From the Guidelines
The best practice for managing SMOF lipid line changes in NICU patients is to administer a daily dose of 2.8-3.5 mg/kg/day of vitamin E, with a maximum dose of 11 mg/day, to minimize oxidation risk and prevent complications such as bronchopulmonary dysplasia and retinopathy of prematurity. This recommendation is based on the strongest and most recent evidence from the ESPGHAN/ESPE/NESP/CSPEN guidelines on pediatric parenteral nutrition: vitamins 1. The guidelines suggest that vitamin E is a powerful biological antioxidant that protects the integrity of biologic membranes by inhibiting lipid peroxidation, and that the administration of a daily dose of 2.8-3.5 mg/kg/day is adequate to maintain the normal range of serum vitamin E in premature infants receiving parenteral nutrition (PN).
Some key points to consider when managing SMOF lipid line changes in NICU patients include:
- The use of new-generation lipid emulsions that contain a mixture of pure olive oil, pure fish oil, or various blends of soy, olive, medium-chain triglycerides, and fish oil, which provide a good source of PUFAs, energy, MUFAs, and n-3, and contain high levels of vitamin E 1.
- The administration of vitamin E simultaneously with fat emulsions or the use of a vitamin E ester to prevent absorption onto tubing materials 1.
- The protection of the infusion devices for PN from light, although vitamin E is little affected by exposure to light 1.
- The use of a dedicated lumen of a central venous catheter to prevent incompatibility issues with other medications.
- The consistent infusion rate, avoiding rapid changes that could cause lipid intolerance.
It is also important to note that the amount and types of vitamin E homologues in various lipid emulsions can vary considerably, especially with respect to the α-isoform, and that the use of combined vitamin supplements can result in administration of amounts that are twice those recommended 1. Therefore, it is essential to carefully monitor the vitamin E status of premature infants receiving PN and adjust the dose accordingly. Additionally, the ESPEN guidelines on parenteral nutrition: intensive care suggest that olive oil-based parenteral nutrition is well tolerated in critically ill patients, and that mixed lipid emulsions including fish oil can improve the pharmacological profile of such mixtures 1.
From the Research
Best Practices for SMOF Lipid Line Changes in NICU
- The best practice for managing SMOF lipid line changes in NICU patients involves using a new-generation lipid emulsion, such as SMOFlipid, which has been shown to decrease oxidative damage and oxidative-stress-associated morbidity compared to olive oil-based emulsions 2.
- SMOFlipid has been found to have a higher total antioxidant capacity (TAC) compared to olive oil-based lipid emulsions, which can help minimize oxidation risk 2.
- The use of SMOFlipid has also been associated with a lower incidence of parenteral nutrition-associated cholestasis (PNAC) and lower peak direct bilirubin levels in preterm infants 3.
Oxidation Risk Management
- Vitamin E plays an important role in inhibiting unregulated lipid peroxidation and can help minimize oxidation risk 4.
- The antioxidant effects of vitamin E depend on the nature of both oxidants and substrates being oxidized, and it is essential to appreciate this when managing oxidation risk 4.
- SMOFlipid has been found to be hepatoprotective in preterm neonates receiving long-term total parenteral nutrition (TPN), which can help reduce the risk of oxidation-related complications 3.
Clinical Outcomes
- The use of SMOFlipid has been associated with improved biochemical parameters and delayed progression of parenteral nutrition-associated liver disease (PNALD) 5.
- However, the effect of SMOFlipid on clinically relevant neonatal outcomes, such as mortality and rates of severe neonatal morbidities, is still being evaluated, and long-term effects need to be further studied 5.
- SMOFlipid appears to be well tolerated in preterm infants with minimal side effects, and some growth benefits have been observed 5.