Newsletter

[ Vol. 12 No. 2 ] (May - August 2011 )
Parenteral nutrition is a potion

Gil Hardy
Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand

A POTION IS A CONCOCTION THAT HEALS
Pioneers such as Dr Sriram demonstrated that PN heals and sustains life for home patients or the immature neonate. Complications are preventable by not overfeeding and immunosuppression is attenuated by Glutamine. There is no longer a causal link between catheter infections and mortality with good practice guidelines, specialist nurses and improved line management.

DOES EN DELIVER WITHOUT PROBLEMS?
Some with blind faith in EN believe PN is dangerous. They incorrectly equated PN with poison but it remains invaluable therapy for gut failure. EN delivers only 46-51% whereas combined EN/PN achieves 63% of nutrition targets. Upper digestive intolerance can be associated with pneumonia, longer ICU stay and increased risk of death with EN. Meta-analysis confirms that EN does carry a lower infective risk, but at the cost of a non-significant trend towards increased complications, with no mortality advantage. Immuno-EN is worse than PN, with higher ICU mortality in severe sepsis.

DOES PN INCREASE RISK WITHOUT ADDED PATIENT BENEFIT?
PN is not without risks, but ICU is a safe environment for risky procedures with experienced staff to prevent complications. New amino acids, anti-inflammatory Fish or Olive Oil emulsions for stable All-in-One formulations are now available. Best practice recommends including Glutamine for lower incidence of catheter infections, and improved survival of patients with Candida infections. 

CAN PN BE SAFER THAN EN?
A pragmatic UK study found no difference in septic morbidity, but EN had higher non-septic complications and the mortality risk of EN exceeded PN. In the Cochrane meta-analysis for pancreatitis, differences between EN and PN do not achieve significance. 

CONCLUSION
PN is a life-saving potion. We should consider Glutamine and Olive Oil-containing All-in-One mixtures and follow guidelines of best practice before we draw negative comparisons between EN and PN. Not prescribing PN when EN fails will increase mortality.

From  
PENSA 2009
“Energizing Nutrition Support Practice for Life”
June 5-7 2009, Shangri-La Hotel, Kuala Lumpur, Malaysia 
Page: 47