Correspondence
Parenteral Nutrition in the Critically Ill Patient
N Engl J Med 2010; 362:81-84January 7, 2010
- Article
To the Editor:
In his review article on parenteral nutrition in the critically ill patient, Ziegler (Sept. 10 issue)1 does not include a detailed discussion of glycemic control. The original Leuven study combined intensive insulin therapy with early combined enteral and parenteral nutrition in a cardiothoracic surgical population.2 In that study, there was a decreased rate of death among patients in the intensive care unit (ICU) who received intensive insulin therapy. Subsequent studies have not been able to replicate these data but have differed in their methodology and in their ability to achieve metabolic control among patients. In the recent Normoglycemia in Intensive Care Evaluation–Survival Using Glucose Algorithm Regulation (NICE-SUGAR) study,3 the concept of intensive insulin therapy is not in doubt; rather, the implementation of this treatment approach is problematic.4 We address these issues within the therapeutic approach of “intensive metabolic support,” in which both intensive insulin therapy and early combined enteral and parenteral nutrition are necessary.5
Corey S. Scurlock, M.D.
Jayashree Raikhelkar, M.D.
Jeffrey Mechanick, M.D.
Mount Sinai School of Medicine, New York, NY
corey.scurlock@mountsinai. org Dr. Scurlock reports receiving a lecture fee from Select Medical. No other potential conflict of interest relevant to this letter was reported.
5 References1
Ziegler TR . Parenteral nutrition in the critically ill patient. N Engl J Med 2009;361:1088-1097
Full Text | Web of Science | Medline2
van den Berghe G ,Wouters P ,Weekers F , et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001;345:1359-1367
Full Text | Web of Science | Medline3
The NICE-SUGAR Study Investigators
Full Text | Web of Science | Medline4
Van den Berghe G ,Schetz M ,Vlasselaers D , et al. Intensive insulin therapy in critically ill patients: NICE-SUGAR or Leuven blood glucose target? J Clin Endocrinol Metab 2009;94:3163-3170
CrossRef | Web of Science | Medline5
Scurlock C ,Raikhelkar J ,Mechanick JI . Intensive metabolic support: evolution and revolution. Endocr Pract 2008;14:1047-1054
Medline
To the Editor:
Ziegler well summarizes the major issues regarding parenteral nutrition in the critically ill patient. In the presented case, however, no recommendation is made regarding the type of intravenous lipid emulsion the patient should receive. Influencing this field are novel insights that fish oil–based intravenous lipid emulsions may be less harmful than soybean oil–based emulsions, especially with an increased duration of parenteral nutrition.1
Since 2004, we have treated more than 125 children who have intestinal failure and cholestasis with a fish oil–based emulsion under a compassionate-use protocol. We have recently shown the safety and efficacy of fish oil monotherapy in the treatment of liver disease associated with parenteral nutrition.2 Children receiving a fish oil–based emulsion had a lower overall rate of bloodstream infections than did children who received the conventional soybean oil–based emulsion (Table 1Table 1
Infections in Children Receiving Intravenous Lipid Emulsion Containing Either Fish Oil or Soybean Oil during Parenteral Nutrition.). In addition, a recent systematic review showed that fish oil supplementation significantly improved the outcomes of critically ill patients.3 The n−3 fatty acid metabolites that are present in fish oil have antiinflammatory properties4 and may thus potentially benefit the critically ill patient.Vincent E. de Meijer, M.D.
Kathleen M. Gura, Pharm.D., B.C.N.S.P.
Mark Puder, M.D., Ph.D.
Children's Hospital Boston, Boston, MA
mark.puder@childrens. harvard. edu Drs. Gura and Puder report being named on a patent application for the use of Omegaven in the treatment of liver disease associated with parenteral nutrition, which was filed on their behalf by Children's Hospital Boston. No other potential conflict of interest relevant to this letter was reported.
4 References1
de Meijer VE ,Gura KM ,Le HD ,Meisel JA ,Puder M . Fish oil-based lipid emulsions prevent and reverse parenteral nutrition-associated liver disease: the Boston experience. JPEN J Parenter Enteral Nutr 2009;33:541-547
CrossRef | Web of Science | Medline2
Puder M ,Valim C ,Meisel JA , et al. Parenteral fish oil improves outcomes in patients with parenteral nutrition-associated liver injury. Ann Surg 2009;250:395-402
Web of Science | Medline3
Marik PE ,Zaloga GP . Immunonutrition in critically ill patients: a systematic review and analysis of the literature. Intensive Care Med 2008;34:1980-1990
CrossRef | Web of Science | Medline4
Calder PC . n-3 Fatty acids, inflammation, and immunity -- relevance to postsurgical and critically ill patients. Lipids 2004;39:1147-1161
CrossRef | Web of Science | Medline
To the Editor:
Ziegler does not mention the drugs propofol and clevidipine as caloric sources. Propofol is one of the most widely used sedatives in the ICU worldwide.1,2 It is formulated as an emulsion in a phospholipid vehicle, providing 1.1 kcal per milliliter from fat.3 Clevidipine is a dihydropyridine calcium-channel blocker that is also formulated as a lipid emulsion, providing 2 kcal per milliliter from fat.4 Calories that are infused from propofol and clevidipine can be considerable over a 24-hour period, and a large-dose infusion of either agent alone can provide the entire daily lipid needs for a patient in the ICU. Clinicians should account for lipid calories from propofol and clevidipine when calculating the nutrition-support regimen and monitor patients receiving these medications to avoid overfeeding.
Bryan Dotson, Pharm.D.
Steven D. Tennenberg, M.D.
Harper University Hospital, Detroit, MI
bdotson@dmc.org No potential conflict of interest relevant to this letter was reported.
4 References1
Arroliga A ,Frutos-Vivar F ,Hall J , et al. Use of sedatives and neuromuscular blockers in a cohort of patients receiving mechanical ventilation. Chest 2005;128:496-506
CrossRef | Web of Science | Medline2
Soliman HM ,Melot C ,Vincent JL . Sedative and analgesic practice in the intensive care unit: the results of a European survey. Br J Anaesth 2001;87:186-192
CrossRef | Web of Science | Medline3
Jacobi J ,Fraser GL ,Coursin DB , et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002;30:119-141
CrossRef | Web of Science | Medline4
Kenyon KW . Clevidipine: an ultra short-acting calcium channel antagonist for acute hypertension. Ann Pharmacother 2009;43:1258-1265
CrossRef | Web of Science | Medline
To the Editor:
With regard to complications associated with the use of central venous catheters, Ziegler does not discuss ultrasonography-guided catheter placement, which is now routinely and widely used. Many studies1-4 have been published about this technique, with data showing a reduction in adverse events. In addition, in our own unpublished study, which was based on data from a dedicated vascular access service, we compared long-term placement of central venous catheters with the use of either the landmark technique or the ultrasonography-guided technique. We observed a reduction in adverse effects, including procedural complications, the number of attempts at placement, and late complications, with the ultrasonography-guided technique (Table 1Table 1
Comparison of Rates of Surgical and Late Complications in the Placement of a Central Venous Catheter with or without Ultrasonography.).Adriano Peris, M.D.
Simona di Valvasone, M.D.
Giovanni Zagli, M.D.
Careggi Teaching Hospital, Florence, ItalyNo potential conflict of interest relevant to this letter was reported.
4 References1
McGee DC ,Gould MK . Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-1133
Full Text | Web of Science | Medline2
Galloway S ,Bodenham A . Long-term central venous access. Br J Anaesth 2004;92:722-734
CrossRef | Web of Science | Medline3
Feller-Kopman D . Ultrasound-guided internal jugular access: a proposed standardized approach and implications for training and practice. Chest 2007;132:302-309
CrossRef | Web of Science | Medline4
Randolph AG ,Cook DJ ,Gonzales CA ,Pribble CG . Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Crit Care Med 1996;24:2053-2058
CrossRef | Web of Science | Medline
To the Editor:
In an otherwise excellent review, Ziegler unfortunately perpetuates the myth that protein intake should be restricted in patients with hepatic encephalopathy. He cites no evidence to support this statement. Indeed, in his reference list are the 2009 nutrition support guidelines of the Society of Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition,1 the 2006 enteral guidelines of the European Society for Parenteral and Enteral Nutrition (ESPEN),2 and the ESPEN 2009 parenteral guidelines,3 all of which explicitly recommend that protein intake not be restricted in patients with liver disease, including those with encephalopathy. Since malnutrition is very common in this vulnerable group of patients, who are prone to catabolism and the deleterious effects of body protein loss, such a selective use of these guidelines is regrettable.
Suzie Ferrie, R.D., C.N.S.C.
Royal Prince Alfred Hospital, Camperdown, NSW, Australia
suzie.ferrie@sswahs. nsw. gov. au No potential conflict of interest relevant to this letter was reported.
3 References1
McClave SA ,Martindale RG ,Vanek VW , et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). JPEN J Parenter Enteral Nutr 2009;33:277-316
CrossRef | Web of Science | Medline2
Plauth M ,Cabre E ,Riggio O , et al. ESPEN guidelines on enteral nutrition: liver disease. Clin Nutr 2006;25:285-294
CrossRef | Web of Science | Medline3
Plauth M ,Cabre E ,Campillo B , et al. ESPEN guidelines on parenteral nutrition: hepatology. Clin Nutr 2009;28:436-444
CrossRef | Web of Science | Medline
Author/Editor Response
Scurlock et al. and others1 suggest that different approaches to nutritional support in recent large trials of intensive insulin therapy in patients in the ICU may have played a role in the differential efficacy results observed. It remains unclear whether the benefits to surgical patients in the ICU were due to the negation of potential deleterious effects of early feeding by the use of intensive insulin therapy or, as suggested by Bistrian,2 whether early and adequate feeding was an essential component of the efficacy of intensive insulin therapy. The efficacy of the therapeutic approach of early and adequate nutritional support, in combination with intensive insulin therapy, remains to be determined in ongoing randomized clinical trials (ClinicalTrials.gov numbers, NCT00512122, NCT00248638, and NCT00802503).
De Meijer et al. suggest the efficacy of intravenous fish oil in pediatric patients with the short-bowel syndrome and subsequent cholestasis who are dependent on parenteral nutrition. In critically ill adults, adequately powered, double-blind, randomized clinical trials evaluating the efficacy of intravenous fish oil infusions given as a component of parenteral nutrition are few, and the results to date are mixed.3 Detailed commentary on this issue was beyond the scope of my article.
I agree with Dotson and Tennenberg that substantial intravenous calories may accrue from propofol and clevidipine, which are commonly used in the ICU. Thus, the estimated daily caloric load from these agents (as well as the administered calories from dextrose-containing intravenous fluids) needs to be monitored and the dextrose and lipid calories from parenteral nutrition appropriately adjusted on a day-to-day basis to avoid overfeeding.
Peris et al. show data suggesting that real-time ultrasonography-guided placement of a central venous catheter is associated with significantly reduced adverse effects, as compared with “blind” methods, as recommended in recent European clinical practice guidelines.4
In response to Ferrie: European clinical practice guidelines suggesting that protein intake need not be restricted in patients with encephalopathy are based on a grade C recommendation (i.e., expert opinion or clinical experience) and on an unblinded study of enteral diet in patients who were not in the ICU.5 Clinical practice guidelines are not written as absolute requirements but rather offer recommendations on the basis of available published data and expert opinion. Thus, it is inevitable that recommendations for specific aspects of nutritional support differ between recent American guidelines and European guidelines. We have adopted the conservative approach of limiting the dose of protein or amino acids, at least for several days, in such patients to diminish the effect of this potential contributor during diagnostic evaluation.
Thomas Ziegler, M.D.
Emory University School of Medicine, Atlanta, GA
tzieg01@emory.edu Since publication of his article, the author reports no further potential conflict of interest.
5 References1
Van den Berghe G ,Schetz M ,Vlasselaers D , et al. Intensive insulin therapy in critically ill patients: NICE-SUGAR or Leuven blood glucose target? J Clin Endocrinol Metab 2009;94:3163-3170
CrossRef | Web of Science | Medline2
Bistrian BR . Tight glucose control in critically ill adults. JAMA 2008;300:2726-2726
CrossRef | Web of Science | Medline3
Friesecke S ,Lotze C ,Kohler J ,Heinrich A ,Felix SB ,Abel P . Fish oil supplementation in the parenteral nutrition of critically ill medical patients: a randomised controlled trial. Intensive Care Med 2008;34:1411-1420
CrossRef | Web of Science | Medline4
Pittiruti M ,Hamilton H ,Biffi R ,MacFie J ,Pertkiewicz M . ESPEN Guidelines on Parenteral Nutrition: central venous catheters (access, care, diagnosis and therapy of complications). Clin Nutr 2009;28:365-377
CrossRef | Web of Science | Medline5
Cordoba J ,Lopez-Hellin J ,Planas M , et al. Normal protein diet for episodic hepatic encephalopathy: results of a randomized study. J Hepatol 2004;41:38-43
CrossRef | Web of Science | Medline
- Citing Articles (1)
Citing Articles
1
Jeffrey I Mechanick, Mette M Berger. (2011) Have the metabolic support pendulums in the intensive care unit stopped swinging?. Current Opinion in Clinical Nutrition and Metabolic Care 14:2, 168-170
CrossRef
