Alternatives to total parenteral nutrition in the critically ill patient.

Alternatives to total parenteral nutrition (TPN) can play an invaluable role in the support of the critically ill patient. However, the efficacy of this depends on: (1) early nutritional assessment; (2) sequential nutritional assessment as dictated by the clinical condition of the patient; (3) careful estimation of requirements based on calculated energy expenditure and use of the "stress-index"; (4) early use of enteral feedings in combination with peripheral and central intravenous routes, especially with the use of "feeding modules" to provide patient's specific concentrated diet; (5) use of intravenous fat as an isotonic supplement to dextrose in the presence of carbohydrate intolerance; (6) avoid overfeeding as rigorously as underfeeding; (7) continued clinical trials to determine optimal nutritional/metabolic support of the critically ill.