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Badr M, Goulard M, Theret B, Roubertie A, Badiou S, Pifre R, Bres V, Cambonie G. Fatal accidental lipid overdose with intravenous composite lipid emulsion in a premature newborn: a case report. BMC Pediatr 2021; 21:584. [PMID: 34930217 PMCID: PMC8686371 DOI: 10.1186/s12887-021-03064-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 12/08/2021] [Indexed: 01/30/2023] Open
Abstract
Background Tenfold or more overdose of a drug or preparation is a dreadful adverse event in neonatology, often due to an error in programming the infusion pump flow rate. Lipid overdose is exceptional in this context and has never been reported during the administration of a composite intravenous lipid emulsion (ILE). Case presentation Twenty-four hours after birth, a 30 weeks’ gestation infant with a birthweight of 930 g inadvertently received 28 ml of a composite ILE over 4 h. The ILE contained 50% medium-chain triglycerides and 50% soybean oil, corresponding to 6 g/kg of lipids (25 mg/kg/min). The patient developed acute respiratory distress with echocardiographic markers of pulmonary hypertension and was treated with inhaled nitric oxide and high-frequency oscillatory ventilation. Serum triglyceride level peaked at 51.4 g/L, 17 h after the lipid overload. Triple-volume exchange transfusion was performed twice, decreasing the triglyceride concentration to < 10 g/L. The infant’s condition remained critical, with persistent bleeding and shock despite supportive treatment and peritoneal dialysis. Death occurred 69 h after the overdose in a context of refractory lactic acidosis. Conclusions Massive ILE overdose is life-threatening in the early neonatal period, particularly in premature and hypotrophic infants. This case highlights the vigilance required when ILEs are administered separately from other parenteral intakes. Exchange transfusion should be considered at the first signs of clinical or biological worsening to avoid progression to multiple organ failure. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-03064-6.
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Affiliation(s)
- Maliha Badr
- Department of Neonatal Medicine and Paediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France
| | - Marion Goulard
- Department of Neonatal Medicine and Paediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France
| | - Bénédicte Theret
- Department of Neonatal Medicine and Paediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France
| | - Agathe Roubertie
- Department of Neuropaediatrics, Gui de Chauliac Hospital, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Stéphanie Badiou
- Department of Biochemistry and Hormonology, Lapeyronie Hospital, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Roselyne Pifre
- Department of Neonatal Medicine and Paediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France
| | - Virginie Bres
- Department of Medical Pharmacology and Toxicology, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Gilles Cambonie
- Department of Neonatal Medicine and Paediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France. .,Pathogenesis and Control of Chronic Infection, INSERM UMR 1058, University of Montpellier, Montpellier, France.
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Hayes BD, Gosselin S, Calello DP, Nacca N, Rollins CJ, Abourbih D, Morris M, Nesbitt-Miller A, Morais JA, Lavergne V. Systematic review of clinical adverse events reported after acute intravenous lipid emulsion administration. Clin Toxicol (Phila) 2016; 54:365-404. [PMID: 27035513 DOI: 10.3109/15563650.2016.1151528] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Intravenous lipid emulsions (ILEs) were initially developed to provide parenteral nutrition. In recent years, ILE has emerged as a treatment for poisoning by local anesthetics and various other drugs. The dosing regimen for the clinical toxicology indications differs significantly from those used for parenteral nutrition. The evidence on the efficacy of ILE to reverse acute toxicity of diverse substances consists mainly of case reports and animal experiments. Adverse events to ILE are important to consider when clinicians need to make a risk/benefit analysis for this therapy. METHODS Multiple publication databases were searched to identify reports of adverse effects associated with acute ILE administration for either treatment of acute poisoning or parenteral nutrition. Articles were selected based on pre-defined criteria to reflect acute use of ILE. Experimental studies and reports of adverse effects as a complication of long-term therapy exceeding 14 days were excluded. RESULTS The search identified 789 full-text articles, of which 114 met the study criteria. 27 were animal studies, and 87 were human studies. The adverse effects associated with acute ILE administration included acute kidney injury, cardiac arrest, ventilation perfusion mismatch, acute lung injury, venous thromboembolism, hypersensitivity, fat embolism, fat overload syndrome, pancreatitis, extracorporeal circulation machine circuit obstruction, allergic reaction, and increased susceptibility to infection. CONCLUSION The emerging use of ILE administration in clinical toxicology warrants careful attention to its potential adverse effects. The dosing regimen and context of administration leading to the adverse events documented in this review are not generalizable to all clinical toxicology scenarios. Adverse effects seem to be proportional to the rate of infusion as well as total dose received. Further safety studies in humans and reporting of adverse events associated with ILE administration at the doses advocated in current clinical toxicology literature are needed.
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Affiliation(s)
- Bryan D Hayes
- a Department of Pharmacy , University of Maryland Medical Center and Department of Emergency Medicine, University of Maryland School of Medicine , Baltimore , MD , USA
| | - Sophie Gosselin
- b Department of Medicine, McGill Faculty of Medicine, Emergency Medicine , McGill University Health Centre , Montréal , Canada ;,c Province of Alberta Drug Information Services , Alberta , Canada ;,d Centre antipoison du Québec , Québec , Canada
| | - Diane P Calello
- e Medical Toxicology, Department of Emergency Medicine , Morristown Medical Center, Emergency Medical Associates , Morristown , NJ , USA
| | - Nicholas Nacca
- f Department of Surgery, Division of Emergency Medicine , University of Vermont , Burlington , VT , USA
| | - Carol J Rollins
- g Banner-University Medical Center Tucson, University of Arizona College of Pharmacy , Tucson , AZ , USA
| | - Daniel Abourbih
- h Department of Medicine, Division of Emergency Medicine , University of Toronto , Toronto , Canada
| | - Martin Morris
- i Life Sciences Library , McGill University , Montréal , Canada
| | | | - José A Morais
- j Division of Geriatric Medicine , McGill University , Montréal , Québec , Canada
| | - Valéry Lavergne
- k Department of Medical Biology , Sacré-Coeur Hospital, University of Montréal , Montréal , Canada
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Vasudevan C, Johnson K, Miall LS, Thompson D, Puntis J. The effect of parenteral lipid emulsions on pulmonary hemodynamics and eicosanoid metabolites in preterm infants: a pilot study. Nutr Clin Pract 2013; 28:753-7. [PMID: 24177284 DOI: 10.1177/0884533613507285] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2023] Open
Abstract
BACKGROUND Soy-based intravenous fat emulsion (IVFE) is known to cause a rise in pulmonary artery pressure in the preterm infant, thought to be mediated through eicosanoid metabolites of linoleic acid. We compared the effect of soy-based IVFE and an olive-oil-based IVFE containing less than half the content of linoleic acid on pulmonary artery pressure and eicosanoid metabolites in preterm infants receiving parenteral nutrition. METHODS In this pilot study at a regional neonatal intensive care unit (ICU), infants received either a soy-based or olive-oil-based IVFE as part of an otherwise identical feeding protocol. Pulmonary artery pressure and urinary thromboxane B2 and prostaglandin F1 alpha were measured at baseline and maximum lipid infusion. RESULTS There was a greater fall in pulmonary artery pressure in the olive-oil-based IVFE group compared with the soy-based IVFE group. A decrease in urine thromboxane/prostaglandin F1 alpha ratio was seen only in the olive-oil-based IVFE group. CONCLUSIONS In the parenterally fed preterm infant, an olive-oil-based IVFE may have a beneficial effect on pulmonary artery pressure when compared with soy-based IVFE. Effects on pulmonary vascular tone are likely to be mediated through alterations in eicosanoid metabolism. A randomized trial is warranted to compare the effects of different lipid emulsions.
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Affiliation(s)
- Chakrapani Vasudevan
- Chakrapani Vasudevan, MRCPCH, DCH, DNB, University Department of Paediatrics, Floor D, Clarendon Wing, Leeds General Infirmary, Leeds LS2 9NS, UK. C.
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Affiliation(s)
- Robert J Shulman
- Department of Pediatrics, Baylor College of Medicine, USDA/ARS Children's Nutrition Research Center, Texas Children's Hospital, Houston, Texas 77030, USA.
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Abstract
For an investigation of the clinical sequelae of parenteral lipid infusions during the first week of life, 42 neonates (less than 1750 gm birth weight) were randomly assigned to receive parenteral alimentation with (IL) (Vitrum) or without a parenteral lipid infusion (NL) for 5 days. Follow-up clinical status was monitored and compared, and plasma prostaglandin levels were analyzed. Chronic lung disease was increased in duration and tended to be more severe after lipid administration. The number of days of mechanical ventilation (37 +/- 35 vs 21 +/- 18) and supplemental oxygen therapy (51 +/- 39 vs 28 +/- 23) was significantly increased in the IL group. Five IL infants developed stage 3 bronchopulmonary dysplasia, in comparison with none of the NL infants. Seven IL infants were discharged on a regimen of supplemental oxygen therapy versus none of the NL infants. Thromboxane B2 levels were significantly increased in the babies receiving Vitrum. We conclude that early administration of Vitrum in the premature neonate is associated with increased respiratory difficulty in the ensuing weeks of life.
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Affiliation(s)
- C Hammerman
- Department of Pediatrics, University of Chicago, IL 60637
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Kao LC, Cheng MH, Warburton D. Triglycerides, free fatty acids, free fatty acids/albumin molar ratio, and cholesterol levels in serum of neonates receiving long-term lipid infusions: controlled trial of continuous and intermittent regimens. J Pediatr 1984; 104:429-35. [PMID: 6368776 DOI: 10.1016/s0022-3476(84)81111-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
We compared intermittent (8 hours/day) versus continuous (24 hours/day) isocaloric lipid infusion regimens in 28 neonates. The lipid dose was increased incrementally by 0.5 gm/kg/day to either 3 gm/kg/day or until fat contributed 40% of daily calories. Serum total triglycerides, free fatty acids, free fatty acids/albumin molar ratio, and total cholesterol levels were measured prior to the daily lipid infusion, at the end of the intermittent infusion, and at 8 hours during the continuous infusion. Neonates less than 32 weeks postconception had significant fluctuation of triglycerides, free fatty acids, and free fatty acids/albumin molar ratio during the intermittent regimen at all lipid doses, but not during the continuous regimen. Neonates greater than or equal to 32 weeks postconception had significant fluctuation of serum triglycerides, free fatty acids, and free fatty acids/albumin molar ratio during the intermittent regimen with a lipid dose greater than or equal to 2 gm/kg/day, but not during the continuous regimen at all lipid doses. Serum free fatty acids correlated closely with serum triglycerides during both regimens (r = 0.89, P less than 0.001). Serum total cholesterol rose with increasing lipid doses during both regimens (f = 8.16, P less than 0.05). We conclude that neonates less than 32 weeks postconception tolerate the continuous regimen better than the intermittent regimen at all lipid doses; neonates greater than or equal to 32 weeks postconception tolerate both regimens well at lipid dose less than 2 gm/kg/day, but tolerate a continuous regimen better with lipid dose greater than or equal to 2 gm/kg/day.
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Hilliard JL, Shannon DL, Hunter MA, Brans YW. Plasma lipid levels in preterm neonates receiving parenteral fat emulsions. Arch Dis Child 1983; 58:29-33. [PMID: 6402989 PMCID: PMC1628146 DOI: 10.1136/adc.58.1.29] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Concentrations of various plasma lipid fractions were determined during 96 hours of continuous parenteral infusions of lipid emulsions in 10 normally-grown neonates whose birth-weights ranged from 960 to 1760 g and whose gestational ages ranged from 26 to 32 weeks. Total lipid, triglyceride, free glycerol, and free fatty acid concentrations were measured. During lipid infusions, mean plasma concentrations of all lipid fractions increased above the mean preinfusion values if 2 g/kg a day or more of lipid emulsion was used. There were no further significant increases in mean plasma lipid levels if the infused dosage was increased to 3 or 4 g/kg a day. At these higher infusion rates however, there were considerable individual variations. The only neonate less than 27 weeks of gestation had plasma lipid levels severalfold higher than any of his peers, his plasma was frankly creamy on visual inspection, and the study had to be stopped. Further investigations are needed to determine the optimal modalities of parenteral nutrition with fat emulsions.
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Hunt CE, Gora P, Inwood RJ. Pulmonary effects of Intralipid: the role of Intralipid as a prostaglandin precursor. Prog Lipid Res 1981; 20:199-204. [PMID: 6804960 DOI: 10.1016/0163-7827(81)90037-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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