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October 20, 1999

Total Parenteral Nutrition for Critically Ill Patients

Author Affiliations

Margaret A.WinkerMD, Deputy EditorIndividualAuthorPhil B.FontanarosaMD, Interim CoeditorIndividualAuthor

JAMA. 1999;282(15):1423-1425. doi:10-1001/pubs.JAMA-ISSN-0098-7484-282-15-jac90009

To the Editor: The meta-analysis by Heyland and colleagues1 of TPN in the critically ill patient is marred by a major flaw in that the adequacy of the dose of TPN or control enteral nutrition delivered to patients is not assessed. Thus, we cannot tell if TPN did not improve outcomes because it is inherently unable to do so, if the amount of TPN given was inadequate for the energy and protein needs of the patients, or if both TPN and the control intervention (oral diet plus intravenous fluids) provided important and comparable amounts of nutrients. Any meta-analysis of a pharmacologic intervention must consider whether the dose of medication given was correct; the same is necessary for assessment of a nutritional intervention. In the absence of such information, the conclusions of Heyland et al1 regarding the effectiveness of TPN cannot be supported. Maybe inadequate TPN is not useful, but neither is inadequate penicillin for pneumococcal pneumonia. Assessment of nutritional interventions should be subject to the same rigor as any other aspect of evidence-based medicine.

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