Adequacy of three-compartment parenteral nutrition bags to current European guidelines for adults: a simulation study

The use of three-compartment parenteral nutrition bags (3CPNBs) has widely expanded due to their potential time- and cost-saving advantages compared to hospital-compounded parenteral nutrition bags (HCPNBs). However, there is limited evidence of commercial 3CPNBs to adequately meet current nutritional guidelines.

This study assessed the nutritional adequacy of all commercial 3CPNBs available in Spain, according to current European guidelines, across four clinical scenarios for adult patients.

A simulation-based study was performed to evaluate the protein and caloric content of 3CPNBs commercially available in Spain. Four clinical scenarios were defined: early and late phases of intensive care (I1 and I2), surgical (Q), and medical (M) inpatients. Two sub-analyses were conducted: a 3CNPB-centered assessment of each formulation's theoretical adequacy for each scenario, and a patient-centered analysis involving 1000 simulated adult patients per scenario (total: 4000 simulations). Patients' weight was computer generated reflecting the published Spanish adult-population values (tested by the Anderson-Darling test and one-sample t-test). Nutritional requirements were calculated using ESPEN guidelines, and adequacy was defined as meeting protein and caloric targets within ±5% range. 3CPNBs were further screened for guideline-concordant composition.

A total of 50 commercial 3CPNBs were identified, but 15 bags (30.0%) were excluded based on predefined criteria. Then, 35 were included in the study. While 51.4% formulations met adequacy criteria across all scenarios, 34.3% were suitable for only one, and 8.6% were unsuitable for any scenario. More than half (57.1%) failed to cover even 10% of patients in any scenario. ICU scenarios, I1 and I2, showed the lowest coverage, with only around 30% of patients with an appropriate 3CPNBs. Many weight strata showed less than 50% coverage depending on the scenario. In the 64-81,99 kg strata, around the population mean, 45.9% lacked an appropriate 3CPNBs across all scenarios.

Substantial variability existed in the adequacy of commercial 3CPNBs to ESPEN guidelines. Many formulations failed to meet the criteria or were not usable across all scenarios. Many patients with body weight around population mean had no adequate 3CPNBs. These findings supported the need for critical evaluation of 3CPNBs and still place HCPNBs as a flexible alternative, especially in complex and critically ill populations.