Accidental lipid overdose in a preterm infant: A case report

Abstract

BACKGROUND:

Intravenous lipid emulsions (ILEs) provide essential fatty acids during parenteral nutrition (PN). Serious adverse events including death can occur from overdose. We report an accidental overdose in a preterm infant.

METHOD:

On Day 2 of life, a 29-week gestational age (GA) twin was accidentally given 47.5 mL of Intralipid20% (≈3x daily amount) in 50-minutes.

RESULTS:

No apparent clinical deterioration occurred, although blood samples were lipaemic. Outcomes at 2 years corrected GA were similar to that of his twin. Service changes were made to infusion packaging and administration to avoid similar errors.

CONCLUSIONS:

Medication errors in neonates are unfortunately common. Published articles usually focus on poor outcomes, which can increase the distress for parents of children where errors have occurred. Publishing the full spectrum of outcomes instead allows parents and professionals to be aware of all possibilities and lessons learnt, even if serious harm was avoided.

Keywords

Accidental overdose intravenous lipid emulsion preterm infant

1 Introduction

Intravenous lipid emulsions (ILE), a component of parenteral nutrition (PN), are frequently administered to preterm infants and infants with gastrointestinal problems while they establish milk feeding [1]. ILE is often infused separately from other components of PN and accidental overdoses can occur. Reports of such overdoses cite serious adverse effects, such as respiratory distress, fat overload syndrome, metabolic acidosis, and death [2 –8].

We report an accidental overdose of soybean oil emulsion (Intralipid 20%) in a preterm infant, one of twins. We describe the twin’s neonatal course and outcomes at 2-year corrected gestational age (GA) follow-up, and discuss the implications of such errors, system changes that could prevent them, and the parents’ perspective of the experience.

2 Case Presentation

Monochorionic diamniotic (MCDA) male twins (Twins 1 and 2) were born by spontaneous vaginal delivery at 29 weeks’ gestation, weighing 1329 g and 1273 g, respectively (Table 1). Their mother, a 32-year old Caucasian, was gravida 1 and had no other pregnancy complications. She received antenatal magnesium sulfate but the course of labour was too rapid for a complete course of antenatal steroids.

Table 1
Neonatal course and two-year corrected age follow-up of the case and his twin brother

Infant parameters Twin 1 Twin 2

Gestational age at birth 29 weeks and 5 days 29 weeks and 6 days^*

Birth weight (g) 1329 1273

Apgar score at 1min 6 3

Apgar score at 5min 9 8

Resuscitation breaths Yes Yes

Respiratory support received

Initial support CPAP Mechanical ventilation

Days of mechanical ventilation 0 6

Days of CPAP 16 30

Days on supplemental oxygen 19 29

Oxygen at discharge none Low flow oxygen (0.1 L/min)

Cranial ultrasound Small cyst at right caudothalamic notch Grade 1 left-sided GMH

Weight at discharge (g) 2920 2920

Feeding at discharge Full milk feeds via breast/NG tube Full milk feeds via NG tube

Length of hospital stay (days) 70 70

Clinical course after discharge home

Hospital admissions 0 0

Medications None None

Follow up at 2 years CGA

Weight (kg) 13.4 12.5

Height (cm) 91.0 89.1

Head circumference (cm) 51 49

PARCA-R (percentile)

Language score 79 (7.6) 71 (2.8)

Non-verbal cognition score 90 (26.3) 84 (13.6)

BSID-III (percentiles)

Cognition score 100 (50) 95 (37)

Motor score 94 (34) 82 (12)

Language score 83 (13) 76 (8)

Social emotional score 85 (16) 85 (16)

Adaptive behaviour score 85 (16) 70 (2)

Infant parameters	Twin 1	Twin 2
Gestational age at birth	29 weeks and 5 days	29 weeks and 6 days^*
Birth weight (g)	1329	1273
Apgar score at 1min	6	3
Apgar score at 5min	9	8
Resuscitation breaths	Yes	Yes
Respiratory support received
Initial support	CPAP	Mechanical ventilation
Days of mechanical ventilation	0	6
Days of CPAP	16	30
Days on supplemental oxygen	19	29
Oxygen at discharge	none	Low flow oxygen (0.1 L/min)
Cranial ultrasound	Small cyst at right caudothalamic notch	Grade 1 left-sided GMH
Weight at discharge (g)	2920	2920
Feeding at discharge	Full milk feeds via breast/NG tube	Full milk feeds via NG tube
Length of hospital stay (days)	70	70
Clinical course after discharge home
Hospital admissions	0	0
Medications	None	None
Follow up at 2 years CGA
Weight (kg)	13.4	12.5
Height (cm)	91.0	89.1
Head circumference (cm)	51	49
PARCA-R (percentile)
Language score	79 (7.6)	71 (2.8)
Non-verbal cognition score	90 (26.3)	84 (13.6)
BSID-III (percentiles)
Cognition score	100 (50)	95 (37)
Motor score	94 (34)	82 (12)
Language score	83 (13)	76 (8)
Social emotional score	85 (16)	85 (16)
Adaptive behaviour score	85 (16)	70 (2)

^*born at 00:25hours the following day. CGA, corrected gestational age; CPAP, continuous positive pressure ventilation; GMH, germinal matrix haemorrhage.

Following stabilization at birth with brief continuous positive airway pressure, Twin 2 was intubated due to inadequate respiratory effort and low oxygen saturation, given surfactant, and mechanically ventilated. On day 2, he had rising c-reactive protein levels and had suspected infection that was treated with antibiotics. In keeping with recommended practice, PN [9], including ILE, infusion was started after birth via an umbilical venous catheter for both twins. For Twin 2 on day 2, the ILE bag was changed, and the infusion pump reset with an intention to deliver the daily 15.9 ml (i.e., 12.5 ml/kg) over 24 hours. Fifty minutes later, the nurse saw that 45.7mLof the ILE had been given. The infusion was stopped and it was noted that the pump was set incorrectly. Twin 2 had received 5.85 g of triglycerides in 50 minutes (instead of ∼0.07 g of his total 1.6 g/kg/day), which also gave a large volume of fluids (54.8 mL/hour) over this short time.

He was reviewed immediately. There was no apparent clinical deterioration. Capillary blood gas showed pH-7.21; PCO₂-7.8kPa; PO₂-5.5kPa; lactate-1.6 mmol/L, Base Excess –5.5 mmol/L; bicarbonate-19.6 mmol/L; and glucose of 9.3 mmol/L. Coarse dense lung fields were seen on x-ray, consistent with lung disease of prematurity, findings similar to his previous images. The laboratory reported that the blood sample was “grossly lipaemic” but an exact triglyceride level was undeterminable. Serum electrolytes and renal function were normal (sodium-139 mmol/L; potassium-4.0 mmol/L; urea-6.5 mmol/L; creatinine-42umol/L). Bilirubin level was 129 micromol/L, but the laboratory could not report alanine aminotransferase levels or coagulation studies due to interference from lipaemia. Subsequent investigations showed normal kidney and liver functions with raised triglyceride level (13.0 mmol/L) ∼12 hours after the overdose. As he remained clinically stable, no intervention was made to remove the excess lipid or fluid. His urine output increased on day 3 but other parameters remained stable. He was discharged home partially NG fed and on supplemental oxygen at 0.1 L/min. He came off these supports after a few weeks at home.

The twins were discharged after 70 days. Both had growth and neurodevelopmental assessments at 2 years corrected GA including the Parent Report of Children’s Abilities-Revised (PARCA-R) and Bayley Scales of Infant Development III (BSID-III; Table 1). Twin 1 scored average (–1 SD to < +1 SD) in nonverbal cognition with a mild delay (–2 SD to < -2 SD) in language ability, while Twin 2 had mild delay in both nonverbal cognition and language ability. BSID-III performance was similar for both twins, falling into the average ranges for cognitive and social emotional development, mild delay in language development, and Twin 2 also had mild motor and adaptive behavior delays.

2.1 Communication with parents

In keeping with principles of “duty of candour,” [10] parents were informed about the error. They were understandably distressed and asked what harm could occur. Information shared with them included a review of reported cases and possible interventions. The parents were concerned, as their own online inquiries revealed case reports of death, other adverse events, and need for interventions. They agreed that despite these reports, as the infant was clinically stable, no active intervention was required. The parents were regularly updated and participated actively in the investigation and risk management process that followed. At the two-year follow-up, they recalled this and reflected that they would like to share their experience so that families of any future similar case would have the information that not all infants with lipid overdoses suffer serious adverse consequences.

2.2 Investigation into the error

An investigation revealed that the error occurred at the point of entering the infusion rate into the pump, as the total daily volume of PN was accidentally entered as the rate. The hospital had a standard policy of two nurses double-checking the medications and calculations for the infusion rate. This is in keeping with the previous safety alert issued by NHS Improvement [11], which highlighted incidences where the pump rates were set such that the lipids were infused at the rate meant for the aqueous solution, other incorrect infusion rates were entered, or volumes were miscalculated when changes were made. In our reported case, the error was because the total lipid volume was incorrectly entered and, in the policy at that time, however, there was no requirement for a second nurse to oversee that this rate was correctly entered into the pump, although double-checking at the point of calculation of the volume did occur. Lack of double-checking at the input step was identified as the root cause of the error. An associated ‘near hit’ was also identified: the ILE was supplied in a standard 100 mL bag. If the error had not been noted quickly, due to regular checks, the infant would have received an even larger overdose.

3 Discussion

Infants, particularly those born preterm, are exposed to various drugs and are at a high risk of medication errors [12 –14]. The risk for harm is eight times more likely in newborns as compared to adults [13]. Many such errors result from inadequate prescribing practices or technological errors (e.g., incorrect pump settings) and, when fully investigated, are believed to be risks that can be largely reduced [12, 13].

ILEs are widely used to optimise nutrition in preterm infants but can have adverse effects, even at recommended doses (Table 2) [15 –22]. Most infants receive ILEs safely, but inadvertent overdose is reported in the literature and can cause immediate life-threatening effects, such as acute severe hypertriglyceridaemia, which worsens respiratory disease in premature infants [23, 24]. Table 3 describes case reports of accidental overdoses of ILEs [2 –8]. Single or double-volume plasma exchange therapy was used in 5 cases to reduce elevated triglyceride levels. This was unsuccessful in Badr et al’s case, who hypothesized that significant delay before implementing exchange therapy due to unfamiliarity may have limited its efficacy. The infant in their report also had multiple comorbidities that likely contributed to the poor outcome.

Table 2
Reported adverse effects of intralipid emulsion in neonates and infants

Study ID Setting and study design Patient Characteristics Event Outcome

Bae 2018 neonatal unit 4 newborn infants Contamination of SMOF lipid solution - 4 deaths

Seoul, Korea Case series - Citrobacter freundii in blood (all 4 infants) and CSF (3/4 infants)

- Contamination likely when multiple 20 mL aliquots were taken from one100 ml bottle

Barson 1978 neonatal unit Manchester, UK Case series - 34 weeks’ GA; NEC 11 days of ILE; max rate: 0.10 g/kg/hour Autopsy: - fat emboli in the lung vessels of all 4 infants.

All received a mixture of 20% Intralipid. - alveolae with fat-laden macrophages

- fat emboli were not seen in any other organs.

- 27 weeks’ GA; NEC 14 days of ILE; max rate: 0.27 g/kg/hour

- term infant; anorectal malformation 12 days of ILE; max rate: 0.51, g/kg/hour

- term infant; Hirschsprung’s disease 18 days of ILE; max rate: 0.70, g/kg/hour

Hulman & Levene 1986 neonatal unit, Leicester, UK - 34 weeks’ GA - critically ill - parenteral nutrition, - 8 h after the beginning of infusion suffered cardiac arrest and died.

Case report - Female with 10% Intralipid at 0.08 g/hour - Autopsy: intralipid microembolism (100×40 um)

- tracheo-oesophageal fistula closed on day 2 - received 0.64 g of fat

- Cause of death: cardiac failure due to a large ventriculoseptal defect

Mughal 1984 neonatal unit Salford, UK Case report - 26 weeks’ GA Intralipid by continuous infusion over 20 hours using a syringe pump. - Fat globules identified in a tracheal aspirate.

- 800 g BW - Male - Respiratory distress syndrome Lipids started at 0–5 g/kg/day, increasing to a maximum of 4 g/kg/day. Day 41- deterioration in respiratory status and fever - Pulmonary lipid micro-embolisation suspected –PN stopped.

- Rapid improvement in respiratory status,

- Extubated on day 49

Puntis & Rushton 1991 Neonatal unit Birmingham, UK Case series of autopsy reports 41 infants who received PN Median (range) - GA: 28 weeks (25–40) - All received amino acid/ dextrose solution (Vamin 9 glucose, KabiVitrum) Pulmonary intravascular lipid found in: - 15/30 (50%) who received Intralipid

- 30/41 also given IV fat emulsion (Intralipid 10%, KabiVitrum). - none who did not receive Intralipid

- Lipid infusion rates (range) 0.5 to 3.0 g/kg/day

- BW: 880 g (450–2820). Infants with positive lipid staining had received significantly more fat than those in whom intravascular lipid microemboli were not found

38/41 required mechanical ventilation

3/41 had necrotising enterocolitis

Sinclair 2018 NICU, Randwick, Australia Retrospective case series 195 infants GA < 29 weeks Lipid emulsion 38/195 (19.5%) developed hypertriglycemia

- Started at 1 g/kg/day soon after birth - 10 (5.1%): more than one episode

- Increased by 1 g/kg daily - 11 (5.6%): severe (>4.5 mmol/L)

- Maximum 3 g/kg/day - Continued until at least 120 ml/kg/day of enteral feeds. - all severe cases: ILE ceased and triglyceride levels returned to normal.

- no overt signs of fat overload directly attributable to ILE

Until Oct 2015: Clinoleic 20% (80% Olive oil and 20% Soybean oil)

Thereafter: SMOF (30% soybean oil, 30% MCTs, 25% olive oil, 15% fish oil)

BW, birth weight; CSF, cerebrospinal fluid; GA, gestational age; ILE, intravenous lipid emulsion; MCT, medium chain triglycerides; NEC, necrotising enterocolitis; PN, parenteral nutrition; SMOF, soybean oil (30%), medium-chain triglycerides (MTC, 30%), olive oil (25%), and fish oil (15%).

Table 3

Case reports of intralipid emulsion overdoses in neonates and infants

Study ID	Setting	Patient Characteristics	Event	Outcome
Badr 2021	neonatal unit Montpelier, France	30 weeks’ GA	Day 2:28 ml ILE over 4 h (25 mg/kg/min)	- Acute respiratory distress with increased oxygen requirement.
	Case report	BW: 930g	ILE: 50% MCT and 50% soybean oil	- Capillary blood gas: pH, 6.98; PCO₂, 56 mmHg; PO₂, 45 mmHg; bicarbonate, 13 mmol/L; lactate, 11.4 mmol/L.
			∼6 g/kg of lipids administered at 7 ml/h over 4 h instead of over 24 h	- Echocardiography: pulmonary hypertension
				- Transient improvement with inhaled nitric oxide; ventilation for 10 hours
				- Plasma exchange attempted 22 hours after overdose.
				- Circulatory shock and bleeding
				- Died 69 h after the overdose
Fairchild, 1999	Neonatal unit	32 weeks’ GA	Day 5:24 g/kg of ILE in 1h	- tachypnoea and reduced oxygen saturation
	Maryland, Baltimore, USA	BW: 2160 g	Error in infusion pump setting	- lethargic but arousable.
		One of dizygotic twins		Blood sample- grossly lipaemic
				- serum triglyceride 11,000 mg/dL
				2 h later,3 episodes of apnoea and bradycardia repeat serum triglyceride 12900 mg/dL
				Double volume exchange transfusion 160 microg of acid citrate dextrose-preserved packed red blood cells reconstituted with fresh frozen plasma
				- Respiratory symptoms resolved and did not recur
				- Serum triglyceride 2046 mg/dL
Gura 2010	Children’s Hospital, Boston, USA	N = 5 Age (range): 2 mo to 1y NEC, total colonic Hirschsprung’s pseudobstruction, or jejunal atresia	Fish oil emulsion (Omegaven^®) rate 0.17 g/kg/h but accidently given 0.2–5 g/kg/h	transient elevations in serum triglyceride levels but returned to baseline once the infusion was stopped.
				No signs of fat overload syndrome or respiratory distress.
Hoofien et al., 2019	Children’s hospital; Tel Aviv, Israel	Age: 6 mo Griscelli syndrome - vomiting and diarrhoea two months after bone marrow transplantation, possibly intestinal graft vs. host disease	Day 2: started on PN including Lipofundin^®	- no clinical deterioration - significant hypertriglyceridemia (6417 md/dl) with normal cholesterol levels.
			20% (50% soybean oil and MCT)
			Day 5	- remained in PICU for 24 h with no new clinical symptoms.
			- 38 ml/hr (5.4 ml/kg/hr) ILE for 3.5 hours (10X maximum daily amount)	- Triglyceride levels resolved to normal over 24 h
			- Incorrect setting of ILE pump
Khasawneh & Hani 2018	Children’s hospital Jordan	Age: 3 mo Male BW: 2600 g Cow’s milk allergy and chronic diarrhoea.	PN due to chronic diarrhoea.	- acute reaction: (fever (at 38.5° C), rapid shallow breathing; bile-stained emesis; drop in oxygen saturation (88–90%) improved with nasal cannula oxygen - blood sample grossly lipaemic
			ILE: Intralipid (20% soybean based; 1.5 g/kg at a rate of 1.5 ml/hr.
			Day 5:	- serum triglyceride 4840 mg/dl
			- 200 ml over 6 h - incorrect pump setting	- single volume exchange transfusion - triglyceride level dropped to 88 mg/dl
				- respiratory status improved
				- no further symptoms
Khriesat 2015	Children’s hospital	GA: 32 weeks	1 week later: intestinal obstruction; started PN	- acute reaction: vomiting, tachypnoea, respiratory distress, hyperthermia, and extreme pallor
	Jordan	BW: 1400 g;Male	9 h after starting infusion:	- lipaemic blood samples
		Day 4: ileostomy for perforated terminal ilium and peritonitis	- ILE infusion of 24 ml/hour instead of 2.4 ml/hour	- single volume exchange with rapid improvement in symptoms over the next few hours.
		3 mo: ileostomy closure	- Incorrect pump setting
Rodriguez-Castano 2018	neonatal unit Madrid, Spain	GA: 25 weeks BW: 920 g Started on PN at 8 h	ILE ordered at 0.4 ml/hour (2 g of lipid/kg/day)	- lethargy, apnoea, metabolic acidosis and hemodynamic instability
			- inadvertently received 60 ml of 20% fat emulsion (13 g/kg) for 8 h	- mechanical ventilation and inotropic support
			- due to device failure	- Blood samples grossly lipaemic
				- double-volume exchange transfusion
				- Serum triglyceride after the exchange transfusion: 1652 mg/dl
				- 24 hours later: 19 mg/dl
				- Extubation to CPAP and discontinuation of inotropic within 24 hours.

BW, birth weight; CPAP, continuous positive airway pressure; GA, gestational age; ILE, intralipid emulsion; MCT, medium chain triglycerides; NEC, necrotising enterocolitis.

The type of lipid in the ILE may be related to the level of harm from overdose. Soybean oil emulsions containing omega-6 compounds (Intralipid 10% and 20% formulations) have been related to worse outcomes. Fish oil compounds or those including medium chain triglycerides (MCT) appear to induce only transient hypertriglyceridaemia, perhaps due to different metabolic pathways that facilitate rapid plasma clearance [4, 5]. We found only one other case where an overdose of soybean ILE in an infant resulted in asymptomatic hypertriglyceridaemia (Table 4), and this included an ILE mixed with MCT that may have ameliorated the effects [5].

Fortunately, in our case, the infant did not suffer any apparent adverse consequences. Although gross lipaemia was present immediately following overdose, there was no acute clinical deterioration and plasma exchange was not performed. His growth and neurodevelopmental outcomes are within the expected range for his gestational age albeit with some mild delays. Up to one third of very preterm infants (28–32 weeks’ GA) show mild neurodevelopmental delay at two years of age [25, 26]. Compared with his brother, he was more unwell after birth requiring mechanical ventilation and had raised inflammatory markers before the ILE overdose, but the subsequent clinical course was similar.

It is likely that there are other cases of ILE overdose where the recipient remains stable with conservative management. Such cases though are unlikely to be submitted for publication, due to the erroneous assumption that lack of harm makes them less interesting and less publishable. Publication biases against null hypotheses or “negative” results are well-known in medicine [27, 28], including those regarding drug errors [28]. However, an unintended consequence of such underreporting is that parents seeking information in the aftermath of such incidents see a picture skewed towards worse outcomes. The parents reported here highlighted this and expressed the need for more balanced reporting.

Additionally, regardless of the severity of outcome, drug errors must be investigated and strategies to prevent recurrence planned and implemented. Lessons learnt from near hits must be shared, as they are as valuable as the lessons from errors that lead to serious harm. Human factors are implicated in approximately two-thirds of medication errors in neonatal units, particularly administration errors for infusion pumps [4 , 29]. In all the reported cases of infant ILE overdose, accidental incorrect programming of the pump was responsible. Locally, we implemented a nurse ‘double-check’ system for pump rate input, in addition to that already in place for double-checking calculations and correct medication/formula, to prevent recurrence, but continued vigilance and staff training are required to ensure repetitions are avoided. Additionally, we repackaged the lipid emulsion to limit the volume of any future errors [29]. One of the main factors in our error was that the lipid was in a large container (100 mL bag), allowing a large volume to be given if the volume calculation or rate input into the pump is wrong. Using a syringe with a smaller volume (e.g., 25 mL) is one way to limit the volume that can be accidentally given. Similarly, using a drug library in the pump with preset rate limits can also help but such pumps can be expensive and not available to all neonatal units. Such strategies, made at the system level, have been proposed to reduce and limit human and drug errors [29 –32].

4 Conclusion

ILEs are fundamental to provide adequate nutrition but can have significant adverse effects, particularly in overdose. We report a case of accidental ILE overdose due to incorrect infusion pump setting without adverse outcome. Medication errors in neonates are unfortunately common and can cause harm to the infant and significant distress to the parents. Most publications focus on cases with adverse outcomes. We need to report outcomes more consistently so that parents and health care professionals can see the full spectrum of potential consequences.

Abbreviations

BSID-III

Bayley Scales of Infant Development III

gestational age

ILE

intravenous lipid emulsions

PARCA-R

Parent Report of Children’s Abilities-Revised

parenteral nutrition

Conflict of Interest

The authors have no conflicts of interest relevant to this article to disclose.

Funding

No funding was secured for this study.

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Study ID	Setting and study design	Patient Characteristics	Event	Outcome
Bae 2018	neonatal unit	4 newborn infants	Contamination of SMOF lipid solution	- 4 deaths
	Seoul, Korea Case series			- Citrobacter freundii in blood (all 4 infants) and CSF (3/4 infants)
				- Contamination likely when multiple 20 mL aliquots were taken from one100 ml bottle
Barson 1978	neonatal unit Manchester, UK Case series	- 34 weeks’ GA; NEC	11 days of ILE; max rate: 0.10 g/kg/hour	Autopsy: - fat emboli in the lung vessels of all 4 infants.
	All received a mixture of 20% Intralipid.			- alveolae with fat-laden macrophages
				- fat emboli were not seen in any other organs.
		- 27 weeks’ GA; NEC	14 days of ILE; max rate: 0.27 g/kg/hour
		- term infant; anorectal malformation	12 days of ILE; max rate: 0.51, g/kg/hour
		- term infant; Hirschsprung’s disease	18 days of ILE; max rate: 0.70, g/kg/hour
Hulman & Levene 1986	neonatal unit, Leicester, UK	- 34 weeks’ GA	- critically ill - parenteral nutrition,	- 8 h after the beginning of infusion suffered cardiac arrest and died.
	Case report	- Female	with 10% Intralipid at 0.08 g/hour	- Autopsy: intralipid microembolism (100×40 um)
		- tracheo-oesophageal fistula closed on day 2	- received 0.64 g of fat
				- Cause of death: cardiac failure due to a large ventriculoseptal defect
Mughal 1984	neonatal unit Salford, UK Case report	- 26 weeks’ GA	Intralipid by continuous infusion over 20 hours using a syringe pump.	- Fat globules identified in a tracheal aspirate.
		- 800 g BW - Male - Respiratory distress syndrome	Lipids started at 0–5 g/kg/day, increasing to a maximum of 4 g/kg/day. Day 41- deterioration in respiratory status and fever	- Pulmonary lipid micro-embolisation suspected –PN stopped.
				- Rapid improvement in respiratory status,
				- Extubated on day 49
Puntis & Rushton 1991	Neonatal unit Birmingham, UK Case series of autopsy reports	41 infants who received PN Median (range) - GA: 28 weeks (25–40)	- All received amino acid/ dextrose solution (Vamin 9 glucose, KabiVitrum)	Pulmonary intravascular lipid found in: - 15/30 (50%) who received Intralipid
			- 30/41 also given IV fat emulsion (Intralipid 10%, KabiVitrum).	- none who did not receive Intralipid
			- Lipid infusion rates (range) 0.5 to 3.0 g/kg/day
		- BW: 880 g (450–2820).		Infants with positive lipid staining had received significantly more fat than those in whom intravascular lipid microemboli were not found
		38/41 required mechanical ventilation
		3/41 had necrotising enterocolitis
Sinclair 2018	NICU, Randwick, Australia Retrospective case series	195 infants GA < 29 weeks	Lipid emulsion	38/195 (19.5%) developed hypertriglycemia
			- Started at 1 g/kg/day soon after birth	- 10 (5.1%): more than one episode
			- Increased by 1 g/kg daily	- 11 (5.6%): severe (>4.5 mmol/L)
			- Maximum 3 g/kg/day - Continued until at least 120 ml/kg/day of enteral feeds.	- all severe cases: ILE ceased and triglyceride levels returned to normal.
				- no overt signs of fat overload directly attributable to ILE
			Until Oct 2015: Clinoleic 20% (80% Olive oil and 20% Soybean oil)
			Thereafter: SMOF (30% soybean oil, 30% MCTs, 25% olive oil, 15% fish oil)