Lipid Emulsions

Glucose was the only nonprotein source of energy until intravenous lipids were developed during the 1920s to the 1960s. The first emulsion available for clinical use was Lipomul, a cottonseed oil-based formulation. Because there were many adverse effects from its use, it was withdrawn from clinical use in the mid-1960s. After extensive testing, Wretlind developed Intralipid, a soybean-based emulsion, in 1961. It was well tolerated and is the most familiar intravenous fat emulsion currently available. It is available in 10, 20, and 30%

Table 2 Pediatric parenteral nutritional requirements

<2000g

0-4 years

5-18years

Energy (kcal/kg/day)

120

90-108

40-70

Protein (g/kg/day)

3-3.5

2.0-3.0

1-1.5

Fat (g/kg/day)

<3

<3

<2

Sodium (mEq/kg/day)

2-3

2-4

2-4

Potassium (mEq/kg/day)

2-3

2-4

2-4

Chloride (mEq/kg/day)

2-3

2-4

2-4

Calcium

mEq/kg/day

3-4.5

2-3

0.5-2.5

mg/kg/day

60-90

40-60

10-50

Magnesium (mEq/kg/day)

0.35-0.6

0.25-0.5

0.25-0.5

Phosphate (mM/kg/day)

1.5-2.5

1-2

1-2

Zinc (mg/kg/day)

400

300

100

Selenium (mg/kg/day)

1-3

1-3

1-2

Trace elements (ml/l)

2

2

2

Multi vitamins (ml/day)

5

5

5-10

solutions. The advantage of the 20 and 30% solutions over the 10% solution is the lower ratio of phospholipids to triglyceride, which minimizes the increase in plasma lipoprotein X levels. Lipid emulsions provide essential fatty acids in addition to a concentrated energy source, which is particularly advantageous for patients requiring fluid restriction. Trials are under way on the use of emulsions that contain a blend of long-chain fat with medium-chain fats and those with fish oil blends. Also, structured fat emulsions are being studied for clinical use. These specialized emulsions may have advantages in patients with liver disease and those with sepsis.

Lipid emulsions are usually initiated at 1 g/kg/day and advanced to 2 or 3 g/kg/day or 30-50% of total energy. Serum triglyceride levels are monitored for tolerance. Hypertriglyceridemia may occur in situations of stress, sepsis, and renal and liver insufficiency/failure. In addition, a number of medications can cause hypertriglyceridemia. In these situations, a reduction in fat infusion is warranted, usually by infusing over 18-20 h instead of 24 h.

A minimum of 3-5% of total energy requirement is necessary to meet essential fatty acid requirements. In infants with indirect hyperbilirubinemia, it may be prudent to lower intravenous fat infusion to avoid potential risk of kernicterus since free fatty acids may displace bilirubin from albumin binding sites.

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