Hospital Pharmacy - December 2020 - 379

Dickerson et al
(64%) and mechanically ventilated for greater than 48
hours (92%). The mean age for the population was 60
years with a mean APACHE II score of 23, and a mean
BMI of 27.3 kg/m2. Patients were categorized by the
fraction of calculated caloric target achieved during the
first 11 days after ICU admission (category 1 severely
hypocaloric: <30%; category II mildly hypocaloric:
30% to 70%; category III near target calorie intake:
>70%). Daily caloric targets were determined by any
strategy selected by the treating physician. The median
fraction of calculated caloric target achieved and daily
calorie intake via enteral or parenteral nutrition in categories I, II, and III were 4.3%, 1 kcal/kg; 52.3%,
12.3 kcal/kg; and 100%, 23.5 kcal/kg, respectively. The
overall in-hospital mortality rate was 20.4% after 96
hours but within 30 days of ICU admission. The investigators compared hazard ratios for the 30-day risk of
dying for different categories of daily calorie intake
achieved early (Day 1-11) or delayed (Day 5-11) from
ICU admission. Early or delayed mildly hypocaloric
nutrition was associated with a decreased risk of death
compared to severely hypocaloric nutrition. In the heterogenous critically ill study population, the risk of
death was not further reduced with early or delayed
near target calorie intake compared to early, mildly
hypocaloric nutrition.
This study poses an important clinical question
regarding the impact of caloric intake on short-term survival in critically ill patients, but study limitations make
interpretation of the investigators' findings difficult.
Given the large heterogenous population and retrospective design, it is challenging to determine the association
between daily caloric intake and patient survival. Since
the patients were retrospectively divided into tertiles, it is
possible that some patients received less calories than
others due to issues such as severity of illness, EN intolerance, and hyperglycemia. Additionally, while there
was a correlation between the daily caloric intake and
protein provided by nutrition support (r ¼ .89), the detail
regarding protein intake was limited. Without all regimens designed to maintain a fixed nonprotein calories to
nitrogen ratio, it is unlikely that all patients in each
tertile received the same amount of protein. This is a
major confounder in the study because protein may
have a greater impact on outcomes than calories in critical illness. Clinicians should be aware that critically ill
patient subpopulations may have different calorie and
protein requirements for optimal outcomes. Based on
subgroup analyses, surgical patients and patients with
high acute physiology and chronic health evaluation
(APACHE) II scores were generally less responsive to
caloric intake than the entire cohort. Furthermore,
body weight may modify nutrition effects (ie, obese
patients may need less and underweight may need
more calories). Future prospective studies need to

379
address the impact of caloric intake in critically ill
patient subpopulations, including consideration of nutritional risk.
6. Ong et al.11 Intravenous Fish Oil and Serum Fatty
Acid Profiles in Pediatric Patients with Intestinal
Failure-Associated Liver Disease
FO contains a small amount of essential fatty acids
(linoleic and a-linolenic acids) and there is concern that a
FO-ILE can cause an EFAD. This observational study
evaluated 47 pediatric patients (median age of 3.6
months at the start of FO; interquartile range 2.4 to
9.6 months) with intestinal failure and cholestasis who
were receiving FO-based ILE at a dose of 1 g/kg/d
during a 6-month treatment course. Patients were also
required to have 2 serial serum fatty acid profile measurements to meet inclusion criteria and were excluded if
they received an oral FO supplement or had a liver
transplant. The study objective was to quantify the risk
for abnormal fatty acid concentrations in children
treated with FO-ILE. During the study period, a-linolenic, arachidonic, and eicosatrienoic (mead) acid values
decreased while docosahexaenoic and eicosapentaenoic
acid increased (P < .001 for all). The triene-tetraene
ratios for all patients remained unchanged (mean
ratio ¼ 0.02, P ¼ 1) but patients were 1.8 times more
likely to develop a low linoleic acid concentration
while receiving FO-ILE versus historic SO-ILE (95%
CI: 1.4-2.3, P < .01) and 1.6 times more likely to develop
high docosahexaenoic acid concentration while receiving
FO-ILE versus historic SO-ILE (95% CI: 0.9-2.6,
P ¼ .08). While an observed decrease in essential fatty
acid concentrations was observed, EFAD, defined as
either an overall triene-tetraene ratio > 0.2 for all age
groups or as varying ranges including values < 0.2
dependent on age-specific triene-tetraene ratios, was
not observed.
This study is limited by small sample size, observational design, absence of a comparator group, various
levels of prematurity among the population, potential
variability in malabsorption, and a limited number of
time points evaluated (ie, baseline, 3 months, and 6
months). Data may also be confounded by an increase
in EN, approximately 5% of total daily caloric intake at
the beginning of the study versus approximately 29% at
the end of the study, which may impact fatty acid level
provision throughout the study period. However, all
patients remained on PN with FO-ILE throughout the
study period. The age-specific triene-tetraene ratios utilized for EFAD determination were developed based on
limited sample sizes therefore more research in the diagnosis of EFAD is needed. Based on this study's findings,
provision of 1 g/kg/day of FO-ILE is not associated with
EFAD but differences in the level of individual fatty

Hospital Pharmacy - December 2020

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