 The most important complication of nutritional support is

the failure to achieve the desired goals because of

inadequate monitoring.
 The general goals are to support:
o lean body mass
o support the structure and function of the organs
o prevent nutrient deficiencies
o do no harm
 It is more common to have complications with the early
stages of TPN initiation.
 The patient population are usually challenged with
multiple system dysfunction.
Complications of TPN can be divided into three groups.
 Metabolic
 Catheter related problems
 Sepsis
 Glucose metabolism
 Hyperglycemia is common from rapid infusion of high
concentrations of glucose.
o This can be intensified by a patient with Diabetes, steroid
therapy and infection.
o Stress can also affect the release of glucocorticoids.
o Monitor Blood sugars and urine to determine the treatment plan
using regular insulin added to the TPN or given sub Q.
o Many patients may check their glucose levels frequently at the
start of therapy then with labs as ordered.
 Hypoglycemia will occur with stopping the TPN abruptly.
o Administering a 10% Dextrose solution can prevent the
symptoms of this.
o Most Home care patients have a taper during the beginning and
end of the TPN administration to help prevent this.
 Hepatic dysfunction
 Fatty Liver is caused from utilizing carbohydrates in
excess for a major source of calories.
o Cholecystitis is due to the complete disuse of the GI tract
causing bile stasis in the gall bladder.
o Liver function tests should be monitored once weekly.
o Cycling the TPN from 24 hrs to 12 hrs gives the liver time to rest
as well as utilizing lipids as a calorie source.
o Lowering the glucose concentration can prevent or promote
resolution.
 Other hepatobiliary dysfunctions include cholestasis,
cholelithiasis, steatosis and steatohepatitis.
 Formation of biliary sludge can begin at 3 weeks and
increases by week 13 of TPN infusion.
Refeeding syndrome
 Occurs when an attempt to compensate for caloric intake
begins and the patient is malnourished.
o The fat and protein stores are used for energy in the absence of
carbohydrates.
 When TPN is introduced and the body begins to use the
carbohydrate metabolism there is an increase in insulin
production. This causes the uptake of electrolytes
particularly Phosphate.
 The low phosphate levels cause the refeeding syndrome
with symptoms of rhabomyolsis, respiratory failure,
arrhythmias, cardiac failure, seizures and coma.
 Liver functions should be checked for bilirubin, ALT,
AST, ALP.
Metabolic bone disease
 abnormal bone metabolism characterized by decreased bone
density and increased fracture risk.
 It’s contributing factors are excessive infusion of aluminum,
calcium, protein or glucose and the patients nutritional state.
 It is detected by increased levels of calcium in the blood,
excessive losses of calcium and phosphorus in the urine, low
blood levels of vitamin D.
 It can cause bone pain, osteopenia and bone fractures.
 This occurs more frequently in long term TPN use.
 Close monitoring of labs are necessary and discontinuation of
TPN therapy may be the solution to reverse the disease
process.
Catheter occlusion can be caused by poor flushing
technique and non-compliance, fibrin sheath formation,
venous thrombosis and precipitate formation from
medications or lipid residue. Treatment may include:
 Re-education to the care giver to proper flushing
technique and line care
 Use of TPA (tissue plasminogen activator) for thrombus
formation.
 70% ethanol locks
 Line replacement
Sepsis is the most serious and challenging complication.
Many components of the TPN formula predispose the
patient to infection.
 Lipids: the fats support the growth of broad range of
pathogens.
 Hyperosmolar formula :cause inflammation and
thrombosis within the vein forming a biofilm at end of
the central line.
 High dextrose concentration provides a good
environment for bacteria to grow.
 Central Line Associated bloodstream Infection (CLABSI)
are related to TPN therapy as well as the type of patients
being treated.
o They are usually malnourished, immuno-compromised and
require IV therapy for an extended period of time.
 The organisms that are most common are
staphylococcus epidermitis, staph aureus and candida.
 Temperature, chills, increased pulse, or elevated WBC’s
should be monitored for any changes.
  Fluid and Electrolyte Imbalance
Cause Treatment Prevention Monitoring
Overhydration: Excess fluid Reduce fluid Initiate PN only after fluid balance is I/O, daily weights,
administration, particularly for renal administration, stable, careful intake and output BUN levels, Na levels
insufficiency or immediately after trauma provide diuretics monitoring with calculation of fluid and hematocrit
needs and intake from other sources
Dehydration: Inadequate fluid Increase fluid Same as overhydration Same as
administration, overdiuresis, excessive administration overhydration
unreplaced fluid loss
Hyperkalemia: Renal insufficiency or Reduce K or K Careful lab monitoring and calculation of Serum K Levels
excessive potassium (K) administration binders provided K levels
Hypokalemia: Inadequate amounts Adjust amount of Same as hyperkalemia Same as
provided; increased loss from diarrhea, supplement hyperkalemia
fistulas, and burns; increased needs provided
related to anabolism
Hypernatremia: Excessive water loss Reduce Na in Avoid excessive intake and careful fluid Serum and urinary
infusion and fluid replacement NA levels, I/O
replacement
Hyponatremia: Depletion of fluid through Adjust fluid and Provide Na replacement unless Same as
sweating or GI losses, excessive diuretic Na intake and containdicated by cardiac, renal or fluid hypernatremia
therapy, dilutional states, including CHF condition status
and syndrome of inappropriate antidiuretic indicates
hormone (SIADH)
  Glucose Metabolism
Cause Treatment Prevention Monitoring
Hyperglycemia: Rapid infusion of Provide insulin Slow initial administration of dextrose, Frequent blood and
concentrated dextrose solution; high-risk and/or part of reduce dextrose provided, provide urine determinations
conditions include diabetes, sepsis, and nonprotein insulin as needed
steroid medication calories as lipid
Hypoglycemia: Rapid discontinuation Administer Taper PN solution; if abrupt DC occurs, Frequent blood or
(DC) of PN dextrose hang 10% dextrose to prevent rebound urine determinations
hypoglycemia especially during DC
  Mineral Imbalance
Cause
Hyperphosphatemia: Seen
in long-term PN with
phosphorus-containing
solutions; also seen in
decreased renal excretion
Hypophosphatemia: Often
seen in malnutrition;
predisposing factors include
alcohol abuse, diabetes,
mellitus, antacid ingestion,
and increased phosphorus
requirements of anabolism
Hypermagnesemia:
Excess magnesium (Mg)
administration; inability to
excrete Mg because of renal
insufficiency
S/S Treatment Preventio Monitoring
n
Parethesia of extremities, DC phosphorus (P) Reduce P as Serum levels 1-2x
flaccid paralysis, listlessness, provide serum calcium indicated by weekly
menal confusion, weakness, (Ca) repletion serum levels
hypertension, cardiac
arrhythmias, prolonged
elevated phosphorus levels,
which may result in tissue
calcification
May include respiratory Administer intravenous Use P in PN, Serum level 1-2x
distress phosphate (PO4) or add 13.6 mmol/day; weekly; more
PO4 to solution has been shown frequently with
to prevent PO4 replacement.
depletion in
most patients
Sharp drop in blood pressure Remove or decrease Restrict as Plasma levels 1-
and respiratory paralysis; Mg in PN; severe cases appropriate 2x weekly; or
cardiac toxicity progressing may require mechanical more frequently as
rom increased conduction vantilation, dialysis, indicated.
time, hypotension, and correction of fluid deficit,
premature ventricular and administration of
  Mineral Imbalance, Cont.
Cause S/S Treatment Preventio Monitoring
n
Hypomagnesemia: Risk Nonspecific symptoms; GI and Administer periphral Progive Mg in Serum levels 1-2x
factors include diuretic use, neuromuscular hyperactivity, magnesium; add Mg to PN solution weekly during
diabetic ketoacidosis, GI convulsions, and cardiac solution initiation of PN
disease, aminoglycoside arrhythmia and weekly
use, alcoholism, and thereafter; more
chemotherapy frequent
monitoring may be
necessary during
hypomagnesium,
repletion, and
chemotherapy
Hypercalcemia: Neoplasia, Thirst, polyuria, muscle Administer isotonic Restrict as Plasma Ca levels
excess vitamin D weakness, loss of appetite; saline, provide inorganic appropriate 1-2x weekly
administraion, prolonged nausea, vomiting, constipation, PO4 supplement,
immobilization, and stress itching mithramycin,
corticosteroids
Hypocalcemia: Decreased Paresthesia; tetany Provide additional Administer Plasma Ca leels
vitamin D intake; amounts of Ca approximately 1-2x weekly; if
hypoparathyroidism; 15 mEq daily to serum albumin
reduced Ca intake, achieve Ca level is depressed,
increased GI losses, balance obtain ionized Ca
  Nutritional
Cause S/S Treatmen Prevention Monitoring
t
Carbohydrate Overfeeding: CO2 retention, cardiac Decrease Carefully calculate nutrient Respiratory
Rapid increase of feedings above tamponade infusion to requirements; ensure quotients may
requirements, particularly in acceptable appropriate distribution of help determine
patients with compromised level enegry substrate proper energy
pulmonary or cardiac function substrate mix
Protein Overfeeding: continued Elevated BUN levels; Reduce amino Carefully calculate protein Serum BUN levels
infusion of protein in excess of excess nitrogen acid content requirement; provide 1-2x weekly;
requirements excretion adequate calories from nitrogen balance
carbohydrate and/or fat weekly
Essential Fatty Acid Dermatitis; alopecia; Provide lipid Provide 2%-4% of caloric Physical
Deficiency: Inadequate fat changes in pulmonary, emulsion at needs as linoleic acid, or examination for
intake; biochemical signs appear neurological, and red cell least 2x weekly 8%-10% of calories from symptoms
1-2 weeks on fat-free regimen membranes fat; fat intake achieved by
500mL of 10% fat
emulsion 2-3x weekly
Thiamine Deficiency: Elevated blood and urine Adequate Provide thiamine daily in Blood and urine
Concentrated glucose infusion lactate and pyruvate thiamine intake PN lactate and
without adequate thiamine levels, abnormal ECG, per pyruvate levels 2x
cardiomegaly, and intravenous weekly in patients
dyspnea RDA at risk
  Hepatic
Cause S/S Treatment Prevention Monitoring
Fatty Liver: Presumed to be Moderate Reduce amount of Balanced nutreint Liver function tests
infusion of carbohydrate in elevation shown in carbohydrate solutions containing at least 1x weekly
excess of hepatic oxidative liver function tests administration; energy from carbohydrate
capacity; overfeeding of calories cycling of PN has and fat; avoid overfeeding
and/or fat been tried, but results
are inconclusive; rule
out (R/O) other
causes
Cholestasis: Unknown Progressive Prevent overfeeding; Use GI tract if possible Liver function tests
increases in total known to resolve at at least 1x weekly
serum bilirubin DC of PN and return
level; elevated to normal diet; R/O
serum alkaline other cause
phosphatase level
  Refeeding Syndrome
Cause S/S Treatment Prevention Monitoring
Initation of PN, Acute fluxes; fluid-dependent Adjust electrolytes, Careful initiation and slow Serum electrolyte
expecially in severly edema, CHF, pulmonary minerals, and advancement of PN. monitoring daily
malnourished edema. Electrolytes- vitamins as needed. Careful monitoring during and more
patients decreased serum K, P, Mg, as Administer diuretics the first 24-48 hr of PN frequently as
result of intracellular shift; as needed therapy indicated during
water-soluble vitamin PN initiation
deficiency, glucose intolerance
as lethargy, weakness, and
confusion
Cause S/S Treatment Prevention Monitoring
Pneumothorax: Small pneumothorax Experience with catheter Chest x-ray is
Venous anomalies; may resolve placement is necessary; performed and line
inexperience with untreated. Larger some institutions ensure placement is
catheter placement pneumothorax may this by restricting confirmed before
technique require chest tube privileges for central line line is used.
placement insertion
Air Embolism: Dyspnea, cyanosis, chest pain, High death rate if Propper dressing and Observe for signs
Central line tachycardia, elevated central immediate action not catheter care techniques; and symptoms
interrupted and venous pressure, taken. Place patient proper training of patient
patient inspires air disorientation, shock, coma, in reverse and caregivers
while line is open cardiac arrest Trendlenburg’s
position left side
immediately
Catheter Catheter snare Remove needle and Ensure catheter is
Embolization: technique or surgical catheter at same time intact when
Pulling catheter back removal of catheter removed; if not,
through needle used tip obtain chest x-ray
for insertion
Cause S/S Treatment Prevention Monitoring
Venus Thrombosis: Urokinase, Proper selection of Observe
Mechanical trauma streptokinase, catheter material; addition corresponding arm
to vein; hypotension; catheter change of heparin to PN for swelling
infection; solution
osmolality or
precipitates
Catheter Inability to aspirate blood. Urokinase, Proper catheter care Observe for
Occlusion: Failure Resistance to flushing; streptokinase, inability to infuse
to flush catheter with sluggish infusion. Tissue catheter change
heparin; fibrin plasminogen activator (TPA)
sheath formation;
precipitate formation
 Cause S/S Treatment Prevention Monitoring
Catheter-Related Sepsis: Unexplained fever; Removal of Strick adherence to Monitor for signs
Improper technique in catheter chills; red, indurated catheter and aseptic technique during and symptoms;
insertion; infusion of area or purulent replacement at line insertion, line assess for glucose
contaminated solution; multiple- discharge around another site and manipulation, and catheter intolerance as
line violation and manipulation; catheter site; positive concurrent care possible early
skin colonization adjacent to catheter tip culture antibiotic therapy warning sign of
catheter site; hematogenous and positive blood impending sepsis
seeding of catheter by culture to confirm
bloodborne organisms from other infection
distant infections

Table 17-5, Complications of Parenteral Nutrition, Infusion Nursing