What should be done if a dose of intravenous (IV) lipids is missed?

Management of Missed IV Lipid Doses in Parenteral Nutrition

If a dose of intravenous (IV) lipids is missed, it should be administered as soon as possible, ensuring that the daily maximum recommended dose is not exceeded and with appropriate monitoring of triglyceride levels. 1

Rationale for Prompt Administration

Intravenous lipid emulsions (ILEs) are an essential component of parenteral nutrition (PN) for several important reasons:

• They provide an efficient source of calories 1
• They prevent essential fatty acid deficiency 1
• They are integral to balanced nutrition in patients requiring PN 1

Implementation Algorithm for Missed Doses

1. Administer the missed dose as soon as possible

   • This ensures continuity of essential fatty acid provision
   • Prevents nutritional deficits that could impact morbidity and mortality

2. Respect daily maximum dose limits

   • Preterm/term infants: Do not exceed 4 g/kg/day 1
   • Children: Do not exceed 3 g/kg/day 1
   • Adults: Follow standard dosing protocols (typically 0.8-1.5 g/kg/day) 1

3. Adjust administration rate based on patient status

   • For stable patients: Can administer at standard rate
   • For high-risk patients: Consider slower infusion with more frequent monitoring

Monitoring Requirements After Administering Missed Dose

• Check serum triglyceride levels:

  • Within 1-2 days after administering the missed dose 1
  • Target triglyceride levels:
    • Preterm/term infants: <3.0 mmol/L (265 mg/dL) 1
    • Children: <3.4-4.5 mmol/L (300-400 mg/dL) 1

• Increase monitoring frequency in high-risk patients 1, 2:

  • Patients with sepsis
  • Malnourished patients
  • Extremely low birth weight infants
  • Patients receiving high glucose or lipid dosages

Special Considerations

Patients with Sepsis

• Lipid clearance may be reduced due to decreased lipoprotein lipase activity 1
• Continue lipid administration but with more frequent monitoring 1
• Maintain at least minimum essential fatty acid requirements 1

Hyperglycemia

• If hyperglycemia is present, reduce glucose intake first rather than lipid infusion 2
• Excessive glucose can cause lipogenesis and contribute to hypertriglyceridemia 2

Continuous vs. Intermittent Administration

• In newborns including preterm infants: Continuous administration over 24 hours is recommended 1
• For patients on cyclic PN (e.g., home PN): Lipids should be given over the same duration as other PN components 1

Potential Complications to Monitor

• Hypertriglyceridemia (most common)
• Metabolic acidosis (with excessive doses) 3
• Pulmonary function changes (particularly with soybean oil ILEs) 1

By following these guidelines, clinicians can ensure that patients receive appropriate lipid supplementation while minimizing risks associated with missed doses or improper administration.