Nutrition Support Blog: The Truth Hurts

On the television series Happy Days (a sitcom about life during the 1950’s in the US, for those who may not have been around yet to see it), there was a recurring gag about one of the lead characters. The Fonz (Fonzie) was SO cool that he could never admit that he was ever wrong about anything.  When forced to admit that he was wrong, or apologize, he could not even make himself force out the words, and only with great effort ever uttering gibberish ..“I’m Wrooo..” (or something).

http://www.youtube.com/watch?v=uwkU8-d1gIk&noredirect=1

While this sort of behavior is humorous on a sitcom, in real life a total inability to admit mistakes can be extremely unattractive.  Of course, no one likes to be wrong, and the more life-experience I gain, the more I have realized that it takes a certain strength of character to openly admit mistakes.  Admitting error can be especially difficult in professional situations, where an authority has written or lectured about current knowledge, and then new research reveals the error of an older paradigm.  There is a natural temptation to dismiss the new findings, even if it means coming up with unlikely reasons why the new research is not valid.

In recent months the research about early supplemental PN¹ has been the type of controversial research that threatens to upset previous notions, and may lead to changes in the European nutrition support guidelines – see our e-journal club from July 2011 for more details:

http://www.healthsystem.virginia.edu/pub/dietitian/inpatient/dh/E-journal%20Club/july-e-journal-club.html

However, with every research there is some discussion, dispute and controversy.  One of the questions raised at Clinical Nutrition Week and in editorials was the possibility that initial glucose infusions administered to the early PN group were responsible for the significantly increased infections, and not the PN.  Considering that the early PN group only received 200 more dextrose calories on the 1^st day of the study, and 600 additional dextrose calories on day 2 (compared to the late PN group) – we were surprised that anyone would call this “glucose loading”.  Especially in view of how much more glucose and calorie loading happened over the next 7+ days once PN started – very apparent on the graph of calories provided below (see the blue bars).

While it might seem improbable that hypocaloric dextrose for less than 48 hours would be a greater source of infections than PN over 5-7 days, it may well be that excessive calories from any source can create problems when patients are very insulin resistant.  Only additional research can tell us who is right and who is wroo,…wrooo – not so very right.

Blue Bars = Early Initiation           Red Bars = Late Initiation

“There's nothing so passionate as a vested interest disguised as an intellectual conviction.”                      

                                                     - Sean O'Casey

Reference

1)   Casaer MP, Mesotten D, Hermans G, Wouters PJ,et al.  Early versus Late Parenteral Nutrition in Critically Ill Adults. N Engl J Med. 2011 Aug 11;365(6):506-17.