Hyperlipidemia

Patients receiving IV lipid emulsion may be at risk for hyperlipidemia and hyper-triglyceridemia. Hyperglycemia can lead to hypertriglyceridemia and is the most common cause of hypertriglyceridemia in patients receiving PN. Hyperlipidemia in patients receiving PN may lead to a reduction in pulmonary gas diffusion and pulmonary vascular resistance (especially in patients with underlying pulmonary and vascular disease).36 Severe hypertriglyceridemia (especially when serum triglyceride con-

centrations exceed 1,000 mg/dL or 11.3 mmol/L) can precipitate acute pancreatitis.

Hypertriglyceridemia may develop as a result of increased fatty acid synthesis due to hyperglycemia or impaired lipid clearance or in patients with history of hyperlip-

idemia, obesity, diabetes, alcoholism, kidney failure, liver failure, multiorgan failure, sepsis, pancreatitis, or as a result of medications (e.g., propofol, corticosteroids, cyc-

losporine, and sirolimus). Propofol is formulated in a 10% lipid emulsion (which is not cleared as effectively as the 20% or 30% lipid emulsions) and may lead to hyper-triglyceridemia. It also has been proposed that propofol could have direct effects on lipid metabolism, given that hypertriglyceridemia associated with propofol infusion has been observed with lipid doses that are lower than those typically given in PN.38,39

A higher PL:TG ratio in the 10% lipid emulsion has been proposed to cause the appearance of the abnormal lipoprotein X particles (rich in phospholipids [approximately 60%] and cholesterol [approximately 25%], small amounts of triglycerides) 8,38

in the blood. Lipoprotein X may compete with lipid particles for metabolism by lipoprotein lipase. Therefore, IV lipid emulsions with a lower PL:TG ratio (i.e., 20% or 30% lipid emulsions) have improved clearance compared with emulsions with a higher PL:TG ratio (i.e., 10% lipid emulsion)8,38 and should preferentially be used, especially in patients with hypertriglyceridemia. Lipid clearance may be improved by newer formulations of mixed medium-and long-chain triglycerides; however, these products are not yet approved for use in the United States.

Monitor serum triglyceride concentrations regularly during PN therapy (e.g., at the initiation of PN, then once or twice per week initially, and thereafter depending on clinical condition). If a patient develops hypertriglyceridemia, identify and correct the underlying cause(s) if possible (e.g., treatment of hyperglycemia or reduction of dextrose and/or lipid dose). Prolonging the infusion of IV lipid emulsion (e.g., over 24 hours) may improve clearance; however, this may require hanging two containers daily because each container of lipid emulsion should infuse for only 12 hours based on USP 797 and infection-control policies and practices. If a patient is receiving propofol, take into account the calories administered from the 10% lipid emulsion in propofol (1.1 kcal/mL or 4.6 kJ/mL). For safety reasons, IV lipid emulsion should be withheld in patients receiving propofol. It also should be held when the serum is lipemic or when serum triglyceride concentrations are greater than 400 mg/dL (4.5 mmol/L). When this occurs, restart IV lipid emulsions when the serum triglyceride concentration is approximately 200 to 400 mg/dL (2.3-4.5 mmol/L) (or less), and administer IV lipids only two to three times per week to prevent essential fatty acid deficiency.

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