Central Venous

Catheters and
Complications of
Parenteral Nutrition

Objectives

To identify the appropriate methods of central venous

access for parenteral nutrition

To describe catheter-related, metabolic, and GI

complications of parenteral nutrition

To explain how to prevent catheter-related, metabolic

and GI complications of parenteral nutrition

Different type of Central Venous

Catheter
Hickman Catheters

Catheters for Central Venous

Access

Choosing CVC, the insertion site, placement

technique based on condition of patient and duration
of PN.
Temporary (< 4 weeks) or permanent (> 4 weeks)
Various lengths, gauges, and number of ports (single
lumen more preferable than 2 or 3 lumens, to avoid
increase risk of infection)
Catheters treated with antibacterials
Infusion via a dedicated catheter lumen

Temporary Subclavian Catheter

(duration of PN < 4 weeks)

McCarthy MC, et al. JPEN 1987;11:259-262

Peripheral Central Venous

Catheter

PICC = Peripherally-Inserted-Centralcatheter

Garanowski L. J Intraven Nurs 1993;16:167-194

Central Venous Access

Subclavian
Vein
Vena subclavia

YugularJugular
interna
Internal

Cephalic
Vena ceflica
Vein

External
Yugular externa
Jugular

Central
CatterVenous
venoso
Catheter
central
Vena
Superior
cava
superior
Vena
Cava

Axillary
Vein
Vena
axilar

Brachial
Vein
Vena
braquial

Basilic
Vein
Vena
baslica
In: Krey SH, Murray RL, eds. Dynamics of Nutritional Support. Norwalk, CT: Appleton-Century-Crofts;
p. 382.

Central Venous Access

First choice : subclavian vein

Second choice : internal vein Jugular and external
jugular vein.
Third choice : cephalic and basilic vein
Last choice : femoral vein

Permanent Central Venous

Access

Tunneled subclavian catheter or Implantable infusion

port, requires surgical procedure. Exit point located far
from airway. Recommended when PN > 4 weeks

Subclavian Catheter Dressing

Dressing should be changed using strict, aseptic

technique every 48-72 hours

Conclusion in choosing CVC

Single lumen more preferable.

First choice via subclavian vein.
Dressing : 48-72 hours
Very rarely permanent CVC

Parenteral Nutrition:
Complications

Catheter-related
Metabolic
Gastrointestinal

Ryan JA. Complications of total parenteral nutrition. In: Fischer JE, ed. Total Parenteral
Nutrition. Little, Brown and Company; 1976

Parenteral Nutrition:
Complications
Catheter-related
Insertion
pneumothorax
chylothorax
hemothorax
air embolus
arterial puncture
nerve injury
Dempsey DT. Complications of total parenteral nutrition. In: Torosian MR, ed.
Nutrition for the Hospitalized Patient. New York: Marcel Dekker, 1995

Parenteral Nutrition:
Complications
Catheter-related
Mechanical complications
poor catheter placement (malpositioned catheter,
5,5-55%)
phlebitis
thrombosis
catheter occlusion
rupture
embolus
Ryan JA. Complications of total parenteral nutrition. In: Fischer JE, ed. Total Parenteral
Nutrition. Little, Brown and Company; 1976. ASPEN Board of Directors. JPEN 2002;26 Suppl
1:37SA

Parenteral Nutrition:
Complications
Catheter-related
Infection
catheter insertion site
subcutaneous tunnel
colonization
bacteremia
sepsis

Kemp L, et al. JPEN 1994;18:71-74

Reed CR. Intensive Care Med 1995;21:177-183

Hospital-dependent Risk factors

Physician experienced
Duration catheterization
Number of lumens
Insertion sites
Use of maximum barrier protection
surgical hand scrubbing
sterile clotting-long sleeved gown, cap, mask)
sterile gloves
wide sterile field

Kemp L, et al. JPEN 1994;18:71-74

Reed CR. Intensive Care Med 1995;21:177-183

Parenteral Nutrition:
Complications
Metabolic
Hyperglycemia (max rate dextrose infusion no greater than 4-5
mg/kg/minute), hypercapnia
Hypoglycemia
Complication from lipid used (hypertriglyceridemia,
immunosuppression, lipid overload syndrome)
Electrolyte imbalance
Prerenal azotemia
Abnormal acid-base balance
Refeeding syndrome measure P, Mg, K, and glucose
Dempsey DT. Complications of total parenteral nutrition. In: Torosian MR, ed. Nutrition for the
Hospitalized Patient. NY: Marcel Dekker, Inc.; 1995; Solomon SM. JPEN 1990;14:90-97

Parenteral Nutrition:
Complications
Gastrointestinal
Liver function disorder, GI atrophy, gastritis and ulcer.
GI atrophy associated with absence of: luminal
nutrient,mechanical stimulation of the gut, insufficient
supplies of primary enterocyte fuel source.
GI atrophy begins to develop within 48 h of enteral fasting
and maybe permissive for the bacterial translocation.
Complication can be decreased by providing small
amounts of food enterally when possible and transitioning
to tube or oral feeding as soon as possible.

Parenteral Nutrition:
Complications
Overfeeding
Administering more than 35 kcal/kg results in:
hepatic steatosis
hyperglycemia
prerenal azotemia
hypertriglyceridemia
increased CO2 production
respiratory distress syndrome
Dempsey DT. In: Torosian MH, ed. Nutrition for the Hospitalized Patient. New York: Marcel
Dekker Inc.; 1995

Summary: Appropriate Therapy

Parenteral nutrition is indicated when:

Enteral nutrition is contraindicated

Enteral nutrition cannot be established or maintained
Oral or enteral nutrition does not satisfy all nutritional
requirements

Aspen Board of Directors: JPEN 2002;26 Suppl 1:18SA-19SA

Summary: Access Devices for

Parenteral Nutrition
Parenteral nutrition catheters are selected based on:

Expected duration of therapy

Number of lumens needed
Quality of peripheral vein access

Garanowski L. J Intraven Nurs 1993;16:167-194

Summary: Monitoring
Parenteral nutrition must be carefully monitored to:

Maintain electrolyte and acid-base balance

Ensure that nutritional goals are met
Avoid mechanical, metabolic, and GI complications

Ryan JA. Complications of Total Parenteral Nutrition. In: Fischer JE, ed. Total Parenteral
Nutrition. Little, Brown and Company; 1976