Is administration of lipids (intravenous fat emulsions) through a peripheral intravenous (IV) line considered standard of care in 2025 for severely malnourished hospitalized patients?

Administration of Lipids Through Peripheral IV in Severely Malnourished Hospitalized Patients

Peripheral administration of lipids is an appropriate and safe approach for short-term nutritional support in severely malnourished hospitalized patients, and can be considered standard of care when the expected duration of parenteral nutrition is less than 10-14 days. 1

Rationale for Peripheral Lipid Administration

• Lipid emulsions can be safely administered through peripheral veins and provide a concentrated energy source while helping prevent essential fatty acid deficiency in malnourished patients 2
• An increase in energy intake can be achieved in the short-term by administration of lipids using peripheral venous access, making it a valuable option for severely malnourished patients 1
• Peripheral parenteral nutrition (PPN) allows early infusion of nutritional substrates during acute illness without the need to insert a central venous catheter, reducing procedural risks 1

Clinical Parameters for Peripheral Lipid Administration

• Peripheral PN can cover nutrition needs in malnourished patients with regimens incorporating up to 1700 kcal, 60 g of amino acids, 60-80 g of lipids, and 150-180 g of carbohydrates per day in a typical volume of 2400 ml 1
• The osmolarity of peripheral parenteral nutrition should not exceed 850-900 mOsm/l to minimize phlebitis risk 1
• Using very fine bore silicon or polyurethane catheters and infusion pump-controlled continuous administration, peripheral nutrition can be tolerated up to 1000 mOsm/l 1
• The "osmolarity rate" (number of milliosmols infused per hour) correlates well with phlebitis risk and should be limited when using peripheral administration 3

Duration Considerations

• The peripheral route should be limited to those with an anticipated duration of feeding of no more than 10-14 days 1
• If the expected PN period is between 4-7 days, nutrition can be hypocaloric with 2 g carbohydrate and 1 g amino acids/kg body weight administered via a peripheral catheter 1
• For PN expected to last more than 7-10 days, a central venous catheter should be inserted 1

Monitoring and Safety Considerations

• Close monitoring of plasma triglycerides is essential in malnourished patients, with adjustment of lipid infusion rate if necessary 2
• Triglyceride values should be kept below 12 mmol/L (approximately 1,000 mg/dL) to prevent fat overload syndrome 2
• Phosphate, potassium, and magnesium levels should be normalized before starting PN, especially in malnourished patients, to prevent refeeding syndrome 4
• In patients with alcoholic liver disease, vitamin B1 (thiamine) must be administered prior to starting glucose infusion to reduce the risk of Wernicke's encephalopathy 4

Lipid Emulsion Selection

• Use lipid emulsions with a content of n-6 unsaturated fatty acids lower than in traditional pure soybean oil emulsions 1
• Composite lipid emulsions containing fish oil may have less pro-inflammatory effects and more antioxidant effects than pure soybean oil emulsions, potentially benefiting critically ill malnourished patients 2, 5
• For patients requiring long-term parenteral nutrition, consider using mixed LCT/MCT (long-chain/medium-chain triglyceride) formulations 2

Practical Implementation

• For administration of parenteral nutrition, an all-in-one (three-chamber bag or pharmacy prepared) should be preferred instead of a multibottle system 1
• Standardized operating procedures (SOP) for nutritional support are recommended to secure effective nutritional support therapy 1
• The use of peripherally inserted catheters for peripheral (midline catheters) PN might help in controlling the incidence of infectious or thrombotic complications 1

Special Considerations for Severely Malnourished Patients

• Start PN immediately in moderately or severely malnourished patients who cannot be fed sufficiently either orally or enterally 1
• In malnourished patients, physical activity is a necessary condition for significant muscle gain when receiving parenteral nutrition 1
• Regular blood glucose monitoring is essential to avoid PN-related hyperglycemia, with glucose infusion rates reduced to 2-3 g/kg/d in case of hyperglycemia 1, 4