695251 PENXXX10.1177/0148607117695251Journal of Parenteral and Enteral NutritionWorthington et al
`
`research-article2017
`
`Consensus Recommendation
`
`When Is Parenteral Nutrition Appropriate?
`
`Journal of Parenteral and Enteral
`Nutrition
`Volume 41 Number 3
`March 2017 324 –377
`© 2017 American Society
`for Parenteral and Enteral Nutrition
`DOI: 10.1177/0148607117695251
`https://doi.org/10.1177/0148607117695251
`journals.sagepub.com/home/pen
`
`Patricia Worthington, MSN, RN, CNSC1; Jane Balint, MD2;
`Matthew Bechtold, MD, FACP, FASGE, FACG, AGAF3;
`Angela Bingham, PharmD, BCPS, BCNSP, BCCCP4;
`Lingtak-Neander Chan, PharmD, BCNSP, CNSC, FACN5; Sharon Durfee, RPh, BCNSP6;
`Andrea K. Jevenn, RD, LD, CNSC7; Ainsley Malone, MS, RD, CNSC, FAND, FASPEN8;
`Maria Mascarenhas, MBBS9; Daniel T. Robinson, MD10; and Beverly Holcombe, PharmD, BCNSP , FASHP, FASPEN11
`
`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)
`
`Table of Contents
`
`Page
`
`Abstract
`Key Terms and Definitions
`Summary of Recommendations
`Target Audience and Scope
`Format of PN Consensus Recommendations
`Methodology
`Question 1: Is PN ever routinely indicated for any specific
`medical diagnosis, clinical condition, or disease state?
`Question 2: Are there any circumstances in which PN is
`the optimal/preferred route for nutrition support?
`Question 3: What clinical factors should be assessed to
`determine if EN is feasible, including contraindications to
`EN, the functional status of the gastrointestinal tract, and
`the ability to achieve and maintain safe enteral access?
`Question 4: In patients for whom EN is not feasible, what
`is a reasonable time frame for initiating PN? (For patients
`who are well nourished, malnourished, nutritionally-at-
`risk, or hemodynamically or metabolically unstable)
`Question 5: What factors play a role in selecting and
`placing the appropriate vascular access device for PN
`administration?
`Question 6: In which patients is peripheral PN a
`reasonable choice in providing nutrition support?
`Question 7: In which patients is intradialytic PN a
`reasonable choice for nutrition support?
`Question 8: What is the role of perioperative PN in
`patients undergoing elective/nonurgent surgery?
`Question 9: Is PN appropriate for patients in palliative care?
`Question 10: Which patients are appropriate for home PN therapy?
`Question 11: Under what circumstances can PN be safely
`initiated in the home setting?
`
`324
`325
`325
`329
`330
`330
`331
`
`337
`
`338
`
`340
`
`344
`
`348
`
`351
`
`353
`
`355
`358
`362
`
`Question 12: What strategies should healthcare
`organizations implement to reduce the risk of clinical
`complications associated with PN?
`Question 13: For patients receiving PN, which parameters
`should be monitored to assess progress toward
`therapeutic goals, the need to adjust the PN prescription,
`and when to wean or discontinue this therapy?
`Question 14: How should healthcare organizations track/
`monitor PN use for appropriateness?
`Question 15: What are the areas for future research?
`
`363
`
`365
`
`372
`
`375
`
`From the 1Thomas Jefferson University Hospital, Philadelphia, Pennsylvania,
`USA; 2Nationwide Children’s Hospital, The Ohio State University,
`Columbus, Ohio, USA; 3University of Missouri, Columbia, Missouria, USA;
`4University of the Sciences, Philadelphia, Pennsylvania, USA; 5University
`of Washington, Seattle, Washington, USA; 6Central Admixture Pharmacy
`Services, Inc, Denver, Colorado, USA; 7Cleveland Clinic Foundation,
`Cleveland, Ohio, USA; 8Mt Carmel West Hospital, Columbus, Ohio, USA;
`9The Children’s Hospital of Philadelphia, Perelman School of Medicine,
`University of Pennsylvania, Philadelphia, Pennsylvania, USA; 10Ann
`& Robert H. Lurie Children’s Hospital, Feinberg School of Medicine,
`Northwestern University, Chicago, Illinois, USA; and the 11American Society
`for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA.
`Financial disclosure: None declared.
`Conflicts of interest: Sharon Durfee, employee of Central Admixture Pharmacy
`Services, Inc, serves in a clinical capacity and has no sales responsibilities.
`Received for publication January 17, 2017; accepted for publication
`January 22, 2017.
`This article originally appeared online on February 17, 2017.
`
`Corresponding Author:
`Beverly Holcombe, PharmD, BCNSP, FASHP, FASPEN, ASPEN, 8630
`Fenton St, Suite 412, Silver Spring, MD 20910, USA.
`Email: beverlyh@nutritioncare.org
`
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`Key Terms and Definitions
`
`Intestinal failure: The reduction of gut function below the mini-
`mum necessary for the absorption of macronutrients and/or
`water and electrolytes such that intravenous supplementation
`is required to maintain health and/or growth.1
`Intestinal insufficiency (or deficiency): The reduction of gut
`absorptive function that does not require intravenous sup-
`plementation but may require oral supplementation, enteral
`nutrition, or vitamin and trace element supplementation to
`maintain health and/or growth.1
`Malnutrition, adult: An acute, subacute, or chronic state of
`nutrition in which a combination of varying degrees of
`overnutrition or undernutrition, with or without inflamma-
`tory activity, has led to a change in body composition and
`diminished function.2
` The etiology-based nutrition diagnoses in adults in clini-
`cal practice settings are as follows:
`
`
`
`Starvation-related malnutrition: Chronic starvation without
`inflammation (eg, anorexia nervosa).
`Chronic disease-related malnutrition: Inflammation is chronic
`and of mild to moderate degree (eg, organ failure, pancre-
`atic 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).2,3
`
`Malnutrition, pediatric: An imbalance between nutrient require-
`ment 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.4,5
`
`Nutritionally-at-risk: Consider the individual nutritionally-at-
`risk if any of the following is present.
`
`Nutritionally-At-Risk Adult
`••
`
`Involuntary weight loss of 10% of usual body weight
`within 6 months or 5% within 1 month
`••
`Involuntary loss of 10 lb within 6 months
`•• Body mass index (BMI) less than 18.5 kg/m2
`••
`Increased metabolic requirements
`•• Altered diets or diet schedules
`••
`Inadequate nutrition intake, including not receiving
`food or nutrition products for more than 7 days6
`
`Nutritionally-At-Risk Child
`•• Weight for length, weight for height, or sex less than
`10th percentile (–1.28 z score)
`•• BMI for age or sex less than 5th percentile (–1.64 z score)
`••
`Increased metabolic requirements
`••
`Impaired ability to ingest or tolerate oral feeding
`
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`
`•• Documented inadequate provision of or tolerance to
`nutrients
`Inadequate weight gain or a significant decrease in
`usual growth percentile6
`
`••
`
`Nutritionally-At-Risk Neonate
`
`High Risk
`••
`Preterm less than 28 weeks at birth
`•• Extremely low birth weight less than 1000 g
`••
`Infant establishing feeds after episode of necrotizing
`enterocolitis or gastrointestinal perforation
`Infants with severe congenital gastrointestinal malfor-
`mations (eg, gastroschisis)6
`
`••
`
`Moderate Risk
`••
`Preterm 28th–31st weeks, otherwise well
`••
`Intrauterine growth restriction (weight less than 9th
`percentile)
`•• Very low birth weight 1000–1500 g
`••
`Illness or congenital anomaly that may compromise
`feeding6
`
` 3.
`
` 2.
`
`References
` 1.
`Pironi L, Arends A, Baxter J, et al. ESPEN endorsed recommendations.
`Definition and classification of intestinal failure in adults. Clin Nutr.
`2015;34(2):171-180.
`Soeters PB, Reijven PL, van Bokhorst-de van der Schueren MA, et al. A
`rational approach to nutritional assessment. Clin Nutr. 2008;27(5):706-716.
`Jensen GL, Bistrian B, Roubenoff R, Heimburger DC. Malnutrition syn-
`dromes: a conundrum vs continuum. JPEN J Parenter Enteral Nutr.
`2009;33(10):710-716.
` 4. Mehta NM, Corkins MR, Lyman B, et al. Defining pediatric malnutrition:
`a paradigm shift towards etiology-related definitions. JPEN J Parenter
`Enteral Nutr. 2013;37(4):460-481.
` 5. Becker P, Carney LN, Corkins MR, et al. Consensus statement of the
`Academy of Nutrition and Dietetics/American Society for Parenteral
`and Enteral Nutrition: indicators recommended for the identification and
`documentation of pediatric malnutrition (undernutrition). Nutr Clin Pract.
`2015;30(1):147-161.
` 6. American Society for Parenteral and Enteral Nutrition (ASPEN)
`definition of terms, style, and conventions used in ASPEN Board of
`Directors–approved documents. https://www.nutritioncare.org/Guidelines_
`and_Clinical_Resources/Clinical_Practice_Library/Special_Reports/.
`Accessed November 1, 2016.
`
`Summary of Recommendations
`
`These consensus recommendations are designed to identify
`best practices, guide day-to-day clinical decisions, reduce vari-
`ations in practice, and enhance patient safety. They are not
`intended to supersede the judgment of the healthcare profes-
`sional based on the circumstances of the individual patient.
`
`1: Parenteral Nutrition Use Based on
`Medical Diagnosis or Disease State
`
`Adult
`1A: Do not use parenteral nutrition (PN) based solely on
`medical diagnosis or disease state.
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`1B: Prior to initiating PN, conduct a full evaluation of the
`feasibility of using enteral nutrition (EN); reserve PN for
`clinical situations in which adequate EN is not an option.
`
`Neonatal
`1C: Consider PN for neonates in the critical care setting,
`regardless of diagnosis, when EN is unable to meet
`energy requirements for energy expenditure and growth.
`
`Pediatric
`1D: Use PN for children when the intestinal tract is not
`functional or cannot be accessed or when nutrient needs
`to provide for growth are greater than that which can be
`provided through oral intake or EN support alone.
`
`2: Circumstances Where PN Is the Preferred
`Method of Nutrition Support
`
`Adult
`2A: Use PN in patients who are malnourished or at risk for
`malnutrition when a contraindication to EN exists or
`the patient does not tolerate adequate EN or lacks suf-
`ficient bowel function to maintain or restore nutrition
`status (Tables 1.1 and 1.2).
`
`Neonatal and Pediatric
`2B: Initiate PN for total or supplemental nutrient provision
`if EN is not feasible or not sufficient to meet total
`nutrient needs.
`
`3: Determining When EN Is Not Feasible
`
`Adult
`3A: Evaluate clinical factors derived from history, physical
`examination, and diagnostic evaluations in determin-
`ing if EN is contraindicated (Table 3.1).
`
`Neonatal and Pediatric
`3B: Initiate PN and withhold EN in neonatal and pediatric
`patients when a clear contraindication to EN exists,
`such as intestinal injury and perforation.
`3C: Assess intestinal function and perfusion, as well as
`overall hemodynamic stability, when evaluating readi-
`ness for EN, rather than relying on strict adherence to a
`list of contraindications to EN, such as the presence of
`umbilical catheters or use of vasoactive medications.
`
`4: Time Frame for Initiating PN
`
`Adult
`4A: Initiate PN after 7 days for well-nourished, stable adult
`patients who have been unable to receive significant (50%
`or more of estimated requirements) oral or enteral nutrients.
`4B: Initiate PN within 3 to 5 days in those who are nutri-
`tionally-at-risk and unlikely to achieve desired oral
`intake or EN.
`
`4C: Initiate PN as soon as is feasible for patients with base-
`line moderate or severe malnutrition in whom oral
`intake or EN is not possible or sufficient.
`4D: Delay the initiation of PN in a patient with severe meta-
`bolic instability until the patient’s condition has improved.
`
`Neonatal
`4E: Begin PN promptly after birth in the very low birth
`weight infant (birth weight less than 1500 g). Insufficient
`data exist to suggest a specific time frame in which PN is
`ideally initiated in more mature preterm infants or criti-
`cally ill term neonates.
`
`Pediatric
`4F: For the infant, child, or adolescent with a self-limited
`illness, it is reasonable to delay starting PN for 1 week.
`However, initiate PN within 1–3 days in infants and
`within 4–5 days in older children and adolescents
`when it is evident that they will not tolerate full oral
`intake or EN for an extended period.
`
`5: Selecting Appropriate Vascular Access for
`PN Administration
`
`Global Recommendations
`5A: Individualize the selection of vascular access device
`(VAD) for PN administration based on an evaluation of
`the risks and benefits of the device, clinical factors,
`and psychosocial considerations.
`5B: Choose the smallest device with the fewest number of
`lumens necessary for the patient’s needs.
`5C: Dedicate 1 lumen of the VAD for PN administration
`when possible.
`5D: Position the tip of the central venous access device
`(CVAD) in the lower third of the superior vena cava
`near the junction with the right atrium.
`5E: Confirm optimal position of the CVAD tip prior to ini-
`tiating PN.
`
`6: Peripheral PN
`
`Adult
`6A: Use peripheral PN only for short-term purposes, no
`more than 10–14 days, as supplemental PN or as a
`bridge therapy during transition periods, where oral
`intake or EN is suboptimal or clinical circumstances do
`not justify placing a CVAD.
`6B: Estimate the osmolarity of peripheral PN formulations.
`6C: Maintain an upper limit of 900 mOsm/L for the periph-
`eral PN formulations.
`
`Neonatal and Pediatric
`6D: In well-nourished neonatal and pediatric patients, use
`peripheral PN for short-term purposes until oral intake or
`EN can be established or to serve as a bridge to central PN.
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`7: Intradialytic PN
`
`Global Recommendations
`7A: Do not use intradialytic PN (IDPN) as the sole source
`of nutrition intervention in malnourished patients with
`chronic kidney disease (CKD).
`7B: Consider IDPN for adult and pediatric patients with
`CKD who are malnourished and unable to tolerate
`adequate oral intake or EN.
`
`8: Perioperative PN
`
`Adult
`8A: Consider preoperative PN in severely malnourished
`patients unable to tolerate sufficient oral intake or EN.
`8B: Reserve postoperative PN for severely malnourished
`patients unable to tolerate EN for more than 7 days,
`unless initiated preoperatively.
`
`Neonate and Pediatric
`8C: Consider preoperative and postoperative PN in mal-
`nourished neonates and children who are unable to tol-
`erate oral intake or EN.
`
`9: PN Use in Palliative Care
`
`Global Recommendations
`9A: Do not use PN solely to treat poor oral intake and/or
`cachexia associated with advanced malignancy.
`9B: Limit the use of PN in palliative care to carefully
`selected candidates, with an expected survival of 2–3
`months, for whom oral intake or EN is not feasible.
`9C: Evaluate clinical factors and performance status when
`selecting candidates for PN at the end of life.
`9D: Involve patients and caregivers in a clear and complete
`dialogue regarding realistic goals of PN as well as the
`potential risks and burdens of therapy.
`
`10: Home PN
`
`Adult
`10A: Consider home PN (HPN) for patients with intestinal
`failure who are clinically stable and able to receive
`therapy outside an acute care setting.
`10B: Perform a thorough evaluation of medical and psy-
`chosocial factors that influence suitability for HPN.
`10C: Address financial considerations/insurance coverage
`and patient responsibilities with patient and caregiver.
`
`Pediatric
`10D: Consider HPN for carefully selected, clinically stable
`pediatric patients who are expected to require PN for
`an extended period.
`10E: Discharge all pediatric patients to the care of a pedi-
`atric home care team and infusion provider with pedi-
`atric experience.
`
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`
`11: Initiating PN in the Home Setting
`
`Adult
`11A: Establish organizational policies that delineate cir-
`cumstances in which initiation of PN can take place
`outside the acute care setting.
`11B: Delineate patient-centered eligibility criteria for initi-
`ating PN safely in the home setting.
`11C: Develop strict protocols and procedures for initiating
`PN in the home setting, monitoring response to ther-
`apy, and documenting outcomes.
`11D: Conduct a comprehensive medical, clinical, and psy-
`chosocial assessment of HPN candidates to assess risk
`factors for adverse events related to initiating PN.
`11E: Consider initiating PN therapy at home only when
`assessment confirms that the benefits greatly outweigh
`the risks.
`
`Pediatric
`11F: In pediatric patients, do not initiate PN in the home set-
`ting; admit all patients to the hospital for initiating HPN.
`
`12: Reducing the Risk of PN-Associated
`Complications
`
`Global Recommendations
`12A: Employ standardized processes for managing PN.
`12B: Incorporate measures to reduce the risk of complica-
`tions into organizational policies and procedures for
`administering PN.
`12C: Utilize an interprofessional team of clinicians with
`expertise in nutrition support to manage PN.
`12D: Educate PN prescribers, and demonstrate prescribing
`competencies for all clinicians writing PN orders.
`
`13: PN Monitoring
`
`Global Recommendations
`13A: For patients of all ages and in all healthcare settings,
`provide interprofessional monitoring of clinical sta-
`tus and response to PN therapy by clinicians with
`expertise in managing PN.
`13B: Modify the PN prescription as indicated per ongoing
`evaluation of gastrointestinal function, nutrition status,
`electrolyte balance, and (for pediatric patients) growth.
`1:
` Wean PN when oral intake and/or EN achieves 50%–
`75% of requirements for energy, protein, and micro-
`nutrients, unless impaired gastrointestinal function
`precludes 100% absorption of nutrient needs.
` Consider using a weaning protocol during the
`transition from PN to EN.
`
`2:
`
`14: Tracking Appropriateness of PN Use
`
`Adult
`14A: Conduct a clinical review for each patient to assess PN
`appropriateness prior to compounding the PN admixture.
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`14B: Implement a quality improvement process (eg, clini-
`cal audit, plan-do-study-act cycle, medication use
`evaluation) to ensure appropriate use of PN based on
`the best available evidence.
`
`Pediatric
`14C: Emphasize the measurement of PN appropriateness
`in neonates, children, and adolescents as a priority in
`institutional quality improvement efforts.
`14D: Design metrics for monitoring PN appropriateness for
`each pediatric healthcare network or institution with
`available
`information
`technology and personnel
`resources to measure and adjust local practices.
`
`15: Areas for Further Research
`
`Introduction
`
`Background
`
`Since its inception nearly 50 years ago, PN has transformed
`clinical care while triggering an enduring debate about the role
`of intravenous nutrition in a variety of patient populations.1 PN
`offers a life-sustaining option in situations where impaired gas-
`trointestinal function prevents oral intake or EN. Yet, random-
`ized controlled trials have not consistently demonstrated the
`effectiveness of PN administration, including studies compar-
`ing PN with EN or PN with the standard progression from intra-
`venous fluids to an oral diet, with no nutrition intervention.2 In
`fact, in some cases, PN administration appeared to contribute to
`unfavorable clinical outcomes.2 It has been suggested that dis-
`parities in study design and the use of clinical practices now
`considered suboptimal may have contributed to the unfavorable
`results of these studies.3,4 The use of PN in patients with suffi-
`cient gastrointestinal function to allow successful EN may also
`contribute in unfavorable outcomes in comparisons of PN with
`EN. In addition, a failure to consider metabolic and pathophysi-
`ologic patient characteristics when interpreting and designing
`nutrition studies may be a factor in the lack of evidence support-
`ing the effectiveness of PN.5
`Historical prescribing patterns for PN may also have influ-
`enced outcomes. Early enthusiasm for intravenous feeding led
`to extensive use of PN for a broad range of medical conditions,
`at times irrespective of nutrition status or gastrointestinal func-
`tion.3,4,6,7 More recent studies conducted with modern protocols
`for management of PN suggest that PN can be safely adminis-
`tered to critically ill patients without adversely affecting out-
`comes.8,9 Although many questions about PN therapy remain
`unanswered, it is clear that judicious selection of candidates and
`adherence to evidence-based clinical practice guidelines form
`the foundation of appropriate PN therapy.
`
`Trends in PN Use
`
`Comprehensive data related to patterns of PN utilization are
`scarce. One large-scale description of PN use in U.S. hospitals
`
`revealed that PN was administered most frequently in non–criti-
`cal care settings, followed by neonatal intensive care units and
`intensive care units.10 In this study, duration of PN averaged 6.5
`days and 6.1 days for noncritical care patients and critically ill
`patients, respectively, with a longer duration (8.9 days) in neona-
`tal intensive care units. The average age of adults receiving PN
`was 66 years, older than the mean age of the entire study popula-
`tion.10 Another recent report of PN use found that 12.8% of
`adults receiving PN were 80 years of age or older with outcomes
`similar to those of their younger counterparts.11
`Information derived from hospital discharges regarding trends
`in PN use indicates that after more than tripling in the years from
`1993 to 2010, PN use has declined for 4 consecutive years.12,13
`Figure 1 depicts this trajectory. In 2014, the most recent year for
`which data are available, the ICD-9 code for PN was linked to
`292,655 hospital discharges, a statistically significant drop from
`levels reported in 2010 (P < .01). This downward trend persists
`when the data are normalized for total hospital discharges, which
`have also fallen in recent years.13 As shown in Figure 2, PN use
`fell from 0.93% of hospital discharges in 2010 to 0.82% in 2014.
`When stratified by age, the data show that PN utilization has
`remained stable in patients less than 1 year of age, at approxi-
`mately 0.3% of hospital stays. The steepest decline—from 0.24%
`to 0.19%—took place in adults aged 65 years or older. Additional
`data gathered in a large retrospective cohort study from 2001–
`2008 suggest that a decline in PN use occurred among critically
`ill adults in the years before the downward trend became evident
`in national database statistics.14
`No studies have examined the reasons underlying these
`trends, but a number of factors in today’s healthcare environment
`could play a role, including greater adherence to guidelines and
`practice recommendations, changing perceptions regarding the
`risks and benefits of PN administration, cost-containment efforts,
`drug shortages, and concern regarding the hazards of excess fluid
`administration in critically ill patients.12,14 Although this informa-
`tion sheds some light on current trends in PN use, the available
`data address only PN administered in hospitals and do not include
`individuals who receive PN outside the acute care setting, which
`has expanded across the continuum of care to include long-term
`acute care, skilled nursing facilities, rehabilitation centers, and
`home care. However, no comprehensive data are available to
`suggest an increased use of PN outside of hospitals.
`
`Appropriate PN Therapy
`
`The broad range of healthcare settings in which PN therapy
`currently takes place, combined with the decline in dedicated
`nutrition support teams, raises the potential for gaps to exist in the
`expertise of the clinicians initiating and managing PN therapy.15
`Within this context, efforts to delineate appropriate PN use aim to
`promote clinical benefits while minimizing the risks associated
`with the therapy.16 This process begins with recognizing clinical
`indications for PN as well as situations in which PN is not likely
`to be of benefit. After the judicious selection of candidates, appro-
`priate PN use continues with developing a PN prescription that
`meets individual requirements, monitoring the response to
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`Figure 1. Total number of hospital discharges with the ICD-9 code of 99.15, parenteral nutrition, 1993–2014. Data from National
`Inpatient Sample of the Healthcare Cost and Utilization Project from the Agency for Healthcare Research and Quality. http://hcupnet.
`ahrq.gov/. Accessed November 22, 2016.
`
`Figure 2. Parenteral nutrition utilization as a percentage of total hospital discharges. Data from National Inpatient Sample of the Healthcare
`Cost and Utilization Project from the Agency for Healthcare Research and Quality. http://hcupnet.ahrq.gov/. Accessed November 22, 2016.
`
`therapy, adjusting the therapeutic plan as indicated, and ensuring a
`prompt, seamless transition when PN is no longer required. A col-
`laborative approach that crosses professional and departmental
`boundaries is an essential component of appropriate PN therapy.
`The recommendations found in this document build on previous
`ASPEN PN safety initiatives, including “A.S.P.E.N. Clinical
`Guidelines: Parenteral Nutrition Ordering, Order Review,
`Compounding, Labeling, and Dispensing” and “A.S.P.E.N.
`Parenteral Nutrition Safety Consensus Recommendations.”16,17
`
`Target Audience and Scope
`
`In the spring of 2014, the ASPEN Board of Directors convened
`an interprofessional task force composed of physicians, nurses,
`
`dietitians, and pharmacists, charged with examining clinical
`questions surrounding PN use. In the initial phase of this proj-
`ect, the group decided against developing a paper narrowly
`focused on indications for PN based on medical diagnosis, in
`favor of a document that provides guidance on the appropriate
`use of PN therapy in a variety of clinical circumstances. Thus,
`the recommendations found in this paper extend beyond the
`selection of candidates to include additional factors that consti-
`tute appropriate PN therapy, such as those shown in Table 1.
`This document addresses PN use in adult, pediatric, and
`neonatal populations—in all phases of the lifespan and across
`the healthcare continuum. Recommendations specific to
`geriatric patients are included as warranted by supporting
`literature. The consensus recommendations are intended to
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`Table 1. Elements of Appropriate PN Use.
`
`•
`
` Identify clinical indications for PN, including manifestations
`of acute and chronic intestinal failure
`• Recognize situations in which PN is not likely to be of benefit
`•
` Initiate PN based on gastrointestinal function, nutrition status,
`and clinical status
`•
` Select the vascular access device best suited to the therapy planned
`•
` Implement measures to promote safety and reduce adverse outcomes
`• Evaluate response to therapy
`• Adjust in the therapeutic plan based on ongoing monitoring
`• Assess continued need for PN
`• Transition promptly to oral or enteral nutrition as feasible
`• Collaborate across disciplines and departmental boundaries
`
`PN, parenteral nutrition.
`
`provide clinical guidance regarding PN therapy for organiza-
`tions and individual professionals, including physicians,
`nurses, dietitians, and pharmacists. 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 recommenda-
`tions contained within the document are designed to inform
`decisions made by additional stakeholders, such as policy mak-
`ers and third-party payers, by providing current perspectives
`regarding the use of PN in a variety of healthcare settings.
`
`Format of PN Consensus
`Recommendations
`
`In contrast to clinical practice guidelines developed by ASPEN,
`this paper addresses questions regarding the appropriate use of PN
`for which the strength of the evidence in the literature does not sup-
`port GRADE level recommendations, instead relying on weaker
`supporting literature, expert opinion, and consensus recommenda-
`tions. In a departure from previous ASPEN standards, the consen-
`sus recommendations for each question appear as concrete action
`statements without qualifiers such as “shall,” “should,” or “may.”
`These recommendations are not clinical guidelines as
`defined by ASPEN; however, the need to deliver clinical prac-
`tice information to clinicians, even when it is of a consensus
`nature from practice experts, remains an important role of
`ASPEN (www.nutritioncare.org). In the absence of high-qual-
`ity evidence applicable to all clinical circumstances, the con-
`sensus recommendations are designed to identify best practices,
`guide day-to-day clinical decisions, reduce variations in prac-
`tice, and enhance patient safety. These recommendations are
`not intended to supersede the judgment of the healthcare profes-
`sional based on the circumstances of the individual patient.
`
`Methodology
`
`The interprofessional members of the task force identified key
`decision points and clinical management issues related to
`
`appropriate PN therapy. From this outline, the group developed
`questions that were revised through a series of meetings until
`agreement was reached regarding the scope and relevance of
`each question. Both adult and pediatric clinical experts con-
`tributed to the responses to each question.
`Literature searches were then performed with keywords
`related to the topic parenteral nutrition and intravenous
`nutrition, both as individual terms and in combination with
`modifiers such as indications, outcomes, adverse events, com-
`plications, standards, adult, neonate, pediatric, child, and
`geriatric. Additional keyword searches were conducted to
`include the focus of each question, including enteral nutrition
`contraindications, malnutrition, nutrition screening, perioper-
`ative, peripheral PN, intradialytic PN, home PN, palliative
`care, monitoring, and quality assurance. The literature search
`included MEDLINE, PubMed, Cochrane Database of Systemic
`Reviews, the National Guidelines Clearinghouse, and an
`Internet search with the Google Scholar search engine for
`scholarly articles, as well as manual searches of bibliographies
`for full-text articles published in English through an end date
`of September 2016. Abstracts, theses, conference reports, and
`other forms of “gray literature” were not included.
`Despite extensive clinical experience with PN across the
`healthcare continuum, relatively few high-level controlled
`studies address outcomes of PN administration in patients who
`are not critically ill. Overall, the available papers displayed
`considerable heterogeneity in quality and methodology. The
`panel gave preference to randomized controlled trials, but
`other sources of evidence were used to support the recommen-
`dations, including non