Hospital Pharmacy - June 2017 - 418

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Hospital Pharmacy 52(6)

complications of PN. Cost-effectiveness and ease of access
were not assessed in this meta-analysis, but these factors in
combination with the reduction in ICU LOS with EN support
the use of the enteral route. Therefore, the interpretation of
this meta-analysis should be affirmation of guideline recommendations to preferentially use EN in critically ill adult
patients with functional gastrointestinal tracts.16
8.

Olthof et al. No clinical or biochemical evidence for
essential fatty acid deficiency in home patients who
depend on long-term mixed olive oil- and soybean
oil-based parenteral nutrition.7

The objective of this study was to determine whether
essential fatty acid (EFA) intake was adequate in long-term
patients who are dependent on HPN utilizing an 80% olive
oil/20% soybean oil LE. Thirty adult patients with short
bowel syndrome or a gastrointestinal motility disorder who
received the mixed olive oil-soybean oil emulsion at a dose
of 0.97 g/kg/d as part of the required HPN for 5 to 7 days per
week for 3 months were evaluated. The lipid profiles of the
HPN patients were compared with 30 sex- and age-matched
healthy controls.
The investigators demonstrated that the triene (eicosatrienoic or mead acid)/tetraene (arachidonic acid) ratio (a biochemical marker for evidence of EFA deficiency) was
significantly higher in HPN patients compared with controls
(0.019 vs 0.015, respectively) but remained well below the
upper limit of the normal range (0.2). None of the HPN
patients exhibited other evidence (eg, skin lesions or innate
immune cell dysfunction) of EFA deficiency. Other studies
that employed the use of olive oil/soybean oil LE in PN
patients have also demonstrated the efficacy of this alternative LE in prevention of EFA deficiency.46,47
It is important to consider the dosage of EFA when evaluating adequacy of the parenteral lipid intake as soybean oil
and olive oil have differing EFA content. The amounts of
linoleic acid (LA) and alpha-linolenic acid (ALA) in soybean
oil are approximately 53% and 8%, respectively, compared
with 80% olive oil/20% soybean oil LE with 19% and 2.5%
LA and ALA content, respectively. Thus, the mixed olivesoybean oil-based product has a notable 65% reduction in
EFA amounts. Estimated intakes of the EFAs, LA, and ALA
were 0.17 and 0.02 g/kg/day for patients in this study, respectively. These daily doses of the EFAs would be considered
adequate for HPN patients weighing 50 kg or more.48
In summary, alternative LEs appear to provide adequate
EFAs when given 4 to 7 days per week (~1-1.3 g/kg/d) in longterm patients.7,49 This is in contrast to use of 100% soybean LE
whereby minimal doses of 500 mL of 20% emulsion weekly48
and 5 to 10 g daily50 have been shown to prevent EFA deficiency. Unfortunately, this alternative LE product, despite
approval by the FDA in 2013, is currently not commercially
available in the United States. Only a 100% soybean oil and a
30% soybean oil, 30% medium chain triglycerides, 25% olive

oil, and 15% fish oil LE are available for use in the United
States. Clinicians must recall this dosage difference in commercially available LEs for prevention of EFA deficiency
especially if the patients are unable to adequately absorb
enteral sources of fat.
9.

Yeh et al. Adequate nutrition may get you home:
effect of caloric/protein deficits on the discharge destination of critically ill surgical patients.9

The objective of this study was to determine whether adequate nutrition intake during ICU stay was associated with
discharge destination to home or nonhome in critically ill surgical patients. This was a prospective, observational cohort
study in adult patients admitted to the surgical ICU who
received EN for at least 72 hours. Patients continued in the
study until either ICU discharge, receipt of 14 consecutive
days of EN, achievement of sustained oral intake, or death.
Caloric and protein goals were 25 to 30 kcal/kg/day and 1.5 to
2 g/kg/day, respectively. Caloric and protein deficits were
determined by calculation of actual daily intakes from goal
intakes. Each patient was stratified as either high (≥6000
kcal) or low (<6000 kcal) total caloric deficit and high (≥300
g) or low (<300 g) protein deficit for comparison.
A total of 213 patients (mean age of 63 years, BMI of 25.6
kg/m2, and APACHE II score of 14) were studied. Most
patients (n = 141) were designated as low deficit for both
calories and protein. Patients in high total caloric and high
protein deficit groups received EN for a significantly greater
number of days (14 vs 7 and 14 vs 6 for caloric and protein
deficit groups, respectively, P < .0001 for both). Thirty-three
patients (15%) were discharged to home. On univariant analysis, the researchers found that a high macronutrient deficit
was associated with less favorable discharge disposition (OR
of 0.25 for caloric deficit and OR of 0.30 for protein deficit).
High macronutrient deficit was also found to significantly
decrease 28-day ventilator-free days (14 vs 22, P < .001),
lead to more complications (3 vs 1, P < .001), longer ICU
LOS (20 vs 10 and 23 vs 10 days for caloric and protein deficit groups, respectively, P < .001 for both), and longer hospital LOS (33 vs 21 and 35 vs 20 days for caloric and protein
deficit groups, respectively, P < .001 for both). The researchers concluded that inadequate nutrient delivery was associated with lower rates of discharge to home and that adequate
nutrition delivery may lead to favorable clinical outcomes
after critical illness in surgical ICU patients.
This is the first trial to look at both caloric and protein deficits as it relates specifically to discharge disposition in surgical ICU patients. Other trials have focused on the effects of
caloric deficits on traditional in-hospital, short-term outcomes
such as mortality, complications, and LOS. Results of such
trials have been mixed with some showing positive outcomes
related to adequate nutrition intake51-53 and others suggesting
adequate or aggressive nutrition delivery resulting in a lack of
benefit or potential harm.34,54-56 Reasons for these differing

Table of Contents for the Digital Edition of Hospital Pharmacy - June 2017