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Change to Mixed-Lipid Emulsion From Soybean Oil-Based Lipid Emulsion in Pediatric Patients
Krista L Haines1,2, Tetsu Ohnuma2,3, Chi Dang Hornik4
1Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
Insights
Switching to a mixed lipid emulsion (4-OLE) in critically ill pediatric patients significantly reduced hospital length of stay and urinary tract infection risk. This soy-lean strategy is safe and effective for pediatric parenteral nutrition.
Area of Science:
- Pediatric critical care medicine
- Nutritional support
- Pharmacology of lipid emulsions
Background:
- Critically ill children often require parenteral nutrition (PN).
- Mixed lipid emulsions (LE) may offer improved outcomes compared to traditional soybean oil-based LE.
- Soybean oil reduction strategies are being explored in pediatric PN.
Purpose of the Study:
- To investigate the association between a hospital-wide transition to a mixed lipid emulsion (4-OLE) and clinical outcomes in pediatric patients receiving PN.
- To compare outcomes before and after the implementation of 4-OLE.
Main Methods:
- Retrospective cohort study at a US academic referral center.
- Included pediatric patients (1 month to 17 years) requiring PN from May 2016 to September 2019.
- Compared outcomes between patients receiving Intralipid (IL) before the switch and 4-OLE after the switch using multivariable regression.
Main Results:
- The study included 684 children on PN; 478 received 4-OLE and 206 received IL.
- The 4-OLE group showed a significant decrease in hospital length of stay (LOS) for both all children and ICU cohorts.
- A reduced risk of urinary tract infections (UTIs) was observed in the 4-OLE group compared to the IL group.
Conclusions:
- Switching to a 4-OLE formula in pediatric PN patients was associated with a significant reduction in hospital LOS.
- The findings suggest that adopting a soy-lean strategy with 4-OLE is feasible, safe, and beneficial for pediatric patients requiring PN.
- This approach may lead to improved clinical outcomes in this vulnerable population.
Importance:
Critically ill pediatric patients often require parenteral nutrition (PN) in the intensive care unit (ICU). Literature suggests mixed lipid emulsions (LE) with soybean oil reduction strategies may improve outcomes.
Objective:
To examine the association of a hospital-wide switch to a mixed-lipid formula (4-OLE) with pediatric outcomes.
Design, Setting, And Participants:
Retrospective cohort study at a large US academic referral center. Pediatric patients aged 1 month to 17 years requiring parenteral nutrition from May 2016 to September 2019 were included. Data were analyzed from October 2020 to February 2023.
Exposure:
In 2017, Duke University Health System fully converted to a soybean oil/MCT/olive/fish oil lipid (4-OLE) from pure soybean oil-based LE in pediatric patients. Pediatric patients before the change (Intralipid [IL] group) were compared with patients after (4-OLE group).
Main Outcomes And Measures:
Clinical outcomes were compared between treatment periods via multivariable regression models. The primary outcome was hospital length of stay (LOS). Fourteen secondary outcomes included hospital mortality of any cause, 30-day or 90-day readmission, pneumonia, urinary tract infections (UTIs), total caloric delivery, and liver function tests (aspartate aminotransferase, alanine transaminase, alkaline phosphatase, and total bilirubin).
Results:
A total of 684 children dependent on PN were identified (342 were critically ill), with 30% (206 children) in the preswitch (IL) period and 70% (478 children) in the postswitch (4-OLE) period; 123 were male (59.7%). In comparing IL vs 4-OLE, there was a significant difference in median (IQR) age (4.0 [1.2-13.0] vs 3.0 [0.8-9.0] years, respectively; P = .04), without difference in body mass index or baseline comorbidities except for significant differences in cancer diagnosis (26 patients in the IL group [12.6%] vs 29 patients in the 4-OLE group [6.1%]; P = .004) and chronic obstructive pulmonary disease (24 patients in the IL group [11.7%] vs 30 patients in the 4-OLE group [6.3%]; P = .02). In the all children cohort, 4-OLE was associated with shorter hospital LOS (IRR, 0.81; 95% CI, 0.05-0.78), and reduced UTI risk (OR, 0.33; 95% CI, 0.18-0.64). In the ICU cohort, 4-OLE was associated with shorter hospital LOS (IRR, 0.81; 95% CI, 0.78-0.83), and reduced UTI risk (OR, 0.23; 95% CI, 0.11-0.51). Other secondary outcomes were not significant.
Conclusions And Relevance:
In this observational study of clinical outcomes among children dependent on PN, a switch to 4-OLE in a large academic hospital was associated with a significant decrease in hospital LOS in ICU and non-ICU patients. These findings suggest switching to a soy-LE sparing strategy using 4-OLE is feasible, safe, and associated with improved clinical outcomes in pediatric PN patients.
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