Total Parenteral Nutrition
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Future developments in total
David F Driscoll, PhD
In this series we have described the state of the art regarding total parenteral nutrition (TPN). Here I
present my thoughts on where the field will go.
dvances in this therapy Recently, great strides have been made in ill patient with significant end-organ or
A will likely not be so much
related to the introduction
of new or novel nutrients,
but rather will be made in
refining the delivery of this important
medical therapy. Future innovations will
most likely be in enhancements in ana-
the area of focused metabolic management,
particularly with respect to identifying the
connection between glucose homeostasis
and adverse clinical outcomes during TPN
therapy. Excessive parenteral glucose has
been shown to lead to significant morbidi-
ty and mortality in the intensive-care unit
multi-organ dysfunction. Part of the histori-
cal problems we have witnessed have result-
ed from the failure to treat TPN in terms of
dosing, as we would with antibiotics and
other drug therapies. This probably con-
tributes to many significant nutrition-related
complications reported, such as infection,
lytical techniques to elucidate molecular as shown in the seminal work of Van den increased time on mechanical ventilators
mechanisms of action of substances Berghe, et al . It is important to define and acid-base disturbances. And remember
such as glutamine and long-chain fatty the blood glucose level, since intensive that TPN is administered without the “phys-
acids. Improvements in safety are also insulin management is required, but further iological brake” of a response from the gas-
likely to be significant, as well as the work is needed to achieve safer practice. In trointestinal tract. Enteral nutrition is often
adoption and subsequent refinement of the intensive-care unit, TPN therapy should limited by GI intolerance, a physiological
nutritional guidelines. I see three fertile largely be directed at supporting the meta- adaptation that often reduces over-treatment.
areas for research: lipid emulsions, bolic response to injury rather than provid-
focused metabolic management, and ing full nutritional support during acute It is time for pharmacists to answer the
improved pharmaceutical safety. metabolic stress. One approach is to meet calls to make TPN therapy safer for the
the protein needs of the patient, but to do so patients we serve.
Presently, several lipid emulsions are in a hypocaloric manner until the inflam-
commercially available that contain long- matory response remits or metabolic stress Author
chain, based on soybean, safflower, is significantly less. It is laudable that both David F Driscoll, PhD
olive and fish oils; as well as medium- the European and the American societies Assistant Professor of Medicine
chain triglycerides (MCT). Some exist for parenteral and enteral nutrition Harvard Medical School
as single-oil entities using soybean and (ESPEN, ASPEN) have produced par- Boston, MA 02215, USA
fish oils, while others are available in enteral nutrient intake guidelines for adults firstname.lastname@example.org
various oil mixtures including soy- and infants [3, 4]. Ideally these guide-
bean-safflower, soybean-MCT, soy- lines should be unified and additional References
bean-olive, soybean-MCT-fish and nutrient strategies added for complex situa- 1. Driscoll DF. Lipid injectable emulsions:
soybean-MCT-fish-olive oil emulsions. tions during critical illness. 2006. Nutr Clin Pract. 2006;21:381-6.
Not only are these formulations indi- 2. Van den Berghe G, Wouters P, Weekers F, et
al. Intensive insulin therapy in critically ill
cated as a source of energy, but several Finally, and near and dear to the hearts of
patients. N Engl J Med. 2001;345(2):139-67.
oils have potentially important phar- pharmacists, there should be significant 3. ASPEN Board of Directors, Task Force for
macological actions that may be bene- improvements in the pharmaceutical safety the Revision of Safe Practices for Parenteral
ficial in certain patients. The best of the parenteral admixture. Pharmaco- Nutrition. J Parenter Ent Nutr. 2004;28(6):
dose/oil combination has yet to be poeial methods of analysing compatibility S39-S70.
found, but clearly there are possible and stability issues in TPN admixtures 4. Guidelines on Paediatric Parenteral and
benefits such as a reduction in the sys- should be applied whenever possible to Enteral Nutrition. J Pediatr Gastro Nutr.
temic inflammatory response during standardise the approach and hence results
5. Driscoll DF. Stability and compatibility
acute illness, reduced TPN-associated from such studies . To summarise, we assessment techniques for total parenteral
liver disease in infants, as well as treat- need to do a better job in defining the best nutrition admixtures: setting the bar accor-
ment of liver disease in patients on doses of nutrients for various patient condi- ding to pharmacopeial standards. Curr Opin
long-term TPN at home . tions. The real challenge is in the critically in Clin Nutr Metab Care. 2005;8(3):297-303.
• Volume 14 • 2008/3 EJHP is the Official Journal of the European Association of Hospital Pharmacists (EAHP) www.ejhp.eu 47