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Dickerson et al
outcomes include patient selection, method of nutrition delivery, lack of study participants to meet predefined nutritional
goals, unknown baseline nutritional status, small number of
patients discharged to home, observational design, and single
study site leading to possible skewed results and reduced
external validity. In summary, while it appears that limiting
the total caloric and protein deficits provide a better chance of
discharge to home, reduction in LOS, complications, and
time requiring mechanical ventilation, large interventionbased trials are needed to fully address this question.
10. Ziegler et al. Efficacy and safety of glutamine-supplemented parenteral nutrition in surgical ICU
patients: an American multicenter randomized controlled trial.10
The purpose of this study was to evaluate whether PN
supplemented with glutamine (GLN) dipeptide improves
clinical outcomes in surgical ICU patients using a prospective, randomized, controlled, double-blind, parallel-group,
intent-to-treat, multicenter study design. A total of 150 adult
patients who were <14 days postoperative following cardiac,
vascular (nonneurologic), esophageal, gastric, or intestinal
surgery and expected to require PN for ≥7 days were enrolled.
Energy and protein goals were 1.3 times basal energy expenditure and 1.5 g/kg/d, respectively. Soybean oil-based fat
emulsion was provided daily as a separate infusion and was
dosed to provide 30% of the nonprotein calories. EN (tube
feeding and oral diet) was utilized, as indicated, and the
amount of PN was proportionally decreased. Tube feeding
formulas were not GLN- or arginine-enriched. The study PN
was continued up to 28 days or discontinued when the patient
received >50% of caloric intake goal via EN for a consecutive 48-hour period. Patients were randomized to receive
standard PN (STD-PN) utilizing conventional amino acids,
or GLN-supplemented PN (GLN-PN) utilizing 20% alanylGLN-dipeptide (0.5 g/kg/d) and conventional amino acids (1
g/kg/d). The groups were similar in baseline characteristics
and daily nutrient intakes via PN and EN. There were no differences between the STD-PN and GLN-PN groups for the
total number of new health care-associated infections or
6-month cumulative mortality. Adverse events and other
clinical outcomes were similar between groups.
The results of this study are disappointing given the existence of published research in critically ill patients that have
suggested metabolic and clinical benefits of PN supplemented
with GLN. This study was a rigorous attempt to minimize
heterogeneity by controlling variability between groups, such
as maintaining tight blood glucose control, ensuring nearly
identical intake of protein and calories between groups, and
excluding patients with malignancy, burns, trauma, shock, or
significant renal/hepatic dysfunction. The GLN dosing regimen used appeared to provide an adequate amount based on
achieving significantly increased and sustained plasma GLN
levels above control levels for 14 days, while other studies

have been criticized for not achieving this. It may be plausible
that the lack of effect of GLN was due to the administration of
the dipeptide GLN compound versus the individual amino
acid GLN formulation; however, further research regarding
therapeutic equivalency of the GLN formulations is warranted. Other recent double-blind randomized controlled trials have failed to consistently demonstrate clinical benefits of
GLN-supplemented PN in medical/surgical ICU patients
using intention-to-treat analysis.38,57-59 It is important to note
that GLN-supplemented PN appears to be safe and was not
associated with an increase in adverse events. There may be a
subset of critically ill patients who benefit from GLNsupplemented PN, but available evidence does not support its
use in the surgical intensive care unit patient at this time.

Conclusion
With the large volume of publications pertinent to nutrition
support therapy and appearance in a variety of journals, it
is extremely difficult for the pharmacist engaged in nutrition support practice to stay current with the literature. We
have identified what the author participants consider to be
the "most important" papers from the primary literature to
pharmacy nutrition support practice and provided an additional list of pertinent guidelines, consensus, and recommendation papers from various organizational groups.
Although only those highest ranked articles by a majority
consensus were discussed, other publications may be
important depending on the patient population and the role
of the pharmacist at a specific institution. It is recommended that informed pharmacists, engaged in nutrition
support therapy, be familiar with those articles that are
applicable to their clinical practice. Despite omission from
the "most important" articles collection by this group, it is
also suggested that the list of other articles in the supplemental online document also be reviewed in an effort to
identify those publications that are pertinent to the reader's
practice.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

References
1. Al-Dorzi HM, Albarrak A, Ferwana M, Murad MH, Arabi YM.
Lower versus higher dose of enteral caloric intake in adult critically ill patients: a systematic review and meta-analysis. Crit
Care. 2016;20:358.
2. Anderson C, MacKay M. Physical compatibility of calcium
chloride and sodium glycerophosphate in pediatric parenteral

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