Are intravenous (IV) infusions of lipids contraindicated in patients with infection?

IV Lipid Infusions in Patients with Infection

IV lipid infusions are not contraindicated in patients with infection, but require close monitoring of triglyceride levels and potential adjustment of infusion rates. 1

Rationale for Using IV Lipids During Infection

• IV lipids are an integral part of parenteral nutrition (PN) regimens, providing essential fatty acids and energy while allowing lower carbohydrate provision, which facilitates better glucose control 1
• When infused at appropriate rates (1-2 g/kg/day), lipid emulsions are generally safe and well-tolerated even during critical illness 1
• Lipids are important in critically ill patients with infection as they provide a concentrated energy source and help prevent essential fatty acid deficiency 1
• In critically ill patients, lipid metabolism and turnover are increased as fatty acids are used as a primary fuel source 1

Monitoring Recommendations

• In patients with infection or sepsis, close monitoring of plasma triglycerides is essential, with adjustment of lipid infusion rate if necessary 1
• Triglyceride values should be kept below 12 mmol/L (approximately 1,000 mg/dL), but ideally within normal ranges 1
• During acute infection, lipid clearance may be reduced due to decreased activity of lipoprotein lipase 1
• Monitor for signs of fat overload syndrome, which can include thrombocytopenia, leukopenia, coagulopathy, hepatosplenomegaly, and respiratory distress 1

Lipid Emulsion Selection

• Alternative lipid emulsions with lower soybean oil content may be preferable to traditional soybean oil-based emulsions in critically ill patients 2
• Composite lipid emulsions containing fish oil may have less pro-inflammatory effects and more antioxidant effects than pure soybean oil emulsions 1
• Fish oil-containing emulsions may attenuate the hyperinflammatory state in severe sepsis and acute lung injury 1
• Olive oil and fish oil intravenous lipid emulsions have been reported to reduce the incidence of infections compared to traditional formulations 2

Potential Concerns and Precautions

• If severe unexplained thrombocytopenia occurs, consider monitoring serum triglyceride concentrations and potentially reducing parenteral lipid dosage 1
• In patients with acute respiratory failure, it might be prudent to limit lipid intake during the acute phase, especially when using pure soybean oil emulsions 1
• If persistent hypertriglyceridemia (>12 mmol/L for >72 hours) occurs, temporarily discontinue lipid infusion 1
• A meta-analysis suggested that lipid emulsions might be associated with higher complication rates, but the evidence for a detrimental effect is not strong 1

Special Considerations

• In patients with hypertriglyceridemia-induced pancreatitis, lipid-containing parenteral nutrition should be avoided during acute management 3
• For patients requiring long-term parenteral nutrition who develop infection, consider using mixed LCT/MCT (long-chain/medium-chain triglyceride) formulations, which may have fewer immunosuppressive effects than pure LCT emulsions 1

In conclusion, while IV lipid infusions require careful monitoring in patients with infection, they remain an important component of parenteral nutrition and are not contraindicated. The key is appropriate dosing, monitoring of triglyceride levels, and consideration of alternative lipid emulsion formulations that may have more favorable immunological profiles.