Accidental lipid overdose in a preterm infant: A case report

Area of Science:

• Neonatal Medicine
• Clinical Pharmacy
• Pediatric Nutrition

Background:

• Intravenous lipid emulsions (ILEs) are crucial for providing essential fatty acids during parenteral nutrition (PN).
• Overdose of ILEs can lead to serious adverse events, including mortality.
• Accidental medication errors, such as ILE overdose, pose a significant risk in neonatal care.

Purpose of the Study:

• To report a case of accidental overdose of ILEs in a preterm infant.
• To discuss the clinical outcomes following a significant ILE overdose.
• To emphasize the importance of reporting the full spectrum of outcomes from medication errors in neonates.

Main Methods:

• A 29-week gestational age preterm infant received approximately three times the daily recommended amount of Intralipid 20% over 50 minutes.
• Clinical status and laboratory samples were monitored post-administration.
• Long-term neurodevelopmental outcomes were assessed at 2 years corrected gestational age.

Main Results:

• The infant showed no apparent clinical deterioration despite lipemic blood samples.
• Neurodevelopmental outcomes at 2 years corrected gestational age were comparable to those of the infant's twin.
• Service changes were implemented in infusion packaging and administration protocols to prevent future errors.

Conclusions:

• Medication errors in neonatal care are a common occurrence.
• Reporting only severe outcomes of medication errors can cause undue distress to parents.
• Presenting a full spectrum of outcomes, including cases where harm is avoided, provides valuable lessons for healthcare professionals and families.