Intravenous Lipid Emulsions (ILEs)

Intravenous Lipid Emulsions Brand Names

Clinolipid | Intralipid | Liposyn II | Liposyn III | Nutrilipid | Omegaven | Smoflipid

What is Intravenous Lipid Emulsions

Intravenous lipid emulsions (ILEs) are fat emulsions primarily indicated as a source of calories and essential fatty acids for parenteral nutrition and as a source of essential fatty acids when a deficiency occurs when oral or enteral nutrition is not possible, insufficient, or contraindicated.

ILEs are also used off-label for lipid rescue therapy (LRT) in cases of potentially fatal local anesthetic toxicity and cases of lipophilic agent overdose or poisoning when there is hemodynamic instability unresponsive to resuscitation measures, such as fluid replacement, inotropes, and vasopressors.

ILEs are primarily composed of medium-chain triglycerides (MCTs) and long-chain triglycerides (LCTs) and/or fish oil triglycerides, egg phospholipids, and glycerol. They are classified into various generations based on their fatty acid derivative as well as their inflammatory response.

First-generation ILEs are composed of 100% soybean oil (i.e., Intralipid, Nutrilipid) and are considered pro-inflammatory. Second-generation ILEs are comprised of a 50:50 ratio of MCTs to soybean oil.

Third-generation ILEs are olive-oil containing products with an 80:20 ratio of olive oil to soybean oil. Second- and third-generation lipid emulsions are considered inflammatory neutral.

Fourth-generation ILEs are fish-oil containing products in varying ratios and are considered anti-inflammatory. SMOFlipid is comprised of soybean oil, MCTs, olive oil, and fish oil in a 30:30:25:15 ratio, while Omegaven is 100% fish oil. About 60% of the content of first-generation ILEs is in the form of linoleic acid (omega-6; 50%) and alpha-linolenic acid (omega-3; 10%).

Additionally, they contain LCTs. ILEs with high concentrations of omega-6 have been shown to be pro-inflammatory, and studies have suggested a link between LCTs and an increase in the risk of infection and parenteral nutrition-associated liver disease (PNALD).

Thus, newer generations of ILEs were developed with a different composition of fatty acids in order to reduce these complications.

Omegaven has a total omega-3 fatty acid content of 40% to 54%, compared to an approximately 2% to 4% omega-6 fatty acid content.

Although clinical data have supported the use of newer generation ILEs for their reduction in inflammatory response, outcomes and adverse reaction data are limited.

Most ILEs are indicated for adults and pediatric patients as young as neonates; however, SMOFlipid is only indicated for adults in the US.

However, it is used off-label in other countries for pediatric patients as young as neonates.

Omegaven is indicated as a source of calories and essential fatty acids for pediatric patients with parenteral nutrition-associated cholestasis (PNAC).

Indications

  1. calcium-channel blocker toxicity
  2. essential fatty acid deficiency
  3. essential fatty acid deficiency prophylaxis
  4. lipid resuscitation therapy
  5. nutritional supplementation
  6. parenteral nutrition-associated cholestasis

Side Effects

  1. abdominal pain
  2. agitation
  3. aluminum toxicity
  4. apnea
  5. back pain
  6. bleeding
  7. bradycardia
  8. chest pain (unspecified)
  9. cholecystitis
  10. cholelithiasis
  11. cholestasis
  12. cyanosis
  13. diaphoresis
  14. diarrhea
  15. dizziness
  16. drowsiness
  17. dysgeusia
  18. dyspepsia
  19. dyspnea
  20. elevated hepatic enzymes
  21. erythema
  22. fat overload syndrome
  23. fever
  24. flatulence
  25. flushing
  26. headache
  27. hepatitis
  28. hepatomegaly
  29. hyperglycemia
  30. hypertension
  31. hypertonia
  32. hypertriglyceridemia
  33. infection
  34. injection site reaction
  35. jaundice
  36. leukocytosis
  37. leukopenia
  38. nausea
  39. neutropenia
  40. parenteral nutrition-associated liver disease
  41. phlebitis
  42. pruritus
  43. rash
  44. sinus tachycardia
  45. splenomegaly
  46. steatosis
  47. thrombocytopenia
  48. vomiting

Monitoring Parameters

  • blood glucose
  • CBC
  • INR
  • LFTs
  • prothrombin time (PT)
  • serum bilirubin (total and direct)
  • serum cholesterol profile
  • serum creatinine/BUN
  • serum electrolytes
  • serum triglycerides

Contraindications

  • bleeding
  • bone fractures
  • breast-feeding
  • children
  • cholelithiasis
  • cholestasis
  • chronic lung disease (CLD)
  • chronic obstructive pulmonary disease (COPD)
  • coagulopathy
  • diabetes mellitus
  • egg hypersensitivity
  • electrolyte imbalance
  • fish hypersensitivity
  • hepatic disease
  • hepatitis
  • hyperlipidemia
  • hypertriglyceridemia
  • immunosuppression
  • infants
  • infection
  • laboratory test interference
  • malnutrition
  • neonates
  • obesity
  • pancreatitis
  • peanut hypersensitivity
  • pregnancy
  • premature neonates
  • pulmonary disease
  • refeeding syndrome
  • renal impairment
  • respiratory distress syndrome
  • soya lecithin hypersensitivity
  • trauma

Interactions

  • Acebutolol
  • Acetaminophen; Aspirin, ASA; Caffeine
  • Angiotensin II receptor antagonists
  • Angiotensin-converting enzyme inhibitors
  • Anticoagulants
  • Antithrombin III
  • Apixaban
  • Argatroban
  • Aspirin, ASA
  • Aspirin, ASA; Butalbital; Caffeine
  • Aspirin, ASA; Butalbital; Caffeine; Codeine
  • Aspirin, ASA; Caffeine; Dihydrocodeine
  • Aspirin, ASA; Caffeine; Orphenadrine
  • Aspirin, ASA; Carisoprodol
  • Aspirin, ASA; Carisoprodol; Codeine
  • Aspirin, ASA; Citric Acid; Sodium Bicarbonate
  • Aspirin, ASA; Dipyridamole
  • Aspirin, ASA; Omeprazole
  • Aspirin, ASA; Oxycodone
  • Aspirin, ASA; Pravastatin
  • Atenolol
  • Atenolol; Chlorthalidone
  • Bendroflumethiazide; Nadolol
  • Beta-adrenergic blockers
  • Betaxolol
  • Betrixaban
  • Bisoprolol
  • Bisoprolol; Hydrochlorothiazide, HCTZ
  • Bivalirudin
  • Brimonidine; Timolol
  • Calcium-channel blockers
  • Carteolol
  • Carvedilol
  • Central-acting adrenergic agents
  • Dabigatran
  • Dalteparin
  • Danaparoid
  • Desirudin
  • Dorzolamide; Timolol
  • Doxazosin
  • Edoxaban
  • Enoxaparin
  • Eplerenone
  • Epoprostenol
  • Esmolol
  • Fondaparinux
  • Heparin
  • Hydrochlorothiazide, HCTZ; Metoprolol
  • Hydrochlorothiazide, HCTZ; Propranolol
  • Labetalol
  • Lepirudin
  • Levobetaxolol
  • Levobunolol
  • Loop diuretics
  • Mecamylamine
  • Metoprolol
  • Nadolol
  • Nebivolol
  • Nebivolol; Valsartan
  • Penbutolol
  • Pentosan
  • Phenoxybenzamine
  • Pindolol
  • Platelet Inhibitors
  • Potassium-sparing diuretics
  • Prazosin
  • Propranolol
  • Reserpine
  • Rivaroxaban
  • Thiazide diuretics
  • Thrombolytic Agents
  • Timolol
  • Tinzaparin
  • Vasodilators
  • Warfarin
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