Fat Emulsion (Plant Based)
Medically reviewed by Drugs.com. Last updated on Sep 14, 2019.
(fat e MUL shun plant baste)
- Intravenous Fat Emulsion
- Lipid Emulsion (Plant Based)
- SOFE (Soybean Oil Based Fat Emulsion)
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Clinolipid: 20% (100 mL, 250 mL, 500 mL, 1000 mL)
Intralipid: 20% (100 mL, 250 mL, 500 mL, 1000 mL); 30% (500 mL) [contains egg yolk phospholipids, glycerin]
Nutrilipid: 20% (250 mL, 500 mL, 1000 mL) [contains egg yolk phospholipids, glycerin]
Brand Names: U.S.
- Caloric Agent
Fat emulsion is metabolized and utilized as an energy source; provides the essential fatty acids, linoleic acid, and alpha linolenic acid necessary for normal structure and function of cell membranes; in local anesthetic toxicity, lipid emulsion probably extracts lipophilic local anesthesia from cardiac muscle
In toxicity secondary to highly lipid soluble substances, exogenous lipids provide an alternative source of binding (Rowlingson 2008), commonly known as the "lipid sink" effect. High lipid partition constant and large volumes of distribution are good predictors of success when using lipid therapy (French 2011). Lipid administration may also affect the heart in a metabolically advantageous way by improving fatty acid transport (Weinberg 2006).
Fatty acids, phospholipids, and glycerol are metabolized by cells to adenosine triphosphate (ATP), carbon dioxide, and water
0.5 to 1 hour
Use: Labeled Indications
Caloric/fatty acid source: Source of calories and essential fatty acids for patients requiring parenteral nutrition for extended periods of time (usually for longer than 5 days) or when oral or enteral nutrition is not possible, insufficient, or contraindicated; to prevent and treat essential fatty acid deficiency (except Nutrilipid).
Off Label Uses
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  2009], [Carr  2009], [Castanares-Zapatero 2012], [Cohen 2009], [Dagtekin 2011], [Dix 2011], [Finn 2009], [Foxall 2007], [Franxman 2011], [French 2011a], [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], [AHA [Lavonas 2016]], [ASRA [Neil 2018]]; in patients with any local anesthetic systemic toxicity event judged to be potentially serious, lipid emulsion should be administered soon after airway management [ASRA [Neil 2018]].
Intralipid 20%, 30%: Disturbances in normal fat metabolism such as pathologic hyperlipemia, lipoid nephrosis, or acute pancreatitis if accompanied by hyperlipidemia; pharmacy bulk package is not intended for direct IV administration
Nutrilipid: Known hypersensitivity to egg or soybean proteins or to any component of the formulation; severe hyperlipidemia (serum triglyceride concentrations above 1,000 mg/dL) or severe disorders of lipid metabolism characterized by hypertriglyceridemia
Canadian labeling: Additional contraindications (not in US labeling): Hypersensitivity to egg, soya or peanut protein or to any component of the formulation; acute shock; severe hyperlipidemia; conditions characterized by severely disordered fat metabolism (eg, severe hepatic impairment, acute MI, hemophagocytotic syndrome, shock)
Note: At the onset of therapy, the patient should be observed for any immediate allergic reactions (eg, dyspnea, cyanosis, and fever).
Caloric source: IV: Note: Fat emulsion should not exceed 60% of the total daily calories.
Initial dose: 1 to 1.5 g/kg/day (not to exceed 500 mL Intralipid 10% or 20% or 330 mL Intralipid 30% [over 4 to 6 hours] on the first day of therapy); daily dose may be infused over 12 to 24 hours; maximum daily dose: 2.5 g/kg/day
Essential fatty acid deficiency (EFAD), prevention: IV: Administer at least 2% to 4% of total caloric intake as linoleic acid and 0.25% to 0.5% as alpha linolenic acid (Mirtallo 2004; Mirtallo 2010)
Essential fatty acid deficiency (EFAD), treatment: Intralipid: IV: Administer 8% to 10% of total caloric intake as fat emulsion; may infuse up to once daily (Riella 1975). If EFAD occurs with stress, the dosage needed to correct EFAD may be increased.
Serious hemodynamic or other instability secondary to highly lipid soluble substances (off-label use): Note: Continue chest compressions during administration (lipid must circulate): 20%: IV: 1.5 mL/kg (maximum: 100 mL; ASRA [Neal 2018]) administered over 1 to 3 minutes, followed immediately by an infusion of 0.25 mL/kg/minute (maximum: 200 to 250 mL; ASRA [Neal 2018]) (recommended infusion durations vary; see below); may repeat the bolus as necessary for persistent cardiovascular collapse or if instability re-emerges (ACMT 2016; AHA [Lavonas 2015]; ASRA [Neal 2018]). Some suggest dosing based on lean body weight (AHA [Lavonas 2015]; ASRA [Neal 2018]). Suggested maximum dose: 10 to 12 mL/kg over the first 30 to 60 minutes (AHA [Lavonas 2015]; ASRA [Neal 2018]).
After administration of the initial bolus and continuous infusion, recommendations regarding the continuous infusion vary significantly:
American College of Medical Toxicology: If after the bolus and continuing the infusion for 3 minutes the patient demonstrates a significant response, the infusion rate may be reduced to 0.025 mL/kg/minute (ie, one-tenth the initial rate). If instability re-emerges, the infusion rate may be increased back to 0.25 mL/kg/minute or the bolus may be repeated (ACMT 2016).
American Heart Association recommendations: Continue infusion for 30 to 60 minutes (AHA [Lavonas 2015]).
American Society of Regional Anesthesia and Pain Medicine: Continue infusion for at least 10 minutes after hemodynamic stability has been restored. Consider rebolus or increase the infusion rate to 0.5 mL/kg/minute if hemodynamic instability persists or recurs. (ASRA [Neal 2018])
Refer to adult dosing.
Parenteral nutrition: Intralipid, Nutrilipid: Note: Fat emulsion should not exceed 60% of the total daily calories. At the onset of therapy, the patient should be observed for any immediate allergic reactions such as dyspnea, cyanosis, and fever.
Infants: IV: Initial dose: 1 to 2 g/kg/day, increase by 0.5 to 1 g/kg/day to a maximum of 3 g/kg/day depending upon the needs/nutritional goals; daily dose infused over 24 hours; total infusion time may be incrementally increased (ie, cycled) to a maximum daily infusion over 12 hours (ASPEN Guidelines, 2002; ASPEN Pediatric Nutrition Support Core Curriculum, 2010)
Children 1 to 10 years: IV: Initial dose: 1 to 2 g/kg/day, increase by 0.5 to 1 g/kg/day to a maximum of 2 to 3 g/kg/day depending upon the needs/nutritional goals; daily dose infused over 24 hours; total infusion time may be incrementally increased (ie, cycled) to a maximum daily infusion over 12 hours (ASPEN Guidelines, 2002; ASPEN Pediatric Nutrition Support Core Curriculum, 2010)
Children ≥11 years and Adolescents: IV: Initial dose: 1 g/kg/day; not to exceed 500 mL 20% fat emulsion on the first day of therapy, increase by 1 g/kg/day to a maximum of 2.5 g/kg/day; daily dose infused over 24 hours; total infusion time may be incrementally increased (ie, cycled) to a maximum daily infusion over 12 hours (ASPEN Guidelines, 2002; ASPEN Pediatric Nutrition Support Core Curriculum, 2010)
Essential fatty acid deficiency (EFAD), prevention: Intralipid: Infants, Children, and Adolescents: IV: Administer 8% to 10% of total caloric intake as fat emulsion; infuse 2 to 3 times weekly; may need to increase dose during stress
Local anesthetic toxicity: Infants, Children, and Adolescents: Limited data available: 20% fat emulsion: IV: 0.8 to 3 mL/kg bolus has been used successfully in several pediatric case reports (1 month to 13 years) (Fuzaylov, 2010; Ludot, 2008; Shah, 2009; Wong, 2010); a single case report in a 6-year-old described use of a continuous IV infusion at 0.25 mL/kg/minute to a total dose of 8 mL/kg following the bolus dose (Wong, 2010)
Do not add additives directly to the fat emulsion. When preparing parenteral nutrition admixture, do not add fat emulsion to the TPN container first; destabilization of the lipid emulsion may occur when other solutions (eg, dextrose) are added. Minimize pH-related problems by ensuring that dextrose solutions, which are typically acidic, are not mixed with lipid emulsions alone. First transfer dextrose solution to the TPN admixture container; then transfer amino acid injection; then transfer lipid emulsion. Amino acid injection, dextrose injection, and lipid emulsions may be simultaneously transferred to the admixture container; use gentle agitation during admixing to minimize localized concentration effects; may shake bags gently after each addition. Do not use administration sets and lines that contain di-2-ethylhexyl phthalate (DEHP).
IV: Administer by IV infusion only via peripheral line or by central venous infusion. 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). At the onset of therapy, the patient should be observed for any immediate allergic reactions such as dyspnea, cyanosis, and fever. Change tubing after each infusion. May be simultaneously infused with carbohydrate/amino acid solutions by means of Y-connector located near infusion site or administered in total nutrient mixtures (3-in-1) with amino acids, dextrose, and other nutrients. Fat emulsions of 30% should only be administered in total nutrient mixtures (3-in-1) with amino acids, dextrose, and other nutrients. Hang fat emulsion higher than other fluids (has low specific gravity and could run up into other lines).
Intralipid: Prior to opening the overwrap, the integrity indicator should be inspected. If the indicator is black, the overwrap is damaged; do not use.
Nutrilipid: To avoid air embolism, use a nonvented infusion set or close the air vent on a vented set and use a dedicated line without any connections. Prior to opening the overwrap, the oxygen indicator should be inspected; if the indicator is pink or dark pink, do not use. May be infused concurrently into the same vein as carbohydrate-amino acid solutions by means of a Y-connector located near the infusion site; flow rates of each solution should be controlled separately by infusion pumps. Do not use administration sets and lines that contain di-2-ethylhexyl phthalate (DEHP). See prescribing information for detailed administration information.
Caloric source/EFAD: Initiate infusions of 10% emulsions at 1 mL/minute for 15 to 30 minutes; if no untoward effects occur, the infusion rate may be increased to 2 mL/minute. Initiate infusions of 20% emulsions at 0.5 mL/minute for 15 to 30 minutes; if no untoward effects occur, the infusion rate may be increased to 1 mL/minute.
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; AHA [Lavonas 2015]; ASRA [Neal 2018]).
Phosphorus: ~1.5 mMol /100 mL of emulsion
Caloric content: 10% fat emulsion = 1.1 kcal/mL; 20% fat emulsion = 2 kcal/mL; 30% fat emulsion = 3 kcal/mL
Fat emulsion should not exceed 60% of the total daily calories.
Do not freeze. If accidentally frozen, discard. Do not store partly used containers; fat emulsion can support the growth of various organisms. Do not use if the emulsion appears to be oiling out. Once the closure is penetrated, the contents should be used as soon as possible; the transfer of contents to suitable TPN admixture containers must be completed within 4 hours of closure penetration. Admixtures prepared using fat emulsion should be used promptly or stored under refrigeration at 2°C to 8°C (36°F to 46°F) for 24 hours or less and used completely within 24 hours after removal from refrigeration.
Intralipid, Nutrilipid: Store below 25°C (77°F).
Frequency not defined:
Gastrointestinal: Cholestasis (central lobular), melanosis (brown fat pigmentation in the reticuloendothelial system)
Hematologic & oncologic: Leukopenia, splenomegaly, thrombocytopenia
Hepatic: Fat overload syndrome, hepatomegaly, increased liver enzymes
<1%, postmarketing, and/or case reports: Back pain, chest pain, cyanosis, diaphoresis, dizziness, drowsiness, dyspnea, flushing, headache, hypercoagulability state, hyperlipidemia, hypersensitivity reaction, increased body temperature, infusion site irritation, nausea, pulmonary embolism (fat), sensation of eye pressure, vomiting
ALERT: U.S. Boxed WarningDeaths in preterm infants:
Deaths in preterm infants after infusion of intravenous (IV) fat emulsions have been reported. Autopsy findings included intravascular fat accumulation in the lungs. Treatment of premature and low-birth-weight infants with IV fat emulsion must be based on careful benefit-risk assessment. Strict adherence to the recommended total daily dose is mandatory; hourly infusion rate should be as slow as possible. Preterm infants and low birth weight infants and small for gestational age infants have poor clearance of IV fat emulsion and increased free fatty acid plasma levels following fat emulsion infusion; therefore, serious consideration must be given to administration of less than the maximum recommended doses in these patients to decrease the likelihood of IV fat overload. Monitor the infant's ability to eliminate the infused fat from the circulation (such as triglycerides and/or plasma free fatty acid levels). The lipemia must clear between daily infusions.
Concerns related to adverse effects
• Fat overload syndrome: Although rare, a reduced or limited ability to metabolize lipids accompanied by prolonged plasma clearance resulting in a sudden deterioration in the patient's condition accompanied by fever, anemia, leukopenia, thrombocytopenia, coagulation disorders, hyperlipidemia, liver fatty infiltration (hepatomegaly), deteriorating liver function, and CNS (eg, coma) can occur; usually reversible upon discontinuation.
• Hepatic effects: Parenteral nutrition: Although the exact etiology is unknown and likely multifactorial, parenteral nutrition associated liver disease (PNALD) has been reported in patients receiving parenteral nutrition for extended periods of time, especially preterm infants, and can present as cholestasis or steatohepatitis, fibrosis and cirrhosis, possibly leading to hepatic failure; cholecystitis and cholelithiasis have also been observed. Consider discontinuation or dose reduction in patients who develop abnormal LFTs.
• Hypersensitivity: Allergic reactions (eg, tachypnea, dyspnea, hypoxia, bronchospasm, tachycardia, vomiting, headache, sweating) to lipid emulsion may occur; discontinue infusion immediately if signs or symptoms of hypersensitivity or allergic reactions occur.
• Refeeding syndrome: Parenteral nutrition: Refeeding severely undernourished patients with parenteral nutrition may result in the refeeding syndrome (eg, intracellular shift of potassium, phosphorus, and magnesium as the patient becomes anabolic); thiamine deficiency and fluid retention may also develop. Carefully monitor severely undernourished patients and slowly increase their nutrient intakes, while avoiding overfeeding.
• Anemia: The use of fat emulsion has been associated with anemia likely due to hemodilution (Zellner 1967). Use with caution in patients with anemia.
• Bleeding disorders: Use with caution in patients with bleeding disorders.
• Fat embolism: Use with caution in patients who may be at danger for fat embolism.
• Hepatic impairment: Use with caution in patients with hepatic impairment.
• Pancreatitis: Use with caution in patients with pancreatitis without hyperlipidemia; ensure triglyceride levels remain <400 mg/dL.
• Respiratory disease: Use with caution in patients with respiratory disease.
• Renal impairment: Use with caution; some formulations may contain aluminum, which may accumulate following prolonged administration in renally impaired patients.
• Toxicity secondary to highly lipid soluble substances: Hemodynamic and other instability: Successful resuscitation following the administration of fat emulsion has been reported in animal studies and several human case reports in which cardiovascular toxicity was unresponsive to conventional resuscitation and antidotal measures. Successful resuscitation following the administration of fat emulsion has been reported in pediatric patients (Fuzaylov 2010; Ludot 2008; Shah 2009; Wong 2010). Consider use when toxicity secondary to a highly lipid soluble substance is likely and conventional methods are unsuccessful. Continue CPR throughout treatment with lipid emulsion. Consultation with a medical toxicologist or poison control center is highly recommended.
Concurrent drug therapy issues:
• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.
• Pediatric: [US Boxed Warning]: Deaths in preterm infants following administration of fat emulsion have been reported; autopsy findings included intravascular fat accumulation in the lungs. Premature infants, low birth weight infants, and small for gestational age infants clear intravenous fat emulsion poorly and have increased free fatty acid plasma levels following fat emulsion infusion. Strict adherence to proper infusion rates, dosing, and monitoring are necessary; infusion rate should be as slow as possible; strict monitoring of metabolic tolerance and elimination of infused fat from the circulation must occur. To avoid hyperlipidemia and/or fat deposition, do not exceed recommended daily doses and consider administering less than the maximum recommended doses in preterm and small for gestational age infants. Because free fatty acids displace bilirubin from albumin binding sites, the use of lipid infusions in jaundiced or premature infants should be done with caution.
Dosage form specific issues:
• Aluminum: The parenteral product may contain aluminum; toxic aluminum concentrations may be seen with high doses, prolonged use, or renal dysfunction. Premature neonates are at higher risk due to immature renal function and aluminum intake from other parenteral sources. Parenteral aluminum exposure of >4 to 5 mcg/kg/day is associated with CNS and bone toxicity; tissue loading may occur at lower doses (Federal Register, 2002). See manufacturer's labeling.
• Administration: The too-rapid administration of fat emulsion can cause fluid and/or fat overloading, resulting in dilution of serum electrolyte concentrations, overhydration, congested states, pulmonary edema, impaired pulmonary diffusion capacity, or metabolic acidosis; hourly infusion rate should be as low as possible.
• Three-in-one mixtures: Lipid emulsion in a three-in-one mixture may obscure the presence of a precipitate; follow compounding guidelines, especially for calcium and phosphate additions.
Monitor for signs and symptoms of infection (including vascular access device complications); fluid and electrolyte status; serum osmolarity; blood glucose; blood counts (including platelets and coagulation parameters); signs and symptoms of essential fatty acid deficiency, refeeding syndrome, and/or hypersensitivity reactions.
Monitor liver and renal function tests periodically. Monitor triglycerides before initiation of lipid therapy and at least weekly during therapy (or until triglycerides are stable and when changes are made in the amount of fat administered; ASPEN Guidelines, 2002); monitor especially closely in premature infants, septic infants, and patients with pancreatitis or liver disease.
Pregnancy Risk Factor
Animal reproduction studies have not been conducted. Indications for fat emulsion therapy in pregnant women are the same as in nonpregnant women. The ASPEN guidelines for parenteral and enteral nutrition state that intravenous fat emulsion may be used safely in pregnant women to provide calories and prevent essential fatty acid deficiency (ASPEN Guidelines 2002). Medications used for the treatment of cardiac arrest in pregnancy are the same as in the non-pregnant woman. Doses and indications should follow current Advanced Cardiovascular Life Support guidelines. Appropriate medications should not be withheld due to concerns of fetal teratogenicity (Jeejeebhoy [AHA] 2015). Lipid emulsion therapy has been used successfully in the resuscitation of a pregnant female with suspected bupivacaine toxicity (Dun-Chi Lin 2017; Spence 2007).
• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
• Have patient report immediately to prescriber signs of liver problems (dark urine, fatigue, lack of appetite, nausea, abdominal pain, light-colored stools, vomiting, or jaundice), signs of infection, signs of high blood sugar (confusion, fatigue, increased thirst, increased hunger, polyuria, flushing, fast breathing, or breath that smells like fruit), signs of pancreatitis (severe abdominal pain, severe back pain, severe nausea, or vomiting), severe nausea, severe vomiting, shortness of breath, chest pain, dizziness, passing out, blue/gray skin discoloration, tachycardia, headache, sweating a lot, severe loss of strength and energy, bruising, bleeding, or severe injection site irritation (HCAHPS).
• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.
More about fat emulsion
- Side Effects
- During Pregnancy
- Dosage Information
- Drug Interactions
- Drug class: intravenous nutritional products
- FDA Alerts (2)
- Fat Emulsion (Fish Oil Based) (Wolters Kluwer)
- Fat Emulsion (Fish Oil and Plant Based) (Wolters Kluwer)