Brief Article Open Access
Copyright ©2010 Baishideng. All rights reserved.
World J Gastrointest Oncol. Jan 15, 2010; 2(1): 51-55
Published online Jan 15, 2010. doi: 10.4251/wjgo.v2.i1.51
Hypocaloric peripheral parenteral nutrition with lipid emulsion in postoperative gastrointestinal cancer patients
Chien-Yu Lu, Li-Chu Sun, Ying-Ling Shih, Fang-Ming Chen, Jan-Sing Hsieh, Jaw-Yuan Wang, Nutrition Support Team, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan, China
Chien-Yu Lu, Fang-Jung Yu, Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan, China
Hung-Yi Chuang, Community Medicine, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan, China
Li-Chu Sun, Ying-Ling Shih, Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan, China
Fang-Ming Chen, Jan-Sing Hsieh, Jaw-Yuan Wang, Division of Gastroenterologic and General Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan, China
Chien-Yu Lu, Department of Internal Medicine, Pingtung Hospital, Pingtung 900, Taiwan, China
Hung-Yi Chuang, School of Public Health, Kaohsiung Medical University, Kaohsiung 807, Taiwan, China
Chien-Yu Lu, Fang-Ming Chen, Jan-Sing Hsieh, Jaw-Yuan Wang, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan, China
Author contributions: Lu CY designed the study, prepared for the materials and methods and analyzed the results; Chuang HY offered the idea of this study and helped in statistical analysis; Yu FJ helped conduct the literature review and personal data collection; Sun LC and Shih YL assisted in collection of cases and material preparation; Chen FM and Hsieh JS helped in protocol design and literature review; Wang JY designed and supervised the study and directed its implementation, including quality assurance and control.
Correspondence to: Jaw-Yuan Wang, MD, PhD, Professor, Division of Gastrointestinal and General Surgery, Department of Surgery, Kaohsiung Medical University Hospital, No. 100, Tz-You 1st Road, Kaohsiung 807, Taiwan, China.
Telephone: +886-7-3122805 Fax: +886-7-3114679
Received: February 21, 2009
Revised: July 12, 2009
Accepted: July 19, 2009
Published online: January 15, 2010


AIM: To investigate the use of lipid emulsion substituting for glucose in postoperative hypocaloric peripheral parenteral nutrition (HPPN).

METHODS: This prospective, randomized study was conducted on 20 postoperative gastrointestinal cancer patients. They were randomized and equally divided into interventional group and control group, and both were administered isocaloric and isonitrogenous diets with for lipid emulsion substituting for partial glucose loads in the interventional group.

RESULTS: Nutritional parameters and biochemical data were compared between the two groups before and after 6-d of HPPN. Most investigated variables showed no significant changes after administration of HPPN with lipid emulsion. However, the postoperative triglyceride level was significantly lower in the interventional group than in the control group (P < 0.05). In comparison with lipid emulsion, glucose administration resulted in less decrease in postoperative prealbumin level (P < 0.05).

CONCLUSION: In addition to supplementing with essential fatty acid, it seems that HPPN with lipid emulsion is well-tolerated and beneficial to postoperative gastrointestinal cancer patients.

Key Words: Hypocaloric peripheral parenteral nutrition, Lipid emulsion, Dextrose


Parenteral nutrition has been accepted as an effective means of nutritional supplementation for malnourished patients or those ordered to fast for a period of time. However, parenteral nutritional support often requires access via the central venous route, which sometimes leads to technical complications such as pneumothorax or hemothorax on insertion of central venous catheter, and subsequent catheter-related infection. In clinical practice, patients undergoing surgery for gastrointestinal (GI) tract cancer only need a brief period of fast, to wait for flatus passage and confirm recovering peristaltic function of the bowel. Total parenteral nutrition is indicated for patients having nothing per os or without normal enteral function over one week. Therefore, for those patients evaluated as well-nourished before operation, the short-term hypocaloric parenteral nutrition is more appropriate than total central parenteral nutrition postoperatively.

Hypocaloric peripheral parenteral nutrition (HPPN) appears to be indicated in patients without malnourishment who are planning to undergo a short-term fast following surgery. HPPN is a method using lower glucose loads mixed with soluble alternatives via the peripheral venous route to avoid the complications of hypermetabolism, hyperglycemia and the use of central venous catheters in stressed patients[1,2]. Currently, HPPN (15-20 kcal/kg per day) has been a trend for managing postoperative patients in a situation of moderate malnutrition and short-term fast[3]. Our current study was designed as a prospective, randomized clinical trial to explore the effects of short-term HPPN using lipid emulsion for patients with GI cancers following surgery.


This prospective, randomized study was conducted on 20 patients (8 males and 12 females) between the ages of 33 and 80 years old. All of the patients underwent elective resection for GI cancer at the Department of Surgery of Kaohsiung Medical University Hospital. Patients with underlying diseases, such as hepatic failure, renal failure, dyslipidemia, shock, and congestive heart failure, and patients with any metabolic disorder associated with impaired nitrogen utilization were excluded from this study. The including criteria for our patients are per the following features: (1) GI cancer patients receiving elective resection; (2) Preoperative serum albumin level ≥ 3.0 g/dL; and (3) Blood loss < 500 mL in operation and no need of blood transfusion. Written informed consent was obtained from all subjects and/or guardians for the use of their blood samples. Sample acquisition and subsequent use were also approved by the institutional review board of the Kaohsiung Medical University Hospital. The patients were randomly divided into two groups with isocaloric and isonitrogenous solution (Table 1). In the interventional group, 10 patients were given 120 g of carbohydrate (Taita No.5®, Otsuka Pharmaceuticals, Taipei, Taiwan), 40 g of amino acids (Amiparen® 10% solution, Otsuka Pharmaceuticals, Osaka, Japan) and 40 g of fatty acid (Intralipid®, Fresenius Kabi Pharmacia AB, German). In the control group, 10 patients were given 220 g of carbohydrate and 40 g of amino acids (Amiparen®) and no fat emulsion. The initial blood samples were drawn one day before surgery. The peripheral infusion of parenteral nutrition was administered immediately for 6 d postoperatively.

Table 1 Isocaloric and isonitrogenous constituents of the two groups.
Interventional groupControl group
1Taita No.5® (400 mL/bot)3 bot/d4 bot/d
2Amiparen® (400 mL/bot)1 bot/d1 bot/d
3Intralipid® (100 mL/bot)2 bot/d
50% glucose (20 mL/amp)6 amp/d
Total volume (mL)18002120
Total calories (kcal)10401040

Nutritional assessment, including body weight, anthropometry, serum proteins (prealbumin, transferrin and albumin) and nitrogen balance, were determined one day prior to surgery and on post-operative day 7. In addition, hematological and biochemical parameters, including complete blood count, total lymphocyte count, electrolytes, total bilirubin, alanine aminotransferase, aspartate aminotransferase, blood urea nitrogen, creatinine, triglyceride, cholesterol, glucose, insulin and c-peptide, were also measured. The frequency of thrombophlebitis by peripheral parenteral nutrition was also recorded.

Statistical analysis

All of the continuous data were expressed as mean ± SE. Laboratory data before the administration of HPPN showed no statistical differences between the two study groups, and were regarded as baseline. Statistical analyses were performed using the Statistical Package for the Social Sciences Version 11.5 software (SPSS, Inc., Chicago, IL). The independent Student’s t-test was used to compare the differences between continuous variables in postoperative measurements between the two groups. All of the nominal data were tested with either Fischer’s exact test or the chi-square test. A P value of less than 0.05 was considered to be statistically significant.


Patient demographic data are listed in Table 2. There were no differences in age, gender, preoperative diagnosis and frequency of postoperative complications between the two groups. The study parameter values at baseline, one day before surgery, and after 6 d of peripheral parenteral infusion (day 7) are shown in Tables 3 and 4.

Table 2 Demographic data and postoperative complications in the two groups.
ParameterInterventional group n = 10Control group n = 10P
Age (years ± SE)58.9 ± 2.967.2 ± 3.6NS
Primary lesionNS
Colon cancer76
Gastric cancer34
Wound infection11
Table 3 Routine blood and biochemical data before and after operation between the two groups.
White blood cells (/μL)NS
Intervention group5667.0 ± 767.56564.0 ± 665.3
Control group6222.0 ± 579.46675.0 ± 704.4
Hemoglobin (g/dL)NS
Intervention group11.9 ± 0.311.4 ± 0.3
Control group11.8 ± 0.611.7 ± 0.5
Hematocrit (%)NS
Intervention group35.8 ± 0.734.1 ± 1.1
Control group35.7 ± 1.534.6 ± 1.5
Total lymphocyte count (/μL)NS
Intervention group1596.3 ± 215.11177.8 ± 150.9
Control group1485.9 ± 166.01174.9 ± 98.8
Triglyceride (mg/dL)< 0.05
Intervention group102.2 ± 8.389.0 ± 13.1
Control group105.1 ± 18.9109.6 ± 9.7
Cholesterol (mg/dL)NS
Intervention group155.0 ± 6.7143.6 ± 8.5
Control group170.3 ± 11.7150.8 ± 11.0
Blood urea nitrogen (mg/dL)NS
Intervention group9.7 ± 1.113.2 ± 0.9
Control group11.9 ± 2.313.9 ± 1.4
Creatinine (mg/dL)NS
Intervention group0.9 ± 0.10.7 ± 0.1
Control group1.0 ± 0.10.8 ± 0.1
Aspartate aminotransferase (IU/L)NS
Intervention group13.2 ± 2.414.0 ± 1.6
Control group12.2 ± 1.813.4 ± 1.8
Alanine aminotransferase (IU/L)NS
Intervention group6.1 ± 1.39.5 ± 1.3
Control group6.6 ± 1.010.2 ± 1.4
Total bilirubin (mg/dL)NS
Intervention group0.5 ± 0.080.4 ± 0.05
Control group0.5 ± 0.080.4 ± 0.04
Glucose (gm/dL)NS
Intervention group86.9 ± 3.8122.1 ± 10.8
Control group88.7 ± 4.9119.7 ± 9.8
Insulin (IU/mL)NS
Intervention group8.3 ± 1.218.1 ± 2.7
Control group9.8 ± 2.720.1 ± 3.8
C-peptide (ng/dL)NS
Intervention group1.8 ± 0.54.3 ± 0.6
Control group1.8 ± 0.54.9 ± 1.0
Na (mmol/L)NS
Intervention group139.6 ± 0.7136.3 ± 1.2
Control group139.3 ± 1.1137.2 ± 1.1
K (mmol/L)NS
Intervention group4.2 ± 0.23.8 ± 0.2
Control group4.0 ± 0.13.8 ± 0.1
Cl (mmol/L)NS
Intervention group105.3 ± 0.6102.4 ± 1.3
Control group106.0 ± 0.9101.9 ± 0.8
Table 4 Anthropometry and various nutritional parameters before and after operation between the two groups.
Body weight (kg)NS
Intervention group56.9 ± 3.655.6 ± 3.9
Control group54.8 ± 3.052.2 ± 2.7
Triceps skin fold (cm)NS
Intervention group12.9 ± 2.013.3 ± 2.0
Control group13.4 ± 2.213.5 ± 2.1
Mid-arm circumference (cm)NS
Intervention group25.1 ± 1.224.3 ± 1.1
Control group24.4 ± 0.824.2 ± 0.9
Prealbumin (mg/dL)< 0.05
Intervention group22.0 ± 1.917.7 ± 1.6
Control group21.4 ± 2.319.9 ± 1.2
Transferrin (mg/dL)NS
Intervention group254.4 ± 21.0186.2 ± 18.2
Control group224.8 ± 10.8173.4 ± 12.5
Albumin (gm/dL)NS
Intervention group4.0 ± 0.13.5 ± 0.1
Control group3.9 ± 0.13.4 ± 0.1
Nitrogen balanceNS
Intervention group-5.5 ± 1.4-6.5 ± 1.3
Control group-5.6 ± 1.3-6.4 ± 1.4

Except for triglyceride, all of the hematological and biochemical parameters exhibited no statistical significance in terms of differences between the preoperative and postoperative data between the two groups (all P > 0.05, Table 3). Postoperative triglyceride level in the interventional group was significantly lower than the control group (P < 0.05, Table 3). There were no significant differences in anthropometry, transferrin, albumin level, and nitrogen balance postoperatively between the two groups. However, postoperative prealbumin level showed a significant decrease in the interventional group compared with the control group (P < 0.05, Table 4).


Surgical trauma induces a catabolic response with hypermetabolism and insulin-resistant hyperglycemia[3]. Traditionally, postoperative parenteral nutrition with full calories and high glucose loads results in deteriorating hyperglycemia, hyperosmolar state, increased carbon dioxide generation[4], and net fat synthesis- deposition when the capacity of oxidation is overwhelmed. Thus physicians often have had to prescribe additional insulin to control hyperglycemia. The result of this is forced glucose oxidation and forced lipogenesis, both of which necessitate considerable physiologic effort leading to iatrogenic hypermetabolism. These metabolic alternations have been associated with increased morbidity and mortality in the early and late postoperative periods[5]. Thus, in a randomized controlled study of postoperative patients under intensive care, normoglycemia was achieved by aggressive control with infusion of sufficient insulin to overcome insulin resistance. By this treatment, morbidity and mortality were substantially decreased[6].

Hepatic triglyceride synthesis and secretion of very-low-density lipoprotein (VLDL) are related to the availability of carbohydrate or free fatty acid substrate[7,8]. Consequently, patients receiving parenteral nutrition frequently present significant hypertriglyceridemia[9]. However, the difference in mean triglycerides between post- and pre-operative levels in our interventional group is significantly lower than the control group (Table 3). This suggests that infusion of 20% Intralipid® antagonized the hypertriglyceridemic effect of intravenous glucose by altering the balance between hepatic VLDL synthesis and intravascular VLDL catabolism.

Several biochemical mechanisms for such an effect can be considered[9]. Isocaloric substitution of 20% Intralipid® for glucose could blunt carbohydrate-induced hepatic triglyceride synthesis not only by reducing the daily input of carbohydrate substrate but also by adding an exogenous triglyceride, which in itself can inhibit hepatic triglyceride synthesis[10]. Another possible mechanism relates to the inhibitory effect of insulin on triglyceride hydrolysis and fatty acid release from adipose tissues. Acute hyperinsulinemia induced by parenteral glucose suppressed the release of free fatty acids from peripheral adipose stores[11]. Because hepatic utilization of free fatty acids is regulated solely by their ambient serum concentration, this in turn would lead to a reduction in hepatic triglyceride synthesis and VLDL secretion[8]. Finally, Taskinen et al[12] demonstrated that infusion of glucose plus Intralipid® causes a 1.5-fold greater induction of adipose tissue lipoprotein lipase activity than infusion of glucose alone. This enzyme plays a central role in peripheral VLDL catabolism and hence increased activity would lead to enhanced clearance of VLDL and a decrease in triglyceride levels[13]. The factors regulating VLDL synthesis and clearance are in a delicate balance and the effect of combined glucose and lipid regimens on serum triglycerides may ultimately depend on many variables such as the total daily caloric load, the percent of total calories infused as lipid component, the nutritional status of the patients, or even the daily timing of the infusions[14].

Protein sparing is the major goal of nutritional support, which may be affected by the fuel source of glucose or lipid. The nitrogen sparing effects of glucose and lipid have been addressed in several reports with conflicting results. Some studies have found glucose achieves better nitrogen retention than lipids[15-17], but usually there is no benefit of one fuel source over the other[18-20]. A review of the literature by Iapichino et al[21], attempted to consider the potential confounding factors, and then compare the effects of glucose alone with the glucose-fat mixed system upon protein metabolism. In 40 groups of catabolic patients, a satisfactory nitrogen balance result was more frequently observed with a glucose system (17 of 19 studies) than with a mixed system (12 of 21 studies).

The nitrogen balance showed no significant change between our two parenteral nutritional groups with isocalories and isonitrogen (Table 4), which indicated lipid emulsion and glucose have similar nitrogen sparing effects after a 6-d study period. When compared to the glucose-lipid mixed interventional group, prealbumin was significantly higher in the glucose-based control group after 6 d of parenteral nutrition (Table 4). Prealbumin underwent significant change in our study because of its short half-life (2-3 d), and it showed a somewhat favorable nitrogen retention effect of glucose rather than lipid. However, the traditional nutritional indicators such as albumin level showed no significant change between the two groups (Table 4).

The amino acid supplement (Amiparen®) used in our study contains abundant branched-chain amino acids, which provide a substrate for producing alanine and glutamine, and also prevent amino acid loss from muscle breakdown. It is therefore reasonable to hypothesise that amino acid supplements maintain and/or increase the plasma glutamine concentration and prevent plasma and muscle depletion in the immediate postoperative fasting period. It has been shown that postoperative supply of amino acids improves protein synthesis and decreases early protein catabolism[22]. Consequently, HPPN is a nutritional support regimen based on amino acids, with a lower energy supply in the form of glucose or other alternatives such as lipid emulsion and glycerol[1]. Its purpose is not to turn the negative nitrogen balance of these patients with postoperative injury into a positive balance, but rather to prevent a greater degree of protein breakdown during the postoperative period of fasting[23,24].

In summary, we conclude that HPPN with lipid emulsion is well-tolerated for providing nutritional support in the immediate postoperative period. It thus appears to be appropriate to replace hypercaloric loads which are still used routinely in many postoperative patients. Although HPPN with lipid emulsion is well-tolerated and beneficial to postoperative gastrointestinal cancer patients, further large-scale population-based data sets validated under multicenter settings are needed.


Hypocaloric peripheral parenteral nutrition (HPPN) is appropriate for patients with moderate nutrition who are prepared to have a short-term period of fast. HPPN is designated to contain lower glucose loads supplemented with soluble alternatives via the peripheral venous route to avoid the complications of hyperglycemia and the use of central venous catheters.

Research frontiers

There are conflicting opinions regarding the use of different alternatives substituting for glucose in such an amino acids-based HPPN. The study is designed as a prospective, randomized clinical trial to compare the effects of lipid emulsion substituting for glucose in HPPN for postoperative gastrointestinal (GI) cancer patients.

Innovations and breakthroughs

The study demonstrates that HPPN supplemented with lipid emulsion is advisable to replace conventional hypercaloric (hyperglycemic) loads via the central venous route in postoperative patients necessitating short-term of nutritional support.


HPPN (15-20 kcal/kg per day) supplemented with lipid emulsion is well-suited for providing short-term nutritional support for GI cancer patients following surgery.


HPPN is also termed as median caloric peripheral parenteral nutrition, and the daily caloric supply is about 15-20 kcal/kg.

Peer review

The authors conducted a prospective, randomized controlled study of HPPN with lipid emulsion vs dextrose in postoperative GI cancer patients, and demonstrated that HPPN with lipid emulsion is well-tolerated for these patients.


Peer reviewer: Ming-Xu Da, MD, Department of General Surgery, Gansu People’s Hospital, 160 Donggang West Road, Lanzhou 730000, Gansu Province, China

S- Editor Li LF L- Editor Lalor PF E- Editor Lin YP

1.  Sun LC, Shih YL, Lu CY, Chen FM, Hsieh JS, Chuang JF, Wang JY. Randomized controlled study of glycerol versus dextrose in postoperative hypocaloric peripheral parenteral nutrition. J Invest Surg. 2006;19:381-385.  [PubMed]  [DOI]  [Cited in This Article: ]
2.  Svanfeldt M, Thorell A, Nygren J, Ljungqvist O. Postoperative parenteral nutrition while proactively minimizing insulin resistance. Nutrition. 2006;22:457-464.  [PubMed]  [DOI]  [Cited in This Article: ]
3.  Patiño JF, de Pimiento SE, Vergara A, Savino P, Rodríguez M, Escallón J. Hypocaloric support in the critically ill. World J Surg. 1999;23:553-559.  [PubMed]  [DOI]  [Cited in This Article: ]
4.  Liposky JM, Nelson LD. Ventilatory response to high caloric loads in critically ill patients. Crit Care Med. 1994;22:796-802.  [PubMed]  [DOI]  [Cited in This Article: ]
5.  Hill GL, Douglas RG, Schroeder D. Metabolic basis for the management of patients undergoing major surgery. World J Surg. 1993;17:146-153.  [PubMed]  [DOI]  [Cited in This Article: ]
6.  van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001;345:1359-1367.  [PubMed]  [DOI]  [Cited in This Article: ]
7.  Wolfe BM, Ahuja SP. Effects of intravenously administered fructose and glucose on splanchnic secretion of plasma triglycerides in hypertriglyceridemic men. Metabolism. 1977;26:963-978.  [PubMed]  [DOI]  [Cited in This Article: ]
8.  Mayes PA. Lipid transport and storage. Harper's Biochemistry. 25th ed. New York: McGraw-Hill 2000; 276-277.  [PubMed]  [DOI]  [Cited in This Article: ]
9.  Weinberg RB, Singh KK. Short-term parenteral nutrition with glucose and Intralipid: effects on serum lipids and lipoproteins. Am J Clin Nutr. 1989;49:794-798.  [PubMed]  [DOI]  [Cited in This Article: ]
10.  Archer WR, Lamarche B, Dériaz O, Landry N, Corneau L, Després JP, Bergeron J, Couture P, Bergeron N. Variations in body composition and plasma lipids in response to a high-carbohydrate diet. Obes Res. 2003;11:978-986.  [PubMed]  [DOI]  [Cited in This Article: ]
11.  Steiner G, Lewis GF. Hyperinsulinemia and triglyceride-rich lipoproteins. Diabetes. 1996;45 Suppl 3:S24-S26.  [PubMed]  [DOI]  [Cited in This Article: ]
12.  Taskinen MR, Tulikoura I, Nikkilä EA, Ehnholm C. Effect of parenteral hyperalimentation on serum lipoproteins and on lipoprotein lipase activity of adipose tissue and skeletal muscle. Eur J Clin Invest. 1981;11:317-323.  [PubMed]  [DOI]  [Cited in This Article: ]
13.  Judd RH, Freund H, Deckelbaum RJ. Human plasma lipoproteins and total parenteral nutrition with intravenous fat emulsion. JPEN J Parenter Enteral Nutr. 1984;8:552-555.  [PubMed]  [DOI]  [Cited in This Article: ]
14.  Romon M, Le Fur C, Lebel P, Edmé JL, Fruchart JC, Dallongeville J. Circadian variation of postprandial lipemia. Am J Clin Nutr. 1997;65:934-940.  [PubMed]  [DOI]  [Cited in This Article: ]
15.  Boulétreau P, Chassard D, Allaouchiche B, Dumont JC, Auboyer C, Bertin-Maghit M, Bricard H, Ecochard R, Rangaraj J, Chambrier C. Glucose-lipid ratio is a determinant of nitrogen balance during total parenteral nutrition in critically ill patients: a prospective, randomized, multicenter blind trial with an intention-to-treat analysis. Intensive Care Med. 2005;31:1394-1400.  [PubMed]  [DOI]  [Cited in This Article: ]
16.  Tappy L, Schwarz JM, Schneiter P, Cayeux C, Revelly JP, Fagerquist CK, Jéquier E, Chioléro R. Effects of isoenergetic glucose-based or lipid-based parenteral nutrition on glucose metabolism, de novo lipogenesis, and respiratory gas exchanges in critically ill patients. Crit Care Med. 1998;26:860-867.  [PubMed]  [DOI]  [Cited in This Article: ]
17.  Hart DW, Wolf SE, Zhang XJ, Chinkes DL, Buffalo MC, Matin SI, DebRoy MA, Wolfe RR, Herndon DN. Efficacy of a high-carbohydrate diet in catabolic illness. Crit Care Med. 2001;29:1318-1324.  [PubMed]  [DOI]  [Cited in This Article: ]
18.  Garrel DR, Razi M, Larivière F, Jobin N, Naman N, Emptoz-Bonneton A, Pugeat MM. Improved clinical status and length of care with low-fat nutrition support in burn patients. JPEN J Parenter Enteral Nutr. 1995;19:482-491.  [PubMed]  [DOI]  [Cited in This Article: ]
19.  de Chalain TM, Michell WL, O'Keefe SJ, Ogden JM. The effect of fuel source on amino acid metabolism in critically ill patients. J Surg Res. 1992;52:167-176.  [PubMed]  [DOI]  [Cited in This Article: ]
20.  Shaw JH, Holdaway CM. Protein-sparing effect of substrate infusion in surgical patients is governed by the clinical state, and not by the individual substrate infused. JPEN J Parenter Enteral Nutr. 1988;12:433-440.  [PubMed]  [DOI]  [Cited in This Article: ]
21.  Iapichino G, Radrizzani D, Solca M, Pesenti A, Gattinoni L, Ferro A, Leoni L, Langer M, Vesconi S, Damia G. The main determinants of nitrogen balance during total parenteral nutrition in critically ill injured patients. Intensive Care Med. 1984;10:251-254.  [PubMed]  [DOI]  [Cited in This Article: ]
22.  Jiménez Jiménez FJ, Leyba CO, Jiménez Jiménez LM, Valdecasas MS, Montero JG. Study of hypocaloric peripheral parenteral nutrition in postoperative patients (European project). Clin Nutr. 1995;14:88-96.  [PubMed]  [DOI]  [Cited in This Article: ]
23.  Perioperative total parenteral nutrition in surgical patients. The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group. N Engl J Med. 1991;325:525-532.  [PubMed]  [DOI]  [Cited in This Article: ]
24.  Perioperative parenteral nutrition. Health and Public Policy Committee, American College of Physicians. Ann Intern Med. 1987;107:252-253.  [PubMed]  [DOI]  [Cited in This Article: ]