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Parenteral nutrition

Guidelines

Key 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 College of Gastroenterology (ACG 2024,2019), the American Gastroenterological Association (AGA 2024,2020), the American Society for Parenteral and Enteral Nutrition (ASPEN 2023,2022,2020,2019,2017,2014,2010), the European Consensus Group on Respiratory Distress Syndrome (ECG-RDS 2023), the European Society for Clinical ...
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Diagnostic investigations

Initial assessment: as per ASPEN 2017 guidelines, obtain a full evaluation of the feasibility of enteral nutrition before initiating PN. Assess clinical factors derived from history, physical examination, and diagnostic evaluations to determine if enteral nutrition is contraindicated.
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  • Body composition assessment

Medical management

Non-nutrient medications
As per ASPEN 2014 guidelines:
Include non-nutrient medication in PN 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; do not extrapolate beyond the parameter limits (such as products, concentrations) of the given data
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Avoid including heparin in PN admixtures for reducing the risk of central vein thrombosis.
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Nonpharmacologic interventions

Indications for initiation: as per ASPEN 2017 guidelines, do not use PN based solely on medical diagnosis or disease state. Reserve PN for clinical situations where adequate enteral nutrition is not possible.
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  • Choice of vascular access device

  • Nutrition formulations (choice of formulation)

  • Nutrition formulations (storing and repackaging)

  • Peripheral PN

  • Home PN (indications)

  • Home PN (requirements before initiation)

  • Home PN (choice of vascular access devices)

  • Home PN (maintenance of vascular access devices)

  • Home PN (nutrition formulations)

  • Home PN (monitoring)

  • Home PN (policies and protocols)

Perioperative care

Perioperative PN: as per ASPEN 2017 guidelines, consider administering preoperative PN in severely malnourished patients unable to tolerate sufficient oral intake or enteral nutrition.
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Specific circumstances

Neonatal patients, indications: as per ECG-RDS 2023 guidelines, initiate PN from birth in neonates with neonatal respiratory distress syndrome.
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  • Neonatal patients (calcium and phosphorus intake)

  • Preterm infants

  • Pediatric patients (indications)

  • Pediatric patients (prevention of liver disease)

  • Pediatric patients (management of liver disease)

  • Patients with AKI

  • Patients with CKD

  • Patients with chronic liver disease

  • Patients with IBD

  • Patients with acute pancreatitis

  • Critically ill patients (indications)

  • Critically ill patients (nutritional requirements)

  • Critically ill patients (lipid injectable emulsions)

  • Critically ill patients (glutamine)

  • Palliative care patients

Follow-up and surveillance

Monitoring and discontinuation: as per ASPEN 2017 guidelines, obtain interprofessional monitoring of clinical status and response to PN in patients of all ages and in all healthcare settings, by clinicians with expertise in managing PN.
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Quality improvement

Policies and protocols: as per ASPEN 2017 guidelines, employ standardized processes for the management of PN.
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  • Healthcare professional training