Initiation, Advancement, and Acute Complications of Parenteral Nutrition


BOX 4.3 Risk Factors for Hypertriglyceridemia4,26,28 Alcohol use disorder


Diabetes mellitus (uncontrolled) Familial hyperlipidemia Hepatic disease


Lipid emulsions (10% lipid emulsions or infusion rate greater than 0.11 g/ kg/ h)


Medications such as immunosuppressants (cyclosporine and tacrolimus) and glucocorticoids


Medications formulated with lipid emulsions (propofol or clevidipine)


Metabolic syndrome Multiorgan failure Overfeeding of dextrose Pancreatitis Renal failure (chronic) Sepsis


For patients with triglyceride levels greater than 400 mg/ dL, ILE should be temporarily discontinued from the PN formula.22,25


Once the


triglyceride level is less than 400 mg/ dL, a reduced dose of ILE can be added, with close monitoring of serum triglycerides to ensure tolerance. Lipids can then potentially be advanced back to the goal amount (along with continued triglyceride monitoring). Because use of fat-free PN and/or inadequate fat ingestion from any source for 7 to 10 days can result in EFAD, some ILE is needed.29


EFAD can


be prevented by providing 2% to 4% of total kilocalories as linoleic acid and 0.25% to 0.5% of total kilocalories from α-linolenic acid (equivalent to 500 mL of 20% soybean oil ILE once per week).4,30


Topical vegetable


oils to correct EFAD have been used with variable success and cannot be routinely recommended.31 Use of mixed-oil ILEs with a blend of fat sources (eg, soybean oil,


medium-chain triglycerides, olive oil, or fish oil) may also help prevent hypertriglyceridemia.32


Utilizing mixed-oil ILEs when triglyceride levels


are moderately elevated (250–400 mg/ dL) can lower triglyceride levels while maintaining the same energy provision.32


Although mixed-oil ILEs


may have some benefits, they have not been shown to impact clinical out- comes in patients who are critically ill.5,33 Other concerns associated with ILE include immunosuppression,


interference with lung function in patients with acute lung injury or acute respiratory distress syndrome, and decreased platelet function.34,35


63


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