Version May 2024
Note: At the onset of therapy, the patient should be observed for any immediate allergic reactions (eg, dyspnea, cyanosis, and fever).
Energy/Calories: Note: Lipid emulsion should not exceed 60% of the total daily calories. US guidelines recommend withholding soybean oil-based lipid emulsion for the first 7 to 10 days of peripheral nutrition therapy in the critically ill. If there is a concern for essential fatty acid deficiency, the weekly dose of soybean oil lipid emulsion should be limited to 100 g/week (Ref).
Stable: IV: Initial dose: 1 to 1.5 g/kg/day (not to exceed 500 mL Intralipid 10% or 20% or 330 mL Intralipid 30% [over 4 to 6 hours] on the first day of therapy); daily dose may be infused over 12 to 24 hours; maximum daily dose: 2.5 g/kg/day.
Critically ill:
Intralipid, Nutrilipid: IV: <1 g/kg/day (Ref).
Clinolipid: IV: 1 to 1.5 g/kg/day (Ref).
Essential fatty acid deficiency, prevention: IV: The minimum daily dose of essential fatty acid (EFA) as percent of total energy is at least 2% to 4% linoleic acid and 0.25% to 0.5% alpha-linolenic acid. There is a large difference in EFA content of lipid emulsion products. It is recommended that EFA dose be calculated for each product when lipid emulsion is used only as a source of EFA (Ref).
Essential fatty acid deficiency, treatment: Intralipid: IV: Administer 8% to 10% of total caloric intake as lipid emulsion; may infuse up to once daily (Ref). If EFA deficiency occurs with stress, the dosage needed to correct EFA deficiency may be increased.
Serious hemodynamic or other instability secondary to highly lipid soluble substances (off-label use): Note: May be considered when the patient does not respond to standard resuscitation measures (eg, fluids, vasopressors, inotropes) (Ref); may also consider early use of lipid emulsion (Ref). Continue chest compressions during administration if patient is in cardiac arrest to circulate the lipid emulsion. Consultation with a clinical toxicologist or poison control center is recommended.
Intralipid 20%: IV: 1.5 mL/kg (maximum: 100 mL; (Ref)) administered over 1 to 3 minutes, followed immediately by an infusion of 0.25 mL/kg/minute (maximum: 200 to 250 mL administered over 15 to 20 minutes); (Ref)) (recommended infusion durations vary; see below); may repeat the bolus as necessary for persistent cardiovascular collapse or if instability re-emerges (Ref). Some suggest dosing based on lean body weight (Ref). Maximum suggested dose: 10 to 12 mL/kg over the first 30 to 60 minutes (Ref).
After administration of the initial bolus and continuous infusion, recommendations regarding the continuous infusion vary significantly:
American College of Medical Toxicology: If after the bolus and continuing the infusion for 3 minutes the patient demonstrates a significant response, the infusion rate may be reduced to 0.025 mL/kg/minute (ie, one-tenth the initial rate). If instability re-emerges, the infusion rate may be increased back to 0.25 mL/kg/minute or the bolus may be repeated (Ref).
American Heart Association recommendations: Continue infusion for 30 to 60 minutes (Ref).
American Society of Regional Anesthesia and Pain Medicine: Continue infusion for at least 15 minutes after hemodynamic stability has been restored (Ref). Consider rebolus or increase the infusion rate to 0.5 mL/kg/minute if hemodynamic instability persists or recurs (Ref).
Dosage adjustment for increased serum triglycerides: Stop infusion and monitor if triglycerides >400 mg/dL; restart at a lower dose/infusion rate and advance in smaller increments once triglycerides are <400 mg/dL. Use is contraindicated with triglycerides >1,000 mg/dL (Ref).
Dosage adjustment for concomitant therapy: For patients receiving other lipid emulsion-based medications (eg, propofol, clevidipine), reduce dosage to avoid fat overload syndrome (Ref). Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in the manufacturer's labeling; use with caution.
There are no dosage adjustments provided in the manufacturer's labeling; use with caution.
Refer to adult dosing.
(For additional information see "Lipid emulsion (plant oil-based): Pediatric drug information")
Parenteral nutrition: Intralipid, Nutrilipid: Note: Lipid injectable emulsion should not exceed 60% of the total daily calories. At the onset of therapy, the patient should be observed for any immediate allergic reactions such as dyspnea, cyanosis, and fever.
Infants: IV: Initial dose: 0.5 to 1 g/kg/day; increase by 0.5 to 1 g/kg/day to a maximum of 2.5 to 3 g/kg/day depending upon the needs/nutritional goals (Ref).
Children 1 to 10 years: IV: Initial dose: 1 to 2 g/kg/day; increase by 0.5 to 1 g/kg/day to a maximum of 2 to 2.5 g/kg/day depending upon the needs/nutritional goals (Ref).
Children ≥11 years and Adolescents: IV: Initial dose: 1 g/kg/day, not to exceed 500 mL 20% lipid emulsion on the first day of therapy; increase by 1 g/kg/day to a maximum of 1 to 2 g/kg/day (Ref).
Essential fatty acid deficiency, prevention: Intralipid: Infants, Children, and Adolescents: IV: Administer 8% to 10% of total caloric intake as lipid injectable emulsion.
Serious hemodynamic or other instability secondary to highly lipid soluble substances (including, but not limited to, local anesthetics, calcium channel blockers, tricyclic antidepressants, bupropion, lamotrigine, and quetiapine): Note: Use is reserved for patients not responsive to standard resuscitation measures (Ref).
Infants, Children, and Adolescents: Very limited data available, optimal dose not defined: 20% lipid injectable emulsion: IV: 1.5 mL/kg bolus over 2 to 3 minutes followed immediately by a continuous IV infusion at 0.25 mL/kg/minute; assess response after 3 minutes of infusion. If the patient demonstrates a significant response, the infusion rate may be reduced to 0.025 mL/kg/minute (ie, one-tenth the initial rate). If instability re-emerges, the infusion rate may be increased to 0.25 mL/kg/minute or the 1.5 mL/kg bolus may be repeated (Ref). Suggested maximum dose: 10 to 12.5 mL/kg (Ref).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in manufacturer's labeling; use with caution.
There are no dosage adjustments provided in manufacturer's labeling; use with caution.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
1% to 10%:
Endocrine and metabolic: Hyperlipidemia (≤10%), hyperglycemia (2% to 10%)
Gastrointestinal: Nausea (≤10%), vomiting (≤10%)
Hematologic & oncologic: Hypoproteinemia (2% to 10%)
Hepatic: Abnormal hepatic function tests (2% to 10%)
Frequency not defined:
Cardiovascular: Thrombophlebitis
Gastrointestinal: Cholestasis (central lobular), melanosis (brown fat pigmentation in the reticuloendothelial system)
Genitourinary: Urinary tract infection
Hematologic & oncologic: Leukopenia, splenomegaly, thrombocytopenia
Hepatic: Fat overload syndrome, hepatomegaly, increased liver enzymes
Infection: Septicemia
Miscellaneous: Fever
<1%, postmarketing, and/or case reports: Back pain, chest pain, cyanosis, decreased INR, diaphoresis, diarrhea, dizziness, drowsiness, dyspnea, flushing, headache, hypercoagulability state, hypersensitivity reaction, increased body temperature, infusion site irritation, pruritus, pulmonary embolism (fat), sensation of eye pressure
Clinolipid, Intralipid 10% or 20%, Nutrilipid: Known hypersensitivity to egg, soybean, peanut or to any component of the formulation; severe disorders of lipid metabolism characterized by hypertriglyceridemia (serum triglyceride >1,000 mg/dL).
Intralipid 30%: Hypersensitivity to egg, soybean, peanut, or any component of the formulation; disturbances in normal fat metabolism such as pathologic hyperlipemia, lipoid nephrosis, or acute pancreatitis if accompanied by hyperlipidemia; pharmacy bulk package is not intended for direct IV administration.
Canadian labeling: Additional contraindications (not in US labeling): Severe hyperlipidemia.
Clinoleic: Hypertriglyceridemia associated with acute pancreatitis.
Intralipid: Acute shock; conditions characterized by severely disordered fat metabolism (eg, severe hepatic impairment, acute MI, hemophagocytotic syndrome, shock).
Note: In a life-threatening toxicity situation in which all other interventions have failed, experts recommend that clinicians weigh the risk:benefit ratio of lipid emulsion therapy in patients with contraindications to administration.
Concerns related to adverse effects
• Fat overload syndrome: Although rare, a reduced or limited ability to metabolize lipids accompanied by prolonged plasma clearance resulting in a sudden deterioration in the patient's condition accompanied by fever, anemia, leukopenia, thrombocytopenia, coagulation disorders, hyperlipidemia, hepatomegaly, deteriorating liver function, and CNS (eg, coma) can occur; usually reversible upon discontinuation.
• Hepatic effects: Parenteral nutrition: Although the exact etiology is unknown and likely multifactorial, parenteral nutrition associated liver disease (PNALD) has been reported in patients receiving parenteral nutrition for extended periods of time, especially preterm infants, and can present as cholestasis or steatohepatitis, fibrosis and cirrhosis, possibly leading to hepatic failure; cholecystitis and cholelithiasis have also been observed. Consider discontinuation or dose reduction in patients who develop abnormal LFTs.
• Hypersensitivity: May contain soybean oil and egg phospholipids which may cause hypersensitivity reactions; discontinue infusion immediately and institute appropriate treatment and supportive measures if signs or symptoms of hypersensitivity or allergic reactions occur.
• Hypertriglyceridemia: Impaired lipid metabolism with hypertriglyceridemia may occur in conditions such as inherited lipid disorders, obesity, diabetes mellitus, and metabolic syndrome. In adults with triglycerides >400 mg/dL, reduce dose/infusion rate or stop infusion and monitor triglycerides. In pediatric patients, lower triglyceride levels may be associated with adverse reactions. Assess high-risk patients for their overall energy intake, including other lipid or dextrose sources and medications that may affect lipid and dextrose metabolism, to minimize risk of new or worsening hypertriglyceridemia.
• Infection: Catheter-related bloodstream infections may occur due to lipid emulsions supporting microbial growth; ensure aseptic techniques are used for catheter placement, maintenance, preparation, and administration and frequently assess catheter for signs of infection (eg, discharge, edema, redness).
• Refeeding syndrome: Parenteral nutrition: Refeeding severely undernourished patients with parenteral nutrition may result in the refeeding syndrome (eg, intracellular shift of potassium, phosphorus, and magnesium as the patient becomes anabolic); thiamine deficiency and fluid retention may also develop. Carefully monitor severely undernourished patients and slowly increase their nutrient intakes, while avoiding overfeeding.
• Serum lipemia: Use may result in serum lipemia, especially with high doses or rates of administration (eg, when used for toxic exposure). Serum lipemia has been reported to cause failure of CRRT filters (Rodríguez 2014; Smolinske 2019); may also delay and prevent the analysis of serum electrolytes, hematocrit, LFTs, and coagulation function for up to 39 hours after administration (Cao 2014; Grunbaum 2016; Smolinske 2019).
Disease-related concerns:
• Anemia: The use of lipid emulsion has been associated with anemia likely due to hemodilution (Zellner 1967). Use with caution in patients with anemia.
• Bleeding disorders: Use with caution in patients with bleeding disorders.
• Fat embolism: Use with caution in patients who may be at danger for fat embolism.
• Hepatic impairment: Use with caution in patients with hepatic impairment.
• Pancreatitis: Use with caution in patients with pancreatitis without hyperlipidemia; ensure triglyceride levels remain <400 mg/dL.
• Respiratory disease: Use with caution in patients with respiratory disease.
• Renal impairment: Use with caution; some formulations may contain aluminum, which may accumulate following prolonged administration in renally impaired patients.
• Toxicity secondary to highly lipid soluble substances: Hemodynamic and other instability: Successful resuscitation following the administration of lipid emulsion has been reported in animal studies and several human case reports in which cardiovascular toxicity was unresponsive to conventional resuscitation and antidotal measures. Successful resuscitation following the administration of lipid emulsion has been reported in pediatric patients (Fuzaylov 2010; Heydinger 2021; Ludot 2008; Shah 2009; Wong 2010). Consider use when toxicity secondary to a highly lipid soluble substance is likely and conventional methods are unsuccessful. Continue CPR throughout treatment with lipid emulsion. Consultation with a medical toxicologist or poison control center is highly recommended (ACMT 2017).
Special populations:
• Pediatric: Acute respiratory distress, metabolic acidosis, hypertriglyceridemia, and death have been reported in neonates and infants after rapid infusion. Do not exceed recommended daily doses or hourly infusion rates. Preterm infants and low birth weight infants have poor clearance of IV lipid emulsion and increased free fatty acid plasma levels following lipid emulsion infusion. Clinolipid is not indicated for use in pediatric patients. Pediatric clinical studies did not establish that Clinolipid provides sufficient amounts of essential fatty acids (EFA) in pediatric patients, which may predispose them to neurologic complications due to EFA insufficiency. Because free fatty acids displace bilirubin from albumin binding sites, the use of lipid infusions in jaundiced or premature infants should be done with caution.
Dosage form specific issues:
• Aluminum: The parenteral product may contain aluminum; toxic aluminum concentrations may be seen with high doses, prolonged use, or renal dysfunction. Premature neonates are at higher risk due to immature renal function and aluminum intake from other parenteral sources. Parenteral aluminum exposure of >4 to 5 mcg/kg/day is associated with CNS and bone toxicity; tissue loading may occur at lower doses (Federal Register 2002). See manufacturer's labeling.
Other warnings/precautions:
• Administration: The too-rapid administration of lipid emulsion can cause fluid and/or lipid overloading, resulting in dilution of serum electrolyte concentrations, overhydration, congested states, pulmonary edema, impaired pulmonary diffusion capacity, serum lipemia (Cao 2014; Grunbaum 2016; Smolinske 2019), or metabolic acidosis; acute respiratory failure and lipemia have been described in patients with kidney impairment who received lipid emulsion at higher than recommended infusion rates (Rodríguez 2014). Hourly infusion rate should be as low as possible.
• Laboratory tests: Lipids in the bloodstream may interfere with some laboratory tests (eg, hemoglobin, lactate dehydrogenase, bilirubin, oxygen saturation). Conduct these tests ≥6 hours after stopping the infusion. Some products contain vitamin K, which may counteract anticoagulant activity.
• Three-in-one mixtures: Lipid emulsion in a three-in-one mixture may obscure the presence of a precipitate; follow compounding guidelines, especially for calcium and phosphate additions.
Product oil source for Intralipid and Nutrilipid: soybean
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Emulsion, Intravenous:
Clinolipid: 20% (100 mL, 250 mL, 500 mL, 1000 mL)
Intralipid: 20% (100 mL, 250 mL, 500 mL, 1000 mL); 30% (500 mL) [contains egg yolk phospholipids, glycerin]
Nutrilipid: 20% (250 mL, 500 mL, 1000 mL) [contains egg yolk phospholipids, glycerin]
No
Emulsion (Clinolipid Intravenous)
20% (per mL): $0.23
Emulsion (Intralipid Intravenous)
20% (per mL): $0.21
30% (per mL): $0.14
Emulsion (Nutrilipid Intravenous)
20% (per mL): $0.08
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Emulsion, Intravenous:
Clinoleic: 20% (100 mL, 250 mL, 350 mL, 500 mL, 1000 mL) [contains egg phosphatides]
Intralipid: 20% (100 mL, 250 mL, 500 mL, 1000 mL); 30% ([DSC])
IV: Administer by IV infusion through a 1.2 micron in-line filter only via peripheral line or by central venous infusion. All lipid emulsion infusions should be filtered whether part of an admixture or infused separately using a 1.2-micron in-line filter only (Ref). At the onset of therapy, the patient should be observed for any immediate allergic reactions such as dyspnea, cyanosis, and fever. Change tubing after each infusion. May be simultaneously infused with amino acid and dextrose solutions by means of Y-connector located near infusion site or administered in total nutrient mixtures (3-in-1) with amino acids, dextrose, and other nutrients (Ref). Lipid emulsions of 30% should only be administered in total nutrient mixtures (3-in-1) with amino acids, dextrose, and other nutrients. Hang lipid emulsion higher than other fluids (has low specific gravity and could run up into other lines). Do not exceed an infusion rate of 0.5 mL/kg/hour. See prescribing information for detailed administration information.
Clinolipid: Prior to opening the overwrap of Clinolipid, check the color of the oxygen indicator and compare to the reference color next to the OK symbol. If the color of the oxygen absorber/indicator does not correspond to the reference color, do not use. After opening the bag, use the contents immediately; if not used immediately, use within 24 hours when stored at room temperature. Do not connect flexible bags in series to avoid air embolism due to possible residual gas contained in the primary bag. Do not use vented administration sets with vent in the open position to avoid air embolism. When preparing total parenteral nutrition admixture, do not use the EXACTAMIX Inlet H938173 with an EXACTAMIX compounder to transfer Clinolipid injection; EXACTAMIX Inlet H938174 is recommended.
Intralipid: To avoid air embolism, use a nonvented infusion set or close the air vent on a vented set and use a dedicated line without any connections. Prior to opening the overwrap, the integrity indicator should be inspected. If the indicator is black, the overwrap is damaged; do not use. Do not use administration sets and lines that contain di-2-ethylhexyl phthalate (DEHP).
Nutrilipid: To avoid air embolism, use a nonvented infusion set or close the air vent on a vented set and use a dedicated line without any connections. Prior to opening the overwrap, the oxygen indicator should be inspected; if the indicator is pink or dark pink, do not use. Do not use administration sets and lines that contain DEHP.
Caloric source/EFAD: Initiate infusions of 10% emulsions at 1 mL/minute for 15 to 30 minutes; if no untoward effects occur, the infusion rate may be increased to 2 mL/minute. Initiate infusions of 20% emulsions at 0.5 mL/minute for 15 to 30 minutes; if no untoward effects occur, the infusion rate may be increased to 1 mL/minute.
Serious hemodynamic or other instability secondary to highly lipid soluble substances (off-label use): Administer initial bolus over 1 to 3 minutes followed by a continuous infusion. Chest compressions should continue during administration if patient is in cardiac arrest. Some experts recommend a decreased infusion rate in patients who respond favorably to the initial bolus and infusion (Ref); repeat bolus or an increase in the infusion rate may be considered if instability persists or recurs (Ref).
IV: All lipid injectable emulsion infusions should be filtered using a 1.2 micron in-line filter only (Ref). Administration may occur via peripheral line or central venous infusion using DEHP-free administration sets and lines, including infusion sets that contain PVC. Use a vented infusion set when infused from the bottle, avoid multiple connections, do not connect multiple medications in series, and turn off pump before the bottle runs dry. At the onset of therapy, the patient should be observed for any immediate allergic reactions such as dyspnea, cyanosis, and fever.
Intralipid: Prior to opening the overwrap, the integrity indicator should be inspected. If the indicator is black, the overwrap is damaged; do not use.
Nutrilipid: Prior to opening the overwrap, the oxygen indicator should be inspected; if the indicator is pink or dark pink, do not use.
Parenteral nutrition: May be administered as part of a parenteral nutrition admixture (3-in-1) or infused simultaneously with amino acid and dextrose mixtures by means of Y-connector located near infusion site (flow rates of each solution should be controlled separately by infusion pumps). The 20% lipid injectable emulsions may be simultaneously infused with amino acid and dextrose mixtures by means of Y-connector located near infusion site into either central or peripheral line or administered in total nutrient mixtures (3-in-1) with amino acids, dextrose, and other nutrients. Lipid emulsions of 30% should only be administered in total nutrient mixtures (3-in-1) with amino acids, dextrose, and other nutrients; not intended for direct infusion; must be further diluted to a final concentration not to exceed 20%. All lipid injectable emulsion infusions, whether part of an admixture or infused separately, should be filtered using a 1.2-micron in-line filter only (Ref). Administration may occur via peripheral line or central venous infusion. When administered with dextrose and amino acids, the choice of a central or peripheral infusion depends on the osmolarity of the final infusate (osmolarity ≥900 mOsm/L must be infused through a central vein). Change tubing after each infusion. Experts recommend parenteral nutrition admixtures and lipid injectable emulsions for neonates and infants be protected from light as soon as possible after preparation and through infusion (Ref).
Neonates, Infants, Children, and Adolescents: Daily dose of lipid emulsion is typically infused over 24 hours; patients who have been on a stable TPN regimen for >2 weeks may have total infusion time incrementally decreased (ie, cycled) to 12 to 22 hours a day to decrease hepatic complications associated with TPN use and to ease daily activities (Ref); experts have recommended maximum neonatal rate of 0.15 g/kg/hour (Ref).
Product-specific infusion rates (volume):
Intralipid 20%:
Neonates, Infants, and Children <2 years: IV: Initiate at 0.1 mL/kg/hour for 10 to 15 minutes; if no untoward effects occur, the infusion rate may be increased to 0.75 mL/kg/hour.
Children 2 to <12 years: IV: Initiate at 0.2 to 0.4 mL/kg/hour for 10 to 15 minutes; if no untoward effects occur, the infusion rate may be increased to 0.75 mL/kg/hour.
Children ≥12 years and Adolescents ≤17 years: IV: Initiate at 0.2 mL/kg/hour for 10 to 15 minutes; if no untoward effects occur, the infusion rate may be increased to 0.75 mL/kg/hour.
Adolescents >17 years: IV: Initiate at 0.2 mL/kg/hour for 10 to 15 minutes; if no untoward effects occur, the infusion rate may be increased to 0.5 mL/kg/hour after 30 minutes.
Nutrilipid:
Neonates, Infants, Children, and Adolescents <17 years: Initiate at 0.05 mL/minute for 10 to 15 minutes; if no untoward effects, the infusion may be gradually increased to required rate; maximum rate of infusion: Neonates, Infants, and Children ≤10 years: 0.75 mL/kg/hour; Children and Adolescents 11 to 16 years: 0.5 mL/kg/hour.
Adolescents ≥17 years: Initiate at 0.5 mL/minute for 15 to 30 minutes; if no untoward effects, the infusion may be gradually increased; maximum rate of infusion: 0.5 mL/kg/hour.
Serious hemodynamic or other instability secondary to highly lipid soluble substances: 20% lipid injectable emulsion: Administer initial bolus undiluted over 2 to 3 minutes; bolus typically followed by a continuous infusion. Chest compressions should continue during administration if patient is in cardiac arrest. Some experts recommend a decreased infusion rate in patients who respond favorably to the initial bolus and infusion (Ref); repeat bolus or an increase in the infusion rate may be considered if instability persists or recurs (Ref).
Energy/Calories: Source of energy/calories and essential fatty acids for patients requiring parenteral nutrition for extended periods of time (usually for longer than 5 days) or when oral or enteral nutrition is not possible, insufficient, or contraindicated; to prevent and treat essential fatty acid deficiency (except Clinolipid and Nutrilipid).
Serious hemodynamic or other instability secondary to highly lipid soluble substances
Intralipid may be confused with ViperSlide (lubricant used during atherectomy procedures)
Indications for lipid emulsion therapy in pregnant women are the same as in nonpregnant women. The ASPEN guidelines for parenteral and enteral nutrition state that IV lipid emulsion may be used safely in pregnant women to provide calories and prevent essential fatty acid deficiency (ASPEN Guidelines 2002). Medications used for the treatment of cardiac arrest in pregnancy are the same as in the nonpregnant woman. Doses and indications should follow current Advanced Cardiovascular Life Support guidelines. Appropriate medications should not be withheld due to concerns of fetal teratogenicity (AHA [Jeejeebhoy 2015]). Lipid emulsion therapy has been used successfully in the resuscitation of a pregnant female with suspected bupivacaine toxicity (Dun-Chi Lin 2017; Mock 2021; Spence 2007).
It is not known if lipid emulsion (plant based) is excreted in breast milk. The fatty acids found in lipid emulsion (eg, linoleic acid, linolenic acid) are endogenous to human milk and concentrations are influenced by maternal diet (IOM 2005). According to the manufacturer, the decision to continue or discontinue breastfeeding during therapy should take into account the risk of infant exposure, the benefits of breastfeeding to the infant, and benefits of treatment to the mother.
Phosphorus: ~1.5 mMol /100 mL of emulsion.
Caloric content: 10% lipid emulsion = 1.1 kcal/mL; 20% lipid emulsion = 2 kcal/mL; 30% lipid emulsion = 3 kcal/mL.
Lipid emulsion should not exceed 60% of the total daily calories.
LFTs; monitor for signs and symptoms of essential fatty acid deficiency, fat overload, refeeding syndrome, and/or hypersensitivity reactions.
Monitor triglycerides before initiation of therapy and at least weekly during hospitalization and after changes are made in the dose or rate of the lipid emulsion administered (Mirtallo 2020). Monitor more closely in patients with pancreatitis or hepatic disease or in patients receiving other lipid emulsion-based medications (eg, propofol, clevidipine).
When lipid emulsion is used to prevent essential fatty acid (EFA) deficiency and not as an energy source, monitor for signs and symptoms of EFA deficiency (eg, diffuse, dry scaly rash, alopecia, thrombocytopenia, anemia, and impaired wound healing) (Hamilton 2006).
For long-term use (>6 months), monitor for parenteral nutrition-associated liver disease (cholestasis with elevations in serum bilirubin) (Mirtallo 2020).
Fat overload may be avoided by not exceeding the maximum recommended dose or infusion rate of lipid emulsion. Symptoms include fever, hepatosplenomegaly, icterus, acute respiratory distress syndrome, metabolic acidosis, thrombocytopenia, and bleeding (Mirtallo 2020).
Monitor for signs and symptoms of infection (including vascular access device complications); fluid and electrolyte status; serum osmolarity; blood glucose; blood counts (including platelets and coagulation parameters); kidney function.
Lipid emulsion is metabolized and utilized as an energy source; provides the essential fatty acids, linoleic acid, and alpha linolenic acid necessary for normal structure and function of cell membranes; in local anesthetic toxicity, lipid emulsion probably extracts lipophilic local anesthesia from cardiac muscle.
In toxicity secondary to highly lipid soluble substances, exogenous lipids provide an alternative source of binding (Rowlingson 2008), commonly known as the "lipid sink" effect. High lipid partition constant and large volumes of distribution are good predictors of success when using lipid therapy (French 2011). Lipid administration may also affect the heart in a metabolically advantageous way by improving fatty acid transport (Weinberg 2006).
Metabolism: Fatty acids, phospholipids, and glycerol are metabolized by cells to adenosine triphosphate (ATP), carbon dioxide, and water
Half-life elimination: 0.5 to 1 hour
Excretion: Biliary (phospholipids)
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