Indiana University-Purdue University Indianapolis (IUPUI) / Background: SMOF lipid™ infusion containing soybean oil, medium-chain triglycerides, olive oil, and fish oil has been approved and recommended for use in adults receiving parenteral nutrition (PN). Research shows that SMOF lipid infusion is safe for use in post-operative and critically ill patients. Improved patient outcomes are linked to SMOF lipid use over traditional soybean oil lipid emulsions. Objective: The purpose of this study was to determine the effect of SMOF lipid infusion on incidence of infection, ICU length of stay, hospital length of stay, and mortality in adult trauma patients as compared to parenteral nutrition utilizing 100% soybean oil emulsion or a lipid-free, dextrose and amino acid administration. Methods and Analysis: A retrospective chart review was conducted for adult trauma patients admitted to Eskenazi Health’s surgical intensive care unit (SICU) that received PN from May 2017 to May 2020. Data were collected from the electronic health record and trauma registry. Results: Twenty-nine patients were included who met study criteria: 17 patients in the traditional lipid cohort and 12 in the SMOF lipid cohort. The length of PN therapy was comparable between the traditional and SMOF ILE groups, 13.9 days (± 11.5) and 13.3 days (± 14.3) respectively. All 12 patients in the SMOF lipid cohort received intravenous lipid emulsion (ILE) compared to 42% (n=7) of traditional lipid group patients (p=0.001). SMOF treatment group were provided 100% of estimated energy needs via PN compared to an average of 94% (± 9.7) of estimated energy needs in the traditional lipid treatment group (p=0.036). Incidence of infection during initial hospitalization was significantly lower in the SMOF treatment group (n=3, 25%) compared to the traditional lipid treatment group (n=13, 76%). Mortality was decreased in the SMOF treatment group (0%) when contrasted to the Intralipid treatment group (23.5%), p=0.04. Conclusion: Patients receiving SMOF lipid emulsion within PN therapy had better clinical outcomes compared to those receiving Intralipid soybean-lipid emulsion or a dextrose and amino acid administration.

Preterm infants are not able to tolerate full enteral feeding of breast milk due to gut immaturity. To fill this nutritional gap, parenteral nutrition is introduced while enteral feeding is gradually increased. Of parenteral nutrition, lipid emulsions supply energy, essential and polyunsaturated fatty acids, which significantly affect short- and long-term health outcomes of growth, visual-and neuro-development for preterm infants. However, elevated plasma triglyceride (TG) levels in preterm infants receiving lipid emulsions have been observed despite less lipid intake compared to breast milk fed infants. We hypothesized that unbalanced fatty acid profiles in lipid emulsion was one factor to cause high plasma TGs for preterm infants. In the multi-center, observational, prospective study, the following samples were analyzed using GC-MS: (1) lipid emulsions (n=5) and breast milk (n=112), (2) plasma (n=294) including normal TG (n=116) and high TG (n=88). Lipoproteins in normal TG (n=18) and high TG (n=24) plasma were measured using gel electrophoresis. Fatty acid profiles in lipid emulsions differed from ones in breast milk. Plasma fatty acid profiles were related to dietary fatty acid intake. Accumulation of all fatty acids except C20:5n3 and relatively high (LDL+VLDL) levels (p<0.001) resulted in high TG plasma compared to normal TG plasma. Overall, this study supports the hypothesis that nutrition of lipid emulsions was associated high TG with differences in fatty acid uptake but it is still unclear if the imbalance of fatty acids directly causes high TG. More research is necessary to investigate other factors such as enzyme activity, lipid clearance rate, or different rate of fatty acid metabolism. / Thesis / Master of Science (MSc)

<p>\ / Doctorat en Sciences médicales / info:eu-repo/semantics/nonPublished

Cadre conceptuel et problématique : La cholestase hépatique est une pathologie à large éventail d’étiologies, affectant fréquemment les nouveau-nés. Un diagnostic approprié est essentiel pour la prise en charge clinique, le choix des traitements et l’amélioration du pronostic. Alors que les prématurés ont un risque accru de développement de la cholestase, les algorithmes de traitement ne proposent qu’une prise en charge unique, quel que soit l’âge gestationnel (AG) du patient. Objectif : Déterminer si le profil clinique, la prise en charge et le pronostic de la cholestase néonatale diffèrent selon l’AG. Méthodologie : Une étude de cohorte rétrospective de nouveau-nés atteints de cholestase et admis en néonatologie au CHU Sainte Justine entre janvier 2014 et décembre 2017 a été menée. La cholestase était définie par au moins deux valeurs consécutives de bilirubine conjuguée ≥ 34 μmol/L. La cohorte a été stratifiée en deux groupes d’AG : les extrêmes et les grands prématurés (< 32 semaines AG) et les prématurés modérés ou tardifs et naissances à terme (≥ 32 semaines AG). Résultats : 125 nouveau-nés sur 3 277 ont développé une cholestase. L’incidence globale était de 4% ; cette incidence était 5 fois plus élevée chez les nouveau-nés < 32 semaines d’AG comparativement aux ≥ 32 semaines d’AG. La cholestase était associée à une nutrition parentérale chez 91% des patients avec AG < 32 semaines et seulement 40% des patients avec AG ≥ 32 semaines (p < 0,01). Alors que l'acide ursodésoxycholique était plus prescrit aux nouveau-nés ≥ 32 semaines AG, les émulsions lipidiques à base d'huile de poisson étaient plus administrées aux nouveau-nés < 32 semaines AG, parmi les patients recevant une nutrition parentérale. Conclusion : La cholestase néonatale est associée à deux profils cliniques différents, basés sur l'AG. Nous recommandons que les tests diagnostics et la prise en charge clinique de la cholestase soient adaptés à l'AG. Une nouvelle approche pour l'évaluation d'un nourrisson atteint d'hyperbilirubinémie conjuguée est proposée. / Background and Aims: Cholestasis is a frequent neonatal disease that has a wide range of etiologies. Appropriate diagnosis is essential to clinical management, treatment choices and improvement of outcomes. Most references discuss neonatal cholestasis as one entity. The goal of this study was to determine if the clinical profile, management and outcome of cholestasis differ according to gestational age (GA). Methods: Medical records of infants with cholestasis in the division of neonatology at CHU Sainte Justine, between January 2014 and December 2017, were retrospectively reviewed. Cholestasis was defined as two or more consecutive conjugated bilirubin values ≥ 34μmol/L. The cohort was stratified into two groups: extremely to very preterm (< 32 weeks GA) and moderate to late preterm and term (≥ 32 weeks GA). Results: 125 of 3,277 patients developed cholestasis. Overall incidence of cholestasis was 4%. Incidence was 5 times higher in neonates < 32 weeks GA compared to neonates ≥ 32 weeks GA. Cholestasis was associated with parenteral nutrition in 91% of patients with GA < 32 weeks and 40% of patients with GA ≥ 32 weeks (p < 0.01). While ursodiol treatment was prescribed more to cholestatic neonates ≥ 32 weeks GA, fish oil lipid was administered more to neonates < 32 weeks GA, among patients receiving parenteral nutrition. Conclusions: Neonatal cholestasis was associated with two different clinical profiles based on GA. We recommend diagnostic tests and clinical management of neonatal cholestasis be adapted to GA. A GA-based approach to the evaluation of an infant with conjugated hyperbilirubinemia is proposed.