No longer a last resort: how the 2025 ESPEN guideline for clinical nutrition in surgery repositions parenteral nutrition (PN)
Nutrition support is a fundamental component of surgical care, particularly for patients who are unable to meet their nutritional needs orally or enterally. The 2025 update to the European Society for Clinical Nutrition and Metabolism (ESPEN) guideline on clinical nutrition in surgery reinforces this position, providing updated, evidence-based recommendations on when and how parenteral nutrition, or PN, should be considered as part of a structured perioperative care pathway.
The guideline presents 44 evidence-based recommendations for clinical practice, developed using the GRADE methodology to assess quality of evidence and strength of recommendations, with formal expert consensus reporting. Throughout this post, references to ESPEN guidance reflect specific recommendations as stated in the guideline, including the grade of recommendation and level of expert consensus where reported.
Rather than positioning PN as a last-resort intervention, the guideline emphasizes timely assessment, early decision-making, and integration of nutrition support—including PN—within modern perioperative frameworks.
PN as part of timely nutrition therapy—not delayed by default
A key focus of the 2025 update is the importance of initiating nutrition therapy without unnecessary delay once an indication is established. Prolonged periods of inadequate intake are discouraged, particularly in patients with preexisting malnutrition or those expected to have limited oral or enteral intake for an extended period.
ESPEN states that PN should be initiated in severely malnourished patients when oral or enteral nutrition is not feasible, insufficient, or contraindicated, with decisions guided by gastrointestinal function and patient-specific nutritional needs rather than surgical timing alone.
Parenteral nutrition should be started as soon as possible if there is a contraindication to oral and enteral nutrition (e.g., intestinal obstruction), especially in severely malnourished patients.
(Grade B; strong consensus 96%.)
This recommendation reinforces PN as a necessary and appropriate modality in defined clinical scenarios, rather than a fallback option used only after prolonged underfeeding.
Early identification of nutritional risk drives PN decision-making
A central theme of the 2025 ESPEN update is the importance of early nutritional risk assessment in surgical patients. The recommendations reiterate that patients who are malnourished or at risk of malnutrition should be identified as early as possible—ideally before surgery, but also promptly in the postoperative period when risk becomes apparent.
Supplemental parenteral nutrition when intake is inadequate
ESPEN supports the use of supplemental parenteral nutrition (SPN) when oral or enteral intake does not provide adequate nutritional coverage, reinforcing PN’s role in preventing cumulative energy and protein deficits.
If energy and substrate requirements cannot be met by oral and/or tube feeding alone (<50% of energy requirements) within three to four days, a combination of oral, enteral, and (supplementing) parenteral nutrition should be given. (Grade B; strong consensus 100%.)
This recommendation further underscores PN’s role as part of a continuum of nutrition support, tailored to patient needs and reassessed as clinical conditions evolve.
Standardized PN formulations in clinical practice
The 2025 ESPEN guideline also addresses the role of standardized parenteral nutrition formulations in appropriate clinical settings. Recommendation #14 states that standardized, multi-chamber PN formulations may be used as an alternative to compounded PN in patients who require parenteral nutrition and whose nutritional needs can be met with fixed formulations. ESPEN notes that this approach may be particularly relevant when rapid initiation of PN is needed or when compounding is not feasible, with the recommendation supported by Grade B evidence and strong expert consensus.
For parenteral nutrition, all-in-one (three-chamber, compounded) bags should be preferred to single components (multiple-bottle systems). (Grade B; strong consensus 100%.)
The recommendation emphasizes that formulation choice should be guided by clinical context and patient needs, and that standardized PN represents one option within a broader, individualized nutrition strategy.
Alignment with Enhanced Recovery After Surgery (ERAS®) guidelines
A notable evolution in the 2025 update is the explicit alignment of nutrition recommendations with the Enhanced Recovery After Surgery, or ERAS, framework. Within this context, medical nutrition—which may include PN—is positioned as part of an integrated approach to preoperative care, supporting metabolic stability when oral or enteral strategies are not sufficient.
By embedding this guidance within ERAS, the guideline underscores that nutrition support decisions should be coordinated with broader perioperative planning, including surgical timing, postoperative recovery goals, and anticipated gastrointestinal function.
Applicability in both elective and nonelective surgery
ESPEN makes clear that PN considerations extend across both elective and nonelective surgical settings. While elective surgery may allow more opportunity for preoperative optimization, patients undergoing urgent or emergency procedures may also require timely nutrition support when oral or enteral intake is not possible.
In these settings, PN is framed as a practical means of addressing nutritional needs when other routes are unavailable, supporting continuity of care despite clinical urgency.
Lipid composition as part of PN planning
Postoperative parenteral nutrition, including omega-3 fatty acids, should be used in patients who cannot receive adequate enteral nutrition and, therefore, require predominantly parenteral or combined enteral/parenteral nutrition. (Grade B; strong consensus 100%.)
The guideline notes that intravenous lipid emulsions containing omega-3 fatty acids may be considered as part of PN regimens, with lipid selection guided by patient condition, clinical goals, and tolerance. The recommendation reflects expert consensus and emphasizes that lipid choice should be individualized within a comprehensive nutrition strategy.
Importantly, ESPEN frames lipid composition within a balanced approach to PN, reinforcing that it represents one element of nutrition therapy rather than a standalone decision.
PN within a structured, patient-centered approach
Throughout the 2025 update, ESPEN consistently emphasizes that PN should be delivered within a structured and monitored framework, with regular reassessment of nutritional goals and tolerance.
PN is not a static intervention. As gastrointestinal function improves and oral or enteral intake becomes feasible, nutrition strategies should be adapted to support appropriate transitions while maintaining nutritional adequacy. This patient-centered approach reflects a broader shift in surgical nutrition care—one that prioritizes individualized decision-making, timely intervention, and alignment with overall treatment pathways.
Setting the stage for practical application
Taken together, the 2025 ESPEN guideline provides a framework for when PN is appropriate, how it should be integrated, and why timing matters in surgical patients. By reinforcing early assessment and timely initiation when indicated, PN is positioned as an essential component of comprehensive perioperative nutrition care—supporting clinicians as they navigate complex nutritional needs across the surgical continuum.
Access the 2025 update to the ESPEN guidelines on clinical nutrition in surgery.
OMEGAVEN (fish oil triglycerides) injectable emulsion, for intravenous use
IMPORTANT SAFETY INFORMATION FOR CONSUMERS
These highlights do not include all the information needed to use OMEGAVEN safely and effectively. To learn more about OMEGAVEN for your child, talk to your child’s healthcare provider. OMEGAVEN is available by prescription only. The FDA-approved product labeling can be found at www.freseniuskabinutrition.com/OmegavenPI.
What is OMEGAVEN?
- A fish oil-based intravenous lipid emulsion that is a source of calories and fatty acids in pediatric patients with parenteral nutrition-associated cholestasis (PNAC).
- Does not prevent PNAC.
- It has not been demonstrated that the clinical outcomes seen in pediatric patients are a result of the omega-6:omega-3 fatty acid ratio of the product.
- The hourly infusion rate should not exceed 1.5 mL/kg/hour
OMEGAVEN should not be received by patients who have:
- a known allergy to fish or egg protein or to any of the ingredients in OMEGAVEN.
- a severe bleeding disorder.
- abnormally high levels of lipid (triglycerides) in the blood.
What important safety information should I know about OMEGAVEN?
- Serious Adverse Reactions with Rapid Infusion of Intravenous Lipid Emulsion in Neonates and Infants: Strictly follow the recommended total daily dosage and do not exceed the maximum infusion rate. If poor clearance of fats occurs, the infusion should be stopped, and a medical evaluation started.
- Allergic Reactions: Contact your healthcare provider immediately if you are experiencing an allergic reaction.
- Fat Overload Syndrome, Refeeding Syndrome, Elevated Triglycerides (Hypertriglyceridemia): Your healthcare provider will monitor you for signs and symptoms of early infection and blood levels.
The most common side effects, (>15%) include: vomiting, agitation, slower than normal heartbeat, interruption of breathing, and viral infection.
These are not all the possible side effects associated with OMEGAVEN. Call your healthcare provider for medical advice regarding OMEGAVEN side effects. You are encouraged to report negative side effects of OMEGAVEN. Contact Fresenius Kabi USA, LLC at: 1-800- 551-7176 or FDA at: 1-800-FDA-1088 or www.fda.gov/medwatch. The FDA-approved product labeling can be found at www.FreseniusKabiNutrition.com/OmegavenPI.
KABIVEN (Amino Acids, Electrolytes, Dextrose, and Lipid Injectable Emulsion), for intravenous use
PERIKABIVEN (Amino Acids, Electrolytes, Dextrose, and Lipid Injectable Emulsion), for intravenous use
IMPORTANT SAFETY INFORMATION FOR CONSUMERS
What is Kabiven and Perikabiven?
- Indicated in adult patients as a source of calories, protein, electrolytes and essential fatty acids for parenteral nutrition when oral or enteral nutrition is not possible, insufficient, or contraindicated. Kabiven and Perikabiven may be used to prevent essential fatty acid deficiency or treat negative nitrogen balance in adults.
- Do not exceed the recommended maximum infusion rate of 2.6 mL/kg/hour for Kabiven and 3.7 mL/kg/hour for Perikabiven.
Limitations of Use
Neither Kabiven nor Perikabiven is recommended in pediatric patients less than 2 years old because the fixed amount of the formulations do not meet nutritional needs in this age group.
Do not use Kabiven or Perikabiven in patients who have:
- Simultaneous treatment with ceftriaxone in neonates (28 days of age or younger)
- Known allergy to egg, soybean, peanut or any of the active or inactive ingredients
- Abnormally high levels of lipid (triglycerides) in the blood (with serum triglyceride concentration >1,000 mg/dL)
- Inborn errors of amino acid metabolism (a genetic defect in protein metabolism)
- Cardiopulmonary instability (inability for the heart and lungs to function right)
- Hemophagocytic syndrome (a disorder of the immune system)
Kabiven and Perikabiven may cause serious side effects including:
- Serious Adverse Reactions with Rapid Infusion of Intravenous Lipid Emulsion in Neonates and Infants: Strictly follow the recommended total daily dosage and do not exceed the maximum infusion rate. If poor clearance of fats occurs, the infusion should be stopped, and a medical evaluation started.
- Risk of Parenteral Nutrition-Associated Liver Disease: Increased risk in patients who receive parenteral nutrition for greater than 2 weeks. Your healthcare provider will monitor liver tests.
- Pulmonary Embolism (a blockage in a blood vessel in the lung) and Respiratory Distress (increased breathing rate, bluish skin color changes, wheezing) due to Pulmonary Vascular Precipitates (solid substance in the blood vessel of the lungs): If signs of lung issues occur, stop the infusion and start a medical evaluation.
- Allergic Reactions: Contact your healthcare provider immediately if you are experiencing an allergic reaction
- Precipitation (solid substance in the blood vessel) with Ceftriaxone: Do not administer ceftriaxone simultaneously with Kabiven or Perikabiven via a Y-site.
- Infection, fat overload, hyperglycemia (high blood sugar) and refeeding syndrome: Your healthcare provider will monitor you for signs and symptoms of early infection and blood levels
The most common adverse reactions for Kabiven (≥3%) are nausea, fever, high blood pressure, vomiting, decreased blood hemoglobin, decreased blood total protein, low blood potassium, and increased gamma glutamyltransferase (a liver enzyme). The most common adverse reactions for Perikabiven (≥3%) are high blood sugar, low blood potassium, fever and increased blood lipids.
To report SUSPECTED ADVERSE REACTIONS, contact Fresenius Kabi USA, LLC at 1-800-551-7176, option 5, or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
Tell your doctor if you are taking coumarin and coumarin derivatives, including warfarin: the drug activity may be lessened and your healthcare provider will monitor your blood.
These are not all the possible side effects associated with Kabiven and Perikabiven. Call your healthcare provider for medical advice regarding Kabiven and Perikabiven side effects. You are encouraged to report negative side effects of Kabiven and Perikabiven. Contact Fresenius Kabi USA, LLC at: 1-800-551-7176 or FDA at: 1-800-FDA-1088 or www.fda.gov/medwatch. The FDA-approved product labeling can be found at www.FreseniusKabiNutrition.com/KabivenPI and www.FreseniusKabiNutrition.com/PerikabivenPI.
SMOFlipid® (lipid injectable emulsion, USP), for intravenous use
IMPORTANT SAFETY INFORMATION FOR CONSUMERS
What is SMOFlipid?
- Indicated in adult and pediatric patients as a source of calories and essential fatty acids for parenteral nutrition (PN) when oral or enteral nutrition is not possible, insufficient, or contraindicated.
- The hourly infusion rate in pediatrics should not exceed 0.75 mL/kg/hour and 0.5 mL/kg/hour in adults.
SMOFlipid should not be received by patients who have:
- A known allergy to fish, egg, soybean, or peanut, or to any of the active or inactive ingredients in SMOFlipid.
- Abnormally high levels of lipid (triglycerides) in the blood.
SMOFlipid may cause serious side effects including:
- Serious Adverse Reactions with Rapid Infusion of Intravenous Lipid Emulsion in Neonates and Infants: Strictly follow the recommended total daily dosage and do not exceed the maximum infusion rate. If poor clearance of fats occurs, the infusion should be stopped, and a medical evaluation started.
- Risk of Parenteral Nutrition-Associated Liver Disease: Parenteral nutrition-associated liver disease (PNALD) may progress to liver inflammation and damage caused by a buildup of fat in the liver with scarring and cirrhosis.
- Allergic Reactions: Contact your healthcare provider immediately if you are experiencing an allergic reaction.
- Fat Overload Syndrome, Refeeding Syndrome, Elevated Triglycerides (Hypertriglyceridemia): Your healthcare provider will monitor you for signs and symptoms of early infection and blood levels.
Monitoring/Laboratory Tests: The content of vitamin K may interfere with blood clotting activity of medications.
The most common side effects (>1%) in adult patients include nausea, vomiting, and high levels of glucose in the blood and in pediatric patients include low levels of red blood cells, vomiting, increased levels of liver enzymes (i.e., gamma-glutamyltransferase) and hospital-acquired infections.
These are not all the possible side effects associated with SMOFlipid. Call your healthcare provider for medical advice regarding SMOFlipid side effects. You are encouraged to report negative side effects of SMOFlipid. Contact Fresenius Kabi USA, LLC at: 1-800-551-7176 or FDA at: 1-800-FDA-1088 or www.fda.gov/medwatch. The FDA-approved product labeling can be found at https://freseniuskabinutrition.com/SMOFlipidPI.