Guideline sources The following summarized guidelines for the evaluation and management of parenteral nutrition are prepared by our editorial team based on guidelines from the American Society for Parenteral and Enteral Nutrition (ASPEN 2014). 1 2 Guidelines 1. Diagnostic investigations Clinical assessment: assess clinical factors derived from history, physical examination, and diagnostic evaluations in determining if enteral nutrition is contraindicated. 2. Medical management Nutrition formulation: we suggest that parenteral nutrition with an osmolarity up to 900 mOsm/L can be safely infused peripherally. Higher osmolarity limits, especially when peripheral parenteral nutrition is prepared as a total nutrient admixture, may also be tolerated, but the evidence to support a safe limit is lacking. B https://web.pathway.md/diseases/rec7yEvRHMw7mnNQs 1/4 6/29/23, 10:53 PM Parenteral nutrition Pathway Parenteral nutrition formulations: target an elemental calcium intake of 76 mg/kg per day for short-term parenteral nutrition in neonates. A Non-nutrient medication mixture: Include non-nutrient medication in parenteral nutrition admixtures only when supported by both: pharmaceutical data describing physicochemical compatibility and stability of the additive medication and of the final preparation under conditions of typical use clinical data confirming the expected therapeutic actions of the medication; extrapolation beyond the parameter limits such as products, and concentrations of the given data is discouraged. A Fat emulsions (patients with TPN liver disease): consider reducing the dose of soy oil fat emulsion to < 1 g/kg/d to treat cholestasis in children with parenteral nutrition-associated liver disease. Balance the desirable effect of the reduction of liver indices with the unknown potential effects on growth and development when lipids are restricted. C Ursodeoxycholic acid (patients with TPN liver disease): consider using UDCA to treat elevated liver enzymes in children with parenteral nutrition-associated liver disease. Balance potential beneficial effects against the unknown efficacy of the treatment and the fact that in most cases, the study participants did not have primary intestinal pathology. C Indications: avoid using parenteral nutrition based solely on medical diagnosis or disease state. Show 2 more Contraindications: Begin parenteral nutrition and withhold enteral nutrition in neonatal and pediatric patients when a clear contraindication to enteral nutrition exists, such as intestinal injury and perforation. Evaluate intestinal function and perfusion, as well as overall hemodynamic stability, when evaluating readiness for enteral nutrition, rather than relying on strict adherence to a list of contraindications to enteral nutrition, such as the presence of umbilical catheters or use of vasoactive medications. Timing of care in adults: start parenteral nutrition after 7 days for well-nourished, stable adult patients who have been unable to receive significant oral or enteral nutrients. Show 3 more Timing of care in pediatric patients: Initiate parenteral nutrition promptly after birth in the very low- birth-weight infant. There is insufficient data to suggest a specific time frame in which parenteral nutrition is ideally initiated in more mature preterm infants or critically ill term neonates. Delay starting parenteral nutrition for 1 week in the infant, pediatric, or adolescent patient with a self-limited illness. However, initiate parenteral nutrition within 1-3 days in infants and within 4-5 days in older pediatric and adolescent patients when it is evident that they will not tolerate full oral intake or enteral nutrition for an extended period. Complications: apply standardized processes to manage parenteral nutrition. Show 3 more https://web.pathway.md/diseases/rec7yEvRHMw7mnNQs 2/4 6/29/23, 10:53 PM Parenteral nutrition Pathway Monitoring of treatment response: provide inter-professional monitoring of clinical status and response to parenteral nutrition therapy for patients of all ages and in all healthcare settings, by clinicians with expertise in managing parenteral nutrition. Show 3 more Appropriateness of parenteral nutrition use: carry out a clinical review for each patient to assess suitability of parenteral nutrition prior to compounding the parenteral nutrition admixture. Show 3 more 3. Nonpharmacologic interventions Repackaging of IV fat emulsions: avoid repackaging intravenous fat emulsions into syringes for administration to patients. Prefer other methodologies for repackaged intravenous fat emulsions, such as drawn-down intravenous fat emulsions units. D 4. Therapeutic procedures Vascular access device (VAD) insertion: tailor the selection of vascular access device for parenteral nutrition administration based on an evaluation of the risks and benefits of the device, clinical factors, and psychosocial considerations. Show 4 more 5. Specific circumstances Pediatric patients: consider parenteral nutrition for neonates in the critical care setting, regardless of diagnosis, when enteral nutrition is unable to meet energy requirements for energy expenditure and growth. Show 2 more Peripheral parental nutrition: use peripheral parenteral nutrition only for short-term purposes, no more than 10-14 days, as supplemental parenteral nutrition or as a bridge therapy during transition periods, where oral intake or enteral nutrition is suboptimal or clinical circumstances do not justify placing a central venous access devices. Show 3 more Intradialytic parenteral nutrition: Avoid using intradialytic parenteral nutrition as the sole source of nutrition intervention in malnourished patients with CKD. Consider intradialytic parenteral nutrition for adult and pediatric patients with CKD who are malnourished and unable to tolerate adequate oral intake or enteral nutrition. Perioperative parenteral nutrition: consider preoperative parenteral nutrition in severely malnourished patients unable to tolerate sufficient oral intake or enteral nutrition. Show 2 more Palliative care patients: avoid using parenteral nutrition solely to treat poor oral intake and/or cachexia associated with advanced malignancy. https://web.pathway.md/diseases/rec7yEvRHMw7mnNQs 3/4 6/29/23, 10:53 PM Parenteral nutrition Pathway Show 3 more Home parenteral nutrition: consider home parenteral nutrition for patients with intestinal failure who are clinically stable and able to receive therapy outside an acute care setting. Show 10 more 6. Patient education Healthcare professional education: consider providing education to healthcare professionals to improve parenteral nutrition ordering, thereby reducing errors. C 7. Preventative measures Ethanol lock for prevention of catheter infection: consider ethanol lock therapy to prevent catheter-related bloodstream infection and to reduce catheter replacements in children at risk of parenteral nutrition-associated liver disease. C 8. Follow-up and surveillance Indications for specialist referral: consider referring patients with parenteral nutrition- dependent intestinal failure to multidisciplinary intestinal rehabilitation programs. C Studies 2011 EPaNIC In adults in the ICU who had a score of 3 on nutritional risk screening, late parenteral initiation was superior to early parenteral initiation with respect to duration of stay in the ICU. Michael P Casaer et al. N Engl J Med. 2011 Aug 11. References 1. Boullata JI, Gilbert K, Sacks G et al. A.S.P.E.N. clinical guidelines: parenteral nutrition ordering, order review, compounding, labeling, and dispensing. JPEN J Parenter Enteral Nutr. 2014 Mar-Apr;38 3 334 77. Open 2. Wales PW, Allen N, Worthington P et al. A.S.P.E.N. clinical guidelines: support of pediatric patients with intestinal failure at risk of parenteral nutrition-associated liver disease. JPEN J Parenter Enteral Nutr. 2014 Jul;38 5 538 57. Open 3. Worthington P, Balint J, Bechtold M et al. When Is Parenteral Nutrition Appropriate?. JPEN J Parenter Enteral Nutr. 2017 Mar;41 3 324 377. Open https://web.pathway.md/diseases/rec7yEvRHMw7mnNQs 4/4