Lipids in Parenteral Nutrition: Translating Guidelines into Clinical Practice

During the Lipids in Parenteral Nutrition Summit, a group of internationally renowned experts in clinical nutrition, lipid metabolism, and pharmacology from five continents convened to assess the state of knowledge and develop consensus statements for the use of intravenous lipid emulsions (ILEs) in different patient populations and clinical settings. The consensus statements were developed to offer healthcare professionals practical guidance on common questions regarding the provision of ILEs in parenteral nutrition (PN).[i]

The fatty-acid composition of the lipid emulsions affects the inflammatory process

  • Lipids are an integral part of every PN regimen, providing an energy-dense source of calories and essential fatty acids. Topics[ii]
  • Each lipid has its specific fatty acid composition and biologic effects, with pro- or anti-inflammatory, immuno-stimulating or modulating characteristics.2
  • Lipid emulsions which contain omega-3 polyunsaturated fatty acids (PUFAs) derived from fish oil, particularly docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), have anti-inflammatory, immunomodulatory, and antioxidative properties (Fig. 1).2
  • The description of a novel superfamily of lipid mediators, specialized pro-resolving mediators (SPMs), has widened the understanding of the biological pathways of how DHA and EPA resolve inflammation.2

 

Figure 1: The biphasic immuno-inflammatory response to a traumatic insult, characterized by increased generation of inflammatory mediators and then a shift towards an anti-inflammatory immunosuppressed state, may be further worsened by a preponderance of ω-6 fatty acids but improved by the presence of ω-3 fatty acids DHA and EPA. DHA, docosahexaenoic acid; EPA, eicosapentaenoic acid; HLA, human leukocyte antigen; NFκB, nuclear factor κ B.

 

Fish oil containing ILEs may lead to improved clinical outcomes in hospitalized adults

The expert panel states that there is sufficient evidence to recommend the use of ILEs containing omega-3 PUFAs at a dosage of 0.1-0.2 g fish oil/kg/d as part of the ILE both for critically ill as well as in surgical patients.[iii]

The most recent systematic review and meta-analysis from Pradelli et al.Topics[iv] includes 49 randomized controlled trials (RCTs) with intervention and control groups (n=3,641 patients) on omega-3 fatty acid containing vs. standard PN (non-omega-3 fatty acid containing) in adult hospitalized patients.  Investigating clinical efficacy and laboratory parameter outcomes, the authors show:

  • 40% significant reduction in relative risk of infection
  • 2.14 day significant reduction of hospital length of stay
  • 1.95 day significant reduction of ICU length of stay
  • 56% significant reduction in the risk of sepsis
  • Beneficial effects on important laboratory parameters4
  • The use of omega-3 containing PN results in cost savings vs. standard PN[v]

Therefore, omega-3 fatty acid containing PN is associated with statistically and clinically significant advantages on clinical outcomes.

References
  • iMartindale RG, Berlana D, Boullata J et al., Summary of Proceedings and Expert Consensus Statements From the International Summit "Lipids in Parenteral Nutrition". JPEN J Parenter Enteral Nutr. 2020 Feb;44 Suppl 1:S7-S20.
  • iiCalder PC, Waitzberg DL, Klek S et al., Lipids in Parenteral Nutrition: Biological Aspects. JPEN J Parenter Enteral Nutr. 2020 Feb;44 Suppl 1:S21-S27.
  • iiiMayer K, Klek S, Martindale RG, et al. Lipid use in hospitalized adults requiring parenteral nutrition. J Parenter Enteral Nutr. 2020 Feb;44 Suppl 1:S28-S38.
  • ivPradelli L, Mayer K, Klek S, et al. ω-3 Fatty-Acid Enriched Parenteral Nutrition in Hospitalized Patients: Systematic Review With Meta-Analysis and Trial Sequential Analysis. JPEN J Parenter Enteral Nutr. 2020;44(1):44-57.
  • vPradelli L, Mayer K, Klek S et al., Omega-3 fatty-acid enriched parenteral nutrition regimens in hospitalized patients in EU5 countries: a pharmacoeconomic analysis. Clinical Nutrition 2019; 38, Supplement 1, 2019,

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