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Use of intravenous lipid and hyperbilirubinemia in the first week
D H Adamkin1, P G Radmacher, R L Klingbeil
1Department of Pediatrics, University of Louisville, School of Medicine, KY 40292.
Insights
This study found that initiating intravenous lipid emulsions on day 4 in neonates is generally well-tolerated, with stable bilirubin levels. However, monitoring for lipemia is crucial due to unpredictable patient tolerance to lipid infusions.
Area of Science:
- Neonatal Nutrition
- Clinical Chemistry
- Pediatric Gastroenterology
Background:
- Neonates often require nutritional support via total parenteral nutrition (TPN).
- Lipid emulsions are a critical component of TPN, providing essential fatty acids and calories.
- Assessing lipid tolerance and potential side effects like hyperbilirubinemia in neonates is vital for safe TPN management.
Purpose of the Study:
- To evaluate the tolerance of a 50/50 soybean-safflower lipid emulsion in neonates.
- To assess the impact of initiating intravenous lipids on serum triglycerides, free fatty acids, and unconjugated bilirubin levels.
- To determine the safety of a TPN protocol that starts lipid infusion on postnatal day 4.
Main Methods:
- Serum levels of triglycerides, free fatty acids, unconjugated bilirubin, and albumin were measured in 40 neonates.
- Lipid emulsion was infused at dosages ranging from 0.5-3.5 g/kg/day over 18 hours.
- Data were analyzed comparing very-low-birth-weight neonates with those weighing over 1,500 g.
Main Results:
- Mean serum triglycerides and free fatty acids remained within pre-infusion ranges across all dosages.
- The mean free fatty acid to albumin molar ratio was consistently below 1.0, with no individual exceeding 3.0.
- Peak serum unconjugated bilirubin stabilized or decreased during lipid-inclusive TPN, and no significant differences were observed between weight groups.
Conclusions:
- Initiating intravenous lipid infusion on the 4th postnatal day at 0.5 g/kg/day, with gradual increases, is generally well-tolerated in neonates.
- Despite overall tolerance, a small percentage of neonates exhibited elevated triglyceride levels (>200 mg/dl), highlighting inter-individual variability.
- Continuous monitoring for lipemia is recommended due to the unpredictable nature of lipid tolerance in individual neonates.
Abstract:
Serum triglycerides, free fatty acids, unconjugated bilirubin, and albumin were evaluated in 40 neonates receiving 0.5-3.5 g/kg/day of a 50/50 soybean-safflower lipid emulsion infused during 18 h. The purpose of the study was to evaluate lipid tolerance and unconjugated hyperbilirubinemia according to our total parenteral nutrition protocol, which initiates lipid on postnatal day 4. Mean serum triglycerides and free fatty acids were within the range of prelipid infusion values at all dosages, and no statistically significant differences were noted between very-low-birth-weight neonates and those greater than 1,500 g birth weight. Mean free fatty acid:albumin molar ratio was less than 1.0 at all dosages and no individual patient values exceeded a ratio of 3.0. Mean peak serum unconjugated bilirubin of 5.8 mg/dl on postnatal day 3 was stable or fell the next 10 days of lipid-inclusive total parenteral nutrition. Initiating intravenous lipid on the 4th postnatal day at 0.5 g/kg/day and increasing at 0.5 g/kg/day increments at the end of the 1st postnatal week appears to be tolerated well. However, 5% of serum triglyceride levels exceeded 200 mg/dl. Therefore, in view of the unpredictability of a given patient's tolerance to lipid infusion, there should be monitoring for lipemia.