kg of Adderall XR^Ⓡ, an extended-release amphetamine medication. In dogs, the oral median lethal dose for amphetamines ranges anywhere from 9–11 mg/kg to 20–27 mg/kg. On presentation, the patient was agitated, tachycardic and hypertensive. Initial treatment was instituted with intravenous lipid emulsion (IVLE) therapy, and baseline and post-treatment amphetamine concentrations were quantified in serum and plasma. In both serum and plasma, post-IVLE concentrations of amphetamine were lower 1 h after treatment and IVLE was the only treatment instituted during this time. The dog improved significantly while in hospital and was discharged <24 h after presentation. This is the first known reported use of IVLE for treatment of amphetamine toxicosis with documented decreases in both serum and plasma amphetamine levels shortly after administration of IVLE.

Lipid-Enriched Parenteral Nutrition and Bloodstream Infections in Hospitalized Patients: Is It a Real Concern?

Today, few clinicians are still convinced that lipids are sepsis risk factors in patients receiving parenteral nutrition. This dogma is principally based on old literature. This review deals with the most recent literature search that provided up-to-date data over the past ten years. Systematic research was performed on Pubmed, MEDLINE, and Web of Science. The recent evidence does not justify the exclusion of lipid emulsions in patients receiving parenteral nutrition for fear of bloodstream infection risk. Moreover, lipids represent a substantial proportion of the energy source providing essential fatty acids, potentially improving clinical outcomes in patients often malnourished. Understanding the actual risk factors of sepsis during parenteral nutrition is necessary to optimize patient nutritional status and care and avoid essential fatty acid deficiency. There is an urgent need to make updated nutrition training available at all levels of medical education.

[Parenteral nutrition-associated complications in patients with SARS-CoV-2 infection]

BACKGROUND

it is unknown whether patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19 are at greater risk of developing complications associated with parenteral nutrition (PN).

AIM

to describe the incidence, risk factors, and clinical impact of complications in patients with ARDS-COVID-19 receiving PN.

METHODS

a prospective cohort study of 87 patients with ARDS-COVID-19 infection. The incidence of complications and odds ratios of risk factors were analysed.

RESULTS

age ≥ 65 years (OR, 2.52, 95 % CI: 1.16 to 5.46), obesity (OR, 3.34, 95 % CI: 2.35 to 4.33) and treatment with propofol (OR, 2.45, 95 % CI: 1.55 to 3.35) or lopinavir/ritonavir (OR, 4.98, 95 % CI: 3.60 to 6.29) were risk factors for hipertriglyceridemia. Obesity (OR, 3.11, 95 % CI: 1.10 to 8.75), dyslipidemia (OR, 3.22, 95 % CI: 1.23 to 8.40) or treatment with propofol (OR, 5.47, 95 % CI: 1.97 to 15.1) were risk factors for intravascular catheter-related infection. No risk factors were described for hiperglycemia. Mortality was higher in patients with intravascular catheter-related infection (46.7 % vs 10.8 %, p = 0.014). Mortality risk was higher in older patients (OR, 2.74, 95 % CI: 1.08 to 6.95) or patients with intravascular catheter-related infection (OR, 3.22, 95 % CI: 1.23 to 8.40).

CONCLUSIONS

the incidence of complications associated with PN in patients with COVID-19-related ARDS is frequent. The mortality risk is higher in older patients or those with catheter-related infection.

Lecithin-sodium caseinate self-assembled complexes as emulsifying agents in oil-in-water emulsion: Acidic medium approach

Surfactant-polyelectrolyte complexes (SPECs) based on lecithin and sodium caseinate were produced and the effects of such binding on the physical, chemical and emulsifying properties were evaluated and compared with the two ingredients in isolation. Negative, neutral, and positive charged SPECs were obtained. Zeta potential values and size distributions of the SPECs were dependent on the mass ratio between compounds. Electrostatic association decreased the polydispersity index in comparison with pure compounds solutions. Analysis of interfacial properties showed that solutions containing SPECs promoted a greater reduction of surface tension and interfacial tension with sunflower oil when compared with pure compounds solutions. Emulsions produced with SPECs in 10:1 lecithin:sodium caseinate ratio proved to be more stable than emulsions prepared with pure compounds. Thus, the complexation improved the emulsifying properties of lecithin and sodium caseinate establishing SPECs as potential natural emulsifiers.

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Ratio between compounds plays a role in the emulsifying properties of complexes.

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Complexes promoted faster decrease of interfacial tension with sunflower oil.

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Complexes formed at Lip:NaCas 10:1 ratio improved the stability of emulsions.

ASPEN lipid injectable emulsion safety recommendations part 2: Neonate and pediatric considerations

Lipid injectable emulsions (ILEs) are complex pharmaceutical formulations intended as a source of energy and fatty acids for parenteral nutrition (PN) therapy. Part 1 of this series addressed issues associated with and safety recommendations pertaining to adult ILE use. Part 2 addresses ILE safety in neonatal and pediatric patients. Considerations for ILE use in the neonatal and pediatric populations differ from those of adults. For example, these patients often require higher doses compared with adult counterparts to support growth, development, and daily metabolic needs. ILE is also frequently administered as a separate infusion as opposed to in a total nutrient admixture owing to compatibility and stability issues and limitations to intravenous access in the neonatal and pediatric populations. ILE is the most frequent PN ingredient associated with PN errors occurring in the administration, prescribing, and transcribing processes. Concerns exist with use of in-line filters and repackaging of commercial products for infusion. ILE use in neonatal and pediatric patients has been associated with both minor and major adverse effects, which most often occur with doses exceeding manufacturer recommendations. Gaps in ILE best practices for neonatal and pediatric patients predispose to errors in the PN use system. This paper describes safe-use considerations for ILE products available in the United States in neonatal and pediatric patients, including indications, prescribing, order review, preparation, administration, and monitoring. This paper has been approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.

Role of Dietary Nutritional Treatment on Hepatic and Intestinal Damage in Transplantation with Steatotic and Non-Steatotic Liver Grafts from Brain Dead Donors

Herein, we investigate whether: (1) the administration of glucose or a lipid emulsion is useful in liver transplantation (LT) using steatotic (induced genetically or nutritionally) or non-steatotic livers from donors after brain death (DBDs); and (2) any such benefits are due to reductions in intestinal damage and consequently to gut microbiota preservation. In recipients from DBDs, we show increased hepatic damage and failure in the maintenance of ATP, glycogen, phospholipid and growth factor (HGF, IGF1 and VEGFA) levels, compared to recipients from non-DBDs. In recipients of non-steatotic grafts from DBDs, the administration of glucose or lipids did not protect against hepatic damage. This was associated with unchanged ATP, glycogen, phospholipid and growth factor levels. However, the administration of lipids in steatotic grafts from DBDs protected against damage and ATP and glycogen drop and increased phospholipid levels. This was associated with increases in growth factors. In all recipients from DBDs, intestinal inflammation and damage (evaluated by LPS, vascular permeability, mucosal damage, TLR4, TNF, IL1, IL-10, MPO, MDA and edema formation) was not shown. In such cases, potential changes in gut microbiota would not be relevant since neither inflammation nor damage was evidenced in the intestine following LT in any of the groups evaluated. In conclusion, lipid treatment is the preferable nutritional support to protect against hepatic damage in steatotic LT from DBDs; the benefits were independent of alterations in the recipient intestine.

Acute Hypertriglyceridemia in Patients with COVID-19 Receiving Parenteral Nutrition

Hypertriglyceridemia is a metabolic complication associated with parenteral nutrition (PN). It is unknown if patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19 are more at risk. Our aim was to describe the incidence, risk factors and clinical impact of hypertriglyceridemia in critically ill patients with ARDS-COVID-19 receiving PN. We designed a cohort study of patients with ARDS-COVID-19 infection that required admission to critical care units and nutritional support with PN. Individual PN prescriptions for macronutrients and insulin were provided. Lipid emulsion contained fish oil (SMOFlipid® or Lipoplus®). Hypertriglyceridemia was defined as plasma levels above 400 mg/dL. Eighty-seven patients, 66.6% men, 60.1 ± 10.8 years old, BMI 29.1 ± 5.6 kg/m2, 71% of whom received lopinavir/ritonavir, 56% received Propofol and 55% received Tocilizumab were included. The incidence of hypertriglyceridemia was 37 × 100 patient-days with PN. This complication was more frequent in obese patients (OR 3.34; 95% CI, 2.35-4.33) and in those treated with lopinavir/ritonavir (OR 4.98; 95% CI, 3.60-6.29) or Propofol (OR 2.45; 95% CI, 1.55-3.35). Total mortality was 33.3%, similar between the type of lipid emulsion (p = 0.478). On average, patients with hypertriglyceridemia had a longer requirement of PN compared to the group without elevated triglycerides (TG), probably because of their longer survival (p = 0.001). TG higher than 400 mg/dL was not a protective factor for mortality (OR 0.31; 95% CI, 0.01-1.30). In conclusion, the incidence of hypertriglyceridemia was 37 × 100 patient-days with PN. The risk of this complication is associated with obesity and the use of lopinavir/ritonavir or Propofol.

Validity of Random Triglyceride Levels in Infants Receiving Parenteral Nutrition

Background: Intravenous lipid emulsions (IL) are an important part of parenteral nutrition (PN) to meet essential fatty acid (EFA) requirements and metabolic demands of neonates and preterm infants. Some critically-ill neonates may not metabolize IL effectively which can lead to hypertriglyceridemia. Risks associated with this include increased pulmonary vascular resistance, displaced bilirubins, and platelet or macrophage dysfunction. Serum triglyceride (TG) concentration is used as a marker for lipid tolerance and predictor of potential complications involved with IL administration, but the clinical significance of this is still debated. Management of TG levels with regard to timing of laboratory tests, the ideal goal range, and duration of infusion of IL varies across institutions and is not standardized. Methods: Single-center, retrospective study of newborn infants receiving parenteral nutrition (PN). Fasting and non-fasting TG levels were drawn during the same lipid infusion of 2-3g/kg/day. The primary outcome was the difference between fasting and non-fasting TG levels. Statistical assessment of continuous data was done with student t-test and nominal data was evaluated using X2-test and logistic regression. Results: Forty infants were included with mean gestational age at birth of 29.5 ± 3.4 weeks and mean birth weight of 1.3 ± 0.5 kg. Mean time between lab draws while on same IL dose was 11.6 ± 0.2 h with resulting mean fasting and non-fasting (random) TG levels 82 ± 40 mg/dL (95% CI 68.4, 97.6) and 101 ± 40 mg/dL (95% CI 88.5, 115.8), respectively. Mean difference between TG levels during lipid-free interval and during infusion was -18.6 ± 51.2 mg/dL (95% CI -35.0, -2.3; p = 0.03). Conclusion: We concluded there is no difference in the management of IL, when TG level was drawn randomly or as fasting sample. Obtaining TG level during routine lab draws is appropriate. We extrapolated that the administration of IL over 24 h will not interfere with TG level.

ASPEN Lipid Injectable Emulsion Safety Recommendations, Part 1: Background and Adult Considerations

Lipid injectable emulsions (ILEs) are complex pharmaceutical formulations used as a source of energy and essential fatty acids in parenteral nutrition. Issues associated with ILE use are distinctly different from oral fat and arise from emulsion stability, dose, and infusion tolerance. Since 1975, soybean oil has been the consistent source oil used in ILE formulations in the US. Partly because of safety concerns with the soybean-based ILE and frequent and long-standing problems with product inventory shortages, new ILE products have become available. Gaps in ILE best practices create a risk for ILE safety errors in prescribing, compounding, and administration of these products. This paper provides information on appropriate indications, dosing, and methods to avoid potential errors with ILE products in the US. This paper (Part 1) will focus on ILE background, information, and recommendations for adult patients, whereas Part 2 of this series will focus on neonatal and pediatric patient-specific information.

Microbial Contamination of Neonatal Injectable Lipid Emulsions at 12 and 24 Hours' Infusion Time With Evaluation of Infection Control Measures

OBJECTIVES

This study aimed to assess the microbial contamination rate of injectable lipid emulsion (ILE) repackaged syringes at 12 and 24 hours of their infusion time. Probable risk factors associated with contamination of the ILEs were also assessed. In addition, the antimicrobial resistance pattern of the bacterial isolates was also determined.

METHODS

Samples of ILE were collected from 152 repackaged syringes and their infusion lines after 12 hours and 24 hours of infusion time (73 and 79 samples, respectively). Samples were cultured, the isolates were identified, and the antimicrobial resistance pattern of the bacterial isolates was identified. A checklist was completed throughout the study to observe the compliance to infection control measures by pharmacists (who prepare) and nurses (who administer) the ILE infusions. Results of septic neonatal cultures were taken from records.

RESULTS

Microbial contamination was found in 15.8% of ILE samples. The 2 most common pathogens found among positive samples were Klebsiella pneumoniae (29.2%) and Candida albicans (20.8%). Microbial contamination of repackaged syringes increased from 9.6% at 12 hours to 21.5% at 24 hours. This difference was found to be statistically significant (p = 0.044). A similar trend of predominance of those 2 pathogens, in both ILE and neonatal cultures, was observed. There was a statistically significant better performance of infection control measures of pharmacists rather than nurses. The K pneumoniae isolates (n = 7) showed antibiotic resistance in the following pattern: gentamicin (71.4%), cefazolin (85.7%), and cefoxitin (85.7%).

CONCLUSIONS

The rate of ILE contamination was less at 12 hours' than at 24 hours' infusion time. However, contamination rates at 12 hours were unacceptably high. Klebisella pneumoniae and C albicans were the most common pathogens isolated from ILE. Compliance with infection control measures was significantly worse among nurses compared with pharmacists.

Nutritrauma: A Key Concept for Minimising the Harmful Effects of the Administration of Medical Nutrition Therapy

Critically ill patients often require life support measures such as mechanical ventilation or haemodialysis. Despite the essential role of nutrition in patients’ recovery, the inappropriate use of medical nutrition therapy can have deleterious effects, as is the case with the use of respiratory, circulatory, or renal support. To increase awareness and to monitor the effects of inappropriate medical nutrition therapy, we propose to introduce the concept of nutritrauma in clinical practice, defined as metabolic adverse events related to the inappropriate administration of medical nutrition therapy or inadequate nutritional monitoring.

Clinical Nutrition in Critical Care Medicine - Guideline of the German Society for Nutritional Medicine (DGEM)

PURPOSE

Enteral and parenteral nutrition of adult critically ill patients varies in terms of the route of nutrient delivery, the amount and composition of macro- and micronutrients, and the choice of specific, immune-modulating substrates. Variations of clinical nutrition may affect clinical outcomes. The present guideline provides clinicians with updated consensus-based recommendations for clinical nutrition in adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function.

METHODS

The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. According to the S2k-guideline classification, no systematic review of the available evidence was required to make recommendations, which, therefore, do not state evidence- or recommendation grades. Nevertheless, we considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of other societies. The liability of each recommendation was described linguistically. Each recommendation was finally validated and consented through a Delphi process.

RESULTS

In the introduction the guideline describes a) the pathophysiological consequences of critical illness possibly affecting metabolism and nutrition of critically ill patients, b) potential definitions for different disease phases during the course of illness, and c) methodological shortcomings of clinical trials on nutrition. Then, we make 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in critically ill patients. Among others, recommendations include the assessment of nutrition status, the indication for clinical nutrition, the timing and route of nutrient delivery, and the amount and composition of substrates (macro- and micronutrients); furthermore, we discuss distinctive aspects of nutrition therapy in obese critically ill patients and those treated with extracorporeal support devices.

CONCLUSION

The current guideline provides clinicians with up-to-date recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. The period of validity of the guideline is approximately fixed at five years (2018-2023).

Physical compatibility of MCT/LCT propofol emulsions with crystalloids during simulated Y-site administration

Objective

In intensive care units numerous drugs have to be infused simultaneously, resulting inline incompatibility. Propofol is formulated as a lipid emulsion and it is well known that electrolytes can affect the stability of an emulsion system. Our goal was to evaluate and to compare the physical compatibility of three commercial propofol lipid emulsions of different manufacturers, mixing them with the most commonly used crystalloids in intensive care units.

Methods

Simulated Y-site administration was accomplished by mixing the 2% MCT/LCT propofol emulsions with the commonly used crystalloids in the intensive care unit in a 1:1 ratio in a polypropylene syringe. The aliquot samples were evaluated immediately and at 15, 30, 60 and 120 min after preparation by visual observation, pH and droplet size measurement.

Results

There was no emulsion breakdown or any visible change during the study period. Mixing the propofols with crystalloids, 10% magnesium sulphate or 10% potassium chloride there was no significant change in the droplet size compared with the original propofol emulsions. A slight alteration in droplet size was noticed in a few of the propofol samples, when magnesium, potassium or both were the secondary additives to the crystalloids, but this is not considered clinically relevant.

Conclusion

The physical properties of emulsions are determined by component, therefore the compatibility data in literature has to be evaluated prudently. All three commercially available MCT/LCT propofol emulsions are considered physically compatible with the tested crystalloids.

A new alternative for intravenous lipid emulsion 20% w/w from superolein oil and its effect on lipid and liver profiles in an animal model

PURPOSE

Intravenous lipid emulsion (IVLE) was first used to prevent essential fatty acids deficiency. IVLE with α-tocopherol was reported to provide protection against parenteral nutrition-associated liver disease. This study aims to determine the optimal parameters and conditions in developing a physically stable IVLE from superolein palm oil (SoLE 20%) and its effect on lipid and liver profiles in an animal model.

METHODS

SoLE 20% was prepared using superolein oil and MCT oil (1:1), stabilized with egg lecithin and homogenized using a high pressure homogenizer. Mean droplet size was used as the response variable and was measured using laser diffraction and dynamic light scattering method. Physical stability at 4 °C, 25 °C and 40 °C storage temperatures were determined based on particle size and distribution, polydispersity index, zeta potential, viscosity, vitamin E contents and pH. Sterility and pyrogenicity were also investigated. Rabbits were administered with 1.0 g/kg SoLE 20% for 5 h and repeated daily for 3 days to investigate its effect on blood lipid and liver enzymes profile.

RESULTS

SoLE 20% was succesfully prepared using the optimized parameters of 800 psi, 7 cycles and 1.2 g lecithin. The IVLE prepared had a particle size of 252.60 ± 4.88 nm and was physically stable for 4 weeks at different storage temperatures. SoLE 20% had a high content of natural vitamin E, remained sterile and pyrogen free. It was also safe for intravenous administration and did not alter the blood lipid (p > 0.05) and liver enzymes profiles (p > 0.05) of the rabbits.

CONCLUSION

The optimal parameters to develop a stable superolein based IVLE are 800 psi homogenization pressure, 7 homogenization cycles and using 1.2 g lecithin as the emulsifier. SoLE 20% is safe for intravenous administration and does not significantly alter lipid and liver enzymes profiles of the rabbits.

Acute Management of Hypertension Following Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is responsible for approximately 15% of strokes annually in the United States, with nearly 1 in 3 of these patients dying without ever leaving the hospital. Because this disproportionate mortality risk has been stagnant for nearly 3 decades, a main area of research has been focused on the optimal strategies to reduce mortality and improve functional outcomes. The acute hypertensive response following ICH has been shown to facilitate ICH expansion and is a strong predictor of mortality. Rapidly reducing blood pressure was once thought to induce cerebral ischemia, though has been found to be safe in certain patient populations. Clinicians must work quickly to determine whether specific patient populations may benefit from acute lowering of systolic blood pressure (SBP) following ICH. This review provides nurses with a summary of the available literature on blood pressure control following ICH. It focuses on intravenous and oral antihypertensive medications available in the United States that may be utilized to acutely lower SBP, as well as medications outside of the antihypertensive class used during the acute setting that may reduce SBP.

Apolipoprotein C-II Mimetic Peptide Promotes the Plasma Clearance of Triglyceride-Rich Lipid Emulsion and the Incorporation of Fatty Acids into Peripheral Tissues of Mice

Aim

Plasma apolipoprotein C-II (apoC-II) activates lipoprotein lipase (LPL) and thus lowers plasma triglycerides (TG). We previously reported that a human apoC-II mimetic peptide (C-II-a) decreased plasma TG in apoC-II mutant mice, as well as in apoE-knockout mice. Because it is unknown what tissues take up free fatty acids (FFAs) released from TG after C-II-a peptide administration, we investigated in mice TG plasma clearance and tissue incorporation, using ³H-triolein as a tracer, with and without C-II-a treatment.

Methods and Results

Intralipid® fat emulsion was labeled with ³H-triolein and then mixed with or without C-II-a. Addition of the peptide did not alter mean particle size of the lipid emulsion particles (298 nm) but accelerated their plasma clearance. After intravenous injection into C57BL/6N mice, the plasma half-life of the ³H-triolein for control and C-II-a treated emulsions was 18.3 ± 2.2 min and 14.8 ± 0.1 min, respectively. In apoC-II mutant mice, the plasma half-life of ³H-triolein for injected control and C-II-a treated emulsions was 30.1 ± 0.1 min and 14.8 ± 0.1 min, respectively. C57BL/6N and apoC-II mutant mice at 120 minutes after the injection showed increased tissue incorporation of radioactivity in white adipose tissue when C-II-a treated emulsion was used. Higher radiolabeled uptake of lipids from C-II-a treated emulsion was also observed in the skeletal muscle of C57BL/6N mice only. In case of apoC-II mutant mice, decreased uptake of radioactive lipids was observed in the liver and kidney after addition of C-II-a to the lipid emulsion.

Conclusions

C-II-a peptide promotes the plasma clearance of TG-rich lipid emulsions in wild type and apoC-II mutant mice and promotes the incorporation of fatty acids from TG in the lipid emulsions into specific peripheral tissues.

Controversies in the Use of Lipid Injectable Emulsion in Hospitalized Patients

Soybean oil-based lipid injectable emulsion (SO-based ILE) is an 18-carbon, ω-6 macronutrient providing a concentrated source of calories, which can be administered in or with parenteral nutrition to patients unable to tolerate or consume adequate enteral nutrition. Beyond the provision of energy, SO-based ILE provides linoleic and linolenic acid, 2 essential fatty acids necessary for the prevention of essential fatty acid deficiency. However, SO-based ILE with its high levels of ω-6 fatty acids, long-chain triglycerides, phospholipid emulsifiers, and glycerin has been associated with worsening clinical outcomes, including increase of infections, lengthier intensive care and hospital stay, and prolonged mechanical ventilation. Recognizing this, studies have investigated omitting SO-based ILE in the critically ill patient for the first 7 days to observe if clinical outcomes are improved. Unfortunately, there is extremely limited research, and what is available is controversial. National guidelines have analyzed the studies, and they too are challenged to define a clear, high quality of evidence recommendation. It is important for the healthcare clinician to understand the research around this controversy to make best decisions for their patients.

Comparison of the in vitro cytotoxicity among phospholipid-based parenteral drug delivery systems: Emulsions, liposomes and aqueous lecithin dispersions (WLDs)

Lecithin and isolated phospholipids (mainly phosphatidylcholine) have been used for years as pharmaceutical excipients in parenteral formulations: submicron emulsions, liposomes and mixed micelles. Under development are also other lecithin-based drug delivery systems, e.g. aqueous lecithin dispersions (WLDs). The aim of the study was to investigate the properties and potential cytotoxicity of 7 different phospholipid-based dispersions intended for parenteral administration: emulsions, liposomes and WLDs. Each formulation contained egg phosphatidylcholine (PC) in the concentration range of 0.6-5.0%, and to some formulations other surfactants, such as polysorbate 80 (P80), Solutol HS 15 (HS) and cholesterol (Ch) were added. Particles in all dispersions were homogenous (PDI < 0.26) and submicron in size (Z-average in the range of approx. 100-260 nm). The cytotoxicity of all tested formulations was evaluated by means of 3 independent methods: a 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay, a real-time xCELLigence (RTCA) system, and a flow cytometry analysis, using two cell lines: human embryonic kidney 293 (HEK-293) and human promyelocytic leukaemia (HL-60). The results indicated that regardless of the test method and cell line type, the cytotoxicity of all formulations was low, especially when dispersions diluted to concentrations of =10% were tested. A more pronounced cytotoxic effect was noticed only for the following formulations: E-P80 (emulsion containing P80), WLD (unbuffered aqueous lecithin dispersion) and L-Ch (liposomes containing Ch), tested as less diluted (concentration 10% or 25%). IC50 values measured for these dispersions (on HL-60 cells) amounted to: 10.4 ± 0.5% (v/v), 14.4 ± 0.2% (v/v) and 24.2 ± 0.6% (v/v), respectively. Our investigation confirmed the biocompatibility of all tested phospholipid-based formulations: emulsions, liposomes and also newly-developed WLDs, which can be considered as safe parenteral drug carriers.

Propofol and Clevidipine-induced Hypertriglyceridemia

Hypertriglyceridemia and related pancreatitis due to the use of lipid emulsions such as propofol has been documented, but less is known about the additive adverse effects of propofol and clevidipine lipid emulsions in the literature. We report an unusual case, highlighting the trend of serum triglyceride and pancreatic enzymes (amylase/lipase) with the administration of propofol and clevidipine for a prolonged period in the neurocritical care setting. We present a case of a 27-year-old male who was admitted to the neuroscience intensive care unit (NSICU) for management of severe subarachnoid hemorrhage (SAH) with six-millimeter (mm) midline shift to the left from the rupture of anterior communicating artery aneurysm. The patient was given propofol infusion to maintain sedation and manage intracranial pressures, and clevidipine was chosen over other antihypertensive class for blood pressure management secondary to renal impairment. To focus on the risk of hypertriglyceridemia and associated pancreatitis with the combined use of lipid emulsions we quantified the effect of lipid emulsions on serum triglycerides. We calculated the total calorie and fat content the patient received from the propofol and clevidipine along with the calorie intake from enteral nutrition (Fibersource® tube feed). The patient received a total propofol infusion of 44,391.2 milligrams (mg) over 16 days which accounts for 4,882.99 kilocalories (kcal) and 443.91 grams of fat. He received a total clevidipine infusion of 297 mg over the 48-hour period which contributes 594 kcal and 59.4 grams of fat. The required daily calorie intake through enteral nutrition of Fibresource® was titrated to a goal of 80 mL/hour which provided 2,304 kcal and 76.8 grams of fat each day. We also graphically depicted the rise in the serum triglyceride level after continuous infusion of propofol and clevidipine and subsequent improvement in the amylase and lipase level after the propofol was discontinued. Hence we conclude, careful and periodic monitoring of the serum triglyceride levels and limitation on the total calories from other fat sources such as enteral nutrition can help to mitigate the drug-induced effects.

Soft- and hard-lipid nanoparticles: a novel approach to lymphatic drug delivery

With the current advance in nanotechnology, the development has accelerated of a number of nanoparticle-type drugs such as nano-emulsions, lipid emulsions, liposomes, and cell therapeutics. With these developments, attempts are being made to apply these new drugs to healing many intractable diseases related to antibody production, autoimmune disorders, cancer, and organ transplantation in both clinical and nonclinical trials. Drug delivery to the lymphatic system is indispensable for treating these diseases, but the core technologies related to the in vivo distribution characteristics and lymphatic delivery evaluation of these particle-type drugs have not yet been established. Additionally, the core technologies for setting up the pharmacotherapeutic aspects such as their usage and dosages in the development of new drugs do not meet the needs of the market. Therefore, it is necessary to consider dividing these particle-type drugs into soft-lipid nanoparticles that can change size in the process of body distribution and hard-lipid nanoparticles whose surfaces are hardened and whose sizes do not easily change in vivo; these soft- and hard-lipid nanoparticles likely possess different biodistribution characteristics including delivery to the lymphatic system. In this review, we summarize the different types, advantages, limitations, possible remedies, and body distribution characteristics of soft- and hard-lipid nanoparticles based on their administration routes. We also emphasize that it will be necessary to fully understand the differences in distribution between these soft- and hard-lipid nanoparticle-type drugs and to establish pharmacokinetic models for their more ideal lymphatic delivery.

A call to action for optimizing the electronic health record in the parenteral nutrition workflow

Parenteral nutrition (PN) is a complex therapeutic modality provided to neonates, children, and adults for various indications. Surveys have shown that current electronic health record (EHR) systems are in need of functionality enhancement for safe and optimal delivery of PN. This is a consensus statement from the American Society for Parenteral and Enteral Nutrition, the Academy of Nutrition and Dietetics, and the American Society of Health-System Pharmacists outlining some of the key challenges to prescribing, order review/verification, compounding, and administration of PN using EHRs today and is a call to action for clinicians and vendors to optimize their EHRs regarding the PN build and workflow.

A Call to Action for Optimizing the Electronic Health Record in the Parenteral Nutrition Workflow

Parenteral nutrition (PN) is a complex therapeutic modality provided to neonates, children, and adults for various indications. Surveys have shown that current electronic health record (EHR) systems are in need of functionality enhancement for safe and optimal delivery of PN. This is a consensus statement from the American Society for Parenteral and Enteral Nutrition, the Academy of Nutrition and Dietetics, and the American Society of Health-System Pharmacists outlining some of the key challenges to prescribing, order review/verification, compounding, and administration of PN using EHRs today and is a call to action for clinicians and vendors to optimize their EHRs regarding the PN build and workflow.

A Call to Action for Optimizing the Electronic Health Record in the Parenteral Nutrition Workflow

Parenteral nutrition (PN) is a complex therapeutic modality provided to neonates, children, and adults for various indications. Surveys have shown that current electronic health record (EHR) systems are in need of functionality enhancement for safe and optimal delivery of PN. This is a consensus statement from the American Society for Parenteral and Enteral Nutrition, the Academy of Nutrition and Dietetics, and the American Society of Health-System Pharmacists outlining some of the key challenges to prescribing, order review/verification, compounding, and administration of PN using EHRs today and is a call to action for clinicians and vendors to optimize their EHRs regarding the PN build and workflow.

Inpatient outcomes of preterm infants receiving ω-3 enriched lipid emulsion (SMOFlipid): an observational study

Neonatal units have started to switch from using conventional soy-based to alternate lipid emulsions, like SMOFlipid. SMOFlipid has been associated with an improvement in biochemical parameters and delays progression of parenteral nutrition-associated liver disease (PNALD). This retrospective epoch study aimed to compare clinically relevant neonatal outcomes in preterm infants (< 32 weeks), receiving SMOFlipid versus Intralipid. We compared clinical outcomes in two epochs-epoch 1 (Intralipid, October 2013-June 2015) versus epoch 2 (SMOFlipid, July 2015-March 2017). Primary outcome studied was mortality and rates of severe neonatal morbidities. Univariate and multivariate regression was conducted to determine risk for mortality and PNALD. A total of 222 infants (epoch 1, 123 versus epoch 2, 99) were included in the study. A higher incidence of late onset sepsis (56 versus 30%, p < 0.005) was observed in epoch 1. There was no significant difference in mortality or rates of any other severe neonatal morbidity. The type of lipid emulsion did not have a significant effect on mortality or PNALD on regression analysis.

CONCLUSION

Use of SMOFlipid as the primary lipid emulsion seems to have minimal effect on rates of clinically important neonatal outcomes; however, long-term effects need to be further evaluated. What is Known: • Many neonatal units have started replacing traditional soy-based lipid formulations with SMOFlipid (ω-3 enriched lipid emulsion), as the primary lipid component in parenteral nutrition for preterm infants. • While there is evidence associating improved liver function and balanced essential fatty acid levels in infants receiving SMOFlipid, there is a lack of evidence evaluating relevant clinical outcomes in infants receiving SMOFlipid versus traditional lipid formulations. What is New: • The influence of SMOFlipid on a series of clinical outcomes in an at-risk preterm population is presented. • SMOFlipid appears to be well tolerated in preterm infants with minimal side effects, and some growth benefits seen.

Intravenous Lipid Emulsion Overdose in Infancy: A Case Report and Overview of Opportunities, Challenges and Prevention

Medication errors remain among the major problems seen in hospitals. Such errors can relate to the prescription, dispensation, or administration of drugs. Human factors account for most of these mistakes, but other factors such as infusion pump programming defects should always be considered. Worldwide, medication errors have been reported to affect 2-30% of patients, depending on the institution. Intravenous lipid emulsion (ILE) infusion is frequently used as part of total parenteral nutrition in patients of all ages with feeding and gastrointestinal issues. ILE overdose has been previously reported, with variable clinical outcomes. We report a case of accidental ILE (Intralipid) overdose in a 3-month-old male infant who fully recovered after single-volume blood exchange transfusion. We also review reported cases and summarize potential solutions for ILE overdose. Our review indicates that ILE infusion is a high-risk medication, and opportunities for errors remain even in the best hospital set-ups. Attention should be directed towards proper prescription, dosing, dispensation, and administration. Most of the cases indicate the safety breach was at the nursing drug-administration level, with improper pump use or programming, together with other fluid infusion rate switching, being the main possible defects. Strategies targeting the areas of weakness in the drug-delivery pathway are needed. Special attention should be paid towards nursing duties and working hours. In addition, nursing staff should receive frequent education sessions and should be required to pass competency modules regularly. An error-prevention plan should be established and implemented. This plan needs full collaboration between physicians, pharmacists, and nursing staff.

Functional lipidomics in patients on home parenteral nutrition: Effect of lipid emulsions

AIM

To investigate the fatty acid-based functional lipidomics of patients on long-term home parenteral nutrition receiving different intravenous lipid emulsions.

METHODS

A cross-sectional comparative study was carried out on 3 groups of adults on home parenteral nutrition (HPN), receiving an HPN admixture containing an olive-soybean oil-based intravenous lipid emulsion (IVLE) (OO-IVLE; n = 15), a soybean- medium-chain triacylglycerol-olive-fish oil-based IVLE (SMOF-IVLE; n = 8) or HPN without IVLE (No-IVLE; n = 8) and 42 healthy controls (HCs). The inclusion criteria were: duration of HPN ≥ 3 mo, current HPN admixtures ≥ 2 mo and HPN infusions ≥ 2/wk. Blood samples were drawn 4-6 h after the discontinuation of the overnight HPN infusion. The functional lipidomics panel included: the red blood cell (RBC) fatty acid (FA) profile, molecular biomarkers [membrane fluidity: saturated/monounsaturated FA ratio = saturated fatty acid (SFA)/monounsaturated fatty acid (MUFA) index; inflammatory risk: n-6/n-3 polyunsaturated fatty acid (PUFA) ratio = n-6/n-3 index; cardiovascular risk: sum of n-3 eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) = n-3 index; free radical stress: sum of FA trans isomers = %trans index] and FA pathway enzyme activity estimate (delta-9-desaturase = D9D; delta-6-desaturase = D6D; delta-5-desaturase = D5D; elongase = ELO). Statistics were carried out using nonparametric tests. The amount of each FA was calculated as a percentage of the total FA content (relative%).

RESULTS

In the OO-IVLE group, the percentage of oleic acid in the RBCs was positively correlated with the weekly load of OO-IVLE (r = 0.540, P = 0.043). In the SMOF-IVLE cohort, the RBC membrane EPA and DHA were positively correlated with the daily amount of SMOF-IVLE (r = 0.751, P = 0.044) and the number of HPN infusions per week (r = 0.753; P = 0.046), respectively. The SMOF-IVLE group showed the highest EPA and DHA and the lowest arachidonic acid percentages (P < 0.001). The RBC membrane linoleic acid content was lower, and oleic and vaccenic acids were higher in all the HPN groups in comparison to the HCs. Vaccenic acid was positively correlated with the weekly HPN load of glucose in both the OO-IVLE (r = 0.716; P = 0.007) and the SMOF-IVLE (r = 0.732; P = 0.053) groups. The estimated activity of D9D was higher in all the HPN groups than in the HCs (P < 0.001). The estimated activity of D5D was lower in the SMOF-IVLE group than in the HCs (P = 0.013). The SFA/MUFA ratio was lower in all the HPN groups than in the HCs (P < 0.001). The n-6/n-3 index was lower and the n-3 index was higher in the SMOF-IVLE group in comparison to the HCs and to the other HPN groups (P < 0.001). The %trans index did not differ among the four groups.

CONCLUSION

The FA profile of IVLEs significantly influenced the cell membrane functional lipidomics. The amount of glucose in the HPN may play a relevant role, mediated by the insulin regulation of the FA pathway enzyme activities.

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.

Aggravated nausea and vomiting induced by fat emulsion for hyperemesis gravidarum: A case report

WHAT IS KNOWN AND OBJECTIVE

Total parental nutrition (TPN) for hyperemesis gravidarum (HG) is generally effective and well-tolerated. We report a case of aggravated nausea and vomiting caused by fat emulsion.

CASE DESCRIPTION

A 40-year-old pregnant woman through IVF was admitted to the hospital at 11-week gestation and diagnosed with HG. During TPN treatment, the patient suffered from aggravated nausea and vomiting. We identified fat emulsion as the most likely culprit using challenge, dechallenge and rechallenge.

WHAT IS NEW AND CONCLUSION

This is the first report of fat emulsion aggravating nausea and vomiting in such situation.

Synergistic performance of lecithin and glycerol monostearate in oil/water emulsions

The effects of the combination of two low-molecular weight emulsifiers (lecithin and glycerol-monostearate (GMS)) on the stability, the dynamic interfacial properties and rheology of emulsions have been studied. Different lecithin/GMS ratios were tested in order to assess their impact in the formation and stabilization of oil in water emulsions. The combination of the two surfactants showed a synergistic behaviour, mainly when combined at the same ratio. The dynamic film properties and ζ-potential showed that lecithin dominated the surface of oil droplets, providing stability to the emulsions against flocculation and coalescence, while allowing the formation of small oil droplets. At long times of adsorption, all of the mixtures showed similar interfacial activity. However, higher values of interfacial pressure at the initial times were reached when lecithin and GMS were at the same ratio. Interfacial viscoelasticity and viscosity of mixed films were also similar to that of lecithin alone. On the other hand, emulsions viscosity was dominated by GMS. The synergistic performance of lecithin-GMS blends as stabilizers of oil/water emulsions is attributed to their interaction both in the bulk and at the interface.

Parenteral Nutrition Basics for the Clinician Caring for the Adult Patient

Parenteral nutrition (PN) is a life-sustaining therapy providing nutrients to individuals with impaired intestinal tract function and enteral access challenges. It is one of the most complex prescriptions written routinely in the hospital and home care settings. This article is to aid the nutrition support clinician in the safe provision of PN, including selecting appropriate patients for PN, vascular access, development of a PN admixture, appropriate therapy monitoring, recognition of preparation options, and awareness of preparation and stability concerns.

Intralipid™ administration attenuates the hypotensive effects of acute intravenous amiodarone overdose in a swine model

PURPOSE

To investigate whether a lipid emulsion could counteract the hypotensive effects of amiodarone overdose after an acute intravenous administration and improve 4 h survival in an established model of swine cardiovascular research.

METHODS

Twenty pigs were intubated and instrumented to measure aortic pressures and central venous pressures (CVP). After allowing the animals to stabilize for 60 minutes, amiodarone overdose (1 mg/kg/min) was initiated for a maximum of 20 minutes. Afterwards, the animals were randomized into 2 groups. Group A (n = 10) received 0.9% Normal Saline (NS) and Group B (n = 10) received 20% Intralipid® (ILE). A bolus dose of 2 ml/kg in over 2 min time was initially administered in both groups followed by a 45 min infusion (0.2 ml/kg/min) of either NS or ILE.

RESULTS

All animals survived the overdose and all animals survived the monitoring period of 4 hours. Systolic aortic pressure (SpthAorta) (6.90 vs 14.10 mmHg, P = .006) and mean arterial pressure (MAP) (6.10 vs 14.90 mmHg, P = .001) were higher in the ILE group 2 min after the bolus ILE infusion. This difference was maintained for 15 min after ILE infusion for both SpthAorta (7.85 vs 13.15 mmHg, P = .044) and MAP (7.85 vs 13.15 mmHg, P = .042). Animals that received ILE had higher CVP (11.6 vs 15.7 mmHg, P = .046), an effect which was attenuated 2 and 4 hours post administration. Animals receiving ILE were more acidotic (7.21 vs 7.38, P = .048) in the monitoring period compared to animals receiving NS.

CONCLUSIONS

Intralipid attenuated the hypotensive effects of amiodarone toxicity for a period of 15 minutes compared to animals receiving NS.

Parenteral approaches in malabsorption: Home parenteral nutrition

Severe malabsorption of fluids and nutrients leads to intestinal failure (IF) where intravenous supplementation of nutrients and fluids is necessary to maintain health and/or growth. Long-term treatment of IF implies the start of intravenous support in the outpatient setting (home parenteral nutrition, HPN). Although HPN has proven lifesaving for many patients for more than four decades this strategy remains associated with complications that compromise the quality of life. Many problems relate to the presence of the venous access device and concern infections or vascular occlusion due to thrombosis. Patient training remains key to prevent these complications. Also metabolic problems may arise that involve liver function or composition or bone mineralization. While intestinal transplantation remains inferior to HPN as alternative treatment strategy in terms of survival, promising developments include the introduction of hormones that promote intestinal adaptation, mixed lipid emulsions that decrease liver problems and catheter lock solutions that prevent infections.

The possible role of intravenous lipid emulsion in the treatment of chemical warfare agent poisoning

Organophosphates (OPs) are cholinesterase inhibitors that lead to a characteristic toxidrome of hypersecretion, miosis, dyspnea, respiratory insufficiency, convulsions and, without proper and early antidotal treatment, death. Most of these compounds are highly lipophilic. Sulfur mustard is a toxic lipophilic alkylating agent, exerting its damage through alkylation of cellular macromolecules (e.g., DNA, proteins) and intense activation of pro-inflammatory pathways. Currently approved antidotes against OPs include the peripheral anticholinergic drug atropine and an oxime that reactivates the inhibited cholinesterase. Benzodiazepines are used to stop organophosphate-induced seizures. Despite these approved drugs, efforts have been made to introduce other medical countermeasures in order to attenuate both the short-term and long-term clinical effects following exposure. Currently, there is no antidote against sulfur mustard poisoning. Intravenous lipid emulsions are used as a source of calories in parenteral nutrition. In recent years, efficacy of lipid emulsions has been shown in the treatment of poisoning by fat-soluble compounds in animal models as well as clinically in humans. In this review we discuss the usefulness of intravenous lipid emulsions as an adjunct to the in-hospital treatment of chemical warfare agent poisoning.

Hemodynamic changes with high infusion rates of lipid emulsion. Experimental study in swine

PURPOSE

To evaluate hemodynamic changes caused by sole intravenous infusion of lipid emulsion with doses recommended for treatment of drug-related toxicity.

METHODS

Large White pigs underwent general anesthesia, tracheal intubation was performed, and mechanical ventilation was instituted. Hemodynamic variables were recorded using invasive blood pressure and pulmonary artery catheterization. Baseline hemodynamic measurements were obtained after a 30-minute stabilization period. An intravenous bolus injection of 20% lipid emulsion at 1.5 ml/kg was administered. Additional hemodynamic measurements were made after 1 minute, followed by a continuous intravenous lipid infusion of 0.25 ml/kg/min. Further measurements were carried out at 10, 20 and 30 minutes, when the infusion was doubled to 0.5 ml/kg/min. Assessment of hemodynamic changes were then made at 40, 50 and 60 minutes.

RESULTS

Lipid infusion did not influence cardiac output or heart rate, but caused an increase in arterial blood pressure, mainly pulmonary blood pressure due to increased vascular resistance. Ventricular systolic stroke work consequently increased with greater repercussions on the right ventricle.

CONCLUSION

In doses used for drug-related toxicity, lipid emulsion cause significant hemodynamic changes with hypertension, particularly in the pulmonary circulation and increase in vascular resistance, which is a factor to consider prior to use of these solutions.