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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Recently&#44; several cases requiring the restriction or suppression of intravenous lipid emulsion &#40;ILE&#41; in parenteral nutrition &#40;PN&#41; have been presented in the ICU of our hospital&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Fat-restrictive strategies in PN should be applied in episodes of severe hypertriglyceridemia&#44; commonly related to critical illness&#44; or allergy to components of ILE&#46; In this context&#44; the solution applied to this clinical problem exposes the patient to a new potential risk of developing an essential fatty acid deficiency &#40;EFAD&#41;&#44; difficult to manage&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Linoleic acid &#40;LA&#41; &#40;18&#58;2&#969;-6&#41; and &#945;-linolenic acid &#40;ALA&#41; &#40;18&#58;3&#969;-3&#41; are the essential fatty acids &#40;EFAs&#41; for humans and must be obtained from dietary intake&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> EFAD can lead to various physiological consequences&#44; such as the disturbances in biomembrane structures&#44; cell signaling mechanisms&#44; transduction&#47;transcription procedures&#44; susceptibility to oxidative stress&#44; proinflammatory &#40;n-6-derived eicosanoids&#41;&#44; and anti-inflammatory &#40;n-3-derived eicosanoids&#41; processes&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Its clinical signs are diverse and mainly include skin and hair alterations&#44; diminished immune system status&#44; hematological alterations&#44; and&#47;or hepatic steatosis&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">EFAD is rarely described in the presence of a balanced diet because only 2&#8211;4&#37; and 0&#46;25&#37; of total energy should come from LA and ALA&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However&#44; this clinical entity was reported in 30&#37;&#44; 66&#37;&#44; 83&#37;&#44; and 100&#37; of patients with fat-free PN after 1&#44; 2&#44; 3&#44; and 4 weeks&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> These data may be relevant&#44; especially in those allergies directly related to soybean or indirectly &#40;cross allergies&#41;&#44; such as peanuts&#44; when lipid administration is precluded in PN due to the lack of availability of soybean-free ILEs&#46; A possible alternative could be the use of an ILE based solely on fish oil&#44; as this emulsion has not shown any evidence of EFAD when used as the sole fat source in home PN&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> However&#44; it is not commercialized in Spain&#44; so a request for its importation and for each case must be made to the Spanish Medicines Agency and wait for its approval&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Additional solutions are not good alternatives&#44; either&#46; Switching to enteral nutrition when possible is not feasible in cases of soybean or peanut allergy since all enteral diets marketed include soy lecithin&#46; The topical administration of oils as a source of EFAs has no solid evidence in adult patients as it seems only to act at skin level&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">To provide an early diagnosis and as a monitoring tool of EFAD&#44; we propose to rescue the almost forgotten triene&#47;tetraene ratio &#40;T&#58;T-ratio&#41; &#40;eicosatrienoic acid&#47;arachidonic acid&#41;&#44; a biochemical marker of both&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Serum mead acid &#40;20&#58;3 n-9&#41; to arachidonic acid &#40;20&#58;4 n-6&#41; ratios greater than 0&#46;2 suggest EFAD&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> indicating increased metabolism of oleic acid to mead acid due to inadequate LA and ALA intake&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Biochemical evidence of EFAD with T&#58;T-ratio usually can be detected two weeks before the clinical signs and symptoms appear&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However&#44; EFAD in obese individuals develops over a longer term due to fat mobilization from adipose tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Given the complex management of EFAD and the current limited therapeutic arsenal available&#44; we recommend closely monitoring this clinical entity in patients requiring lipid-restricted PN and establishing the T&#58;T-ratio in hospital biochemical panels for early detection in high-risk situations&#46;</p></span>"
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Letter to the Editor
Available online 14 October 2024
When fat-free parenteral nutrition is required: The strategy that becomes a double-edge sword
Cuando se requiere una nutrición parenteral libre de lípidos: la estrategia que se convierte en una espada de doble filo
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Marta de Antonio-Cuscóa,
Corresponding author
61323@psmar.cat

Corresponding author.
, Agustí Albalat-Torresa, Lucía Picazo Morenob, Javier Mateu-de Antonioa
a Pharmacy Department, Hospital del Mar, Barcelona, Spain
b Critical Care Department, Hospital del Mar, Barcelona, Spain
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From Monday to Friday from 9 a.m. to 6 p.m. (GMT + 1) except for the months of July and August which will be from 9 a.m. to 3 p.m.
Calls from Spain
932 415 960
Calls from outside Spain
+34 932 415 960
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Medicina Intensiva (English Edition)
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¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?