From the Guidelines
The best practice for managing SMOF lipid line changes in NICU patients is to change the administration set every 24 hours and ensure the daily dose of vitamin E does not exceed 11 mg/day, to minimize oxidation risk and optimize patient outcomes. When managing SMOF lipid line changes, it is crucial to consider the susceptibility of lipid emulsions to peroxidation when exposed to light, oxygen, and ambient temperature conditions 1. The administration of SMOF lipid emulsions should be through dedicated lines using non-DEHP tubing with light-protective covering to reduce the risk of oxidation and microbial growth. Key considerations include:
- The entire administration set, including the filter, should be replaced daily rather than every 48-72 hours as might be done with other IV fluids.
- Lipid emulsions should be infused at a consistent rate over 24 hours rather than cycled to maintain stable nutritional delivery and minimize metabolic fluctuations in these sensitive patients.
- The daily dose of vitamin E should be between 2.8 and 3.5 mg/kg/day for preterm infants, but should not exceed 11 mg/day, as high levels of vitamin E can increase the risk of sepsis and necrotizing enterocolitis 1.
- The use of new-generation lipid emulsions containing a mixture of soybean oil, olive oil, medium-chain triglycerides, and fish oil can provide a good source of PUFAs, energy, and vitamin E, and may help to reduce the risk of oxidation and improve patient outcomes 1. It is essential to monitor the patient's vitamin E status and adjust the dose accordingly to prevent deficiency or excess, as the current data suggests that a higher amount of a-tocopherol through PN than previously recommended could be given in infants and children below 11 years, with no harmful effects, but with preservation of liver function and better vitamin E status 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 is to use a mixed-oil emulsion, such as SMOFlipid, which contains a mixture of soybean oil, medium-chain triglycerides, olive oil, and fish oil 2, 3.
- This type of emulsion has been shown to reduce the risk of parenteral nutrition-associated cholestasis (PNAC) in neonates 4.
- SMOFlipid has also been found to be safe and well-tolerated in premature infants, with a potential beneficial influence on cholestasis, n-3 fatty acid, and vitamin E status 3.
Oxidation Risk
- The use of SMOFlipid has been shown to reduce oxidative stress by reducing lipid peroxidation levels in high-risk preterm neonates 2.
- The emulsion's antioxidant properties, such as its high content of vitamin E, may help to minimize oxidation risk 3, 5.
- Olive oil-based lipid emulsions, such as those used in SMOFlipid, have been found to preserve immune, hepatobiliary, and endothelial cell function, and may reduce lipid peroxidation and plasma lipid levels 6.
Lipid Emulsion Management
- The lipid emulsion should be administered according to the manufacturer's instructions and the patient's individual needs 3, 5.
- Monitoring of liver function tests, such as γ-glutamyl transferase, and other laboratory parameters is recommended to assess the safety and efficacy of the lipid emulsion 3, 5.
- The use of SMOFlipid may be beneficial in preventing PNAC in NICU patients who are receiving parenteral nutrition for ≥2 weeks 4.