Accidental lipid overdose in a preterm infant: A case report

BACKGROUND

Intravenous lipid emulsions (ILEs) provide essential fatty acids during parenteral nutrition (PN). Serious adverse events including death can occur from overdose. We report an accidental overdose in a preterm infant.

METHOD

On Day 2 of life, a 29-week gestational age (GA) twin was accidentally given 47.5 mL of Intralipid20% (≈3x daily amount) in 50-minutes.

RESULTS

No apparent clinical deterioration occurred, although blood samples were lipaemic. Outcomes at 2 years corrected GA were similar to that of his twin. Service changes were made to infusion packaging and administration to avoid similar errors.

CONCLUSIONS

Medication errors in neonates are unfortunately common. Published articles usually focus on poor outcomes, which can increase the distress for parents of children where errors have occurred. Publishing the full spectrum of outcomes instead allows parents and professionals to be aware of all possibilities and lessons learnt, even if serious harm was avoided.

Fatal accidental lipid overdose with intravenous composite lipid emulsion in a premature newborn: a case report

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.

A Review of Regional Anesthesia in Infants

Regional anesthesia provides effective anesthesia and pain relief in infants with age-specific data attesting to safety and efficacy. Regional anesthesia decreases exposure to opioids and general anesthetic agents and associated adverse drug effects, suppresses the stress response, and provides better hemodynamic stability compared to general anesthesia. Regional anesthesia can prevent long-term behavioral responses to pain. As a result, the overall number and variety of nerve blocks being used in infants is increasing. While neuraxial blocks are the most common blocks performed in infants, the introduction of ultrasound imaging and a better safety profile has advanced the use of peripheral nerve blocks. Infant-specific pharmacokinetic and pharmacodynamic data of local anesthetic medications are reviewed including risk factors for the accumulation of high serum levels of unbound, pharmacologically active drug. Bupivacaine accumulates with continuous infusion and 2-chloroprocaine can be used as an alternative. Local anesthetic systemic toxicity has the highest incidence in infants less than 6 months of age and is associated with bolus dosing and penile nerve blocks. Local anesthetic toxicity is treated by securing the airway, suppression of seizure activity and implementation of cardiopulmonary resuscitation. Administration of intralipid (intravenous lipid emulsion) is initiated at the first sign of toxicity. A high level of expertise in regional anesthesia is needed when treating infants due to their unique development.

Severe hypertriglyceridemia associated with everolimus drug-eluting stent placement in an infant

We report a case of severe hypertriglyceridemia associated with an everolimus drug-eluting stent in an infant with pulmonary vein stenosis. We review from current literature the mechanisms by which everolimus may cause dyslipidaemia, pharmacokinetics of everolimus in drug-eluting stents, and treatments of hypertriglyceridemia. This case demonstrates the need to closely monitor serum triglyceride levels after everolimus drug-eluting stent placement in infants.

Intravenous Lipid Emulsion Overdose in Infancy: A Case Report and Overview of Opportunities, Challenges and Prevention

Medication errors remain among the major problems seen in hospitals. Such errors can relate to the prescription, dispensation, or administration of drugs. Human factors account for most of these mistakes, but other factors such as infusion pump programming defects should always be considered. Worldwide, medication errors have been reported to affect 2-30% of patients, depending on the institution. Intravenous lipid emulsion (ILE) infusion is frequently used as part of total parenteral nutrition in patients of all ages with feeding and gastrointestinal issues. ILE overdose has been previously reported, with variable clinical outcomes. We report a case of accidental ILE (Intralipid) overdose in a 3-month-old male infant who fully recovered after single-volume blood exchange transfusion. We also review reported cases and summarize potential solutions for ILE overdose. Our review indicates that ILE infusion is a high-risk medication, and opportunities for errors remain even in the best hospital set-ups. Attention should be directed towards proper prescription, dosing, dispensation, and administration. Most of the cases indicate the safety breach was at the nursing drug-administration level, with improper pump use or programming, together with other fluid infusion rate switching, being the main possible defects. Strategies targeting the areas of weakness in the drug-delivery pathway are needed. Special attention should be paid towards nursing duties and working hours. In addition, nursing staff should receive frequent education sessions and should be required to pass competency modules regularly. An error-prevention plan should be established and implemented. This plan needs full collaboration between physicians, pharmacists, and nursing staff.

Successful exchange transfusion in extremely preterm infant after symptomatic lipid overdose

BACKGROUND

Complications of intravenous lipid administration are relatively uncommon. However, inadvertent rapid infusion of intravenous fat emulsion (IVFE) is an inherent risk when fats are infused separately from the dextrose-amino acid solution.

CASE REPORT

Extremely preterm infant, born at 25 weeks and 6 days of gestational age weighing 920 g, who inadvertently received a massive overdose of IVFE due to a device failure. He developed lethargy, apnea, metabolic acidosis and hemodynamic instability requiring mechanical ventilation and inotropic support. Despite discontinuation of IVFE and supportive care, clinical course and metabolic acidosis worsened, so a double-volume exchange transfusion was performed. The procedure was well tolerated, without complications. Serum triglyceride concentration as well as other laboratory data normalized immediately after the exchange transfusion. The patient was extubated to continuous positive airway pressure and inotropic support was discontinued 24 hours after the procedure. He was discharged home at 40 weeks of corrected age with normal magnetic resonance imaging and neurological examination.

CONCLUSION

In cases of profound, symptomatic hypertriglyceridemia due to lipid overdose, double-volume exchange transfusion should be considered, even in extremely preterm infants.

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.

A.S.P.E.N. clinical guidelines: parenteral nutrition ordering, order review, compounding, labeling, and dispensing

BACKGROUND

Parenteral nutrition (PN) is a high-alert medication available for patient care within a complex clinical process. Beyond application of best practice recommendations to guide safe use and optimize clinical outcome, several issues are better addressed through evidence-based policies, procedures, and practices. This document provides evidence-based guidance for clinical practices involving PN prescribing, order review, and preparation.

METHOD

A systematic review of the best available evidence was used by an expert work group to answer a series of questions about PN prescribing, order review, compounding, labeling, and dispensing. Concepts from the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) format were applied as appropriate. The specific clinical guideline recommendations were developed using consensus prior to review and approval by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. The following questions were addressed: (1) Does education of prescribers improve PN ordering? (2) What is the maximum safe osmolarity of PN admixtures intended for peripheral vein administration? (3) What are the appropriate calcium intake and calcium-phosphate ratios in PN for optimal neonatal bone mineralization? (4) What are the clinical advantages or disadvantages of commercially available premade ("premixed") multichambered PN formulations compared with traditional/customized PN formulations? (5) What are the clinical (infection, catheter occlusion) advantages or disadvantages of 2-in-1 compared with 3-in-1 PN admixtures? (6) What macronutrient dosing limits are expected to provide for the most stable 3-in-1 admixtures? (7) What are the most appropriate recommendations for optimizing calcium (gluconate) and (Na- or K-) phosphate compatibility in PN admixtures? (8) What micronutrient contamination is present in parenteral stock solutions currently used to compound PN admixtures? (9) Is it safe to use the PN admixture as a vehicle for non-nutrient medication delivery? (10) Should heparin be included in the PN admixture to reduce the risk of central vein thrombosis? (11) What methods of repackaging intravenous fat emulsion (IVFE) into smaller patient-specific volumes are safe? (12) What beyond-use date should be used for (a) IVFE dispensed for separate infusion in the original container and (b) repackaged IVFE?

Intravenous lipid emulsion to reverse acute drug toxicity in pediatric patients

OBJECTIVE

To identify and summarize published cases in which intravenous lipid emulsion was used to treat pediatric patients with acute drug toxicities.

DATA SOURCES

PubMed, SCOPUS, and EMBASE were searched up to December 2012 for relevant publications using the terms fat emulsion, lipid emulsion, Intralipid, Liposyn, Medialipide, Medialipid, lipid rescue, ILE, IVLE, IFE, IVFE, or lipid and intoxication, overdose, poisoning, toxicity, resuscitation, antidote, and rescue that were limited to reports in humans aged 18 years or younger.

STUDY SELECTION AND DATA EXTRACTION

A publication was included if an intravenous lipid emulsion was used to treat acute-onset drug toxicity as reported in prospective or retrospective observational studies, case reports, and abstracts for patients aged 18 years or younger.

DATA SYNTHESIS

Fourteen case reports were identified in which intravenous lipid emulsion was used to treat toxicities due to local anesthetics and other medications (amitriptyline, diltiazem, bupropion, dosulepin, lamotrigine, quetiapine, and verapamil). Thirteen cases demonstrated a beneficial response in reversing systemic toxicity; 1 of these patients developed hypertriglyceridemia and pancreatitis. The dosage regimens used in this series were dissimilar.

CONCLUSIONS

There is an increasing interest in use of intravenous lipid emulsions to treat life-threatening toxicity from several lipophilic drugs in adults and children. Although most of the literature describes adult cases, intravenous lipid emulsion has been used in neonates and adolescents, with generally positive outcomes. Given the life-threatening, sometimes near-death situations in which an intravenous lipid emulsion is typically used after conventional resuscitation is unsuccessful and the dramatic positive response to this therapy in most published cases, its use likely will continue. Continued reporting of pediatric cases will guide the optimal use and safety profile of intravenous lipid emulsion for the emergent reversal of drug toxicity.