3.3 Indications, use, and benefits of Parenteral Nutrition (PN)

Summary and recommendations

Parenteral nutrition (PN) is a life-sustaining therapy for patients who cannot be fed adequately and/or safely with food, oral nutritional supplements (ONS) or enteral tube feeding (ETF) for a long period, such as those with intestinal failure (IF) or for a short period, such as surgical, cancer, or critically ill patients. PN is primarily indicated to prevent or treat malnutrition in these patients; without PN, they would die from dehydration and starvation. PN is also used to aid recovery when the gastrointestinal (GI) tract requires rest, and perioperative PN may be used in patients who are malnourished or at high nutritional risk, to prevent nutrition-associated complications after surgery when sufficient oral and/or enteral intake is not feasible. PN can be used to supplement oral or enteral feeding or as the sole source of nutrition (total PN).

PN can be used for patients of any age, and across all healthcare settings (e.g., hospitals, nursing/residential homes, and patients’ own homes). PN use prevalence differs based on geographic location and hospital unit. It is significantly higher in ICU patients compared to non-ICU patients. In ICUs, about 10% of patients receive TPN, with usage peaking at 12% by day 5-6 and rising to 33% by day 5. Non-ICU wards report much lower use, ranging from 3.4% on admission to 5% after two weeks. Geographically, countries like Sweden, Austria, and Italy have higher ICU PN rates, exceeding 25%. PN use increases with the severity of illness and length of stay, particularly in critically ill patients. International and internationally recognised guidelines recommend that PN should be administered as soon as possible in critically ill adults and children and malnourished patients who cannot be fed by the oral or enteral routes. The use of PN has improved patients’ quality of life, transformed the prognosis for many individuals with previously fatal conditions, and is considered one of the most important advances in therapeutics over the last four decades.

Because PN is a life-sustaining therapy for patients with IF, evaluation of its efficacy compared with no nutrition support in randomised controlled trials (RCTs) is not possible. Furthermore, clinical guidelines note that the ability of PN to preserve quality of life (QOL) and promote rehabilitation supports its use in the home setting.

Home PN (HPN) is the cornerstone of treatment for adults and children with chronic intestinal failure and is considered the best option for improving QOL in children with conditions that require long-term PN, and their families. Moreover, since its introduction in the 1970s, the use of HPN has expanded to include patients with IF due to cancer or chronic radiation enteritis, benign chronic IF, and in certain patients with incurable cancer, those undergoing cancer treatment or in advanced cancer stages. In Europe, the estimated prevalence of HPN ranges from 4 to 60 patients per million inhabitants, with wide variation based on country and reporting systems. Over time, the use of HPN has expanded considerably. In Poland, for example, HPN patient-days nearly tripled from 2009 to 2019, reflecting growing clinical demand and accessibility. HPN is a life-saving therapy for patients with cancer who are at risk of death from malnutrition rather than disease progression.

There is little systematic review evidence for the efficacy of PN. However, a number of RCTs and many prospective and retrospective observational studies have shown nutritional (Section 3.3.2), functional (Section 3.3.3) and clinical (Section 3.3.4) benefits with PN in a variety of different age groups, conditions, and healthcare settings. Higher protein and energy intake in critically ill patients is associated with significant reductions in-hospital and 60- day mortality rates and shorter time to discharge alive. Nutrition guidelines recommend that critically ill patients who are malnourished or at nutritional risk receive adequate nutritional support to prevent the significant morbidity and mortality that is associated with starvation or underfeeding in these patients. Guidelines are available for different settings in which PN is administered, including clinical settings and home nutrition, as the handling and dynamics of PN vary across these environments. Perioperative PN is also associated with a reduction in major and infectious complications following surgery in patients who are malnourished or cannot be fed via the oral or enteral routes. Economic analyses show that early initiation of supplemental PN (alongside ETF) is cost-effective in the ICU setting by reducing the incidence of hospital-acquired infections and shortening length of stay.

Both compounded bags and multichamber bags (MCB) are available options for PN. The choice between them depends largely on the patient’s condition and needs, product availability, and the expertise of the nutrition support team. Development of evidence-based guidance on the safe management of PN in the hospital and community settings, together with the introduction of multichamber bag (MCB) technology and alternative IV lipid emulsions, has made PN safe and effective for both short- and long-term use. Recently published studies, including two multicentre randomised studies involving 2,338 and 1,372 critically ill patients, found no increased risk for infectious complications with PN compared with ETF. Use of MCBs significantly reduces costs—by approximately $5.70 per bag—lowers preparation time by 38 minutes, and results in fewer preparation errors and reduced infection risk compared with compounded PN. This approach offers logistical, clinical, and economic advantages, especially in resource-constrained hospital settings. Published data about the potential cost savings and cost-effectiveness of PN across healthcare settings and in different countries are limited.

Although PN is often perceived as costly, it compares favourably with other ICU therapies such as dialysis. A U.S. cost-minimisation study showed that timely PN reduced acute care costs by $3,150 per patient. Moreover, HPN significantly reduces hospital length of stay by enabling earlier discharge and shifting care to the home setting. In one analysis, the annual cost of HPN was 60–76% lower than hospital PN. Importantly, long-term HPN costs tend to decline over time. One study found that after the first year of HPN, annual costs fell by 15% in year 2 and by 40% by year 5—driven by a reduction in complications and hospitalisations. Nonetheless, annual HPN costs per patient remain significantly higher—up to 1.6 times—than the average healthcare spending per individual.

PN can be administered through either a central or peripheral line. A central line is typically used in intensive care units, for cancer patients, and for individuals receiving long-term PN, particularly when a central line is already in place and there is a need for fluid restriction or moderate to high amino acid and calorie supplementation. Peripheral PN, on the other hand, is often used for short-term nutrition support at the ward level or for prehabilitation. It requires no invasive interventions and reduces the risk of catheter-related bloodstream infections.

Conclusion

PN is an important life-sustaining therapy that is used across all healthcare settings in patients of all ages with a variety of medical conditions. The use of HPN is increasing, particularly in patients with cancer and in children with chronic conditions. PN has demonstrated nutritional, functional, and clinical benefits, increasing evidence shows it is not only clinically effective but also economically sustainable particularly when delivered through cost-optimised strategies such as HPN and MCB use. These approaches help reduce complications, hospital length of stay, and healthcare costs, while maintaining or improving quality of life for patients who depend on PN.

Recommendations

On the benefits of PN, the MNI makes the following recommendations.