Tailoring Parenteral Nutrition | Clinical Nutrition LAM Initiative

Tailoring Parenteral Nutrition

Aiming to Meet Each Patient’s Nutritional Requirements

To meet each patient’s energy and protein requirements, it is important to consider the complete clinical picture. Energy intake during parenteral nutrition (PN) must be adjusted to the:1

  • Actual energy expenditure
  • Clinical situation of the patient
  • Nutritional goals based on nutritional status

Actual Energy Expenditure

Several equations are available to predict energy consumption. In clinical practice, the Harris and Benedict equation is the most commonly used to calculate resting energy expenditure (REE). Using this equation, height, body weight, gender, and age are used to estimate an individual’s resting metabolic rate.2

Clinical Situation of the Patient

The patient’s clinical condition, e.g. activity or trauma factors, such as large bone fractures, sepsis, burns, severe infection, chronic renal failure and cancer, must be considered when determining adjustments to PN. Activity or trauma factors, such as large bone fractures, sepsis, burns, severe infection, chronic renal failure and cancer, must be considered. They account for increased energy and protein requirements due to the physical activity and metabolic stress related to the underlying disease.

Nutritional Goals Established with Regard to Nutritional Status

When calculating a patient’s energy and protein requirements, the established objectives of the nutrition therapy must be considered, including:1

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

PN Support in Specific Clinical Situations

Because each patients’ clinical nutrition requirements are influenced by underlying disease and any resulting course of treatment, it is important that PN can be adjusted to meet the needs of those specific clinical situations.

In the charts listed below, recommendations are graded according to the criteria of the Scottish Intercollegiate Guidelines Network (SIGN) and the Agency for Health Care Policy and Research. Grades are as follows:

  • A: Meta-analysis of randomized controlled trials or at least one randomized controlled trial
  • B: At least one well-designed controlled trial without randomization or one other type of well-designed, quasi-experimental study or well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies
  • C: Expert opinions and/or clinical experience of respected authorities

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:3,4,5,6

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:7,8,9

ESPEN guideline on PN in specific clinical situations - part 2

A carefully tailored PN therapy can be administered to support the specific clinical nutrition needs of patients, thereby fighting disease-related malnutrition.

  • 1. a. b. Carpentier Y, Sobotka L. Energy. In: Sobotka L, editor. Basics in Clinical Nutrition. Prague: Galen 2011;247-251.
  • 2. Westerterp KR, Schols AMWJ, Singer P. Energy metabolism. In: Sobotka L, editor. Basics in Clinical Nutrition. Prague: Galen 2011;96-103.
  • 3. Bozzetti F, Forbes A. The ESPEN clinical practice guidelines on Parenteral Nutrition: Present status and perspectives for future research. Clin Nutr 2009;28:359-364.
  • 4. Singer P, Berger MM, Van den Berghe G et al. ESPEN Guidelines on Parenteral Nutrition: intensive care. Clin Nutr 2009;28(4):387-400.
  • 5. Gianotti L, Meier R, Lobo DN et al. ESPEN Guidelines on Parenteral Nutrition: Pancreas. Clin Nutr 2009;28:428-435.
  • 6. Cano N, Aparicio M, Brunori G et al. ESPEN guidelines on parenteral nutrition: Adult renal failure. Clin Nutr 2009;28:401-414.
  • 7. Bozzetti F, Arends J, Lundholm K et al. ESPEN Guidelines on Parenteral Nutrition: Non-surgical oncology. Clin Nutr 2009;28:445-454.
  • 8. Braga M, Ljungqvist O, Soeters P et al. ESPEN Guidelines on Parenteral Nutrition: Surgery. Clin Nutr 2009;28:378-386.
  • 9. 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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