(385) Refractory Coagulopathy Associated With Omegaven in an Infant

Introduction: Children may develop parenteral nutrition associated liver disease (PNALD) rapidly when receiving Intralipid. SMOF and/or Omegaven are now commonly utilized in place of Intralipid, especially in infants. Omega 3 fatty acids have been associated with bleeding in patients receiving higher oral doses. The association of bleeding with Omegavan in children has been reported only once. Data from rat models suggest post translational modifiction of Vitamin K dependent factors result in functional deficiency. However, there are no human studies.

Description: A 4 month old former 25 week infant with a history of surgical necrotizing enterocolitis, PNALD and ongoing respiratory failure was transferred from the referring hospital for evaluation and tracheostomy. Upon review of her laboratories she was noted to have mild elevation in her transaminases and bilirubin. Synthetic function was preserved as measured by total protein and albumin. However, it was noted that she had ongoing and worsening coagulopathy for which she was receiving daily intravenous Vitamin K. The coagulopathy was worsening with a peak PT 27.4 seconds (INR of 2.4.) It was unable to be corrected with fresh frozen plasma. Factors II, V, VII IX, X were deficient. Essential fatty acid profile was also obtained and revealed a significant elevation of EPA and DHA. Upon further review of her parenteral nutrition orders from the outside hospital, it was noted that she was receiving 1.5-2grams/kg/day of Omegaven. Vitamin K was continued, but Omegaven stopped. Over the following weeks, she had gradual improvement in her PT, INR and FVII which normalized over the following 4 months. Vitamin K was discontinued. Improvement of coagulation was associated with normalization of DHA and EPA.

Discussion: Omega 3 fatty acids have been inconsistently associated with bleeding. Bleeding with Omegaven has only previously been reported in one child. This case highlights the potential for coagulopathy resulting from use of Omegaven above the recommended dosing. Further delineation of the mechanism by which Vitamin K factors become deficient is warranted.