Lipid emulsions used in PN

As a critical care pharmacist, you may need to clarify the efficacy and safety of different lipid injectable emulsions (Intralipid, Smoflipid, Omegaven, etc). IV lipids made only of soybean oil (Intralipid, Nutrilipid) have been our go-to for parenteral nutrition (PN). But soybean is linked to inflammation, immunosuppression, and liver dysfunction. That's why newer IV lipids use less or no soybean oil.

          Clinolipid contains a mix of soybean oil and olive oil. Smoflipid is soybean oil, medium chain triglycerides, olive oil, and fish oil. Omegaven is fish oil and is only used in pediatrics. There's not a clear winner when choosing an IV lipid for SHORT-term PNs, such as less than a few weeks. Some evidence suggests fish oil lipids may decrease infections or length of stay in adults with critical illness or major abdominal surgery. But these studies have limitations. Plus it's too soon to say if the advantages are due to the addition of fish oil or less exposure to soybean oil.

Lean toward Smoflipid or Clinolipid over traditional lipids for short-term PN use if cost is comparable. Be aware, there's less experience with Clinolipid in pediatrics. But if newer lipids cost more, think about limiting their use to certain patients, such as those who are critically ill. Also factor ongoing shortages into your choice. For LONG-term PN use, consider a newer IV lipid to reduce cholestasis risk in pediatric patients and possibly adults. Or switch to a newer lipid if PN causes the direct bilirubin to rise above 2 mg/dL. Reserve Omegaven to reverse PN-associated cholestasis in infants and children after trying Smoflipid. Omegaven is the only lipid indicated for this reversal and is the most expensive.

Continue to stock Intralipid or Nutrilipid for local anesthetic toxicity, there aren't enough clinical data yet with other IV lipids. If you stock multiple lipid products, reduce mix-ups by storing them separately and using the brand name, not "fat emulsion 20%". Include tall man lettering (INTRAlipid) and look-alike warning stickers.

REFERENCES

• Martindale RG, Berlana D, Boullata JI, Cai W, Calder PC, Deshpande GH, Evans D, Garcia-de-Lorenzo A, Goulet OJ, Li A, Mayer K, Mundi MS, Muscaritoli M, Pradelli L, Rosenthal M, Seo JM, Waitzberg DL, Klek S. Summary of Proceedings and Expert Consensus Statements From the International Summit "Lipids in Parenteral Nutrition". JPEN J Parenter Enteral Nutr. 2020 Feb;44 Suppl 1:S7-S20. Available at: https://aspenjournals.onlinelibrary.wiley.com/doi/10.1002/jpen.1746

  Pradelli L, Mayer K, Klek S, Omar Alsaleh AJ, Clark RAC, Rosenthal MD, Heller AR, Muscaritoli M. ω-3 Fatty-Acid Enriched Parenteral Nutrition in Hospitalized Patients: Systematic Review With Meta-Analysis and Trial Sequential Analysis. JPEN J Parenter Enteral Nutr. 2020 Jan;44(1):44-57. Available at: https://aspenjournals.onlinelibrary.wiley.com/doi/10.1002/jpen.1672

  Worthington P, Gura KM, Kraft MD, Nishikawa R, Guenter P, Sacks GS; ASPEN PN Safety Committee. Update on the Use of Filters for Parenteral Nutrition: An ASPEN Position Paper. Nutr Clin Pract. 2021 Feb;36(1):29-39. Available at: https://aspenjournals.onlinelibrary.wiley.com/doi/10.1002/ncp.10587