Death by parenteral nutrition

Excerpt

Sir: We thank the authors for their thoughtful and considered views on the use of TPN in the critically ill patient. We fully understand that our strong opposition to the use of this time-honored treatment would induce anxiety from many clinicians. However, the authors provide no data which demonstrate in critically ill patients, that TPN is both safe and efficacious in reducing mortality and morbidity as compared to starvation or to enteral nutrition. Undoubtedly, the introduction of TPN in 1968 was life-saving for those patients with short gut syndrome in whom enteral nutrition was not possible. However, the availability of this new therapeutic intervention led to its indiscriminate use in many disease processes without an appropriate evaluation on its impact on clinical outcome. It soon became clear that TPN was associated with a myriad of complications and was not the panacea as first imagined. Furthermore, the beneficial effects of providing nutrition via the enteral route became well-established. A review of the large body of published scientific data clearly and unambiguously demonstrates that the gut is the preferred route of nutritional support in patients with an intact intestinal tract. Indeed, the earlier enteral nutritional support is initiated in hospitalized patients the better the outcome. TPN is only indicated in that small group of patients in whom enteral nutrition is not possible. In a landmark study, Ochoa and colleagues demonstrated a 78% reduction in the use of TPN with the introduction of a nutrition support service [1]. In this study the reduction in the use of TPN was associated with a dramatic increase in the number of patients who were fed enterally (see Fig. 1). The study by Ochoa and colleagues supports our contention that most patients who receive TPN can be fed enterally. TPN should be viewed in the same light as Class I anti-arrhythmic drugs which were used indiscriminately in patients with cardiac disease until their toxicity was appreciated [2]. TPN, like Class I anti-arrhythmic drugs, is, however, still indicated in a select groups of patients in whom their benefit may out-way the potential risks.

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