Shifting from SMOF to intralipid

[Elijah Cummings]

Good afternoon ,
I have eight neonates on PN .
Regarding fat emulsion , all are on SMOF unfortunately , today it finished and no more for the next 2 days .
I already have intralipid 20% and I want to use it instead .
Any precautions or recommendations?
Thanks

[Lori Washington]

SMOFlipid has the advantage of containing 15% omega 3 fatty acids. those serve to decrease severity of Parenteral Nutrition Associated Liver Disease, PNALD also known as cholestatic jaundice, in long term PN dependant patient. Intralipid of course does not have this advantage, there are no precautions at this shift really, I’m assuming you are faced with the shortage for a limited time. however I you have long term PN dependant babies, like those with short bowel syndrome, you might want to try and give at least 1 gram of their lipids as omega 3 fatty acids. the product I know about is Omegaven, which is 100% omega 3 fatty acids emulsion for IV.

[Ezra Scott]

Intralipid 20% is a good enough alternative, just remember that in some countries (and even in our paediatric hospital until very recently) the fat emulsion of choice is/was intralipid 20%. Just proceed with the same precautions you would use with all lipids and same monitoring requirements (consult PI for max rate of infusion etc).

I completely agree with previous recommendations of using Omegaven 10% in babies reliant on long term PN if the shortage of SMOF continues.

[Mahalia Rogers]

Do you mean lipofundin 20%? Because intralipid 20%
Is purely LCT If I am not wrong that have many complications if used for long term but using for this weekend is ok.

Switching From SMOF to
The mixture LCT/MCT that comes from BBraun or FKABI is so safe and provides the same calories.

[Rachel Phillips]

There is a good reference at the ASPEN portal dealing with product shortages, it explains some strategies to save the remaining little stock for certain patient categories, also alternatives if applicable.

http://www.nutritioncare.org/Guidelines_and_Clinical_Resources/Clinical_Practice_Library/Product_Shortage_Recommendations/

I think being proactive against product shortages is one of the biggest challenges we face all the time.

[Alan Jackson]

Hi Everyone

I have a patient experienced severe abdominal pain (cramps) and muscle aches after receiving intralipid 20% (50gm) in PN 3:1. patient had H/O allergy to soy. Do you recommend switching to SMOF. I am aware both products contain soy.

Thanks

[Rachel Phillips]

First, you have to make sure it was an allergy due to that lipid, usually hypersensitivity to any of TPN components is rare. Once confirmed, so any lipid containing LCT oil will not be applicable for use (including SMOF), unless you want to try any other lipid to confirm the allergy itself!

Also Omegaven (which is 100% refined fish oil) should not be used alone, it has to be mixed as well with LCT oil for use. Also, it has no linoleic acid and alpha linolinec acids (essential fatty acids), so can’t substitute Intralipid.

So, I suggest (again, after you make sure allergy is due to lipid emulsion) that you can rub the patient’s skin by safflower oil (or any oil rich in essential fatty acids), here you don’t give calories, but you only avoid Essential Fatty Acid Deficiency Syndrome.

I hope it helps.

[Alan Jackson]

We gave the patient a test dose 100ml of 20% over 3 hours. She experienced only minor abdominal pain and legs muscle pain. The patient agreed to start full dose 50gm intralipid to be mixed in PN 3:1. Unfortunately, in the middle of infusion the abdominal pain and muscle pain started getting worse. The primary physician decided to stop the infusion and continue only PN 2:1. May be will recommend oral MCT oil ???.

[Rachel Phillips]

Well, if that is what happened, it is not considered allergy, but it is a lipid intolerance, you have now to rule out pancreatitis and/or liver dysfunction, also what was the last lab for serum triglycerides?

After all, and if you can’t define the reason of intolerance, you may now try the SMOF, as a test dose like you did before, and if it is not working again, you may consider the MCT oil, but this will be a caloric source only, not essential fatty acids source, then you may need also to rub the patient’s skin every 2 or 3 days by the external oil.

I have a question to you, if the patient can tolerate oral MCT? why not encouraging enteral feeding then?

[Alan Jackson]

Patient’s reported serum labs for lipase, Total billirubin, direct billirubin, TRG, and cholesterol are all within normal. Patient had no H/O acute or chronic pancreatitis. The only diagnosis uncontrolled Crohn’s disease.

Thanks for your input

[Author]

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