Fat Emulsion (Fish Oil and Plant Based)

(fat e MUL shun fish oyl & plant baste)

• Intravenous Fat Emulsion (Fish-Oil Based)
• Lipid Emulsion (Fish Oil Based)

Caloric/fatty acid source: Source of calories, essential fatty acids, and omega-3 fatty acids for adults requiring parenteral nutrition.

Serious hemodynamic or other instability secondary to highly lipid soluble substances

Data from a limited number of patients studied and case reports suggest that IV fat emulsion may be beneficial for the treatment of serious hemodynamic or other instability not responsive to standard resuscitation measures (eg, fluids, vasopressors, inotropes) secondary to highly lipid soluble substances including, but not limited to: lipophilic local anesthetics, beta-blockers, calcium channel blockers, tricyclic antidepressants, cocaine, benzonatate, bupropion, lamotrigine, quetiapine, and venlafaxine [Arora 2013], [Carr 2009a], [Carr 2009b], [Castanares-Zapatero 2012], [Cohen 2011], [Dagtekin 2011], [Dix 2011], [Finn 2009], [Foxall 2007], [Franxman 2011], [French 2011], [Geib 2012], [Hillyard 2010], [ Jakkala-Saibaba 2011], [Jovic-Stosic 2011], [Kundu 2013], [ Liang 2011], [Litz 2006], [ Lu 2009], [Montiel 2011], [Oakes 2009], [Rosenblatt 2006], [Sirianni 2008], [Weinberg 2009], [Young 2009]. Additional data may be necessary to further define the role of intravenous fat emulsion in this setting.

Based on the American College of Medical Toxicology (ACMT) Position Statement: Guidance for the Use of Intravenous Lipid Emulsion, the American Society of Regional Anesthesia and Pain Medicine (ASRA), and the American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, IV fat emulsion given for hemodynamic or other instability secondary to local anesthetics and other highly lipid soluble substances may be considered when the patient does not respond to standard resuscitation measures (eg, fluids, vasopressors, inotropes) [ACMT 2016], [Lavonas [AHA] 2016], [Neal [ASRA] 2012]. Additional information is available at http://www.lipidrescue.org.

Hypersensitivity to fish, egg, soybean, or peanut protein or any other component of the formulation; severe hyperlipidemia or severe disorders of lipid metabolism characterized by hypertriglyceridemia (serum triglyceride concentrations >1,000 mg/dL)

Canadian labeling: Additional contraindications (not in US labeling): Severe hepatic insufficiency; severe blood coagulation disorders; severe renal insufficiency without access to hemofiltration or dialysis; acute shock; acute pulmonary edema; hyperhydration; decompensated cardiac insufficiency; unstable conditions (eg, severe post-traumatic conditions, uncompensated diabetes mellitus, acute MI, CVA, embolism, metabolic acidosis, severe sepsis, hypotonic dehydration)

Administer by IV infusion via peripheral line or central venous infusion using DEHP-free administration sets and lines. Initial rate of infusion should be 0.5 mL/minute for the first 15 to 30 minutes; gradually increase until reaching the required rate after 30 minutes as tolerated. Do not exceed a rate of 0.5 mL/kg/hour. May be simultaneously infused with amino acid dextrose mixtures by means of Y-connector located near infusion site (flow rates of each solution should be controlled separately by infusion pumps). When administered with dextrose and amino acids, the choice of a central or peripheral infusion depends on the osmolarity of the final infusate (osmolarity ≥900 mOsm/L must be infused through a central vein). All fat emulsion infusions should be filtered whether part of an admixture or infused separately using a 1.2-micron in-line filter only (ISMP 2016). To prevent air embolism, use a nonvented infusion set or close the vent on a vented set, avoid multiple connections, do not connect flexible bags in series, fully evacuate residual gas in the bag prior to administration, do not pressurize the flexible bag to increase flow rates, and if administration is controlled by a pumping device, turn off pump before the bag runs dry.

Serious hemodynamic or other instability secondary to highly lipid soluble substances (off-label use): Administer initial bolus over 1 to 3 minutes followed by a continuous infusion. Chest compressions should continue during administration if patient is in cardiac arrest. Some experts recommend a decreased infusion rate in patients who respond favorably to the initial bolus and infusion (ACMT 2016); repeat bolus or an increase in the infusion rate may be considered if instability persists or recurs. (ACMT 2016; Lavonas [AHA] 2015; Neal [ASRA] 2012).

Caloric content: 2 kcal/mL

Phosphorus: 15 mmol/L

Fat emulsion should not exceed 60% of the total daily calories.

Store at 20°C to 25°C (68°F to 77°F). Store in overpouch until ready for use; once removed from overpouch, use immediately. If not used immediately, the manufacturer suggests storing at 2°C to 8°C (35.6°F to 46.4°F) for no longer than 24 hours; after removal from refrigeration, the emulsion should be infused within 24 hours. Do not freeze. Avoid excessive heat.

1% to 10%:

Cardiovascular: Hypertension (3%), tachycardia (≤1%), thrombophlebitis (≤1%)

Central nervous system: Dizziness (≤1%), headache (≤1%)

Dermatologic: Pruritus (≤1%), skin rash (≤1%)

Endocrine & metabolic: Hyperglycemia (5%), increased serum triglycerides (3%), increased gamma-glutamyl transferase (≤1%)

Gastrointestinal: Nausea (9%), vomiting (7%), abdominal pain (4%), flatulence (4%), dyspepsia (2%), cholestasis (≤1%), diarrhea (≤1%), dysgeusia (≤1%)

Genitourinary: Urinary tract infection (2%)

Hematologic & oncologic: Anemia (2%), C-reactive protein increased (≤1%), leukocytosis (≤1%)

Hepatic: Abnormal hepatic function tests (≤1%), increased serum alkaline phosphatase (≤1%)

Local: Catheter infection (2%), sepsis (2%)

Respiratory: Dyspnea (≤1%), pneumonia (≤1%)

Miscellaneous: Fever (4%)

<1% (Limited to important or life-threatening): Infection