Tailoring Parenteral Nutrition | Clinical Nutrition LAM Initiative

Tailoring Parenteral Nutrition

Aiming to Meet Each Patient’s Nutritional Requirements

Prior to the administration of parenteral nutrition (PN), each patient must undergo an extensive examination to assess the condition of the gastrointestinal (GI) tract, underlying or pre-existing diseases and therapies, and additional considerations like nutritional status, venous access or laboratory values. Once PN is indicated, health care professionals can properly calculate nutrient requirements, which will allow them to adjust clinical nutrition therapy to the needs of the majority of patients.1

To meet each patient’s energy and protein requirements, it is important to consider the complete clinical picture. Energy intake during PN must be adjusted to the:2

  • Actual energy expenditure
  • Clinical situation of the patient
  • Nutritional goals established in regard to nutritional status

Meeting Patient Energy Requirements in View of Actual Energy Expenditure

Several equations are available to predict energy expenditure. For calculating basal energy expenditure (BEE), the Harris and Benedict equation is the most commonly used in clinical practice. Total Caloric Requirements equal the BEE multiplied by the sum of the stress and activity factors.

Click here to read more about how to calculate energy expenditure.

Consider the Clinical Condition

The patient’s clinical condition must be assessed to determine adjustments of PN. Activity or trauma factors must be considered and account for increased energy requirements due to physical activity and metabolic stress related to the underlying disease.

Calculation of energy requirements in the hospital setting should also evaluate and consider activity and trauma factors as recommended by the Austrian Society for Clinical Nutrition (AKE) recommendations 2008.3 The following chart shows how the Harris and Benedict equation calculates energy requirements factoring in resting energy expenditure (REE), stress and activity:3,4,5

Estimation of REE using the Harris and Benedict equation

The following are guidelines of The European Society for Clinical Nutrition and Metabolism (ESPEN) outlining nutrient requirements and administration of PN in specific clinical situations such as intensive care, acute pancreatitis, and acute renal failure:6,7,8

ESPEN guideline on PN in specific clinical situations - part 1

The following ESPEN guidelines are for specific clinical situations such as non-surgical oncology, surgery, and home PN:9,10,11

ESPEN guideline on PN in specific clinical situations - part 2

Factors in Establishing Nutritional Goals

Calculation of a patient’s energy and protein requirements must consider the established objectives of the nutrition therapy, including:2

  • Provision of energy and protein to prevent body wasting during acute illness
  • Recovery of muscle and energy stores during re-convalescence
  • Nutritional status/BMI in severe malnutrition, cachexia, or obesity

The following chart shows how energy requirements relate to nutritional goals:3

Energy requirements in relation to nutritional goals

  • 1. Elia M, Austin P, Stratton RJ. Indications for nutritional support. In: Sobotka L, editor. Basics in Clinical Nutrition. Prague: Galen 2011:223-231.
  • 2. a. b. Carpentier Y, Sobotka L. Energy. In: Sobotka L, editor. Basics in Clinical Nutrition. Prague: Galen 2011:247-251.
  • 3. a. b. c. Austrian Society of Clinical Nutrition (AKE). Recommendations for enteral and parenteral nutrition in adults. Vienna: 2008.
  • 4. Human energy requirements: Energy Requirement of Adults. Report of a Joint FAO/WHO/UNU Expert Consultation. Food and Agriculture Organization of the United Nations 2004.
  • 5. Westerterp KR, Schols AMWJ, Singer P. Energy metabolism. In: Sobotka L, editor. Basics in Clinical Nutrition. Prague: Galen 2011;96-103.
  • 6. Singer P, Berger MM, Van den Berghe G et al. ESPEN Guidelines on Parenteral Nutrition: intensive care. Clin Nutr 2009;28(4):387-400.
  • 7. Gianotti L, Meier R, Lobo DN et al. ESPEN Guidelines on Parenteral Nutrition: Pancreas. Clin Nutr 2009;28:428-435.
  • 8. Cano N, Aparicio M, Brunori G et al. ESPEN guidelines on parenteral nutrition: Adult renal failure. Clin Nutr 2009;18:401-414.
  • 9. Bozzetti F, Arends J, Lundholm K et al. ESPEN Guidelines on Parenteral Nutrition: Non-surgical oncology. Clin Nutr 2009;28:445-454.
  • 10. Braga M, Ljungqvist O, Soeters P et al. ESPEN Guidelines on Parenteral Nutrition: Surgery. Clin Nutr 2009;28:378-386.
  • 11. Staun M, Pironi L, Bozzetti F et al. ESPEN Guidelines on Parenteral Nutrition: Home parenteral nutrition (HPN) in adult patients. Clin Nutr 2009;28:467-479.

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