Can Interlipids (intravenous lipids) be given as temporary nutritional support in severely malnourished hospital patients?

Intravenous Lipids for Temporary Nutritional Support in Severely Malnourished Hospitalized Patients

Intravenous lipid emulsions can be safely administered as part of temporary nutritional support in severely malnourished hospitalized patients when oral or enteral nutrition is insufficient or not possible. 1, 2

Assessment of Nutritional Status and Need for Support

• Every hospitalized patient staying more than 48 hours should be screened for malnutrition, with particular attention to those with visible weight loss, reduced lean body mass, or multiple comorbidities 3
• Diagnosis of malnutrition requires at least one phenotypic criterion (non-volitional weight loss, low BMI, reduced muscle mass) and one etiological criterion (reduced food intake or disease burden/inflammation) according to the Global Leadership Initiative on Malnutrition (GLIM) criteria 3
• Artificial nutrition support is needed when oral intake is absent or likely to be absent for a period of 5–7 days, with earlier implementation needed in already malnourished patients 1

Nutritional Support Algorithm

1. First-line approach: Oral diet with nutritional supplements if the patient can safely consume food orally 3, 4
2. Second-line approach: Enteral tube feeding if oral intake is inadequate and the gastrointestinal tract is functioning 1, 4
3. Third-line approach: Parenteral nutrition (including lipids) when enteral routes are insufficient or contraindicated 1, 4

Administration of Intravenous Lipids

• Peripheral administration of lipids is appropriate and safe for short-term nutritional support in severely malnourished patients when expected duration is less than 10-14 days 2
• Lipid emulsions can be safely administered through peripheral veins, providing a concentrated energy source while preventing essential fatty acid deficiency 2, 5
• 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 1, 2

Dosing and Monitoring

• For peripheral PN, regimens can incorporate 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 2
• Close monitoring of plasma triglycerides is essential, with adjustment of lipid infusion rate if necessary 1, 2
• In patients with sepsis, more frequent monitoring of plasma triglyceride concentration and dose adjustment in case of hyperlipidemia are recommended 1

Special Considerations

• Parenteral amino acids, glucose, and lipid infusion do not affect pancreatic secretion and function, making them safe in patients with pancreatic disorders 1
• In critically ill patients, intravenous lipid emulsion should be an integral part of parenteral nutrition, with composite lipid emulsions with or without fish oil as the first choice 1
• Physical activity should be encouraged alongside nutritional support as it is necessary for significant muscle gain when receiving parenteral nutrition 2

Potential Pitfalls and Complications

• Overfeeding should be avoided when administering parenteral nutrition, as it may contribute to infectious complications 4
• Refeeding syndrome is a risk in severely malnourished patients; phosphate, potassium, and magnesium levels should be normalized before starting PN 2
• Phlebitis at peripheral vein infusion sites may occur but can be minimized by keeping osmolarity below 850-900 mOsm/l and changing infusion sites every 24-48 hours 2, 5
• Concerns about adverse effects of intravenous lipids on pulmonary function exist, particularly in patients with respiratory failure 1

Evidence of Effectiveness

• Positive nitrogen balance can be maintained in patients receiving intravenous lipid-based nutrition, with improvement in other nutritional parameters 5
• Severely malnourished patients have increased median length of hospital stay and increased rate of postoperative complications, highlighting the importance of adequate nutritional support 6
• An Intralipid-based intravenous feeding mixture has been shown to be safe, relatively simple to use, and effective for patients with serious gastrointestinal disease requiring parenteral nutritional support 5

By following this approach to intravenous lipid administration in severely malnourished hospitalized patients, clinicians can provide effective temporary nutritional support while minimizing complications and improving patient outcomes.