Sepsis versus anaphylaxis—differentiating shock etiology: a case report involving Smoflipid

Abstract

This case study illustrates a clinically observed interaction between Smoflipid and the development of anaphylactic shock in a patient on long-term parenteral nutrition. This patient had a history of a well-differentiated retroperitoneal liposarcoma, now resected, which was complicated by duodenal perforation and intraperitoneal drain placement; due to significant gastrointestinal tract dysfunction the patient was maintained on continuous parenteral nutrition via a peripherally inserted central catheter (PICC) line. Following a routine and drain exchange, the patient was admitted to the hospital. The patient subsequently developed anaphylactic-like shock symptomatology, necessitating admission to the critical care unit. Intermittent dual vasopressor use was required. There was also an intermittently visible rash that was noted. The etiology of the shock state was unclear. After review of the patient’s case and clinical course, a potential etiology of his shock state was the inpatient protocolized substitution of Smoflipid instead of Intralipid in the parenteral nutrition regimen. After consultation with Allergic Diseases, Nutrition, and Pharmacy the Smoflipid was discontinued and the patient’s regimen was reverted to the standing home regimen including Intralipid. Following discontinuation of Smoflipid and resumption of Intralipid, the shock physiology resolved. The patient was subsequently transferred from the critical care unit and discharged soon thereafter by the primary surgical service. A formal Allergic Disease evaluation was completed in the outpatient setting. Continuous parenteral nutrition therapy was maintained at home using the previous home Intralipid regimen without issue. This case illustrates a multidisciplinary approach including Surgery, Allergic Diseases, Nutrition, Pharmacy, and Critical Care to address the patient’s acute shock state. In addition, a review of different shock states is presented. A literature review evaluating side effects of Smoflipid and an association of shock to its use is presented.