When Is Parenteral Nutrition Appropriate?

Abstract

Parenteral nutrition (PN) represents one of the most notable achievements of modern medicine, serving as a therapeutic modality for all age groups across the healthcare continuum. PN offers a life-sustaining option when intestinal failure prevents adequate oral or enteral nutrition. However, providing nutrients by vein is an expensive form of nutrition support, and serious adverse events can occur. In an effort to provide clinical guidance regarding PN therapy, the Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) convened a task force to develop consensus recommendations regarding appropriate PN use. The recommendations contained in this document aim to delineate appropriate PN use and promote clinical benefits while minimizing the risks associated with the therapy. These consensus recommendations build on previous ASPEN clinical guidelines and consensus recommendations for PN safety. They are intended to guide evidence-based decisions regarding appropriate PN use for organizations and individual professionals, including physicians, nurses, dietitians, pharmacists, and other clinicians involved in providing PN. They not only support decisions related to initiating and managing PN but also serve as a guide for developing quality monitoring tools for PN and for identifying areas for further research. Finally, the recommendations contained within the document are also designed to inform decisions made by additional stakeholders, such as policy makers and third-party payers, by providing current perspectives regarding the use of PN in a variety of healthcare settings. (JPEN J Parenter Enteral Nutr. 2017;41:324-377) The etiology-based nutrition diagnoses in adults in clinical practice settings are as follows: Starvation-related malnutrition: Chronic starvation without inflammation (eg, anorexia nervosa). Chronic disease-related malnutrition: Inflammation is chronicand of mild to moderate degree (eg, organ failure, pancreatic cancer, rheumatoid arthritis, sarcopenic obesity). Acute disease or injury-related malnutrition:Inflammation is acute and of severe degree (eg, major infection burns, trauma, closed head injury). 2,3Malnutrition, pediatric: An imbalance between nutrient requirement and intake, resulting in cumulative deficits of energy, protein, or micronutrients that may negatively affect growth, development, and other relevant outcomes. It is recommended that growth charts based on a standard deviation z score system be used to track and assess nutrition status in children. 4,5Nutritionally-at-risk: Consider the individual nutritionally-atrisk if any of the following is present. Nutritionally-At-Risk Adult Summary of RecommendationsThese consensus recommendations are designed to identify best practices, guide day-to-day clinical decisions, reduce variations in practice, and enhance patient safety. They are not intended to supersede the judgment of the healthcare professional based on the circumstances of the individual patient.

Barriers and Solutions to Delivery of Intensive Care Unit Nutrition Therapy

“…PN should not be initiated based on medical diagnosis or disease state alone, but instead a thorough evaluation including clinical factors and a physical examination should be completed to determine its appropriateness . For ICU patients who are determined to be severely malnourished or at high nutrition risk with an EN contraindication, guidelines suggest PN be initiated as soon as possible.…”

“…13,48 A meta‐analysis by Braunschweig et al showed no nutrition therapy in malnourished patients was associated with a significantly higher risk for mortality than exclusive PN (relative risk 3.0; 95% confidence interval, 1.09–8.56; P < .05). In well‐nourished or low nutrition risk ICU patients, exclusive PN can be withheld for the first 7 ICU days . However, supplemental PN (SPN) on day 7 can be considered for low or high nutrition risk patients not achieving at least 60% of energy and protein requirements through EN alone .…”

A Call to Action for Optimizing the Electronic Health Record in the Parenteral Nutrition Workflow

“…PN should only be used in patients in whom the benefit outweighs the potential risks. In 2017, the American Society for Parenteral and Enteral Nutrition (ASPEN) published consensus recommendations on the appropriate use of PN . A 2013 ASPEN survey with a gap analysis revealed only 58% of healthcare organizations have precautions in place to prevent errors and patient harm associated with PN …”

Supplemental Parenteral Nutrition: Review of the Literature and Current Nutrition Guidelines

“…Parenteral nutrition (PN), conceived by Stanley Dudrick, Jonathan Rhoads, Douglas Wilmore, and Harry Vars >50 years ago, has significantly impacted the clinical care of patients, saving the lives of individuals who would otherwise have died because of severe malnutrition . Guidelines and recommendations for the use of PN have been described in documents from the American Society for Parenteral and Enteral Nutrition (ASPEN) and European Society for Clinical Nutrition and Metabolism (ESPEN) . Recent ASPEN consensus recommendations indicate that “an enduring debate about the role of intravenous nutrition in a variety of patient populations” exists .…”