Parenteral Nutrition Therapy:

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Malnutrition is associated with an increased frequency of treatment-related complications, longer ICU and hospital length of stay, and increased costs of medical care.^1–6 Patients at high risk for malnutrition should be identified and evaluated for nutrition support.⁷ To improve patient outcomes, it is important to choose the appropriate route of nutrition support for patients at risk for malnutrition.⁸

Enteral nutrition (EN) can improve outcomes in patients with a functioning gastrointestinal (GI) tract who cannot maintain adequate nutrition intake of more than 60% by mouth alone. This is especially true in patients who are malnourished or at risk for malnutrition.⁹ EN has been shown to improve nutritional status and reduce ICU length of stay, and it is associated with fewer infectious complications than parenteral nutrition (PN).^9-11 For patients who are malnourished or at risk for malnutrition, EN should be initiated within the first 24 to 48 hours of hospital admission, including patients in the ICU.⁸ EN via a small-bore nasogastric tube is recommended as the initial location for feedings, even in severe acute pancreatitis. If nasogastric EN is not tolerated, nasojejunal feeds should be attempted. Post-pyloric EN may initially be preferred over nasogastric feeding in a patient with severe gastroparesis or on noninvasive ventilation due to the increased risk for aspiration.⁸ Initiation of EN may be delayed when post-pyloric feeding is desired due to difficulty in correct tube placement. However, specialized equipment and techniques are available to facilitate post-pyloric access allowing safe administration of EN feeding.⁹ Although EN is the preferred route of nutrition support, it may not always be possible. Some contraindications to EN are listed in Table 1.

For patients in whom EN tube placement is contraindicated or who have nonfunctioning GI tracts, PN is an alternate method of nutrition support.^4-12 PN is essential for patients who are malnourished or at risk for malnutrition with GI complications that are not expected to resolve. PN should be initiated as soon as possible in patients with baseline moderate or severe malnutrition and within 3 to 5 days for patients considered at risk for malnutrition and who are unlikely to achieve more than 60% of nutrition needs via EN or by mouth. For well-nourished, stable patients, PN can be initiated after 7 days of no or limited (<50%) nutrition intake.¹² PN is complex and has been associated with a unique set of complications, some of which can be serious or even life-threatening.^13,14 Although a few older published reports could not demonstrate that PN had a consistently favorable effect on patient outcomes,^15,16 new evidence using contemporary doses and approaches to PN therapy has shown beneficial effects that are comparable to those of EN support.¹⁷ Other reports found beneficial effects on body composition and quality of life.^18,19 This new evidence shows PN has evolved from a therapy to avoid to an effective alternative to prevent and treat malnutrition in patients in whom the GI tract is not functioning or who cannot tolerate adequate EN.^9,13 There also are other factors to consider when deciding the appropriateness of PN (Table 2).

This review discusses nutrition assessment, nutritional requirements, PN formulation design, medication compatibility with PN, and guidelines for special diseases. It also provides an overview of evidence-based guidelines and PN practices published by the American Society for Parenteral and Enteral Nutrition (ASPEN).^9,20-23

Nutrition Assessment

Before the decision to initiate nutrition support, a nutrition screen and assessment are required.²³ Nutrition screening is quick and simple, conducted in the first 24 hours of admission with a validated tool to identify patients who are malnourished or at risk for malnutrition and in need of a more in-depth nutrition assessment.^24,25 The nutrition assessment is a more comprehensive and rigorous evaluation that defines the nutrition state and severity of the illness by looking at medical history, history of nutrition (energy) intake, associated amount and duration of weight loss or gain, anthropometric measurements, a physical exam, laboratory data (including markers of inflammation, which reduces lean body mass), and medications.^24-28 The nutrition assessment identifies malnutrition (undernutrition) and the interventions required to improve nutritional status and health outcomes. Factors associated with malnutrition include insufficient intake; increased nutrient needs due to catabolism or wound healing, for example; and impaired absorption, transport, or utilization of nutrients.²⁴ These factors are taken into consideration when diagnosing malnutrition. Two current methods for identifying and diagnosing malnutrition are the Academy of Nutrition and Dietetics and ASPEN Indicators to Diagnose Malnutrition (AAIM)²⁹ and the Global Leadership Initiative on Malnutrition (GLIM) criteria.³⁰

The AAIM assesses the cause and degree of malnutrition. The 3 causes of malnutrition are acute illness or injury, chronic illness, and social/environmental/behavioral circumstances. The 6 characteristics used to determine the degree of malnutrition are weight loss (amount lost and time that loss occurred; Table 3), nutrient (energy) intake, body fat and muscle mass composition, edema, and grip strength for functionality. Two of the 6 characteristics must be present to identify malnutrition and the degree: severe or moderate.²⁹

The GLIM criteria also identify malnutrition by assessing cause and severity but use slightly different parameters or characteristics^30,31 (Table 4). Reduced food intake or assimilation and disease burden/inflammation are the causes assessed, and the percentage of unintentional weight loss, body mass index (BMI), or reduction in muscle mass are the characteristics (criteria) used to identify severity of malnutrition. A cause and characteristic must be identified for malnutrition to be present.^30,31

A useful algorithm for determining the appropriate indications for PN and EN is presented in Figure 1. Clinicians should consider PN if a trial of enteral feeding has failed, if the enteral route is contraindicated, or if the GI tract has severely diminished function because of underlying disease or treatment.^9,13 Contraindications to PN include a functional GI tract, an inability to achieve appropriate venous access, an unstable clinical condition, terminal disease, critical illness, or metabolic derangement for which a favorable response to therapy is not feasible or the risk for complications is too high.¹² In these conditions, the metabolic profile is such that exogenous nutrients are poorly used and frequently cause complications that require prolonged mechanical ventilation, intensive care, or hospitalization.^12,32 Metabolic derangements such as azotemia necessitate cautious use of PN until the patient’s condition improves (Table 5).^19,33 In cases of hypokalemia, hypophosphatemia, and hypomagnesemia, as found in refeeding syndrome, PN should be delayed until all values are corrected and closer to normal range.³⁴

A nutrition consultation form that incorporates the aforementioned concepts can improve use of PN.³⁵ Such a form also documents the need for nutrition support and, with the nutritional assessment, can include a recommendation for route and dose of nutrients to be provided.

Nutritional Requirements

The primary goals of nutrition support are to preserve lean body mass so it is not used for energy oxidation, maintain immune function, and supply the body with adequate energy to support core body functions.²⁴ Over the past several years, there has been continual refinement of PN and guidelines, focusing on the delivery of the safest, most effective doses to meet these goals. Guidelines provide an initial, general framework for nutrient doses; however, each patient’s disease state and nutritional status must be considered when applying these guidelines. For example, hypocaloric PN has been reported to be beneficial in obese patients (BMI >30 kg/m²), resulting in the achievement of positive nitrogen balance and weight loss.^36,37 Nonetheless, if the obese patient’s clinical condition is such that increased energy/nutrients are required for healing (ie, continuous renal replacement therapy, open abdomen, or pressure injuries), then hypocaloric PN may not be appropriate. More detailed PN dosing recommendations for macronutrients are shown in Table 6. While keeping in mind the recommended ranges for carbohydrate (70%-85%) and fat (15%-30%) percentages for the overall caloric requirements, PN prescriptions can be adjusted to meet specific needs of patients. Lipids not only provide required essential fatty acids but also calories; thus, the lipid dose can be increased, allowing the dextrose dose to be decreased while still meeting goal energy/calories in a patient with hyperglycemia or vice versa in a patient with hypertriglyceridemia.

PN nutrient requirements should be reevaluated by routine nutrition assessments and frequent monitoring of lab values, fluid balance including renal function and weight, and respiratory status.²⁵ These monitoring parameters can identify potential under- and overfeeding of calories and protein.

Overfeeding of calories and protein can have serious consequences in patients receiving PN and has led to the specific dosing recommendations provided in Table 6.^9,13,38-42 When maximum doses of macronutrients are exceeded, the consequences outlined in Figure 2 frequently are reported.^13,27,43,44

Micronutrients—which include electrolytes, trace elements, and vitamins—are essential for the metabolism of macronutrients for protein and energy provision, specifically for incorporation into the body cell mass.^45,46 The content of micronutrients in the body fluctuates on the basis of cellular needs, such as in sepsis, trauma, or after surgery,^27,46 inflammation, and deficits occurring during periods of low or no intake or losses. These fluctuations often occur in patients requiring PN and can be difficult to identify, making it essential that daily adequate amounts are provided at the start of PN.^27,46 Daily monitoring of serum electrolytes for the first 2 to 3 days or until stable, as well as periodic (initially and every 2-3 weeks) assessment of vitamin and trace element status, are essential for a patient requiring PN.⁴⁵ Monitoring for micronutrient deficiencies also should be increased during periods of PN product shortages.⁴⁵ Recommendations for dosing of micronutrients in PN are outlined in Table 7.^38,41 When dosing electrolytes, trace elements, and vitamins in the PN, all other supplementation (oral, IV, IV fluids) also must be considered to prevent excessive intake and/or toxicity in long-term PN support.^27,46

PN Formulation Design

Formulations of PN are extremely complex products intended for IV use.²¹ Careful consideration of nutrient dose and avoidance of unstable or incompatible ingredients are necessary. Inconsistent compounding practices have led to serious harm in patients receiving PN.^38,47 To provide consistent, specific guidelines for PN, the National Advisory Group on Standards and Practice Guidelines for Parenteral Nutrition published “Safe Practices for Parenteral Nutrition.”³⁸ These guidelines provide recommendations for the PN label and order, as well as for PN compounding, compatibility, stability, and administration. They call for a standardized PN label format to promote correct interpretation of PN contents across all healthcare environments; describe the pharmacist’s duty to review the PN formula to ensure it is complete and balanced and will be stable and compatible upon admixture; and include admixture processes and quality control requirements that foster safe and accurate compounding of PN formulas (Table 8).^38,48 However, since these PN practices were developed, PN errors have continued to be reported and characterized.^49,50

Shortages of PN products also have contributed to aberrations in procurement, stability, compatibility, compounding, and administration.^51,52 During shortages, it is persistently difficult to provide adequate doses, or even PN therapy at all, to people in need. With these continued issues, ASPEN held a PN Safety Summit in 2011, which focused on discussing processes for improving PN safety, from order to administration.⁵³ The results of the summit guided the development of PN safety consensus recommendations (Table 9).^54-56 As healthcare complexity and the diversity of clinicians ordering PN increase, the competency of personnel involved in the PN process must be ensured. ASPEN recommends that a standardized process to determine competency of those who prescribe, review orders, and compound PN be in place at all facilities providing PN therapy.^57,58

Interest in standard PN formulations prompted ASPEN to create a “Statement on Parenteral Nutrition Standardization.”⁵⁵ This evidence-based analysis of the literature resulted in the recommendations provided in Table 10. This statement recommends a standardized PN process, recognizes the need for clinicians with PN expertise to be involved, and addresses the patient with complex needs for whom a customized PN formulation may be necessary.

Medication Compatibility With PN

Patients receiving PN usually need their medications administered intravenously. Multiple-lumen central venous catheters have alleviated some problems associated with coadministration of drugs with PN.⁵⁹ Although it is recommended that the catheter or port for PN administration be used solely for PN, this is not always possible in patients with limited venous access. Administration of medications with PN may be unavoidable. In these situations, compatibility concerns are relevant.

Fat Content an Important Consideration

The pharmacist’s objective is to ensure the safe, compatible, and effective provision of both pharmacologic therapy and nutrition support. In reviewing a patient’s regimen for compatibility, it is important to consider whether the PN contains injectable lipid emulsions (ILEs). Studies have shown differences in compatibility based on the PN formulation used. Table 11 was developed to provide consistent, reliable, and up-to-date information on the compatibility of drugs administered via Y-site injection with PN.^60-85 Of note, a 3-in-1 admixture and ILE compatibility is specific to the soybean oil emulsion products Intralipid (Fresenius Kabi), Kabiven (Fresenius Kabi), and Nutrilipid (B. Braun). Drug compatibility with Clinolipid (Baxter), Omegaven (Fresenius Kabi), and SMOFlipid (Fresenius Kabi) should be determined by contacting the manufacturer. It is not appropriate to assume that drug compatibility for Intralipid represents compatibility for all ILEs. If no compatibility data exist, the medication should not be administered parenterally.

There is a distinction between Y-site administration and direct admixture of the drug with PN. Adequate assessment of specific pharmacotherapeutic criteria for direct admixture of drugs in PN is required.⁵⁹ These criteria may be summarized as follows:

• Stability and compatibility of the drug with the specific PN admixture over 24 hours must be determined before the medication is added.
• The medication must have appropriate pharmacokinetics and proven efficacy for continuous infusion.
• The medication dose must have remained constant throughout the previous 24 hours before admixture in PN.
• There must be a stable PN infusion rate for at least 24 hours before the medication is added.
• PN must include appropriate labeling to avoid pharmacotherapeutic problems associated with abrupt discontinuation.
• Not all issues with medications and PN are due to incompatibility during admixture. Ceftriaxone should not be administered simultaneously with calcium-containing IV solutions such as PN via a Y-site. In patients other than neonates, ceftriaxone and PN may be administered sequentially if the infusion lines are thoroughly flushed between infusions.

Glucose Control

Hyperglycemia is associated with poor outcomes.⁸⁶ Aggressive use of insulin to manage hyperglycemia predisposes to hypoglycemic events.⁸⁷ Problems with glucose control have been related to the lack of adequate targets for serum glucose in PN patients. ⁸⁸ The frequency of hyperglycemia ranges from 44% (>200 mg/dL) to 90% (>150 mg/dL).⁸⁹ Recent guidelines and practice reviews have addressed glucose control in PN patients.^9,13 A reasonable target level for blood glucose is between 140 and 180 mg/dL.⁹ When hyperglycemia occurs, it is suggested to first reduce dextrose content of sources separate from PN, such as maintenance IV fluids and/or oral liquid diets. If this is not successful, then consider reducing dextrose in the PN by using ILEs as a caloric source. Use of insulin in PN to control glucose also has been advocated, beginning with a dose of 0.1 units per gram of dextrose (15 units/150 g).¹³ Glucose should be monitored every 4 to 6 hours when insulin is added to PN. If the patient’s glucose level exceeds this goal, supplemental insulin should be administered every 4 to 6 hours, and the subsequent PN dose should be adjusted based on the previous day’s sliding-scale insulin use. It is recommended that the dose does not exceed approximately 0.2 units of insulin per gram of dextrose.¹³

PN Guidelines

Guidelines for PN in cancer and critically ill patients initially were published in 2009,^20,22 and the critical care guidelines were updated in 2022.⁹⁰ In cancer patients, nutrition support should not be used routinely. However, when it is indicated, EN is preferred over PN.^20,91 In most instances, a standard diet is preferred over PN, except in severely malnourished patients undergoing surgery. These patients may benefit from PN therapy if it is administered 7 to 14 days before surgery, as long as the potential medical risks associated with delaying surgery are acceptable.²⁰ As noted earlier, perioperative PN was found by Klek et al to deliver comparable results to EN in malnourished cancer patients.¹⁷ Additionally, Pelzer et al found improvements in body composition in advanced pancreatic cancer patients with cachexia.¹⁸ These positive results suggest that PN in cancer patients may be beneficial when used to treat malnutrition.

In critically ill patients, PN showed no significant differences in clinical outcomes compared with EN. When patients have a functioning GI tract that can accommodate feedings, EN should be used instead of PN. PN should be used if EN is contraindicated, and the patient is malnourished or at high nutrition risk before the critical illness. Nutrition should be initiated in patients within 7 to 10 days of ICU admission providing 12 to 25 kcal/kg per day. Goal protein requirements range from 1.2 to 2 g/kg per day. New approaches to PN are presented in the updated 2022 ASPEN critical care guidelines.⁹⁰ The use of supplemental PN within 7 days of ICU admission showed no benefit compared with patients who did not receive supplemental PN.⁹⁰

The last important aspect of the critical care guidelines is the use of ILEs. Previously published critical care guidelines recommended withholding or limiting soybean oil–based ILEs during the first week of PN.⁹ This recommendation is no longer supported. Updated guidelines recommend either 100% soybean oil ILE (eg, Intralipid, Nutrilipid) or mixed oil ILEs (eg, Clinolipid, SMOFlipid) be provided to critically ill patients who require PN, including within the first week of ICU admission. These ILEs are effective sources of energy, and optimizing ILE intake helps avoid excessive dextrose intake and hyperglycemia.⁹⁰

The ASPEN-FELANPE (Federacion Latinoamericana de Terapia Nutricional Nutrición Clínica y Metabolismo) Clinical Guidelines for nutrition support in adult patients with enterocutaneous fistula recommends the use of EN in patients with a fistula output less than 500 mL per day. PN should be considered if the fistula output exceeds 500 mL per day. The guidelines suggest the provision of protein at 1.5 to 2 g/kg per day. More protein—up to 2.5 g/kg per day—may be required in a patient with an enteroatmospheric fistula.⁹¹

The PN guidelines provide some useful information for pharmacists.

A few concepts from the guidelines are outlined below²¹:

• Education of healthcare professionals will improve PN ordering and reduce errors.
• The maximum osmolarity of peripheral PN should be 900 mOsm/L.
• Standardized commercially available PN products such as concentrated amino acids (with or without electrolytes), concentrated dextrose (with or without ILE) in multi-chamber bags can be considered as a PN option, with customization as needed.
• There is no difference in infectious risk between 2-in-1 and 3-in-1 formulations. In home infusion, 3-in-1 formulations may have an increased risk for catheter occlusion.
• Suggested dosing limits for macronutrients to maintain stability in 3-in-1 admixtures are as follows: at least 4% amino acids, at least 10% dextrose, and at least 2% ILE. This guide is only useful for soybean oil emulsions (Intralipid or Nutrilipid). The ILE manufacturer must be contacted for dosing limits when other ILE (Clinolipid, Omegaven, and SMOFlipid) products are used.
• Heparin should not be used in PN admixtures to reduce the incidence of central venous thrombosis.

Transitions of Care

Transitions of care require coordination between numerous healthcare providers. These include inpatient and outpatient providers, care managers, and the patient and/or caregivers. Poor communication during transitions of care has been shown to harm health outcomes and can increase costs to patients and healthcare systems.⁹² Errors with PN—a high-alert medication—during transitions of care can lead to significant adverse events and potential harm to the patient. Risk avoidance strategies with standardized processes and clear communication between providers should be implemented for safe transitions.

ASPEN has outlined key steps and considerations for the transition processes of patients receiving PN.⁹² These steps include the following:

• Determine early in a patient’s treatment if they may be able to transition.
• Perform assessment in preparation for transfer.
• Identify the receiving organization.
• Identify the provider responsible for managing PN.
• Communicate and implement the PN care plan.

Resources for transitions of care may be found at the ASPEN website: bit.ly/3DMaOM4.

Withholding and Withdrawing PN

The decision to use PN can be difficult when a patient is unresponsive to therapy or in the terminal stages of disease. The decision to withhold or withdraw PN should be discussed with the medical staff and the patient or a designee. The discussion should elucidate the patient’s preferences, goals, and values—including religious beliefs—and include a detailed list of the possible benefits and burdens of therapy. If the benefit versus risk is not easy to predict, a trial period to evaluate effectiveness, benefits, and burdens should be considered. Chermesh et al showed that incurable cancer patients had a higher rate of complications from PN than noncancer PN patients; however, if a Karnofsky Performance Status score greater than 50 was achieved, PN was associated with longer survival.⁹³ The process of withholding or withdrawing PN requires an understanding of ethical issues concerning nutrition support.⁹⁴ When necessary, a bioethics committee should be consulted.

Managing PN Shortages

Managing PN shortages requires a strategic approach to ensure patient safety and minimize adverse events. PN has been affected due to the availability of products. Resources regarding PN shortages can be found at the APSEN website with updated information (bit.ly/418rpph).

Conclusion

PN can be effective in treating malnutrition. Its properties, however, confer a unique set of complications that may adversely affect patient outcomes. Optimal use of PN requires careful consideration of the patient’s clinical condition and nutritional state, and the physical and chemical characteristics of the admixture. In addition, use of evolving guidelines for determining the proper indication, dose, and mode of administration of PN facilitates the provision of the most appropriate nutritional therapy.

Suggested Reading

The ASPEN website includes information related to PN safety, including tool kits and practice tools to assist in implementing organizational changes. For more information, visit www.nutritioncare.org/ PNResources. For full references, see below.

Jay Mirtallo Tribute

The authors pay tribute to Jay Mirtallo, MS, RPh, BCNSP, FASHP, FASPEN, the original author of “Parenteral Nutrition Therapy: Assessment Tools and Guidelines.” Mr. Mirtallo was the primary author of this paper for many years. His contributions to the field of PN and pharmacy have made a significant impact on clinicians across many disciplines, as well as enhanced patient care and medication safety.

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Dr. Ayers is a consultant to and speaker for Fresenius Kabi and an advisory board member for American Regent and B. Braun. Drs. Allen and Cutrell reported no relevant financial disclosures.

This content has been developed for use by healthcare professionals to inform other clinicians and/or patients/caregivers. ASPEN is making this content available for informational purposes only. This content is not based on ASPEN Board Approved documents and should not be confused with ASPEN clinical guidelines as it was not developed according to ASPEN guideline processes. Recommendations provided here do not constitute medical or other professional advice and should not be taken as such. To the extent that the information presented here may be used to assist in the care of patients, the primary component of quality medical care is the result of the professional judgment of the healthcare professionals providing care. Circumstances and patient specifics in clinical settings may require actions different from those recommended in this document; in those cases, the judgment of the treating professional should prevail. Use of this information does not in any way guarantee any specific benefit in outcome or survival.

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