1. Clinical Presentation and Initial Assessment

The initial evaluation focuses on identifying malnutrition risk and clear contraindications to enteral nutrition (EN) through a comprehensive history and physical examination.

History

• Feeding Intolerance: Documented high gastric residual volumes, persistent nausea, vomiting, or abdominal distension despite trials of enteral feeding.
• Significant Weight Loss: Unintentional weight loss greater than 5% in one month or more than 10% in six months is a critical indicator. Prolonged periods of fasting or bowel rest (>7 days) also warrant consideration for PN.
• Underlying GI Pathology: Conditions such as severe pancreatitis, prolonged ileus, high-output fistula, or severe mucositis often preclude the use of the gut.
• Medication Review: Assess the impact of medications like opioids, which slow gut motility, and vasoactive agents, which can compromise gut perfusion, on EN tolerance.

Physical Exam

• Signs of Chronic Undernutrition: Look for classic signs including temporal wasting, loss of triceps subcutaneous fat, and prominent clavicles.
• Edema Assessment: Peripheral or sacral edema can be a sign of hypoalbuminemia and may mask the true extent of lean body mass loss.
• Catheter Site Inspection: For patients with existing central lines, inspect for erythema, tenderness, purulence, or fluctuance, which could indicate infection.
• Abdominal Exam: Assess for distension, quality of bowel sounds, and tenderness to help guide the decision between EN and PN.

2. Laboratory Diagnostics

Baseline laboratory values are essential to define the risk of refeeding syndrome, identify pre-existing metabolic complications, and guide initial micronutrient repletion strategies.

Routine Labs

• Electrolytes: Check phosphate, potassium, and magnesium levels before starting PN. Correct if phosphate is <0.65 mmol/L, potassium is <3.5 mEq/L, or magnesium is <1.7 mg/dL to mitigate refeeding risk.
• Glucose: Obtain a baseline glucose and monitor frequently upon PN initiation. Target a range of 110–150 mg/dL to minimize risks of hyperglycemia and hypoglycemia.
• Liver Function Tests: Baseline AST, ALT, alkaline phosphatase, and total bilirubin are needed to monitor PN tolerance and detect parenteral nutrition-associated liver disease (PNALD) or cholestasis over time.
• Triglycerides: A baseline level is required. Hold or use caution with intravenous lipid emulsions if triglyceride levels are >400 mg/dL.

Biomarkers

• C-reactive protein (CRP): Use to track the underlying inflammatory state. A rising CRP can falsely lower levels of nutritional markers like prealbumin.
• Prealbumin: A level <15 mg/dL suggests poor visceral protein synthesis but should only be interpreted when the CRP is stable or decreasing.
• Micronutrient Panels: Consider checking zinc, copper, selenium, and thiamine levels in patients expected to be on PN for a prolonged duration (>2 weeks) or those with high-risk conditions (e.g., alcoholism, malabsorption).

Interpretation Challenges

The acute-phase inflammatory response significantly alters levels of albumin, prealbumin, iron, and zinc, making them unreliable markers of nutritional status in isolation. Always correlate lab values with the patient’s clinical trajectory and inflammatory markers before initiating supplementation.

3. Imaging and Procedural Assessment

Imaging is crucial to confirm safe vascular access for PN administration and to rule out immediate mechanical complications from line placement.

Ultrasound Guidance

• Vessel Visualization: Real-time ultrasound guidance is the standard of care for placing central venous catheters in the internal jugular or subclavian veins.
• Safety: Color Doppler imaging helps definitively distinguish arteries from veins and can identify pre-existing venous thrombosis.
• Asepsis: Use of sterile probe covers and gel is mandatory to maintain an aseptic field and prevent central line-associated bloodstream infections (CLABSI).

Radiographic Confirmation

• Tip Location: A post-procedure chest X-ray is required to verify that the catheter tip is located at the cavoatrial junction (the junction of the lower superior vena cava and the right atrium).
• Complication Screening: The X-ray also serves to rule out procedural complications such as pneumothorax or hemothorax before the high-osmolarity PN solution is infused.

Advanced Imaging

• Fluoroscopy: May be used for line placement in patients with complex anatomy, known central venous stenosis, or in cases of a malpositioned guidewire.
• CT Guidance: Reserved for highly challenging cases where standard access routes are occluded or inaccessible.

4. Classification Systems for Risk Stratification

Applying validated scoring systems helps to objectively quantify nutritional risk, overall illness severity, and the specific risk of refeeding syndrome, thereby guiding the timing and intensity of PN initiation.

Key Points for Application

• Use the Nutritional Risk Screening (NRS-2002) tool upon admission to trigger an early consultation with the nutrition support team.
• Reassess the Sequential Organ Failure Assessment (SOFA) score daily in the ICU to help modulate the PN prescription in response to clinical changes.
• In patients identified as high-risk for refeeding syndrome by ASPEN criteria, initiate a low-calorie, low-carbohydrate PN formulation and ensure frequent electrolyte monitoring for the first 72 hours.

5. Integrated Diagnostic Algorithm

A successful PN program integrates clinical, laboratory, imaging, and scoring data into a standardized, stepwise initiation plan coordinated by a multidisciplinary team.

Multidisciplinary Team Roles

• Pharmacist: Reviews nutrient composition, checks for incompatibilities, manages compounding, and leads metabolic monitoring.
• Dietitian: Determines caloric and protein goals, plans the transition to or from EN, and assesses micronutrient needs.
• Nurse: Provides meticulous catheter care, administers the infusion, and monitors for immediate complications like line infection or hyperglycemia.
• Physician/Provider: Defines the overall nutrition strategy, assesses hemodynamic stability, and places the central venous catheter.

Documentation and Communication

Thorough documentation is key. Record all risk scores (NRS-2002, SOFA), baseline and trending lab values, and imaging reports in the electronic medical record. Use standardized electronic checklists and order templates to ensure all safety criteria are met before the pharmacy compounds and dispenses the PN solution.