Parenteral nutrition at home/long-term parenteral nutrition

Abstract

Purpose

Some diseases require that patients receive parenteral nutrition (PN) over a prolonged time period. Long-term administration of PN can further complicate an already complex therapy, posing additional risk of potential complications. This article is based on presentations and discussions held at the International Safety and Quality of PN Summit, providing insights into aspects of home PN (HPN) and examples of good HPN practice.

Summary

One critical step in the HPN process is when patients transition from a hospital to a home setting, and vice versa. Generally, electronic PN ordering is not feasible in an HPN setting, leading to potential difficulties in communication and coordination. HPN requires that patients (or their home caregivers) administer PN, and thus their education and competency are crucial. Likewise, the choice of PN formulation is of great importance. For example, using more modern intravenous lipid emulsions containing medium-chain triglycerides, olive oil, and/or fish oil can provide benefits in terms of liver function during long-term HPN. Internationally, there are wide variations in delivery of HPN, with compounded PN dominating in some countries while others make greater use of market-authorized multichamber bags (MCBs). Patient-related factors, institutional considerations, and the availability of different MCB formulations, are also contributing factors guiding formulation and delivery system preferences.

Conclusion

Education and communication remain key components of a successful HPN process. The information shared here may help to motivate efforts to improve HPN processes and to consider the often-differing perspectives of patients and their healthcare professionals.

Key Points.

• As home parenteral nutrition (HPN) involves PN in a nonhospital setting, increasing complexity and risk of complications, good communication is critical between multiple organizations, practitioners, and patients, as well as excellent patient education and training (given patients’ and caregivers’ active roles in this process).

• HPN practice varies internationally; compounded PN bags predominate in some locations, but other places make greater use of market-authorized multichamber bags.

• Standardization and flexibility within the HPN process can improve HPN quality and safety and enhance resilience during HPN product shortages.

Parenteral nutrition (PN) involves the intravenous (IV) supply of macronutrients (amino acids, glucose/dextrose, and intravenous lipid emulsion [ILE]), electrolytes, vitamins, and trace elements to meet patients’ nutritional needs. This can occur in a variety of settings, but where PN is given in a patient’s home environment it is termed home PN (HPN).¹ In general, HPN is used in the following situations: (1) as a life-sustaining therapy for patients with chronic intestinal failure from either a benign or malignant disease (often transiently during curative treatments in the latter case); (2) to avoid malnutrition in patients with terminal malignant disease as part of a palliative care program; and (3) to prevent or treat malnutrition in patients who have a functional intestinal tract but who decline other types of medical nutrition.¹ However, in the United States, guidelines recommend HPN only for patients with intestinal dysfunction who are clinically stable and able to receive therapy outside an acute care setting.² Reported prevalence rates for HPN in the US and in Europe are between 5 and 80 cases per million inhabitants,^1,3-6 with some patients using PN as their sole source of nutrition and others receiving a combination of PN and oral/enteral nutrition.⁷

PN in general is a complex therapy, and despite ongoing efforts to reduce risks, it may cause serious harm if not properly prescribed, prepared, administered, and monitored.¹ HPN involves administration within a nonhospital setting, often continuing for a long time, leading to further PN complexity and risk of complications. For instance, multiple groups of healthcare practitioners from different organizations are typically involved for each patient receiving HPN, so additional effort is needed to ensure proper communication and collaboration. In comparison with use of PN in hospitals, patients and/or their home caregiver have active roles in the administration of PN in the home setting. Thus, patient and caregiver education and competency are vital, and it is essential that they have the confidence and capability to cope with HPN.

There are geographical disparities in HPN delivery methods. The use of compounded PN bags predominates in some locations, but other places make greater use of market-authorized multi-chamber bags (MCBs).⁸ Regardless of this choice of delivery method, there is a trend towards greater standardization of PN formulations.⁹ This includes the greater use of MCBs.¹⁰ MCBs are available in two formats: either as a 2-chamber bag (2CB) containing glucose/dextrose and amino acids, or the more modern 3-chamber bag (3CB) containing glucose/dextrose, amino acids, and lipids.¹¹ However, special nutritional requirements or volume supplementation are sometimes needed, resulting in greater HPN complexity and potentially an increased risk of PN process–associated errors. Whereas compounded PN bags have a very short shelf life, often requiring delivery to the patient every 7 to 9 days (though slightly longer shelf life is possible for some compounded formulations),¹² MCBs can be stored for up to 2 years at room temperature prior to activation. Thus, compounded PN bags can limit patients’ independence, and MCBs require the patient or caregiver to be familiar with activating the admixture, introducing additives, and potentially administering supplementary IV fluids that would increase manipulation of the central venous catheter (CVC) circuit, potentially increasing the risk of catheter-related bloodstream infections.¹³

HPN can often be a long-term therapy, and this extended duration can increase patient vulnerability to complications.^1,14,15 Multiple complications may occur during HPN therapy (Table 1).^7,16-18 Some of these issues can be life-threatening, underscoring the need for the prevention and rapid management of these complications.

Table 1.

Potential Complications Associated With HPN and Long-Term PN^7,16-18

Complication type	Complications
Medical/metabolic	Over- or underfeeding, hyperglycemia, hypoglycemia, electrolyte abnormalities, volume overload, dehydration, hypertriglyceridemia, cholestasis, intestinal failure–associated liver disease and nonalcoholic steatohepatitis, metabolic bone disease, and reduced immune competency
Infectious	CLABSI, exit site infection, and tunnel infection
Technical/mechanical	CVAD occlusion, central venous thrombosis, CVAD displacement, and CVAD breaking/rupture
Psychological	Patient/caregiver anxiety about patients’ ability to manage and troubleshoot problems, fear of complications, depression, fatigue, and financial concerns
Somatic	Reduced physical mobility, dexterity issues, fatigue, polyuria, and sexual problems
Social	Limitations in social activities and travelling, and economic constraints

Abbreviations: CLABSI, central line–associated bloodstream infection; CVAD, central venous access device; HPN, home parenteral nutrition; PN, parenteral nutrition.

This article is based on the International Safety and Quality of Parenteral Nutrition Summit, held from November 8 to 10, 2021, at two locations (Charleston, SC, and Bad Homburg, Germany). The article focusses on challenges associated with HPN and also addresses other aspects related to long-term administration of PN. During the meeting a set of consensus statements concerning PN quality and safety were formulated, as detailed in the expert consensus statement publication and summary of proceedings.¹⁹ Some of these consensus statements specifically apply to HPN. It is important to understand that this article does not constitute any recommendations—these are to be found in the expert consensus statement publication¹⁹—but does present and summarize aspects of the international summit as a learning experience.

HPN processes: an example from the US

The Vanderbilt Center for Human Nutrition in Nashville, TN, operates an inpatient adult PN consultation service serving about 20 to 30 patients per day and an outpatient intestinal failure program caring for approximately 150 patients receiving home parenteral support (HPN or home IV fluid therapy). The intestinal failure program is run by an interdisciplinary team consisting of physicians, advanced practice providers, pharmacists, dietitians, and nurses. There is a joint venture in place with a home infusion pharmacy that serves most of these patients, with the remainder served by about 20 different agencies. HPN bags are individually compounded to meet each patient’s IV fluid, macronutrient, and micronutrient needs. Compounded bags may or may not contain an ILE.

At the Vanderbilt Medical Center program, the HPN process is highly standardized and protocol driven. An electronic medical record system incorporates a specific, standardized order template that allows for computerized provider order entry of the outpatient HPN prescription. The HPN order format has unique features when compared with an inpatient PN order, such as dispensing details that enable a 7-day supply and refills, an end date, and free-text details (eg, for ancillary orders, rationing instructions for product shortages, or laboratory monitoring frequency). However, computerized provider order entry software programs incorporating an outpatient HPN order are not widely available owing to their complexity. As a result, PN orders frequently continue to be printed and faxed, or even handwritten and faxed. It would improve patient safety if electronic PN ordering became more widespread, particularly during transitions of care, as per consensus statement HPN-2¹⁹ and as advocated by the American Society for Parenteral and Enteral Nutrition (ASPEN) parenteral nutrition safety committee.^20-22 In addition, there are considerable differences in PN expertise and competency across all institutions. For those prescribers and/or providers having limited expertise, the summit experts advocated standardized PN training programs to foster improved patient safety (consensus statement 14).¹⁹

To reduce the risk of errors when PN patients are discharged from the hospital to home, the Vanderbilt Medical Center program works to facilitate communication and coordination of the discharge process by holding twice-weekly rounds/huddles with members of the HPN clinical team, the home infusion provider, and case management personnel. In addition, certain targeted events potentially associated with patient harm upon hospital discharge are tracked, such as when a home health visit does not occur or HPN is not infused on the evening of discharge, a supply item is missing, or a patient is readmitted within 3 days. These events are discussed within the group on a quarterly basis to identify opportunities for process improvement. Patients are encouraged to be active participants in the error reporting process.

Shortages of one or more PN components are an ongoing issue in the US and other parts of the world (see consensus statement 12),¹⁹ and these events are associated with a high risk of errors. In periods of PN product shortages, the Vanderbilt Medical Center HPN team collaborates with the infusion pharmacist to identify alternative strategies at the time of hospital discharge and throughout HPN therapy. The following general principles are applied: rationing strategies (whenever possible), development of an alternative plan such as oral supplementation (as appropriate) provided by an infusion pharmacy, increased laboratory monitoring (where necessary), ensuring that HPN orders reflect the actual PN components to be given when ingredients are changed, and returning to full dosing when shortages are resolved.

Several reviews have identified barriers to HPN provision, particularly within the US, and made recommendations to improve the HPN process, including the transition between different care settings.^14,17,22-24 A recent position paper by ASPEN offers practical guidance to facilitate a safe transition between the hospital, home, skilled nursing facility, and long‐term acute care hospital settings for adult and pediatric PN patients.²² The recommendations identify key transition steps such as early patient identification and notification of transition, assessment in preparation for patient transfer, identification of the receiving organization and/or accountable PN providers, and communication and implementation of the PN care plan. Steps should be risk-analyzed individually, and practical advice and a PN transition checklist shared between organizations. Such systematic approaches illustrate the complexity of these transitions, but successful PN transition is possible where there is good communication between the involved parties and clearly defined roles (with accountability for fulfilment of responsibilities).²² Ultimately, communication between the PN prescriber/team and the compounding nutrition support team is key during transitions of care. This is even more important when involving organizations outside of the usual network, as is often the case with HPN.

Preparing patients for HPN: insights from a home infusion center in Poland

The Intestinal Failure Center at The Stanley Dudrick’s Memorial Hospital in Skawina, Poland, is one of the largest HPN centers in Poland. The center is organized as a “one-stop shop,” offering all services associated with HPN, so transition of care from one center to another is not generally an issue. Much value is placed on the clinical nutrition process, interdisciplinary care, and patient education. Clinical nutrition is regarded as a multidisciplinary, multiprofessional process, starting with clinical diagnosis and evaluation of malnutrition risk and underlying diseases and then progressing to prescribing and subsequent delivery of enteral and/or PN, to help improve patients’ outcomes. The multidisciplinary HPN team consists of physicians (eg, intensivist, surgeon, and gastroenterologist), nurses with specialist expertise (eg, stoma care, wound care, and/or HPN specialists), a dietitian, a pharmacist, a psychologist, and other specialists as needed. A key role of the HPN coordinators is coordinating the interdisciplinary care team services. They play an essential role in patient education and act as the primary contact partner for the patient. When HPN was initially introduced at this center in the mid-1980s, PN was typically administered as a multibottle system; then followed a phase of “self-made all-in-one admixtures” in which patients admixed their own PN bag (an approach that was banned in due course). HPN patients now receive either professionally compounded PN or MCBs (containing all 3 macronutrients), with or without extra IV fluids.

Patient education has a very specific focus at the Intestinal Failure Center at The Stanley Dudrick’s Memorial Hospital: Not all patients who need long-term PN are suitable for HPN. To be eligible for HPN, patients must be clinically and metabolically stable and capable, willing, and trained for managing PN outside the hospital setting, either at home or in care facilities.^1,25-27 They should be aware of the goals of HPN treatment, such as maintaining fluid, electrolyte, and nutrient balance and reducing the risk of metabolic complications and catheter-related bloodstream infections, allowing for a good quality of life.^1,14,28

Patient education is key for successful HPN. The European Society for Clinical Nutrition and Metabolism (ESPEN) recommends assessing the home environment for HPN suitability before starting patient education.¹ Patients and their caregivers should then undergo an individualized HPN training program, including catheter care, pump use, and the prevention, recognition, and management of complications.¹ This training may occur at the HPN center, though some experts recommend a combination of in-hospital and at-home training, and a particularly extensive program for patients without home health services.^14,23 HPN teaching resources include written materials, visual aids, online videos, and live conferences conducted by patient support groups. However, it should be considered that written information may exceed the literacy level of some patients, so efforts should be made to make instructions brief and easy to understand.^14,29,30 Multiple teaching strategies have shown promise in clinical practice (eg, verbal instructions followed by printed summary materials). As an example of the complexity and thoroughness of the education process at The Stanley Dudrick’s Memorial Hospital, patients’ HPN training schedule is generally about 2 to 3 hours per day at the hospital and lasts for 1 to 2 weeks. HPN patient education is also addressed in consensus statement HPN 3.¹⁹

Practical challenges in daily HPN practice

As part of the meeting, delegates reflected on their practical experience of HPN, including perspectives such as those from a pharmacist who is also an HPN educator, consultant, and HPN patient. They identified issues hindering HPN standardization and affecting the day-to-day quality of HPN provision. In particular, the quality of HPN care in the US can be highly variable because of different HPN providers, differing patient personal situations and environments, and regulatory requirements (Figure 1). In view of this situation, it is important that the patients and their caregivers receive adequate education to identify and deal with problems, such as those listed in Table 1.^7,16-18 Patients must have round-the-clock access to support from experienced healthcare professionals (see consensus statement 13).¹⁹ Note that ASPEN has published useful practice-based standards for HPN nutrition support healthcare professionals.³¹ Furthermore, there was a call for greater flexibility, particularly from large specialist PN centers. Thus, for example, MCBs (ideally containing all 3 macronutrients to avoid separate ILE administration) should be made available not just during an emergency, as familiarization can be acquired during normal nonemergency daily use to help prevent errors occurring.

Figure 1.

Challenges to the quality of home parenteral nutrition (HPN) in the United States. IV indicates intravenous.

HPN formulation shortages: the UK experience

In the United Kingdom, HPN care is funded by the National Health Service (NHS), which contracts with commercial homecare companies to provide this service. Standards are specified in a National Framework Agreement for the Supply of HPN for England covering all aspects of HPN, including PN admixtures, IV fluids, and nursing. Only companies competent to comply with these standards are authorized to provide home care. As of the end of 2021, five commercial companies and one NHS production facility were authorized to provide HPN services. The national framework document is supported by other standard documents used by all home care companies and HPN centers (eg, prescriptions; patient, caregiver, and nurse training competencies; patient needs assessment forms; and a standard ancillary items list).³²

In 2019, the design of the manufacturing process at one of the largest production sites for compounded PN bags in the UK had to be changed to ensure compliance with Medicines and Healthcare products Regulatory Agency standards. This resulted in a reduced production capacity, and patients suddenly faced major disruptions in their supply of compounded HPN bags. The situation escalated into a national crisis, causing an increase in hospital admissions and adverse events, and an emergency plan was formulated to supply HPN to patients and support them and their healthcare teams during the crisis (Table 2).³³

Table 2.

Overview of Measures Taken to Handle Sudden Shortage of Compounded HPN bags in United Kingdom in 2019³³

Focus	Measures
Organizational aspects	Formation of an NHS England national incident management team with clinical support cell (now the National HPN Advice and Management Group) Introduction of rating systems to rate priority needs for compounding (eg, red/amber/green) Obligation to apply to the clinical support cell for compounding slots, with waiting list when needed
Support for the care team	Release of a national advice document on how to convert from a compounded to an emergency noncompounded regimen Senior intestinal failure leaders on call 24 hours a day to advise on complications (acute during peak of disruption) Development of guidelines to support prescription of noncompounded regimens33
Emergency supply	Contingency MCBs, IV fluids, and hospital-compounded bags distributed to patients and care facilities by delivery services

Abbreviations: HPN, home parenteral nutrition; IV, intravenous; MCB, (market-authorized) multichamber bags; NHS, National Health Service.

The aftermath of these PN shortages is still lingering in the UK, compounded by the challenges posed by the COVID-19 pandemic and continued growth in numbers of patients requiring HPN. Thus, for each patient a clinical decision is made to decide whether compounding is necessary based on the feasibility of meeting nutritional needs with MCBs, with or without IV fluids/electrolytes, and separate micronutrient infusions. Applications for compounding slots in England are submitted to the National HPN Clinical Advice and Management Group. A scoring system, developed from initial crisis experiences and by which clinical needs are prioritized, is used. Highest priority is assigned to children, patients with ultrashort bowel syndrome or high-output stoma (requiring >3 L of PN for adults), and those requiring complex electrolytes.

Contrasting roles for MCBs and compounding in the US and Europe

MCB systems in use in Europe and the US differ considerably. In Europe, 3CBs (including all 3 macronutrients: amino acids, dextrose/glucose, and ILEs) predominate, whereas the prevailing system in the US uses 2CBs (containing amino acids and dextrose/glucose), with ILEs given separately. Because the separate administration of ILE is inconvenient in the home setting, some centers may choose to add ILE to the 2CB in a sterile fashion within the pharmacy, but this practice negates the extended shelf life offered with an MCB and requires refrigeration storage of the bag. Overall, the use of MCBs differs greatly among countries and HPN centers. As mentioned previously, at the Vanderbilt center most HPN bags are compounded and customized, with bags normally being prepared in 7-day supply batches and designed to meet all IV fluid and nutrient requirements. The use of MCBs is reserved primarily for periods of product shortages, patient travel, and possibly facilities serving a limited number of patients receiving PN.

In Poland, as in most other European countries, all types of HPN systems are used. An international cross-sectional survey by Pironi et al⁸ conducted in 2015 found that 58.5% of HPN patients in Poland received IV supplementation with MCBs, and more than two-thirds had supplemental IV fluid and electrolytes. The survey also revealed that up to three-quarters of European HPN patients received MCBs, with or without extra IV fluid and electrolytes, compared with approximately 10% in the US. Primary disease also appears to influence the preferred HPN system.⁸ Patients with benign intestinal failure frequently receive compounded admixtures, while MCBs are often preferred for patients with cancer for practical reasons. For example, patients with cancer tend to need frequent hospital admissions, and MCBs, with their greater stability and longer shelf life, allow for ease of storage at home until they are needed after discharge.⁸ The benefits, limitations, and clinical opportunities for MCBs for HPN are shown in Table 3. Of particular note, in Europe it is easier to meet a greater range of nutritional needs using MCBs, as a wider variety of MCB formulations are available there than in other parts of the world such as the US. In addition, using 3CBs supplies amino acids, glucose/dextrose, and ILE (with or without electrolytes) together, which has some advantages over supplying ILEs as a separate infusion, including promotion of an overall physicochemical environment less favorable to microbiological contamination.³⁴

Table 3.

Market-Authorized Multichamber Bags for Provision of Home Parenteral Nutrition: Benefits, Limitations, and Opportunities

Benefits	Limitations	Opportunities
Allows the patient to be more independent, (eg, less frequent delivery, high stability and longer shelf life, and no need for refrigeration) Fewer preparation steps, reducing the number of potential sources for errors during preparation Some degree of customization possible (stability data according to the manufacturer) Admixtures tested and prepared according to industrial standards. MCB is terminally sterilized	Fixed formulation that may not cover every patient’s nutritional needs Additional patient training required as HPN can be more complex (eg, activation of MCB, addition of micronutrients, and additional infusions of IV fluids) Increased manipulation of the central venous catheter circuit (though appears not to be associated with an increased risk of errors in UK)13	Hybrid regimens combining compounded bags and MCBs Allows contingency prescriptions and emergency supply Transition of care appears facilitated Freeing-up resources to concentrate on patient care. Makes PN a more cost-effective option for centers with low usage

Abbreviations: IV, intravenous; MCB, multi-chamber bag; PN, parenteral nutrition.

The aforementioned HPN formulation shortages and subsequent changes in HPN prescribing practices have led to a substantial increase in MCB use in the UK within a few years. Prior to the shortages, compounded admixtures were supplied to the majority of patients requiring calorie support under the care of the Leeds Adult Intestinal Failure Service (one of the largest of such centers in the UK). Recently, however, approximately 40% of these patients have MCBs as part of a noncompounded regimen, with others being managed on “hybrid” prescriptions (a mix of compounded PN and MCBs). All patients now receive an additional noncompounded emergency prescription to be prepared in the event of a sudden reduction in compounding capacity along with a written personalized patient information letter advising on how to use the emergency prescription. Conversion of existing patients from compounded HPN to MCBs was associated with some patient reluctance, as some perceived the switch as being transferred from “tailor-made” compounded to “inferior” standard bags. An expectation to be given individually compounded bags does not generally occur among new HPN patients, so this group tends to be more amenable to receive noncompounded prescriptions.

One potential concern regarding the use of MCBs for HPN is the need to administer supplementary IV fluids and micronutrients, leading to increased manipulation of the bag and/or central venous access device. This may increase the risk of a catheter-related bloodstream infection. However, a retrospective database analysis of the UK compounding crisis found no differences in the incidence of these infections between patients receiving customized HPN and MCBs, or when switching between these two types of HPN.¹³ In general, the occurrence of catheter-related bloodstream infections remains a major concern in the HPN population, with an estimated infection rate of 0.38 to 4.58 episodes per 1,000 catheter days.³⁵ Infection origin is often multifactorial, with risk factors related to the patient (eg, age, underlying disease, the presence of motor disorders), the type of central venous access device, patient education, HPN therapy, and follow-up. Many such infections are caused by gram-positive bacteria from skin,³⁵ so hand hygiene is important alongside regular training and retraining by the hospital (expert) nutrition support team in collaboration with the home care specialists and/or primary care physicians. It is essential that patients receiving HPN and their caregiver have sufficient knowledge to recognize and to respond adequately to CVC-related emergency situations, which in turn may have positive effects such as giving patients greater independence.³⁶

PN formulation for HPN patients

Chronic intestinal failure is a common indication for HPN. Protein and energy requirements can be highly variable in this group and should be based on each patient’s individual condition, and regular evaluation using clinical, anthropometric, and biochemical parameters is required.²⁵ ILEs are an integral part of a balanced HPN formulation.¹⁹ In addition to providing essential fatty acids and nonprotein energy, they can have inflammatory-resolving and immunomodulatory properties when fish oil is incorporated as a lipid source.^25,37 The minimum supply of soybean-oil ILE to prevent essential fatty acid deficiency is 1 g per kilogram of body weight (BW) per week, though patients with chronic intestinal failure without ongoing metabolic complications can be treated safely by limiting the provision of pure soybean ILEs to no more than 1 g per kilogram of BW per day.^25,27 (Note that ASPEN recommends that at least 2%-4% of energy should be from linoleic acid and 0.25%-0.5% from α-linolenic acid.)³⁸ The choice of ILE is a key issue for HPN in particular. A common strategy in Poland, elsewhere in Europe, and now increasingly also in the US is to use an ILE containing medium-chain triglycerides, olive oil, and/or fish oil (in addition to soybean oil) to provide additional benefits in terms of liver function during long-term HPN.^39-43 For example, clinical data indicate that patients receiving HPN who develop liver abnormalities while receiving pure soybean ILE may better tolerate a mixed-oil ILE, allowing for less reliance on glucose/dextrose as a source of nonprotein energy.⁴³ It is also worth mentioning that the use of a mixed-oil ILE, given at recommended doses, has not been shown to lead to essential fatty acid deficiency in clinical practice.^40,41

Conclusion

PN is a complex therapy and remains a source of potentially harmful errors. Long-term administration of HPN in the home setting adds complexity. One area of concern for HPN is the risk of error when patients transition from hospital to home, and vice versa. It is still common for HPN orders to be printed or handwritten and then faxed to infusion pharmacies because of a general lack of availability of computerized provider order entry programs that incorporate complex HPN prescriptions. To promote patient safety, more resources are needed to standardize HPN prescriptions. The ability to electronically transfer the HPN prescription across various institutions and facilities remains an important goal for ensuring quality and safety.

Patients and/or caregivers play an important and active role in HPN care—taking over the administration of PN and other numerous associated responsibilities from healthcare staff. The main prerequisites for successful HPN are a stable medical condition and the patient’s capability and willingness to enter an HPN program. Patients should be introduced to their new obligations slowly and with great sensitivity. Core elements of the educational program are formula admixtures, particularly in the case of MCB use, pump use, catheter care, and the prevention, recognition, and management of complications. Another essential component of a successful HPN program is to assign patients a designated HPN clinician (or other HPN coordinator) to serve as the primary point of contact and help coordinate the interdisciplinary care team services. Patients want and need well-trained and experienced contacts to help them cope; this is a demand that HPN providers should not neglect, as addressing this need helps to ensure higher-quality and safer PN.

A high rate of standardization of the HPN process is advocated to improve the overall risk-benefit ratio and improve quality and safety in general. One approach is greater use of MCBs. Whereas these industrially prepared bags are an integral part of HPN in many European countries, they have a relatively minor role in the US. With the limited MCB formulations currently available in the US, this situation is likely to continue, though a little more openness towards a hybrid MCB/compounding model to allow greater flexibility would be appreciated by patients. HPN product shortages are an ongoing issue, and MCBs (ideally containing all 3 macronutrients to avoid separate ILE administration) may be useful in these situations, as well as offering greater independence and convenience for patients when travelling. The use of MCBs in the home setting, however, should be well planned, and patients should be trained and ready well in advance of emergencies or travelling. Importantly, fixed-formula MCBs do not cover every patient’s nutritional needs: MCB customization or individually compounded PN may be necessary, and, moreover, MCB use does not minimize the need for the careful evaluation of each patient’s nutritional and electrolyte requirements.

Energy requirements for patients requiring HPN should be calculated individually, based on patient needs, and regularly reevaluated. ILEs are an integral part of a balanced HPN formulation, and in addition to providing essential fatty acids and nonprotein energy, they can have inflammatory-resolving and immunomodulatory properties when fish oil is included as a lipid source. In general, the use of ILEs that contain soybean oil as the sole lipid source should be discouraged, as mixed-oil ILEs can provide additional benefits in terms of preserving liver function during long-term HPN. Finally, we hope that the information on HPN from this summit, and published in this article, will help to inform healthcare professionals and improve HPN processes internationally.

Data availability

No new data were generated or analyzed in support of this article.

Disclosures

Fresenius Kabi GmbH provided financial support to organize and invite experts to participate as speakers, based on knowledge and international reputation within the areas of clinical nutrition, to the International Safety and Quality of PN Summit, as well as financial support for the development of this review. Fresenius Kabi had no involvement in the study design; collection, analysis, interpretation of data; or writing of the manuscript. Dr. Martina Sintzel (mcs medical communication services, Erlenbach, Switzerland) drafted this manuscript and Dr. Richard Clark (freelance medical writer, Dunchurch, UK) provided editorial and consultancy services; all were funded by Fresenius Kabi GmbH. These services complied with international guidelines for Good Publication Practice (GPP 2022). Dr. Kumpf has received consulting fees from Fresenius Kabi, American Regent, Takeda Pharmaceuticals, and Vectiv Bio. Dr. Gray has received consulting fees from Fresenius Kabi. Dr. Monczka has received consulting fees from Fresenius Kabi. Dr. Zeraschi has received institutional support for pharmacy education and training from Baxter, B. Braun, and Fresenius Kabi. Dr. Klek has received speaker’s honoraria from Baxter, B. Braun, Fresenius Kabi, Nestlé, Nutricia, Shire, and Vipharm and acted as an advisory board member for Fresenius Kabi, Shire, and Tracheron.