PRESIDENT’S WELCOME:
Welcome to all of our new and current G.A.S.P.E.N. members!
The G.A.S.P.E.N. board is very excited about our programming this year. We are committed to providing nutrition support education and programming across all disciplines. G.A.S.P.E.N.’s summer meeting was held in June at Saint Joseph’s Hospital of Atlanta. Our presenters discussed Ethical Considerations in Nutrition Support, reviewed an article on parenteral fish oil emulsions in critical illness from JPEN, and discussed new and exciting data regarding novel parenteral fat emulsions. A summary of the JPEN article can be found on page 3 of our newsletter. Thank you to our speakers, Azy Armaghan, PharmD, BCNSP, Khatija Jivani, PharmD, and Mary Hise from Baxter for sharing their expertise with us!
In this newsletter we are introducing our survey about providing nutrition support to critically ill patients with obesity. Please see page 4 of the newsletter for our rationale for designing this survey. Many thanks to Andy Evans, RD, MBA for his research and design of the survey! We will be sending out this survey as a Survey Monkey in September or October and will publish the results in our next newsletter. Please take a moment to fill out the survey in order to help us better understand how we are feeding this unique and complicated patient population. Two PGY1 residents from Atlanta Medical Center, Jessica Williams, PharmD and Tabitha McWhorter, PharmD, have summarized an article recently published in Nutrition in Clinical Practice on the micronutrient needs of the elderly. Please see page 8 for this excellent summary of an important topic. I would like to thank Khatija Jivani, our newsletter editor, and all who have contributed articles to this issue of the newsletter. If you would like to publish an article in future editions of the G.A.S.P.E.N. newsletter please contact Khatija Jivani at khatija.shroff@emoryhealthcare.org or Adina Hirsch at adina.hirsch05@gmail.com.
At GASPEN, we strive to provide our members with ongoing educational opportunities and we plan to host another CE event in the near future. Stay tuned for details. Also, early registration for ASPEN’s Clinical Nutrition Week ends on November 15, 2014,
so remember to sign up early!
Wishing all of you a wonderful Fall!
- Adina
Brief Summary of Parenteral Fish Oil Lipid Emulsions in the Critically Ill: A systematic Review and Meta-Analysis
By Khatija Jivani, PharmD
Background
Parenteral lipid emulsions are a dense source of energy and a source of essential fatty acids. The addition of fatty acids to a parenteral nutrition regimen has helped clinicians avoid metabolic complications, such as dextrose-overfeeding. Fatty acids contain many active immunologic properties which can be very significant during critical illness, and this has raised many questions regarding the use of intravenous lipid emulsions (IVLE) in critically ill patients. Lipid emulsions commonly used in critically ill patients are typically rich in long-chain triglycerides (LCTs), especially linoleic acid (omega-6 polyunsaturated fatty acid). Different alternative oil-based IVLEs have been developed over the past few decades which are “soybean-sparing” and contain fish oil (FO), olive oil, and medium-chain triglycerides. Current literature suggests that soybean-containing lipid emulsions may promote production of pro-inflammatory metabolites leading to oxidative stress, which may adversely affect clinical outcomes in a critically ill patient. It is believed that immunomodulation with the omega-3 fatty acids may down regulate these inflammatory mediators and produce an anti-inflammatory effect. Recently, Manzanares et al published a meta-analysis and systematic review on the use of parenteral fish oils in the critically ill, and the purpose of this article was to provide an up-to-date review of all randomized controlled trials of FO-containing IVLEs on relevant clinical outcomes in critically ill patients.
Methods and Outcomes
Authors searched for randomized clinical trials from 1980 to May 2012 which contained keywords such as ‘nutritional support,’ ‘omega 3 fatty acids,’ ‘critically illness,’ etc. They limited the studies to those conducted in critically ill adults and studies with outcomes on mortality, length of stay, and infectious complications. Primary outcome was defined as overall mortality, including hospital mortality, intensive care unit (ICU) mortality, and 28-day mortality. Secondary outcomes included infectious complications and hospital and ICU length of stay. The authors reviewed 44 citations from their search and included six studies in their systematic review and meta-analysis based on the inclusion and exclusion criteria. A p-value of < 0.05 was considered significant and < 0.2 was considered a trend.
Results and Conclusions
Five of the six trials reviewed in the article showed that FO-containing lipid emulsions were associated with a trend toward a reduction in mortality (p = 0.08), which was the primary outcome, and a trend toward a reduction in the duration of mechanical ventilation days (p = 0.17). No difference was seen in reduction of infectious complications or ICU length of stay. The authors concluded that FO-containing lipid emulsions may be associated with a tendency to reduce mortality and ventilation days in the critically ill, but there is insufficient evidence to recommend supplementation with omega-3 FAs in this patient population.
Strength and Weaknesses
The authors provided a comprehensive literature search with specific criteria to reduce bias. They also focused on clinically important primary outcomes in ICU patients such as mortality, length of stay, and infectious complications. Due to a small study size, large p-values and non-significance could be due to lack of power. Markers of inflammation, such as C - reactive protein and erythrocyte sedimentation rate, were not measured. Fish oil emulsions were used as a supplementation to omega-6-containing lipid emulsions so patients were still (theoretically) producing pro-inflammatory metabolites. At this time, more trials are needed before definitive recommendations can be made regarding fish oil IVLE.
Complete article can be found at http://pen.sagepub.com/content/38/1/20.full.
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