Systematic Review of Hypersensitivity to Parenteral Nutrition

Abstract

Hypersensitivity to the components of parenteral nutrition (PN) is a rare but important complication of PN. We performed a systematic review of hypersensitivity to PN to enable us to build an approach to the individual patient who presents with PN hypersensitivity. A systematic literature search was performed in Ovid Medline, CINAHL, Scopus, and Web of Science using terms for "hypersensitivity" AND "parenteral nutrition" and relevant synonyms. A total of 28 articles were analyzed, and 33 hypersensitivities to PN or components of PN were reported in these 28 articles. Reports of hypersensitivity and subsequent conclusions were based on the clinical observations made by each reporting author. These reactions were evenly split between pediatric and adult patients. Hypersensitivity to PN occurred on day of starting PN in 60.6% patients and after that time in 36.3% patients (range: 1-21 days). Of the hypersensitivities that occurred on day 1 of PN, 70% occurred in the first 30 minutes of initiation of PN. Cutaneous manifestations were the most common, followed by anaphylaxis, respiratory symptoms, and hemodynamic instability. The components most frequently identified as allergens were intravenous fat emulsion (48.4%), multivitamin solution (33.3%), and amino acid solution (9%). Based on this review, an algorithm was created to guide the practitioner on management of PN after the occurrence of such a reaction.

ASPEN Lipid Injectable Emulsion Safety Recommendations, Part 1: Background and Adult Considerations

“…But others may present after >1 day. 32 ILE products contain ingredients from several potentially allergenic sources: egg, soybean, fish. Therefore, it is not surprising that over a dozen cases have been published implicating ILE products in allergic reactions.…”

Parenteral nutrition in adults during acute illness: a clinical perspective for clinicians

“…Potential allergens should be considered when PN is prescribed, with the main allergens present being egg, soybean and fish. A recent systematic review found that hypersensitivity reactions are rare, but in the described cases, occurred due to the intravenous fat emulsion (48.4%), multivitamin solution (33.3%) and amino acid solution (9%) . For patients with documented anaphylaxis, caution should be exercised and consultation with a Clinical Immunologist considered.…”

Parenteral Provision of Micronutrients to Pediatric Patients: An International Expert Consensus Paper

“…Acute adverse reactions have also been reported from rapid administration of large doses of some vitamins. 104 Even though currently available commercial TEs and vitamin products are convenient PN additives, beware that they might not meet the nutrition requirements of some pediatric populations (for example, Zn requirements for premature neonates). 2 When only one micronutrient is deficient, it may not be appropriate to increase the total volume of admixture to achieve requirement, as this will increase the provision of all other micronutrient components in the admixture.…”

“…In particular, thiamin, ascorbic acid, pyridoxine, and folic acid should be given daily. 104 Switching to oral or enteral multivitamin/multi-TE supplements should also be considered if appropriate, with certain provisos.…”