Parenteral Nutrition Administration

Overview and Guiding Principles

Parenteral nutrition (PN) represents a critical therapeutic intervention for patients unable to meet nutritional requirements through enteral routes. The decision to initiate PN therapy should emerge from collaborative discussions involving the patient, caregivers, and the interdisciplinary healthcare team, with careful consideration of the projected treatment plan and anticipated duration of therapy.

Two fundamental requirements govern all PN administration: the use of appropriate filtration systems and the employment of electronic infusion pumps equipped with anti-free-flow control mechanisms and functional alarm systems. Additionally, no medications should be added to or co-infused with PN solutions without prior pharmacist consultation regarding compatibility and stability considerations.

Section 1: Planning for Safe Parenteral Nutrition Therapy

1.1 Route Selection

Enteral nutrition should always be considered the preferred route when feasible, with parenteral support reserved for situations where gastrointestinal function is inadequate or inaccessible (Singer et al., 2019; Worthington et al., 2017). This preference reflects both the physiological advantages of enteral feeding and the inherent complexity and risks associated with intravenous nutritional support.

1.2 Understanding the Risk Profile

PN is classified as a complex, high-alert medication. Healthcare organizations must recognize that reported incidents and errors leading to patient harm include microbial contamination of solutions, inappropriate prescriptions, and errors during compounding and dispensing phases (Akbar et al., 2021; Guenter et al., 2017; Mistry et al., 2022; Ayers et al., 2018). This classification demands heightened vigilance throughout the medication use process.

1.3 Interdisciplinary Team Approach

Evidence strongly supports the implementation of interdisciplinary nutritional support teams, which have demonstrated associations with reduced catheter-related infection rates, decreased inappropriate PN utilization, and lower mortality (Guenter et al., 2017; Ayers et al., 2018; Eriksen et al., 2021; Ukleja et al., 2018). Organizations should establish formal mechanisms for error reporting and systematic error analysis to continuously improve safety outcomes.

1.4 Standardization and Order Entry Systems

Standardized order forms, templates, and computerized order entry systems should be implemented throughout the care continuum whenever feasible. These tools have demonstrated effectiveness in preventing prescription-related errors (Ayers et al., 2020; Ayers et al., 2018; Ukleja et al., 2018; Kumpf, 2019). Organizations should also develop written protocols addressing component substitution or conservation methods in anticipation of potential drug or component shortages.

1.5 Care Transitions

Patients transitioning between healthcare settings—whether from acute care to skilled nursing facilities, home environments, or long-term acute care hospitals—require coordinated care using a patient-centered, interprofessional approach. The transition process must systematically address PN orders and formulation specifications, current clinical status, appropriateness for the receiving care setting, patient and caregiver education status, available support systems, insurance coverage, appropriate vascular access device selection, and comprehensive monitoring plans including laboratory study schedules (Ayers et al., 2020; Kumpf, 2019; Adams et al., 2022; Pironi et al., 2020).

Section 2: Vascular Access Device Selection

2.1 General Principles

Vascular access device (VAD) selection requires careful evaluation of expected therapy duration, nutritional requirements, the patient’s vascular condition, and patient preferences. In general, devices with the minimal number of lumens necessary should be selected (Worthington et al., 2017; Ukleja et al., 2018; Kolaček et al., 2018; Kovacevich et al., 2019).

2.2 Pediatric Considerations

For infants and children requiring prolonged PN during hospitalization, peripherally inserted central catheters (PICCs) and tunneled, cuffed central vascular access devices (CVADs) merit consideration as appropriate options (Kolaček et al., 2018; Huang et al., 2018).

2.3 Home Parenteral Nutrition Access

For patients receiving home parenteral nutrition (HPN), both adults and children, tunneled cuffed CVADs or PICCs represent appropriate choices. Implanted vascular access ports may also serve as a viable option when the noncoring needle is changed at minimum every seven days (Pironi et al., 2020; Kolaček et al., 2018; Kovacevich et al., 2019; Hon et al., 2019; Cotogni et al., 2021; Opilla, 2017; Mateo-Lobo et al., 2019; Matysiak et al., 2021).

Section 3: Peripheral Parenteral Nutrition

3.1 Indications and Osmolarity Considerations

Peripheral parenteral nutrition (PPN) solutions containing a final dextrose concentration of 10% or lower may be administered through a peripheral intravenous catheter (PIVC) in specific clinical scenarios: as a bridge to central PN initiation, when oral or enteral intake remains suboptimal, or when the patient’s clinical condition does not justify central vascular access device placement.

Osmolarity requires careful attention when formulating PPN solutions. The American Society for Enteral and Parenteral Nutrition (ASPEN) recommends that osmolarity not exceed 900 mOsm/L; however, research indicates that endothelial damage begins occurring at concentrations as low as 600 mOsm/L. Dextrose concentration and other additives affecting osmolarity must be carefully considered. The optimal osmolarity limit for PPN remains an area requiring further research (Ayers et al., 2020; Worthington et al., 2017; Ukleja et al., 2018; Roethlisberger et al., 2017).

3.2 Phlebitis Risk and Duration Limitations

Clinicians must recognize the elevated phlebitis risk associated with PPN administration. A careful risk-benefit analysis should precede PPN initiation, and therapy duration should not exceed 14 days. Current ASPEN recommendations do not specifically address PPN administration via midline catheters (Ayers et al., 2020; Worthington et al., 2017).

3.3 Midline Catheter Contraindication

Midline catheters are not appropriate for continuous vesicant therapy, PN, or solutions with extreme pH or osmolarity values. The use of midline catheters for PPN lacks established evidence. Importantly, the deeper venous position of midline catheters may obscure early detection of phlebitis, extravasation, and thrombosis—complications requiring prompt recognition and intervention.

Section 4: Filtration Requirements

4.1 Filter Selection and Positioning

All PN solutions require filtration during administration. The filter should be positioned on the administration set as close to the patient as possible. Filter priming must follow manufacturer specifications (Worthington et al., 2021; Gill et al., 2022).

4.2 Filter Specifications

A 1.2-micron filter is appropriate for all PN formulations, including dextrose-amino acid admixtures, lipid injectable emulsions (ILE), and PN solutions containing ILEs (commonly referred to as total nutrient admixtures or TNA).

Section 5: Administration Set and Solution Container Management

5.1 Replacement Intervals

Solution containers and administration sets used for PN—including both TNA formulations and amino acid/dextrose solutions—along with lipid-containing products require replacement every 24 hours. Administration sets used for separately infused ILE must be replaced with each new infusion. The maximum hang time for PN solutions should not exceed 24 hours (Ayers et al., 2020; Ukleja et al., 2018; Pironi et al., 2020).

5.2 Microbiological Considerations

Laboratory studies have demonstrated that both TNA and ILE can support Candida albicans growth following minimal initial contamination, with microorganisms capable of migrating from the fluid container to the CVAD (Gavin et al., 2018). This finding underscores the imperative nature of strict Aseptic Non Touch Technique (ANTT) during all administration set manipulations and supports the requirement for daily administration set replacement.

5.3 Separate Lipid Injectable Emulsion Infusion

When ILE is infused separately from the PN solution, infusion time should be limited to a maximum of 12 hours. If clinical circumstances—such as volume limitations—necessitate separate ILE administration exceeding 12 hours, ASPEN strongly recommends using a new ILE container and administration set for the second 12-hour portion.

The hang time for TNA formulations can be extended to 24 hours because bacterial growth in these solutions is inhibited by reduced pH and increased total osmolarity compared to separately infused ILE (Ayers et al., 2020; Boullata et al., 2020).

5.4 Filter Replacement Coordination

Filters should be changed to coincide with the initiation of new PN mixtures and administration sets. For separately infused ILE, filters require replacement every 12 hours. All filters should be primed immediately before use (Worthington et al., 2021; Gill et al., 2022).

Section 6: Equipment Specifications

6.1 DEHP-Free Materials

PN containers and administration sets used for lipid-based solutions—including ILE and TNA—must be free of Di[2-ethylhexyl]phthalate (DEHP). DEHP is a lipophilic toxin that leaches from commonly used polyvinyl chloride administration sets and containers into lipid-based solutions, presenting a potential toxicity risk (Ayers et al., 2020; Boullata et al., 2022).

6.2 Electronic Infusion Pump Requirements

Electronic infusion pumps with anti-free-flow protection and occlusion alarms are mandatory for PN administration. Organizations should consider implementing electronic infusion pumps with dose error reduction software (DERS), commonly known as smart pumps. These devices are associated with reduced infusion-related medication errors, including error interceptions such as wrong-rate programming, and decreased adverse drug events.

Section 7: Light Protection for Premature Infants

7.1 Rationale for Photoprotection

PN component degradation occurs with light exposure, resulting in oxidation. Preterm infants demonstrate greater susceptibility to these effects than children and adults, facing potential complications from oxidative stress including bronchopulmonary dysplasia, retinopathy, and necrotizing enterocolitis (Ayers et al., 2020; Robinson et al., 2021; Hartman et al., 2018; Hardy et al., 2021; Chessex et al., 2017).

7.2 Implementation Recommendations

ASPEN recommends complete PN light protection for preterm infants, beginning during compounding and continuing through transport, delivery, and administration until the entire PN/ILE infusion is complete. While complete implementation may not be feasible given current product availability, organizations should define achievable steps and implement attainable protection strategies.

7.3 Recommendations for Non-Preterm Patients

For patients who are not preterm infants, ASPEN recommends refrigerating PN solutions and protecting them from light exposure until immediately before infusion. While partial light protection has not demonstrated clinical benefits, further research is needed regarding light protection requirements for children and adults receiving long-term PN.

Section 8: Catheter-Associated Bloodstream Infection Prevention

8.1 Blood Sampling Considerations

Peripheral venipuncture should be considered preferentially over CVAD sampling for patients receiving PN to reduce infection risk (Ayers et al., 2020). However, for patients receiving long-term PN, blood sampling via the CVAD represents an important quality-of-life consideration. When CVAD blood sampling is necessary, strict adherence to ANTT is essential (Kolaček et al., 2018).

8.2 Dedicated Lumen Consideration

When a multilumen CVAD is in place, dedicating a single lumen exclusively to PN administration merits consideration (Worthington et al., 2017; Pironi et al., 2020; Kolaček et al., 2018). However, a systematic review found insufficient data to definitively determine whether lumen dedication results in lower infection risk; this remains an area requiring further research (Gavin et al., 2018).

8.3 Administration Set Timing

Administration sets should not be attached to PN solutions before the time of infusion. The risks associated with spiking containers and priming administration sets in advance have not been adequately studied (Ayers et al., 2020; Ukleja et al., 2018).

8.4 Antimicrobial Lock Therapy

Antimicrobial catheter lock therapy should be considered for patients receiving cyclic HPN as an infection-prevention strategy.

Taurolidine has demonstrated effectiveness in preventing catheter-related bloodstream infections (CR-BSI) in HPN patients. While generally considered safe, rare allergic reactions and VAD-related problems including pain have been reported (Pironi et al., 2020; Wouters et al., 2020; Wouters et al., 2019; Korzilius et al., 2022; Leiberman et al., 2020; Vernon-Roberts et al., 2022; Gompelman et al., 2021; Quirt et al., 2021).

Alternative antimicrobial agents also showing associations with reduced CR-BSI incidence include 4% tetrasodium ethylenediaminetetraacetic acid (EDTA) and 70% ethanol. Ethanol lock therapy should be limited to patients with silicone CVADs (Gompelman et al., 2021; Quirt et al., 2021; Gundogan et al., 2020; Davidson et al., 2017; Hill & Garner, 2021; Reitzel et al., 2019).

8.5 Catheter Repair

For damaged subcutaneously tunneled, cuffed CVADs, catheter repair should be considered as a strategy to extend CVAD survival and reduce risk for future compromised vascular access. Retrospective studies have reported successful extension of CVAD survival without increased central line-associated bloodstream infection (CLABSI) risk (Leiberman et al., 2020; Velapati et al., 2020; Wouters et al., 2019; Salonen et al., 2019).

Section 9: Patient Monitoring

9.1 Comprehensive Monitoring Parameters

Patients receiving PN require systematic monitoring of multiple parameters: body weight, fluid and electrolyte balance, metabolic tolerance with particular attention to glucose control, VAD-related complications including catheter-associated bloodstream infection, organ function, nutrition therapy-related complications, functional performance, and psychological responses to therapy (Ukleja et al., 2018; Pironi et al., 2020; Kovacevich et al., 2019; Davila & Konrad, 2017; Elizabeth et al., 2020; Fonseca et al., 2018).

9.2 Blood Glucose Management

Blood glucose monitoring is essential throughout PN therapy. During initial transition to cyclic infusion regimens, monitoring should occur both during PN infusion and after discontinuation—in both acute care and home settings. Once glycemic stability is established, less frequent monitoring may be appropriate. Insulin may be utilized to achieve glycemic control, administered either subcutaneously, intravenously, or added directly to the PN solution (Ayers et al., 2020; Elizabeth et al., 2020).

Section 10: Patient and Caregiver Education

10.1 Essential Education Components

Patients and family members of patients receiving HPN require comprehensive education addressing: the importance of ANTT during all PN procedures, VAD care and maintenance, weight and hydration monitoring, blood and urine glucose monitoring, electronic infusion pump operation and troubleshooting, and recognition of signs and symptoms requiring clinical notification (Ayers et al., 2020; Pironi et al., 2020; Kovacevich et al., 2019; Gallotto et al., 2019; Pichitchaipitak et al., 2018).

10.2 Lifestyle Integration

Beyond technical competencies, education should assist patients in integrating PN therapy into their daily lives. Ongoing assessment of patient and family coping mechanisms and management capabilities is essential for successful long-term HPN therapy.

References

Adams SC, Gura KM, Seres DS, et al. Safe care transitions for patients receiving parenteral nutrition. Nutr Clin Prac. 2022;37(3):493-508. doi:10.1002/ncp.10861

Akbar Z, Saeed H, Saleem Z, Andleeb S. Dosing errors in total parenteral nutrition prescriptions at a specialized cancer care hospital of Lahore: the role of clinical pharmacist. J Oncol Pharm Pract. 2021;27(3):531-540. doi:10.1177/1078155220923014

Ayers P, Bobo ES, Hurt RT, Mays AA, Worthington PH. Parenteral Nutrition Handbook. 3rd ed. American Society for Parenteral and Enteral Nutrition; 2020.

Ayers P, Boullata J, Sacks G. Parenteral nutrition safety: the story continues. Nutr Clin Prac. 2018;33(1):46-52. doi:10.1002/ncp.10023

Boullata JI, Berlana D, Pietka M, Klek S, Martindale R. Use of intravenous lipid emulsions with parenteral nutrition: practical handling aspects. JPEN J Parenter Enteral Nutr. 2020;44(S1):S74-S81. doi:10.1002/jpen.1737

Boullata JI, Mirtallo JM, Sacks GS, et al. Parenteral nutrition compatibility and stability: a comprehensive review. JPEN J Parenter Enteral Nutr. 2022;46(2):273-299. doi:10.1002/jpen.2306

Chessex P, Laborie S, Nasef N, Masse B, Lavoie JC. Shielding parenteral nutrition from light improves survival rate in premature infants. JPEN J Parenter Enteral Nutr. 2017;41(3):378-383. doi:10.1177/0148607115606407

Cotogni P, Mussa B, Degiorgis C, De Francesco A, Pittiruti M. Comparative complication rates of 854 central venous access devices for home parenteral nutrition in cancer patients: a prospective study of over 169,000 catheter-days. JPEN J Parenter Enteral Nutr. 2021;45(4):768-776. doi:10.1002/jpen.1939

Davidson JB, Edakkanambeth Varayil J, Okano A, et al. Prevention of subsequent catheter-related bloodstream infection using catheter locks in high-risk patients receiving home parenteral nutrition. JPEN J Parenter Enteral Nutr. 2017;41(4):685-690. doi:10.1177/0148607115604118

Davila J, Konrad D. Metabolic complications of home parenteral nutrition. Nutr Clin Prac. 2017;32(6):753-768. doi:10.1177/0884533617735089

Elizabeth PC, Rogelio Ramón PR, Félix Alberto MM. Hyperglycemia associated with parenteral nutrition in noncritical patients. Hum Nutr Metab. 2020;22:200114. doi:10.1016/j.hnm.2020.200114

Eriksen MK, Crooks B, Baunwall SMD, Rud CL, Lal S, Hvas CL. Systematic review with meta-analysis: effects of implementing a nutrition support team for in-hospital parenteral nutrition. Aliment Pharmacol Ther. 2021;54(5):560-570. doi:10.1111/apt.16530

Fonseca G, Burgermaster M, Larson E, Seres DS. The relationship between parenteral nutrition and central line–associated bloodstream infections: 2009–2014. JPEN J Parenter Enteral Nutr. 2018;42(1):171-175. doi:10.1177/0148607116688437

Gallotto M, Rosa CM, Takvorian-Bené M, et al. Caregiver training for pediatric home parenteral nutrition: a 5-session discharge curriculum. J Infus Nurs. 2019;42(3):132-136. doi:10.1097/NAN.0000000000000320

Gavin NC, Button E, Castillo MI, et al. Does a dedicated lumen for parenteral nutrition administration reduce the risk of catheter-related bloodstream infections? A systematic literature review. J Infus Nurs. 2018;41(2):122-130. doi:10.1097/NAN.0000000000000270

Gavin NC, McMillan D, Keogh S, Choudhury MA, Ray-Barruel G, Rickard CM. Effect of delaying replacement of parenteral nutrition intravenous administration sets: preclinical experiments and a dynamic laboratory model of microbial colonization. JPEN J Parenter Enteral Nutr. 2018;42(6):987-997. doi:10.1002/jpen.1039

Gill M, Hirsch A, Wilson N. Filtering out the facts: recommendations to optimize performance of in-line filters for parenteral nutrition and injectable lipid emulsion infusions. J Infus Nurs. 2022;45(3):137-141. doi:10.1097/NAN.0000000000000464

Gompelman M, Paus C, Bond A, et al. Comparing success rates in central venous catheter salvage for catheter-related bloodstream infections in adult patients on home parenteral nutrition: a systematic review and meta-analysis. Am J Clin Nutr. 2021;114(3):1173-1188. doi:10.1093/ajcn/nqab164

Guenter P, Ayers P, Boullata JI, Gura KM, Holcombe B, Sacks GS. Parenteral nutrition errors and potential errors reported over the past 10 years. Nutr Clin Prac. 2017;32(6):826-830. doi:10.1177/0884533617715868

Gundogan K, Dave NJ, Griffith DP, et al. Ethanol lock therapy markedly reduces catheter-related blood stream infections in adults requiring home parenteral nutrition: a retrospective study from a tertiary medical center. JPEN J Parenter Enteral Nutr. 2020;44(4):661-667. doi:10.1002/jpen.1698

Hardy G, Austin PD, Davis MR, et al. Photoprotection of parenteral nutrition: an international perspective. Nutr Clin Prac. 2021;36(5):921-925. doi:10.1002/ncp.10773

Hartman C, Shamir R, Simchowitz V, et al. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: complications. Clin Nutr. 2018;37(6 Pt B):2418-2429. doi:10.1016/j.clnu.2018.06.956

Hill J, Garner R. Efficacy of 4% tetrasodium ethylenediaminetetraacetic acid (T-EDTA) catheter lock solution in home parenteral nutrition patients: a quality improvement evaluation. J Vasc Access. 2021;22(4):533-539. doi:10.1177/1129729820946916

Hon K, Bihari S, Holt A, Bersten A, Kulkarni H. Rate of catheter-related bloodstream infections between tunneled central venous catheters versus peripherally inserted central catheters in adult home parenteral nutrition: a meta-analysis. JPEN J Parenter Enteral Nutr. 2019;43(1):41-53. doi:10.1002/jpen.1421

Huang J, Yu Q, Wen J, et al. Peripherally inserted central catheter-related complications in infants with intestinal failure. Asia Pac J Clin Nutr. 2018;27(6):1225-1229. doi:10.6133/apjcn.201811_27(6).0008

Kolaček S, Puntis JWL, Hojsak I, et al. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Venous access. Clin Nutr. 2018;37(6):2379-2391. doi:10.1016/j.clnu.2018.06.952

Korzilius JW, Gillis VELM, Wouters Y, Wanten GJA. Taurolidine-related adverse events in patients on home parenteral nutrition frequently indicate catheter-related problems. Clin Nutr. 2022;41(10):2178-2184. doi:10.1016/j.clnu.2022.07.025

Kovacevich DS, Corrigan M, Ross VM, McKeever L, Hall AM, Braunschweig C. American Society for Parenteral and Enteral Nutrition Guidelines for the Selection and Care of Central Venous Access Devices for Adult Home Parenteral Nutrition Administration. JPEN J Parenter Enteral Nutr. 2019;43(1):15-31. doi:10.1002/jpen.1455

Kumpf VJ. Challenges and obstacles of long-term parenteral nutrition. JPEN J Parenter Enteral Nutr. 2019;34(2):196-203. doi:10.1002/ncp.10258

Leiberman D, Stevenson RP, Banu FW, Gerasimidis K, McKee RF. The incidence and management of complications of venous access in home parenteral nutrition (HPN): a 19 year longitudinal cohort series. Clin Nutr ESPEN. 2020;37:34-43. doi:10.1016/j.clnesp.2020.03.025

Mateo-Lobo R, Riveiro J, Vega-Piñero B, Botella-Carretero JI. Infectious complications in home parenteral nutrition: a systematic review and meta-analysis comparing peripherally-inserted central catheters with other central catheters. Nutrients. 2019;11(9):2083. doi:10.3390/nu11092083

Matysiak K, Szewczuk M, Sobocki J, Zdziarska M, Siatkowski I. Complications of tunneled peripherally inserted and tunneled-cuffed central catheters in home parenteral nutrition. Nutrition. 2021;91-92:111354. doi:10.1016/j.nut.2021.111354

Mistry P, Smith RH, Fox A. Patient safety incidents related to the use of parenteral nutrition in all patient groups: a systematic scoping review. Drug Saf. 2022;45(1):1-18. doi:10.1007/s40264-021-01134-3

Opilla M. Peripherally inserted central catheter experience in long term home parenteral nutrition patients. JAVA. 2017;22(1):42-45. doi:10.1016/j.java.2016.12.001

Pichitchaipitak O, Ckumdee S, Apivanich S, Chotiprasitsakul D, Shantavasinkul PC. Predictive factors of catheter-related bloodstream infection in patients receiving home parenteral nutrition. Nutrition. 2018;46:1-6. doi:10.1016/j.nut.2017.08.002

Pironi L, Boeykens K, Bozzetti F, et al. ESPEN guideline on home parenteral nutrition. Clin Nutr. 2020;39(6):1645-1666. doi:10.1016/j.clnu.2020.03.005

Quirt J, Belza C, Pai N, et al. Reduction of central line–associated bloodstream infections and line occlusions in pediatric intestinal failure patients receiving long-term parenteral nutrition using an alternative locking solution, 4% tetrasodium ethylenediaminetetraacetic acid. JPEN J Parenter Enteral Nutr. 2021;45(6):1286-1292. doi:10.1002/jpen.1989

Reitzel RA, Rosenblatt J, Chaftari AM, Raad II. Epidemiology of infectious and noninfectious catheter complications in patients receiving home parenteral nutrition: a systematic review and meta-analysis. JPEN J Parenter Enteral Nutr. 2019;43(7):832-851. doi:10.1002/jpen.1609

Robinson DT, Ayers P, Fleming B, et al. Recommendations for photoprotection of parenteral nutrition for premature infants: an ASPEN position paper. Nutr Clin Prac. 2021;36(5):927-941. doi:10.1002/ncp.10747

Roethlisberger D, Mahler HC, Altenburger U, Pappenberger A. If euhydric and isotonic do not work, what are acceptable pH and osmolality for parenteral drug dosage forms? J Pharm Sci. 2017;106(2):446-456. doi:10.1016/j.xphs.2016.09.034

Salonen BR, Bonnes SL, Mundi MS, Lal S. Repair of central venous catheters in home parenteral nutrition patients. Nutr Clin Prac. 2019;34(2):210-215. doi:10.1002/ncp.10262

Singer P, Blaser AR, Berger MM, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019;38(1):48-79. doi:10.1016/j.clnu.2018.08.037

Ukleja A, Gilbert K, Mogensen KM, et al. Standards for nutrition support: adult hospitalized patients. JPEN J Parenter Enteral Nutr. 2018;33(6):906-920. doi:10.1002/ncp.10204

Velapati SR, Schroeder S, Kuchkuntla AR, et al. Repair of central venous catheter in a single-center adult home parenteral nutrition cohort. JPEN J Parenter Enteral Nutr. 2020;44(2):265-273. doi:10.1002/jpen.1611

Vernon-Roberts A, Lopez RN, Frampton CM, Day AS. Meta-analysis of the efficacy of taurolidine in reducing catheter-related bloodstream infections for patients receiving parenteral nutrition. JPEN J Parenter Enteral Nutr. 2022;46(7):1535-1552. doi:10.1002/jpen.2363

Worthington P, Balint J, Bechtold M, et al. When is parenteral nutrition appropriate? JPEN J Parenter Enteral Nutr. 2017;41(3):324-377. doi:10.1177/0148607117695251

Worthington P, Gura KM, Kraft MD, Nishikawa R, Guenter P, Sacks GS. Update on the use of filters for parenteral nutrition: an ASPEN position paper. Nutr Clin Prac. 2021;36(1):29-39. doi:10.1002/ncp.10587

Wouters Y, Causevic E, Klek S, Groenewoud H, Wanten GJA. Use of catheter lock solutions in patients receiving home parenteral nutrition: a systematic review and individual-patient data meta-analysis. JPEN J Parenter Enteral Nutr. 2020;44(7):1198-1209. doi:10.1002/jpen.1761

Wouters Y, Roosenboom B, Causevic E, Kievit W, Groenewoud H, Wanten GJA. Clinical outcomes of home parenteral nutrition patients using taurolidine as catheter lock: a long-term cohort study. Clin Nutr. 2019;38(5):2210-2218. doi:10.1016/j.clnu.2018.09.020

Wouters Y, Vissers RK, Groenewoud H, Kievit W, Wanten GJA. Repair of damaged central venous catheters is safe and doubles catheter survival: a home parenteral nutrition patient cohort study. Clin Nutr. 2019;38(4):1692-1699. doi:10.1016/j.clnu.2018.08.005