Parenteral Nutrition Guidelines

Details of current guidelines and recommendations for when total PN and supplemental PN may be used for nutritional support in different patient populations and clinical settings.

Table 1 provides an overview of the International Guidelines on pediatric parenteral nutrition (PN) available from the European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), European Society for Clinical Nutrition and Metabolism (ESPEN),1 American Society for Parenteral and Enteral Nutrition (ASPEN) and The American Academy of Pediatrics (AAP).2–7

Table 1. Overview of the international guidelines available for the use of PN in pediatric patient populations and clinical settings1–6

Organization Population
ESPGHAN/ESPEN Pediatrics1
ASPEN Adults and pediatrics2,4
Critically ill child3
Hyper/hypoglycemia in neonate5
AAP Neonatal intensive care nutrition6

AAP (American Academy of Pediatrics); ASPEN (American Society for Parenteral and Enteral Nutrition); ESPGHAN (European Society of Paediatric Gastroenerology, Hepatology and Nutrition); ESPEN (European Society for Clinical Nutrition and Metabolism)


International clinical practice guidelines for the use of PN in adults are also available from the European Society For Clinical Nutrition And Metabolism (ESPEN),8–18 the Society of Critical Care Medicine (SCCM)19 and American Society for Parenteral and Enteral Nutrition (ASPEN).2,19–22 The ESPEN and ASPEN guidelines are sub-divided according to patient population (e.g. adult renal failure, critically ill) or patient settings (e.g. home PN) as shown in Table 2.

Table 2. Overview of the international guidelines available for the use of PN in adult patient populations and clinical settings2,4,8–22

Organization Population
ESPEN Surgery9
Adult intensive care10
Adult renal failure11
Gastroenterology12
Pancreas13
Hepatology14
Non-surgical oncology15
Cardiology and pneumology16
Geriatrics17
Home parenteral nutrition in adults18
SCCM/ASPEN Adult critically ill19
ASPEN Adults and pediatrics24
Acute and chronic renal failure20
Anticancer treatment and in hematopoietic cell transplantation21
Adult patients with hyperglycemia22

ASPEN (American Society for Parenteral and Enteral Nutrition); ESPEN (European Society for Clinical Nutrition and Metabolism); SCCM (Society of Critical Care Medicine)


In addition to these international guidelines, country-specific recommendations or guidelines may exist. Nutritional practice patterns may differ between countries and institutions, and it is currently unclear to what extent existing clinical practice guidelines are adhered to and how much treatment variation exists in clinical practice.23 A survey of neonatal intensive care units (NICUs) in France demonstrated that many NICUs fail to meet ESPGHAN/ESPEN nutrition recommendations in regard to protein and calorie intake (Figure 1).23

Figure 1. Many NICUs fail to meet ESPGHAN/ESPEN recommendations for protein and calorie intake23

Calculated from Lapillonne A, et al. J Pediatr Gastroenterol Nutr 2009;48:618–626.23

Nutritional recommendations

The recommended amounts of nutrients for PN differ from those provided orally or enterally. International guidelines for PN provide nutrition recommendations and an overview of these recommendations for pediatric patients1,4 and adult patients are summarized in the following sections.


Nutritional recommendations for pediatric patients

The nutritional requirements differ between infants and children because the rate of growth varies according to developmental stage, and because different organs grow and differentiate at different ages.1 Due to insufficient data, nutritional recommendations for infants and children are not always consistent.


Pediatric patients, especially neonates, have limited energy reserves and are therefore, particularly in danger when malnourished. The smaller an infant is, the smaller the reserves and the shorter the number of days the baby can survive without nutrition.1 Consequently very low birth weight (VLBW) infants, ≤1500g and extremely low birth weight (ELBW) infants ≤1000g have a special need for optimal nutritional care.


The requirements of neonatal intensive care unit or pediatric intensive care unit patients may differ from healthy term neonates/children.1 The total energy needs of otherwise healthy preterm infants depend on the post-conceptual age, and small-for-gestational age infants may need a higher energy intake than appropriate-for-gestational age infants.24


Further details of the PN recommendations in infants (including preterm infants) and children from ESPEN/ESPGHAN and ASPEN are provided in the sections below:


Parenteral protein and energy requirements in pediatric patients

Preterm infants
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Tables 3 and 4 show guidelines for protein and energy provision for preterm infants, developed by the ASPEN4 and ESPEN/ESPGHAN societies.1

Table 3. Protein and energy recommendations for PN in preterm infants by the ASPEN society4

Protein goal per day
(g/kg body weight)
Energy goal per day
(kcal/kg body weight)
Initial period* Stable growing Initial period* Stable growing
ELBW 1–1.5 3.5–3.85 50–60 100–120
VLBW 1–1.5 3.5–3.85 50–60 100–120

ELBW: extremely low birth weight infants; VLBW: very low birth weight infants


*Initial period is typically first 3 days, however may extend longer based on infant's individual circumstances

Table 4. Amino acid and energy recommendations for PN in preterm infants by the ESPEN/ESPGHAN societies1

Age (years) Amino acid goal per day
(g/kg body weight)
Energy goal per day
(kcal/kg body weight)
Preterm 1.5–4.0 110–120

Infants and children
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Tables 5 to 6 show guidelines for protein and energy provision for infants and children, developed by the ASPEN4 and ESPEN/ESPGHAN societies.1

Table 5a. Amino acid recommendations for PN in healthy infants and children by ESPEN/ESPGHAN1 societies

Age ESPEN/ESPGHAN Amino acid goal per day
(g/kg body weight)
Term neonates 1.5–3.0
2nd month to 3rd year 1.0–2.5
3–18 years 1.0–2.0*

*For critically ill patients (aged 3–12 years) the advisable amino acid intake may be higher (up to 3g/kg/day)

Table 5b. Protein requirements for PN in healthy infants and children by ASPEN4 society

Age ASPEN estimate of protein requirements per day
(g/kg body weight)
Term neonates 2.0–3.0
1– 10 years 1.0–1.2
Adolescence 0.9 (boys), 0.8 (girls)

The ASPEN guidelines state there are insufficient data to make evidence-based recommendations for macronutrient intake in critically ill children. They do give estimated protein requirements for injured children of various age groups as follows: 0–2 years, 2–3 g/kg/day; 2–13years, 1.5–2 g/kg/day; and 13–18 years, 1.5 g/kg/day.3 The clinical status of the individual patient may change rapidly, which requires reassessment and adjustments of the nutritional therapy.

Table 6. Energy recommendations for PN in infants and children by the ASPEN4 and ESPEN/ESPGHAN societies.1

Age (years) Energy goal per day
(kcal/kg body weight)
0–1 90–120 (ASPEN)
90–100 (ESPEN/ESPGHAN)
1–7 75–90
7–12 60–75
12–18 30–60

Reasonable values for energy expenditure can be derived from formulae, e.g. Schofield. However, in individual patients, measurement of resting energy expenditure (REE) may be useful. REE may be measured rather than calculated to estimate calorie needs due to a different individual variability and over or underestimation by the predicting equations.1

Other nutrition requirements in pediatric patients

A summary of the ESPGHAN/ESPEN1and ASPEN4 guideline recommendations regarding the provision of lipids, glucose and fluids in preterm infants and term infants and children are detailed below.

Lipid recommendations
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ESPEN/ESPGHAN1

In order to prevent essential fatty acid deficiency a minimum linoleic acid intake of 0.25 g/kg/day should be given to preterm infants and 0.1 g/kg/day to term infants and older children.


Parenteral lipid intake should usually be limited to a maximum of 3–4 g/kg/day (0.13–0.17 g/kg per hour) in infants and 2–3 g/kg/day (0.08–0.13 g/kg/hour) in older children.


In newborn infants who cannot receive sufficient enteral feeding, intravenous lipid emulsions should be started no later than on the third day of life, but may be started on the first day of life.


ASPEN4

  • Full term infants up to 1 year of age should be allowed an unrestricted fat intake.
  • Children between 1 and 2 years of age should have very limited or no restrictions on fat intake.
  • Between age 2 and 5–6 years, children should transition from a high-fat diet to a fat-modified (moderate fat) diet (less than 30% of total energy from fats and less than 10% from saturated fats).

Glucose recommendations
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Table 7. Glucose recommendations for pediatric patients by the ESPEN/ESPGHAN societies.1

Weight range (kg) Recommended parenteral glucose supply
(g/kg body weight and day)
Day 1 Day 2 Day 3 Day 4
Up to 3 10 14 16 18
3–10 8 12 14 16–18
10–15 6 8 10 12–14
15–20 4 6 8 10–12
20–30 4 6 8 <12
>30 3 5 8 <10

Reproduced from J Pediatr Gastroenterol Nutr, 41(Suppl. 2), Koletzko B, Goulet O, Hunt J, et al.

Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric
Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), Supported by the European Society of Paediatric Research (ESPR), pp. S1–S87., Copyright (2005), with permission from ESPGHAN.


In preterm infants glucose infusion should be started with 4–8 mg/kg/min. Glucose administration to full term neonates and children up to 2 years of age should not exceed 18 g/kg/day (13 mg/kg/min). In critically ill children, glucose intake should be limited to 5mg/kg/min (7.2 g/kg/day)


ASPEN4

  • Carbohydrates should comprise 40–45% of the calorie intake in infants and children.
  • Small amounts of carbohydrates should be used in infants and children who are not otherwise receiving nutrition support to suppress protein catabolism.
  • In infants who are lactose tolerant, lactose should be the predominate enteral carbohydrate administered in the first 3 years of life.
  • Preterm infants should receive a formula that has a 50/50 mixture of lactose and glucose polymers.
  • For the neonate, carbohydrate delivery in PN should begin at approximately 6–8 mg/kg/min of dextrose and be advanced, as tolerated, to a goal of 10–14 mg/kg/min.
  • Carbohydrate administration should be closely monitored and adjusted in the postoperative period in neonates and children to avoid hyperglycemia.

Fluid and electrolyte recommendations
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Table 8. Parenteral fluid and electrolyte recommendations for term and preterm infants during the first postnatal week by the ESPEN/ESPGHAN societies1

Recommended fluid intake (ml/kg body weight/day)
Days after birth 1st day 2nd day 3rd day 4th day 5th day 6th day
Term neonate 60–120 80–120 100–130 120–150 140–160 140–180
Preterm neonate >1500 g 60–80 80–100 100–120 120–150 140–160 140–160
Preterm neonate <1500 g 80–90 100–110 120–130 130–150 140–160 160–180
Recommended Na+, K+, Cl- supply (mmol/kg body weight/day
*Na+ 0–3(5)
**K+ 0–2
CI- 0–5

The expected weight loss depends on treatment conditions (fluid intake) and environmental factors (humidity etc.)

*Careful adjustment of water and electrolyte administration is needed in extremely low birth weight infants at onset of diuresis and in polyuric patients.

**K+ supplementation should usually start after onset of diuresis.

Reproduced from J Pediatr Gastroenterol Nutr, 41(Suppl. 2), Koletzko B, Goulet O, Hunt J, et al.

Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric
Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), Supported by the European Society of Paediatric Research (ESPR), pp. S1–S87., Copyright (2005), with permission from ESPGHAN.

Table 9. Fluid and electrolyte recommendations for PN in term and preterm infants during the intermediate phase prior to the establishment of stable growth by the ESPEN/ESPGHAN societies1

Birth weight Fluid intake
(ml/kg body weight/day)
Na+ intake
(mmol/kg body weight/day)
K+ intake
(mmol/kg body weight/day)
CI- intake
(mmol/kg body weight/day)
Term neonate 140–170 2.0–5.0 1.0–3.0 2.0–3.0
>1500 g 140–160 3.0–5.0 1.0–3.0 3.0–5.0
<1500 g 140–180 2.0–3.0 (5) 1.0–2.0 2.0–3.0

Reproduced from J Pediatr Gastroenterol Nutr, 41(Suppl. 2), Koletzko B, Goulet O, Hunt J, et al.

Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric
Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), Supported by the European Society of Paediatric Research (ESPR), pp. S1–S87., Copyright (2005), with permission from ESPGHAN.

Table 10. Fluid and electrolyte recommendations for PN in term and preterm infants during the first month of life with stable growth by the ESPEN/ESPGHAN societies1

Fluid intake
(ml/kg body weight/day)
Na+ intake
(mmol/kg body weight/day)
K+ intake
(mmol/kg body weight/day)
Term neonate 140–160 2.0–3.0 1.5–3.0
Preterm neonate 140–160 3.0–5.0(7.0) 2.0–5.0

Reproduced from J Pediatr Gastroenterol Nutr, 41(Suppl. 2), Koletzko B, Goulet O, Hunt J, et al.

Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric
Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), Supported by the European Society of Paediatric Research (ESPR), pp. S1–S87., Copyright (2005), with permission from ESPGHAN.

Table 11a. Electrolyte recommendations for PN in term infants after the first month of life and for children by the ESPEN/ESPGHAN societies1

Electrolyte Infants Children >1 year
Na+ (mmol/kg body weight/day) 2.0–3.0 1.0–3.0
*K+ (mmol/kg body weight/day) 1.0–3.0 1.0–3.0

*K+ supplementation should usually start after onset of diuresis.

Reproduced from J Pediatr Gastroenterol Nutr, 41(Suppl. 2), Koletzko B, Goulet O, Hunt J, et al.

Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric
Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), Supported by the European Society of Paediatric Research (ESPR), pp. S1–S87., Copyright (2005), with permission from ESPGHAN.

Table 11b. Fluid intake recommendations for PN in term infants after the first month of life and for children by the ESPEN/ESPGHAN societies1

Age Fluid intake
(ml/kg body weight/day)
(maximum volumes in brackets)
Term infants from the second month of life 120–150 (180)
1–2 years 80–120 (150)
3–5 years 80–100
6–12 years 60–80
13–18 years 50–70

Reproduced from J Pediatr Gastroenterol Nutr, 41(Suppl. 2), Koletzko B, Goulet O, Hunt J, et al.

Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric
Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), Supported by the European Society of Paediatric Research (ESPR), pp. S1–S87., Copyright (2005), with permission from ESPGHAN.


ASPEN recommends that fluid needs vary with the age and weight of the child and should be adjusted accordingly. Water and electrolyte requirements should be adjusted in pediatric patients undergoing surgical procedures or who have ongoing losses from stomas or other sites.4

Trace elements and vitamin recommendations
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Infants and children receiving PN should receive parenteral vitamins and may need PN to be supplemented with trace elements. The amounts for these differ between children of different ages and phases of development, as summarized in Tables 12–14.1

Table 12. Recommended amounts of calcium, phosphorous and magnesium for PN in infants and children by the ESPEN/ESPGHAN societies1

Age Suggested calcium intake, mg/kg (mmol/kg) Suggested phosphorus intake, mg/kg (mmol/kg) Magnesium intake,mg/kg (mmol/kg)
0–6 months 32 (0.8) 14 (0.5) 5 (0.2)
7–12 months 20 (0.5) 15 (0.5) 4.2 (0.2)
1–13 years 11 (0.2) 6 (0.2) 2.4 (0.1)
14–18 years 7 (0.2) 6 (0.2) 2.4 (0.1)

Reproduced from J Pediatr Gastroenterol Nutr, 41(Suppl. 2), Koletzko B, Goulet O, Hunt J, et al.

Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric
Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), Supported by the European Society of Paediatric Research (ESPR), pp. S1–S87., Copyright (2005), with permission from ESPGHAN.

Table 13. Recommended amounts of trace elements for PN in infants and children by the ESPEN/ESPGHAN societies1

Trace element Recommendation
Chromium Supplementation is considered unnecessary
Copper 20μg/kg/day
Iodine 1μg/kg
Manganese In children receiving long-term PN, a low-dose supply of no more than 1.0 μg/kg/day is recommended (maximum dose: 50 μg/day for children)
Molybdenum 1 μg/kg/day recommended for low birth weight infants
For infants and children, 0.25 μg/kg/day is recommended (maximum dose: 5.0 μg/day)
Selenium 2–3 μg/kg/day is recommended for parenterally fed LBW infants
Zinc
  • Preterm infants 450–500 μg/kg/day
  • Infants <3 months: 250 μg/kg/day
  • Infants ≥3 months: 100 μg/kg/day
  • Children: 50 μg/kg/day (maximum 5.0 mg/day)

Adapted from J Pediatr Gastroenterol Nutr, 41(Suppl. 2), Koletzko B, Goulet O, Hunt J, et al.

Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric
Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), Supported by the European Society of Paediatric Research (ESPR), pp. S1–S87, Copyright (2005), with permission from ESPGHAN.

Table 14. Recommended amounts of trace elements for PN in infants and children by the ASPEN society4

Trace element Parenteral
Chromium 0.2 μg/kg
Copper 20 μg/kg
Iodine 1 μg/kg
Iron Maintenance doses not well (sic)

August D, Teitelbaum D, Albina J, et al. JPEN J Parenter Enteral Nutr (26, 1 Suppl.)

pp. 1SA–138SA, copyright © 2002 by the American Society for Parenteral and Enteral Nutrition Reproduced by permission of SAGE Publications.


Optimal doses and conditions of infusion for vitamins in infants and children have not been established, therefore, recommendations in Tables 15a and b are based on expert opinion.1

Table 15a. Recommended amounts of vitamins for infants and children by the ESPEN/ESPGAN societies1

Vitamin Infants
(Dose/kg body weight/day)
Children
(Dose/day)
Vitamin A (μg)* 150–300 150
Vitamin D (μg) 0.8 (32 IU) 10 (400 IU)
Vitamin E (mg) 2.8–3.5 7
Vitamin K (μg) 10 (recommended, but currently not possible)** 200

*1 μg RE (retinol equivalent) = 1 μg all-tans retinol = 3.33 IU vitamin A.

**Current multivitamin preparations supply higher vitamin K amounts without apparent adverse clinical effects.

Reproduced from J Pediatr Gastroenterol Nutr, 41(Suppl. 2), Koletzko B, Goulet O, Hunt J, et al.

Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric
Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), Supported by the European Society of Paediatric Research (ESPR), pp. S1–S87., Copyright (2005), with permission from ESPGHAN.

Table 15b. Recommended amounts of water-soluble vitamins for PN in infants and children by the ESPEN/ESPGHAN societies1

Vitamin Infants
(Dose/kg body weight/day)
Children
(Dose/day)
Ascorbic acid (mg) 15–25 80
Thiamine (mg) 0.35–0.50 1.2
Riboflavin (mg) 0.15–0.2 1.4
Pyridoxine (mg) 0.15–0.2 1.0
Niacin (mg) 4.0–6.8 17
Vitamin B12 (μg) 0.3 1
Pantothenic acid (mg) 1.0–2.0 5
Biotin (μg) 5.0–8.0 20
Folic acid (μg) 56 140

Reproduced from J Pediatr Gastroenterol Nutr, 41(Suppl. 2), Koletzko B, Goulet O, Hunt J, et al.

Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric
Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), Supported by the European Society of Paediatric Research (ESPR), pp. S1–S87., Copyright (2005), with permission from ESPGHAN.

Table 16. Recommended amounts of vitamins for PN in infants and children by the ASPEN society4

Vitamin Parenteral
Thiamin 1.2 mg
Riboflavin 1.4 mg
Niacin 17 mg
Folic acid 140 μg
Pantothenic acid 5 mg
Vitamin B6 1 mg
Vitamin B12 1 μg
Biotin 20 μg
Ascorbic acid 80 mg
Vitamin A 700 μg (retinol equivalent)
Vitamin D 10 μg
Vitamin E 7 mg
Vitamin K 200 μg
Carnitine 2–10 mg/kg

August D, Teitelbaum D, Albina J, et al. JPEN J Parenter Enteral Nutr (26, 1 Suppl.)

pp. 1SA–138SA, copyright © 2002 by the American Society for Parenteral and Enteral Nutrition Reproduced by permission of SAGE Publications.

Nutritional recommendations for adult patients

The nutrient dosing requirements of adults who need PN should be based on a comprehensive nutrition assessment for each individual patient. Requirements are likely to vary with nutrition status, disease state, organ function, metabolic condition, medication usage, and duration of nutrition support.4

Parenteral protein and energy recommendations for adult patients
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A patient's calorie intake should be sufficient to meet basal energy expenditure requirements (these can vary with disease state) and to enable a level of physical activity that will maintain a healthy body mass index. In the absence of indirect calorimetry to measure energy expenditure, predictive equations can be a valuable tool to estimate energy requirements. However, guidelines issued jointly by the SCCM and ASPEN advise that predictive equations should be used with caution, as they provide a less accurate measure of energy requirements than indirect calorimetry, and can be particularly problematic in obese patients.19


Table 17 summarizes the daily amounts of energy and protein recommended by ASPEN4 for unstressed adult patients with adequate organ function (referred to hereafter as 'healthy adults'), and by ESPEN10 and SCCM/ASPEN19 for adult ICU patients.

Table 17. Amounts of parenteral protein and energy recommended by ASPEN for healthy adults,4 and by ESPEN10 and SCCM/ASPEN19 for adult ICU patients

Protein goal per day
(g/kg body weight)
Energy goal per day
(kcal/kg body weight)
Healthy adults 0.8–2.0* 20–35
Adult ICU patients of normal weight 1.3–1.5** 25 initially, increasing to target over the next 2–3 days***
Obese (BMI >30) adult ICU patients ≥2.0g/kg ideal body weight for Class I and II patients (BMI 30–40); ≥2.5g/kg ideal body weight for Class III patients (BMI ≥40)** ≤11–14 (or ≤22–25kcal/kg ideal body weight)****

BMI, body mass index; ICU, intensive care unit

*For healthy adults receiving PN, data support the use of around 186 mg/kg of essential amino acids daily to provide up to 25–35% of the patient's protein intake25

**In ICU patients, the parenteral protein/amino acid solution should contain 0.2–0.4g/kg/day of L glutamine10

***During acute illness, energy intake should be matched as closely as possible to the measured energy expenditure in patients of normal body weight. The SCCM/ASPEN guidelines recommend that mild permissive underfeeding should be considered, at least initially, in all ICU patients receiving PN.19 Once energy requirements have been determined, 80% of these should serve as the ultimate parenteral feeding dose. Subsequently, as the patient stabilizes, PN may be increased to meet energy requirements.19


In all classes of obesity, the SCCM/ASPEN guidelines recommend that the goal of the PN regimen should be ≤60–70% of target energy requirements.19

Parenteral lipid and carbohydrate recommendations for adult patients
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Table 18 shows the daily amounts of lipids and carbohydrates recommended by ASPEN for administration to healthy adults,4 and by ESPEN for administration to adult ICU patients.10

Table 18a. Amounts of parenteral lipids and carbohydrates recommended by ASPEN for healthy adults4

Lipid goal per day
(g/kg body weight)
Carbohydrate goal per day
(g/kg body weight)
Healthy adults* ≤2.5 ≤7

*Lipid and carbohydrate goals taken from: [No authors]. Safe practices for parenteral nutrition formulations. National Advisory Group on Standards and Practice Guidelines for Parenteral Nutrition. JPEN J Parenter Enteral Nutr 1998;22:49–66.26

Table 18b. Amounts of parenteral lipids and carbohydrates recommended by ESPEN for adult ICU patients10

Lipid goal per day
(g/kg body weight)
Carbohydrate goal per day
(g/kg body weight)
Adult ICU patients 0.7–1.5 ≥2

For healthy adults, the ASPEN guidelines recommend that linoleic acid and α-linolenic acid should comprise around 1–2% and around 0.5%, respectively, of daily energy requirements, to prevent essential fatty acid deficiency.4


For ICU patients, lipid emulsions should be an integral part of PN, both for energy and to ensure the provision of essential fatty acids.10 Commercially-available parenteral lipid formulations include:

  • Soybean oil-based formulations, often referred to as long-chain triglycerides (LCT)
  • 'Pharmaceutical' mixtures (usually 50:50) of soybean LCT and medium-chain triglycerides from coconut oil (MCT)
  • 'Pharmacological' mixtures, which are triglyceride mixtures with each glycerol molecule having a distribution of fatty acids with different chain lengths
  • Olive oil and soybean mixtures (80:20)
  • Mixtures of lipids including fish oil (e.g. mixtures of soybean, MCT, olive oil, and fish oil)
  • Fish oil alone, to be used as a supplement in combination with other emulsions.

The ESPEN guidelines advocate the administration of intravenous LCT, MCT, or mixed emulsions at a rate of 0.7–1.5 g/kg over 12–24 hours in adult ICU patients, and note that olive oil-based PN is well tolerated in this population.10 However, the SCCM/ASPEN guidelines recommend that, during the first week in an ICU, patients should receive parenteral formulations that do not contain soy-based lipids.19 Addition of the omega-3 fatty acids eicosapentaenoic acid and docosahexaenoic acid to lipid emulsions is recommended, as these have demonstrable effects on cell membranes and inflammatory processes.10 Moreover, fish oil-enriched lipid emulsions probably shorten patients' ICU stay.10 Although studies have shown clinical advantages of mixed LCT/MCT emulsions over soybean LCT alone, the ESPEN guidelines point out that these findings have yet to be confirmed by prospective, controlled, clinical studies.10


With respect to carbohydrates, the ESPEN guidelines recommend a minimum carbohydrate intake of around 2 g glucose/kg body weight/day for adult ICU patients.10 However, care must be taken to avoid hyperglycemia (glucose >10mmol/L), which contributes to mortality in this patient population. The SCCM/ASPEN guidelines advise implementation of a protocol to promote 'moderately strict' serum glucose control in ICU patients receiving PN, and suggest that a range of 110–150 mg/dL may be most appropriate.19

Fluid and electrolyte recommendations for adult patients
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The ASPEN guidelines state that around 30–40 mL/kg is generally sufficient to meet the fluid requirements of adults.4,26


Daily electrolyte requirements for adult patients with adequate organ function are summarized in Table 19.

Table 19. Daily amounts of electrolytes recommended by ASPEN for healthy adults4,26

Electrolyte Parenteral dose
Sodium 1–2 mEq/kg/day
Potassium 1–2 mEq/kg/day
Chloride As needed to maintain acid-base balance with acetate
Calcium 10–15 mEq/day
Magnesium 8–20 mEq/day
Phosphorus 20–40 mmol/day

August D, Teitelbaum D, Albina J, et al. JPEN J Parenter Enteral Nutr (26, 1 Suppl.) pp. 1SA–138SA, copyright © 2002 by the American Society for Parenteral and Enteral Nutrition. Adapted by Permission of SAGE Publications.


As critically ill patients are prone to fluid and sodium overload, and frequently suffer from renal dysfunction, ESPEN concludes that it is neither adequate nor appropriate to propose electrolyte guidelines either on the basis of body weight or as a fixed component of PN.10 Instead, this Society recommends that the electrolyte requirements of adult ICU patients should be determined by plasma electrolyte monitoring.10

Vitamin and trace element recommendations for adult patients
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A recently published ASPEN position paper suggested a number of changes to existing recommendations for the levels of vitamins and trace elements in parenteral multivitamin and multi-trace element products.27 Current recommended amounts of vitamins and trace elements for healthy adults are detailed in Table 20.27

Table 20. Amounts of vitamins and trace elements recommended by ASPEN for healthy adults who require PN27

Recommended parenteral dose
Fat-soluble vitamins
Vitamin A 990 μg or 3300 IUa
Vitamin D 5 μg or 200 IUb
Vitamin E 10 mg or 10 IUc
Vitamin K 150 μg
Water-soluble vitamins
Thiamine 6 mg
Riboflavin 3.6 mg
Niacin 40 mg
Pantothenic acid 15 mg
Vitamin B6 6 mg
Vitamin B12 5 μg
Vitamin C 200 mg
Folate 600 μg
Biotin 60 μg
Other nutrients
Choline Not available for PN use
Trace elements
Copper 0.3–0.5 mg
Chromium 10–15 μg
Fluoride Not routinely added in USd
Iodine Not routinely added in USd
Iron Not routinely added in USd (given 25–50 mg/monthly as separate IV infusion when indicated)
Manganese 0.06–0.1 mg
Molybdenum Not routinely added in USd
Selenium 20–60 μg
Zinc 2.5–5 mg

IU, international unit; IV, intravenous; PN, parenteral nutrition

a1 μg RAE (retinol activity equivalent) = 1 μg retinol = 12 μg β-carotene = 24 μg α-carotene or β-cryptoxanthin.

b1 IU of retinol = 0.3 μg retinol or 0.3 μg RAE.

cTo convert IU α-tocopherol to mg: IU x 0.67 mg RRR-α-tocopherol, natural form ("d-α-tocopherol") or IU x 0.45 mg all-rac-α-tocopherol, synthetic form ("dl-α-tocopherol"), dl-α-tocopheryl acetate (1 IU = 1 mg = 1 USP unit) is used in IV multivitamin preparation.

dFluoride (0.57–1.45 mg), iodine (10–130 μg), iron (1–1.95 mg), molybdenum (10–25 μg), and cobalt (0–1.47 μg) are routinely added to PN products in Europe.

Vanek VW, et al, Nutr Clin Pract 27(4) pp. 440–491, copyright © 2012 by the American Society for Parenteral and Enteral Nutrition. Reproduced by Permission of SAGE Publications


In its guidelines, ESPEN recommends that all PN prescriptions for ICU patients should include a daily dose of multivitamins and trace elements, as these are not incorporated in commercially available PN formulations.10 However, vitamin E is included in all lipid emulsions used for PN, hence additional supplementation of this particular vitamin is not normally required.10


Daily administration of a commercially available, comprehensive multivitamin regimen will generally be adequate, but ESPEN notes that thiamine and vitamin C deficiency pose special risks in ICU patients. Therefore, thiamine supplementation up to 100–300 mg/day is recommended during the first 3 days spent in an ICU by a patient with possible thiamine deficiency, and especially when alcohol abuse is suspected.10


Table 21 summarizes the availability of trace elements in standard formulations, and the modification of requirements in ICU patients.

Table 21. Trace element availability in standard formulations, and modifications recommended by ESPEN for ICU patients10

Trace element Range present in commercially available formulations Modification of requirements in ICU patients
Chromium (μg) 10–15
Cobalt (μg) 0–1.47 -
Copper (mg) 0.48–1.27 ↓*
Fluoride (mg) 0.57–1.45 -
Iron (mg) 1–1.95 -↓
Iodine (μg) 10–130
Manganese (mg) 0.2–0.55
Molybdenum (μg) 10–25 ?
Selenium (μg) 20–70 ↑**
Vanadium (μg) 0 ?
Zinc (mg) 3.27–10

*Requirement reduced except in major burns patients, in whom it should be increased 5-fold for the duration of open wounds10

**To avoid selenosis, selenium doses should probably not exceed 750–1000 μg per day in ICU patients

Reproduced from Clinical Nutrition, Vol 28(4), Singer P, et al. ESPEN Guidelines on Parenteral Nutrition: Intensive care, pp., 387–400, Copyright © 2009, by the European Society for Clinical Nutrition and Metabolism.


In prolonged PN, if the patient remains critically ill, monthly determination of plasma concentrations of trace elements is advocated to enable detection of any gross deficiencies, which can then be corrected with the individual element.10

References
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