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To examine the effects of different IV fat emulsions on clinical outcomes in critically ill patients.Secondary analysis of data from a prospective multicenter study.An international sample of ICUs.Adult patients who were admitted to the ICU for more than 72 hours, were mechanically ventilated within 48 hours, received exclusive parenteral nutrition for more than or equal to 5 days, and did not change IV fat emulsion type during the data collection period.Demographic and clinical data were collected for up to 12 days, until death, or discharge from the ICU, whichever came first. Clinical outcomes were recorded at 60 days following ICU admission.Lipid-free, soybean, medium-chain triglyceride, olive, and fish oils in parenteral nutrition were compared using an adjusted Cox proportional hazard model to examine time to termination of mechanical ventilation alive, time to ICU discharge alive, and time to hospital discharge alive.A total of 451 patients were included in this study: 70 (15.5%) in the lipid-free group, 223 (49.5%) in the soybean oil group, 65 (14.4%) in the medium-chain triglyceride group, 74 (16.4%) in the olive oil group, and 19 (4.9%) in the fish oil group. When compared with lipid-free parenteral nutrition, patients who received fish oil had a faster time to ICU discharge alive (hazard ratio, 1.84; 95% CI, 1.01–3.34; p = 0.05). When compared with soybean oil, patients who received olive oil or fish oil had a shorter time to termination of mechanical ventilation alive (hazard ratio, 1.43; 95% CI, 1.06–1.93; p = 0.02 and hazard ratio, 1.67; 95% CI, 1.00–2.81; p = 0.05, respectively) and a shorter time to ICU discharge alive (hazard ratio, 1.76; 95% CI, 1.30–2.39; p < 0.001 and hazard ratio, 2.40; 95% CI, 1.43–4.03; p = 0.001, respectively).Use of alternative IV fat emulsions in parenteral nutrition, particularly olive and fish oil, was associated with improved clinical outcomes.