Impact of Lipid Emulsions in Parenteral Nutrition

Presented by: Todd W. Canada, PharmD, BCNSP, FASHP, FTSHP

The highly informative lecture was started by asking the question, What are lipids and are they
important? The necessity of essential fatty acids (EFAs) were identified along with the
symptoms of EFA deficiency, such as impaired growth, skin lesions, steatosis, renal toxicity, and
pulmonary abnormalities. Of note2-4% of total calories must come from EFAs or 4g-8g EFAs
based on 2000 kcal/day are required to prevent EFAD).

In regards to EFA, notable variances between n-3 and n-6 immunological effects were identified.
EPA derived from n-3 produces prostaglandins 3, and leukotrienes 5, while n-6 produces
prostaglandins 2 and leukotrienes 4. Omega-3 is known to be less pro-inflammatory, while n-6 is
more pro-inflammatory. To recall the inflammatory effects, Todd left us with the following
clever catch-phrase: Two and four leaves you on the floor, three and five, you stay alive.

Next, immunoregulation of varying intravenous lipid emulsions (IVLE) were reviewed from a
study by Grimm et al.1 comparing the effect of various lipids on the number of days a rat heart
graft survived. The study compared soybean, safflower, fish, and safflower/fish oil to a saline
control. Results indicated that safflower oil alone is most immunosuppressive, with fish oil a
close second. However, when safflower and fish oil are combined, the effect was lesser than that
of the saline control.

In regards to administering IVLEs, a continuous IVLE infusion (0.05 g/kg/hr) can prevent
impaired RES (reticuloendothelial system) function associated with bolus infusion (0.13
g/kg/hr). In relation to ARDS (acute respiratory distress syndrome), infusing lipids at a high rate
can lead to impaired oxygenation, indicating that slow, long infusions are preferred.

The connection between PN Associated Liver Disease and IVLE were also discussed, noting that
a reduction in IVLE results in a reduction in both serum phytosterols and bilirubin. Also,
changing from an IVLE high in phytosterols to one low in phytosterols is associated with
improved PN-Associated Liver Disease.

In summary, lipids are essential to the human diet and can be particularly influential in critically
ill patients with malnutrition. The biological effects of fatty acids are dose dependent and
guidelines and systematic reviews recommend limiting n-6 saturated and unsaturated fatty acids.
It should be noted that commercial IVLE products vary in fatty acid composition, and high
phytosterol content may be a risk in developing PN-associated liver disease.

1. Grimm H, et al. Immunoregulation by parenteral lipids: impact of the n-3 to n-6 fatty acid
ratio. JPEN J Parenter Enteral Nutr 1994;18:417-21.