Clinical Effects of Inadvertent Increased Lipid Infusion in Neonates: Two Case Reports.
Journal
Advances in neonatal care : official journal of the National Association of Neonatal Nurses
ISSN: 1536-0911
Titre abrégé: Adv Neonatal Care
Pays: United States
ID NLM: 101125644
Informations de publication
Date de publication:
01 Feb 2023
01 Feb 2023
Historique:
pubmed:
9
4
2022
medline:
31
1
2023
entrez:
8
4
2022
Statut:
ppublish
Résumé
Utility of total parenteral nutrition (TPN) with an intravenous lipid emulsion (IVLE) component is common in the neonatal intensive care unit; however, there are inherent risks to TPN use. With IVLE administered separate from other TPN components, opportunities exist for additional error and subsequent potential harm. We present 2 cases in term infants where IVLE infusions were noted to be inadvertently administered at higher than prescribed rates, prompting concern for lipemia and end-organ damage due to hyperviscosity. Both infants developed iatrogenic hypertriglyceridemia and hyponatremia. Upon recognition of the error, IVLE was immediately discontinued in each case. Triglyceride levels were serially monitored until they reached a normal level. Electrolyte panels and hepatic function panels were also drawn to assess for electrolyte derangements and function. Radiologic studies were performed for evaluation of end-organ effects of hyperviscosity. Triglyceride levels for both infants normalized within 7 hours. Both infants survived to discharge without any known effects related to the inadvertent excessive lipid infusion. It is helpful to perform a root-cause analysis for these types of events; have the exact amount of lipids in the bag needed and no overfill; consider having lipids in 4-hour dosage aliquots; require 2 nurses to verify infusion rates hourly; and educational sessions and unit protocols for any infusion may reduce the risk of administration error.
Sections du résumé
BACKGROUND
BACKGROUND
Utility of total parenteral nutrition (TPN) with an intravenous lipid emulsion (IVLE) component is common in the neonatal intensive care unit; however, there are inherent risks to TPN use. With IVLE administered separate from other TPN components, opportunities exist for additional error and subsequent potential harm.
CLINICAL FINDINGS
RESULTS
We present 2 cases in term infants where IVLE infusions were noted to be inadvertently administered at higher than prescribed rates, prompting concern for lipemia and end-organ damage due to hyperviscosity.
PRIMARY DIAGNOSIS
UNASSIGNED
Both infants developed iatrogenic hypertriglyceridemia and hyponatremia.
INTERVENTION
METHODS
Upon recognition of the error, IVLE was immediately discontinued in each case. Triglyceride levels were serially monitored until they reached a normal level. Electrolyte panels and hepatic function panels were also drawn to assess for electrolyte derangements and function. Radiologic studies were performed for evaluation of end-organ effects of hyperviscosity.
OUTCOMES
RESULTS
Triglyceride levels for both infants normalized within 7 hours. Both infants survived to discharge without any known effects related to the inadvertent excessive lipid infusion.
CONCLUSION
CONCLUSIONS
It is helpful to perform a root-cause analysis for these types of events; have the exact amount of lipids in the bag needed and no overfill; consider having lipids in 4-hour dosage aliquots; require 2 nurses to verify infusion rates hourly; and educational sessions and unit protocols for any infusion may reduce the risk of administration error.
Identifiants
pubmed: 35394955
doi: 10.1097/ANC.0000000000000986
pii: 00149525-202302000-00005
doi:
Substances chimiques
Fat Emulsions, Intravenous
0
Lipids
0
Triglycerides
0
Types de publication
Case Reports
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
23-30Informations de copyright
Copyright © 2022 by The National Association of Neonatal Nurses.
Déclaration de conflit d'intérêts
The authors declare no conflicts of interest.
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