Lipid clearance and total parenteral nutrition: the importance of monitoring plasma lipids

Intravenous lipid emulsion for the treatment of poisonings in 313 dogs and 100 cats (2016-2020)

Introduction

The aim of this retrospective study was to analyze the effect and potential adverse effects of intravenous lipid emulsion (ILE) in poisoned dogs and cats over a 5 years period.

Methods

Medical records of 313 dogs and 100 cats receiving ILE between 2016-2020 were analyzed for suspected toxicant, clinical signs, ILE dosages and frequency, the effect and adverse effects of ILE, and patient outcome.

Results

Dogs and cats were poisoned with mostly unidentified toxicants (48%), rodenticides (8%), recreational drugs and nuts (7% each) and other toxicants. Clinical signs included neurologic deficits (63%), cardiovascular signs (29%), thermoregulation (21%) or gastrointestinal abnormalities (17%). Treatment with ILE was initiated within a median of 6.0 h (1.0-91.0 h) after poisoning. Dogs and cats received a total amount of median 8.0 mL/kg (1.5-66.6 mL/kg) and 15.8 mL/kg (1.8-69.4 mL/kg) ILE, respectively. A positive effect was observed in 74% of the patients, whereas clinical signs worsened in 4% of the patients after ILE administration. No subjective effect was detected in 22% of the patients. Suspected or possible adverse effects of ILE occurred in 6% of the patients, including neurological signs (temporarily reduced consciousness and ataxia), bradycardia, hyperthermia, vomiting, diarrhea, respiratory distress, worsening of the general behavior, facial swelling, and thrombophlebitis. The overall survival rate was 96%. One dog who potentially experienced adverse events was euthanized.

Conclusion

ILE treatment was successful in most patients but can be associated with adverse effects. Administration of ILE should be carefully selected on an individual basis after weighing the possible benefits against potential adverse effects.

Manual plasma exchange to treat an accidental overdose of intravenous lipid emulsion in a dog with baclofen toxicosis

CASE DESCRIPTION

An approximately 2-year-old sexually intact male German Shorthair Pointer was presented for treatment of baclofen toxicosis.

CLINICAL FINDINGS

The dog had signs of severe baclofen toxicosis (no gag reflex, intermittent vocalization, and stupor) and received intravenous lipid emulsion (142 mL/kg) as a constant rate infusion over 11 hours. Severe hypertriglyceridemia (29,221 mg/dL; reference interval, 19 to 133 mg/dL) developed, followed by cardiovascular depression (poor peripheral perfusion, hyperlactatemia, and hypertension), severe hypoglycemia (26 mg/dL), acute kidney injury (serum creatinine, 3.6 mg/dL), intravascular hemolysis, and coagulopathy (hypocoagulable thromboelastogram and marked bilateral epistaxis).

TREATMENT AND OUTCOME

Therapeutic plasma exchange was performed in 4 stages to treat the hypertriglyceridemia. For each stage, an approximately 500-mL aliquot of blood (22 mL/kg) was removed and centrifuged, and the patient’s RBCs and allogenic fresh-frozen plasma were returned to the dog. Approximately 1.2 times the dog’s plasma volume was exchanged, reducing the serum triglyceride concentration to 1,349 mg/dL and improving the dog’s cardiovascular function and coagulation. Hours after the procedure was completed, the dog regurgitated and developed acute respiratory distress as a result of presumptive aspiration pneumonia, and the owner elected to have the dog euthanized.

CLINICAL RELEVANCE

Veterinarians should be aware of possible complications associated with administration of intravenous lipid emulsion, and veterinary-specific guidelines for the maximum dose of intravenous lipid emulsion should be developed to help prevent adverse effects. TPE appears to be an effective method for treating iatrogenic hypertriglyceridemia in dogs.

Multiple same day cryolipolysis treatments for the reduction of subcutaneous fat are safe and do not affect serum lipid levels or liver function tests

Objective

Cryolipolysis is a safe and effective non‐surgical procedure for reducing subcutaneous fat. It spares adjacent structures, is associated with few adverse events, and is well‐tolerated by patients. Previous studies involving one or two simultaneous treatment sites have shown no effect on serum lipid levels or liver tests. The purpose of this study was to determine whether multiple same day treatments (abdomen plus both flanks) result in changes in these blood tests, and is safe.

Study Design

Thirty‐five adult males and females underwent same‐day cryolipolysis (CoolSculpting System, ZELTIQ Aesthetics) of the lower abdomen and flanks for reduction of subcutaneous fat. Serum lipids and liver tests were measured prior to treatment and at 1, 4, and 12 weeks post‐treatment. Expected treatment side‐effects were assessed immediately post‐treatment and at the 12‐week follow‐up visit. Adverse events were also monitored.

Methods

Treatment consisted of one cycle to the lower abdomen using a large vacuum applicator and simultaneous treatment of both flanks, one cycle each, with medium vacuum applicators .Time between the abdomen and flanks procedures was not to exceed 30 minutes.

Results

The procedures were well‐tolerated by patients; expected treatment effects were in general mild or moderate, and resolved without intervention. There were no clinically meaningful changes from baseline to any subsequent time point in any serum lipid test. This was also true for all liver tests. There were no treatment‐related adverse events.

Conclusion

Multiple cycle, same day cryolipolysis treatment of the lower abdomen and both flanks is well‐tolerated and safe. It does not lead to changes in serum lipids or liver tests at any of the measured time points following the procedure. Lasers Surg. Med. 49:640–644, 2017. © 2017 The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals Inc.

Systematic review of clinical adverse events reported after acute intravenous lipid emulsion administration

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.

Does the type of parenteral lipids matter? A clinical hint in critical illness

BACKGROUND & AIMS

An altered lipid profile is common among intensive care unit (ICU) patients, but evidence regarding the impact of different fatty acid (FA) emulsions administered to patients requiring parenteral nutrition (PN) is scarce. This study aimed to compare the plasma triglycerides (TG) response to two types of commercial lipid emulsions: a structured mixture of long- and medium-chain triglycerides (LCT/MCT) or LCTs with n-9 FA (LCT+) in ICU patients.

METHODS

In this retrospective observational study conducted in a multidisciplinary ICU: two groups were defined by the type of emulsion used. Inclusion criteria were: consecutive patients on PN staying ≥4 days with one TG determination before commencing PN and at least one during PN. Recorded variables included energy intake, amount and type of nutritional lipids, propofol dose, glucose and protein intake, laboratory parameters, and all drugs received. Hypertriglyceridemia (hyperTG) was defined as TG >2 mmol/L.

RESULTS

The dynamic impact of the emulsion was analyzed in 187/757 patients completing the inclusion criteria (112 LCT/MCT and 75 LCT+). The demographic variables, severity indices, diagnostic categories, and outcomes did not differ between the two groups. Seventy-seven patients (41%) presented hyperTG. Both groups received similar daily energy (1604 versus 1511 kcal/day), lipids (60 versus 61 g/day), and glucose intake (233 versus 197 g/day). There was no increase of TG concentration in those receiving the LCT/MCT emulsion compared to those receiving the LCT+ emulsion (0 and 0.2 mmol/L, respectively, p < 0.05).

CONCLUSION

LCT/MCT emulsions are associated with a less pronounced increase of plasma TG levels than LCT+ emulsions.

Re-feeding food-deprived male meadow voles affects the sperm allocation of their rival males

An individual's nutritional status affects the manner in which same- and opposite-sex conspecifics respond to that individual, which may affect their fitness. Male meadow voles, Microtus pennsylvanicus, increase their sperm allocation if they encounter the scent mark of an unfamiliar male that is not nutritionally challenged. If, however, the scent mark comes from a male that has been food deprived for 24 hours, stud male voles do not increase their sperm allocation. Food deprived males may be viewed as being lower quality and a reduced risk of sperm competition by rival males. We hypothesized that stud males in promiscuous mating systems tailor their sperm allocations depending on whether rival males have been food deprived and then re-fed. We predicted that newly re-fed males will be considered a strong risk of sperm competition because of the potentially high fitness and survival costs associated with food deprivation in males, and that they will cause stud males to increase their sperm allocation. Our results, however, showed that the recovery period from 24 hours of food deprivation was a relatively slow process. It took between 96 hours and 336 hours of re-feeding male scent donors that were food deprived for 24 hours to induce stud males to increase their sperm allocation to levels comparable to when scent donors were not food deprived. Stud male voles may be conserving the amount of sperm allocated until the male scent donors have recovered from food deprivation and subsequent re-feeding.

Improvement of drug safety by the use of lipid-based nanocarriers

Drug toxicity is an important factor that contributes significantly to adverse drug events in current healthcare practice. Application of lipid-based nanocarriers in drug formulation is one approach to improve drug safety. Lipid-based delivery systems include micelles, liposomes, solid lipid nanoparticles, nanoemulsions and nanosuspensions. These carriers are generally composed of physiological lipids well tolerated by human body. Delivery of water-insoluble drugs in these formulations increases their solubility and stability in aqueous media and eliminates the need for toxic co-solvents or pH adjustment to solubilize hydrophobic drugs. Association or encapsulation of peptides/proteins within lipid-based carriers protects the labile biologics against enzymatic degradation, hence reducing the therapeutic dose required and risk of dose-dependent toxicity. Most importantly, lipid-based nanocarriers alter the pharmacokinetics and biodistribution of drugs through passive and active targeting, leading to increased drug accumulation at target sites while significantly decreasing non-specific distribution to other tissues. Furthermore, surface modification of these nanocarriers reduces immunogenicity of drug-carrier complexes, imparts stealth by preventing opsonization and removal by phagocytes and minimizes interaction with circulating blood components. In view of heightening attention on drug safety in patient treatment, lipid-based nanocarrier is therefore an important and promising option for formulation of pharmaceutical products to improve treatment safety and efficacy.

Qual é a importância clínica e nutricional da síndrome de realimentação?

INTRODUÇÃO: A síndrome de realimentação caracteriza-se por alterações neurológicas, sintomas respiratórios, arritmias e falência cardíacas, poucos dias após a realimentação. Ocorre em consequência do suporte nutricional (oral, enteral ou parenteral) em pacientes severamente desnutridos. OBJETIVO: Avaliar de suas causas e a aplicação das medidas dietéticas profiláticas apropriadas visando a prevenção e diminuição da morbimortalidade desta condição. MÉTODOS: Foi realizado levantamento bibliográfico na SciELO, LILACS, Medline/Pubmed, Biblioteca Cochrane e sites governamentais nos idiomas português, inglês e espanhol. Os levantamentos foram sobre os últimos 15 anos, selecionando os descritores: síndrome de realimentação, desnutrição, hipofosfatemia, hipocalemia, hipomagnesemia. CONCLUSÃO: O acompanhamento de parâmetros metabólicos e de níveis de eletrólitos antes do início do suporte nutricional e periodicamente durante a alimentação deve ser baseado em protocolos, no estado da doença subjacente e na duração da terapia. Equipe multidisciplinar de terapia nutricional pode orientar e educar outros profissionais de saúde na prevenção, diagnóstico e tratamento dessa síndrome.

Fatty emaciation: a case report of suspected fat overload syndrome in oral refeeding

Refeeding syndrome has been observed in patients receiving nutrition after a prolonged period of malnourishment and is characterized by multiple metabolic derangements. Besides hypophosphatemia and hypoglycemia, lipemia has been described in association with parenteral nutrition administration to the malnourished. The authors describe one anorexic patient who developed lipemia during oral refeeding, followed by a precipitous drop in hematocrit suggestive of fat overload syndrome.

Dyslipidemia in the Critically Ill

Total and HDL cholesterol levels fall at the onset of acute illness and the cholesterol levels normalize as the patient recovers. Hypocholesterolemia may predispose the critically ill patient to sepsis and adrenal failure. Early enteral nutrition and tight glycemic control accelerate the recovery of the cholesterol levels.

Metabolic and catheter complications of parenteral nutrition

Since its introduction in the 1960s, total parenteral nutrition (TPN) has played a vital role in improving clinical outcomes for patients with acute and chronic illnesses. The evolution of TPN solutions and vascular access techniques, combined with an increased awareness and better understanding of the physiology of TPN, have improved the safety of this therapy. Nevertheless, complications are not uncommon and can be life threatening. This article provides an updated review on the metabolic and catheter complications associated with TPN.

Evaluation of complications and prognostic factors associated with administration of total parenteral nutrition in cats: 75 cases (1994–2001)

OBJECTIVE

To determine frequency and types of complications, prognostic factors, and primary diseases affecting clinical outcome associated with administration of total parenteral nutrition (TPN) in cats.

DESIGN

Retrospective study.

ANIMALS

75 cats that received TPN for > or = 12 hours.

PROCEDURE

Medical records were reviewed, and information was obtained on signalment, history, problems at initial evaluation, physical examination findings, weight and changes in weight while receiving TPN, duration in the hospital before initiation of TPN, the type of TPN catheter used, duration of TPN administration, and final diagnosis. Laboratory results obtained immediately prior to TPN and at 24 and 96 hours following initiation of TPN administration were compared.

RESULTS

Reports of weight loss at initial evaluation, hyperglycemia at 24 hours, or diagnosis of chronic renal failure were significantly associated with increased mortality rate. Greater serum albumin concentrations prior to and at 96 hours following TPN administration were significantly associated with decreased mortality rate. Mechanical and septic complications were infrequent and not associated with increased mortality rate. Most cats had multiple diseases. The overall mortality rate was 52%; among 75 cats, 36 recovered, 23 were euthanatized, and 16 died as a result of their primary illness or complications associated with their illness.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated high mortality rate in cats maintained onTPN that had multiple concurrent diseases associated with a poor prognosis. Indicators of poor prognosis included a history of weight loss, hyperglycemia at 24 hours following TPN administration, hypoalbuminemia, and chronic renal failure.

The importance of clinical factors in parenteral nutrition-associated hypertriglyceridemia

AIMS

The purpose of this study was to establish the relevance of several clinical factors associated with parenteral nutrition (PN) hypertriglyceridemia and to construct a predictive model for this complication.

METHOD

This multicenter study included all patients with initial serum triglyceridemia <3 mmol and receiving a minimum of 7 days' PN therapy. The study ended for each patient when hypertriglyceridemia developed or PN was terminated. Two multivariate models were constructed, one to study the clinical factors and the second to predict plasma triglyceridemia. A total of 22 clinical factors studied as independent variables were included in the multiple-step regression models only when they showed a P-value over 0.1. Statistical significance was determined by the confidence interval of the odds ratio (OR) and the partial regression coefficient (b).

RESULTS

The study included 260 patients from 14 hospitals. Lipid administration was 0.83+/-0.37 g/kg/day. Among the total, 68 patients (26.2%) showed hypertriglyceridemia. Variables included in both models were serum glucose (OR, 2.63; b, 0.06), renal failure (OR, 10.56; b, 1.70), corticoid administration >0.5 mg/kg (OR, 7.98; b, 0.97), pancreatitis (OR, 4.38; b, 0.64), sepsis (OR, 4.48; b, 0.24), lipids infused (OR, 3.03; b, 0.24) and heparin administration >3 mg/kg/day (OR, 0.11; b, -1.21).

CONCLUSION

Although the rate of lipid infusion was low, certain clinical factors modified triglyceridemia. Nevertheless, relatively fast plasma clearance of lipids infused indicates that a reduction in lipid supply could be a quick, effective measure for controlling hypertriglyceridemia. Thus, careful monitoring of patients with clinical factors predicting risk in the model studied, with adjustment of lipid perfusion rates accordingly, is suggested to avoid hypertriglyceridemia.

The importance of the refeeding syndrome

In this review we discuss the refeeding syndrome. This potentially lethal condition can be defined as severe electrolyte and fluid shifts associated with metabolic abnormalities in malnourished patients undergoing refeeding, whether orally, enterally, or parenterally. It can be associated with significant morbidity and mortality. Clinical features are fluid-balance abnormalities, abnormal glucose metabolism, hypophosphatemia, hypomagnesemia, and hypokalemia. In addition, thiamine deficiency can occur. We describe which patient groups are more at risk for this syndrome and the clinical management of the condition.

Feeding the intensive care patient

The present review highlights recent findings (focusing on papers published between October 1999 and December 2000) in nutritional support of intensive care unit patients. During the past year, research focused on the use of enteral nutrition versus parenteral nutrition, and on the best composition of enteral nutrition and parenteral nutrition according to the clinical condition of the patient. With regard to enteral nutrition, the pH of nutritional support, the timing of administration and the technique of tube placement were debated. Immunomodulating agents and hormonal manipulations may improve outcomes of critically ill patients, but still warrant further research before they can be recommended for routine clinical use.