Essential fatty acid deficiency: a consequence of fat-free total parenteral nutrition

A case of essential fatty acid deficiency (EFAD) associated with fat-free total parenteral nutrition (TPN) therapy in a 53-year-old white male is reported. The patient's tube feedings (Sustacal) were discontinued and a fat-free TPN solution of 25% dextrose injection, 4.25% amino acid injection (Freamine II) and appropriate electrolytes, vitamins and minerals was started when an upper GI study showed complete obstruction of his esophageal-colonic anastomosis. After nearly 1.5 months of fat-free TPN therapy, a diffuse scaly rash appeared on the patient's elbows, groin, arms and legs, and plasma fatty acid analysis showed a gross fatty acid deficiency. One liter of 10% soybean oil emulsion (Intralipid) then was added to 3 liters of TPN daily; linoleic acid accounted for 12% of the total calories of this solution. After 14 days of Intralipid therapy, the patient's skin lesions had cleared and plasma fatty acids had returned to normal. The patient was discharged on tube feedings of Sustacal providing sufficient linoleic acid (8.4% of calories) to prevent recurrence of EFAD. The pathophysiology, diagnosis and treatment of EFAD, and the role of linoleic acid in the disease are reviewed. TPN protocols should include recommendations for administration of linoleic acid to all patients receiving continuous infusion of fat-free TPN.