3. Complications of parenteral nutrition

TPN101

1. Complications Of Parenteral Nutrition 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: lean body mass support the structure and function of the organs prevent nutrient deficiencies 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.

2. Complications Of Parenteral Nutrition Cont. Complications of TPN can be divided into three groups . Metabolic Catheter related problems Sepsis

3. Metabolic Complications Glucose metabolism Hyperglycemia is common from rapid infusion of high concentrations of glucose. This can be intensified by a patient with Diabetes, steroid therapy and infection. Stress can also affect the release of glucocorticoids. Monitor Blood sugars and urine to determine the treatment plan using regular insulin added to the TPN or given sub Q. 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. Administering a 10% Dextrose solution can prevent the symptoms of this. Most Home care patients have a taper during the beginning and end of the TPN administration to help prevent this.

4. Metabolic Complications Cont Hepatic dysfunction Fatty Liver is caused from utilizing carbohydrates in excess for a major source of calories. Cholecystitis is due to the complete disuse of the GI tract causing bile stasis in the gall bladder. Liver function tests should be monitored once weekly. Cycling the TPN from 24 hrs to 12 hrs gives the liver time to rest as well as utilizing lipids as a calorie source. 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.

5. Refeeding syndrome O ccurs when an attempt to compensate for caloric intake begins and the patient is malnourished. 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 Complications, Cont.

6. 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. Metabolic Complications, Cont.

7. Catheter Related Complications C atheter 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

8. Catheter Related Complications, Cont. 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. H igh dextrose concentration provides a good environment for bacteria to grow.

9. Central Line Associated bloodstream Infection ( CLABSI ) are related to TPN therapy as well as the type of patients being treated. 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. Catheter Related Complications, Cont.

10. Fluid and Electrolyte Imbalance Complications of Parenteral Nutrition: Metabolic Cause Treatment Prevention Monitoring Overhydration : Excess fluid administration, particularly for renal insufficiency or immediately after trauma Reduce fluid administration, provide diuretics Initiate PN only after fluid balance is stable, careful intake and output monitoring with calculation of fluid needs and intake from other sources I/O, daily weights, BUN levels, Na levels and hematocrit Dehydration : Inadequate fluid administration, overdiuresis , excessive unreplaced fluid loss Increase fluid administration Same as overhydration Same as overhydration Hyperkalemia : Renal insufficiency or excessive potassium (K) administration Reduce K or K binders provided Careful lab monitoring and calculation of K levels Serum K Levels Hypokalemia : Inadequate amounts provided; increased loss from diarrhea, fistulas, and burns; increased needs related to anabolism Adjust amount of supplement provided Same as hyperkalemia Same as hyperkalemia Hypernatremia : Excessive water loss Reduce Na in infusion and fluid replacement Avoid excessive intake and careful fluid replacement Serum and urinary NA levels, I/O Hyponatremia : Depletion of fluid through sweating or GI losses, excessive diuretic therapy, dilutional states, including CHF and syndrome of inappropriate antidiuretic hormone (SIADH) Adjust fluid and Na intake and condition indicates Provide Na replacement unless containdicated by cardiac, renal or fluid status Same as hypernatremia

11. Glucose Metabolism Complications of Parenteral Nutrition: Metabolic, Cont. Cause Treatment Prevention Monitoring Hyperglycemia : Rapid infusion of concentrated dextrose solution; high-risk conditions include diabetes, sepsis, and steroid medication Provide insulin and/or part of nonprotein calories as lipid Slow initial administration of dextrose, reduce dextrose provided, provide insulin as needed Frequent blood and urine determinations Hypoglycemia : Rapid discontinuation (DC) of PN Administer dextrose Taper PN solution; if abrupt DC occurs, hang 10% dextrose to prevent rebound hypoglycemia Frequent blood or urine determinations especially during DC

12. Mineral Imbalance Complications of Parenteral Nutrition: Metabolic, Cont. Cause S/S Treatment Prevention Monitoring Hyperphosphatemia : Seen in long-term PN with phosphorus-containing solutions; also seen in decreased renal excretion Parethesia of extremities, flaccid paralysis, listlessness, menal confusion, weakness, hypertension, cardiac arrhythmias, prolonged elevated phosphorus levels, which may result in tissue calcification DC phosphorus (P) provide serum calcium ( Ca ) repletion Reduce P as indicated by serum levels Serum levels 1-2x weekly Hypophosphatemia : Often seen in malnutrition; predisposing factors include alcohol abuse, diabetes, mellitus, antacid ingestion, and increased phosphorus requirements of anabolism May include respiratory distress Administer intravenous phosphate (PO 4 ) or add PO 4 to solution Use P in PN, 13.6 mmol /day; has been shown to prevent PO 4 depletion in most patients Serum level 1-2x weekly; more frequently with replacement. Hypermagnesemia : Excess magnesium (Mg) administration; inability to excrete Mg because of renal insufficiency Sharp drop in blood pressure and respiratory paralysis; cardiac toxicity progressing rom increased conduction time, hypotension, and premature ventricular contractions to cardiac arrest Remove or decrease Mg in PN; severe cases may require mechanical vantilation , dialysis, correction of fluid deficit, and administration of calcium gluconate Restrict as appropriate Plasma levels 1-2x weekly; or more frequently as indicated.

13. Mineral Imbalance, Cont. Complications of Parenteral Nutrition: Metabolic, Cont. Cause S/S Treatment Prevention Monitoring Hypomagnesemi a : Risk factors include diuretic use, diabetic ketoacidosis, GI disease, aminoglycoside use, alcoholism, and chemotherapy Nonspecific symptoms; GI and neuromuscular hyperactivity, convulsions, and cardiac arrhythmia Administer periphral magnesium; add Mg to solution Progive Mg in PN solution Serum levels 1-2x weekly during initiation of PN and weekly thereafter; more frequent monitoring may be necessary during hypomagnesium , repletion, and chemotherapy Hypercalcemia : Neoplasia , excess vitamin D administraion , prolonged immobilization, and stress Thirst, polyuria, muscle weakness, loss of appetite; nausea, vomiting, constipation, itching Administer isotonic saline, provide inorganic PO 4 supplement, mithramycin , corticosteroids Restrict as appropriate Plasma Ca levels 1-2x weekly Hypocalcemia : Decreased vitamin D intake; hypoparathyroidism ; reduced Ca intake, increased GI losses, decreased PO 4 intake Paresthesia; tetany Provide additional amounts of Ca Administer approximately 15 mEq daily to achieve Ca balance Plasma Ca leels 1-2x weekly; if serum albumin level is depressed, obtain ionized Ca level

14. Nutritional Complications of Parenteral Nutrition: Metabolic, Cont. Cause S/S Treatment Prevention Monitoring Carbohydrate Overfeeding : Rapid increase of feedings above requirements, particularly in patients with compromised pulmonary or cardiac function CO2 retention, cardiac tamponade Decrease infusion to acceptable level Carefully calculate nutrient requirements; ensure appropriate distribution of enegry substrate Respiratory quotients may help determine proper energy substrate mix Protein Overfeeding : continued infusion of protein in excess of requirements Elevated BUN levels; excess nitrogen excretion Reduce amino acid content Carefully calculate protein requirement; provide adequate calories from carbohydrate and/or fat Serum BUN levels 1-2x weekly; nitrogen balance weekly Essential Fatty Acid Deficiency : Inadequate fat intake; biochemical signs appear 1-2 weeks on fat-free regimen Dermatitis; alopecia; changes in pulmonary, neurological, and red cell membranes Provide lipid emulsion at least 2x weekly Provide 2%-4% of caloric needs as linoleic acid, or 8%-10% of calories from fat; fat intake achieved by 500mL of 10% fat emulsion 2-3x weekly Physical examination for symptoms Thiamine Deficiency : Concentrated glucose infusion without adequate thiamine Elevated blood and urine lactate and pyruvate levels, abnormal ECG, cardiomegaly, and dyspnea Adequate thiamine intake per intravenous RDA Provide thiamine daily in PN Blood and urine lactate and pyruvate levels 2x weekly in patients at risk

15. Hepatic Complications of Parenteral Nutrition: Metabolic, Cont. Cause S/S Treatment Prevention Monitoring Fatty Liver : Presumed to be infusion of carbohydrate in excess of hepatic oxidative capacity; overfeeding of calories and/or fat Moderate elevation shown in liver function tests Reduce amount of carbohydrate administration; cycling of PN has been tried, but results are inconclusive; rule out (R/O) other causes Balanced nutreint solutions containing energy from carbohydrate and fat; avoid overfeeding Liver function tests at least 1x weekly Cholestasis : Unknown Progressive increases in total serum bilirubin level; elevated serum alkaline phosphatase level Prevent overfeeding; known to resolve at DC of PN and return to normal diet; R/O other cause Use GI tract if possible Liver function tests at least 1x weekly

16. Refeeding Syndrome Complications of Parenteral Nutrition: Metabolic, Cont. Cause S/S Treatment Prevention Monitoring Initation of PN, expecially in severly malnourished patients Acute fluxes; fluid-dependent edema, CHF, pulmonary edema. Electrolytes- decreased serum K, P, Mg, as result of intracellular shift; water-soluble vitamin deficiency, glucose intolerance as lethargy, weakness, and confusion Adjust electrolytes, minerals, and vitamins as needed. Administer diuretics as needed Careful initiation and slow advancement of PN. Careful monitoring during the first 24-48 hr of PN therapy Serum electrolyte monitoring daily and more frequently as indicated during PN initiation

17. Complications of Parenteral Nutrition: Technical Cause S/S Treatment Prevention Monitoring Pneumothorax : Venous anomalies; inexperience with catheter placement technique Small pneumothorax may resolve untreated. Larger pneumothorax may require chest tube placement Experience with catheter placement is necessary; some institutions ensure this by restricting privileges for central line insertion Chest x-ray is performed and line placement is confirmed before line is used. Air Embolism : Central line interrupted and patient inspires air while line is open Dyspnea, cyanosis, chest pain, tachycardia, elevated central venous pressure, disorientation, shock, coma, cardiac arrest High death rate if immediate action not taken. Place patient in reverse Trendlenburg’s position left side immediately Propper dressing and catheter care techniques; proper training of patient and caregivers Observe for signs and symptoms Catheter Embolization : Pulling catheter back through needle used for insertion Catheter snare technique or surgical removal of catheter tip Remove needle and catheter at same time Ensure catheter is intact when removed; if not, obtain chest x-ray

18. Complications of Parenteral Nutrition: Technical, Cont. Cause S/S Treatment Prevention Monitoring Venus Thrombosis : Mechanical trauma to vein; hypotension; infection; solution osmolality or precipitates Urokinase , streptokinase, catheter change Proper selection of catheter material; addition of heparin to PN Observe corresponding arm for swelling Catheter Occlusion : Failure to flush catheter with heparin; fibrin sheath formation; precipitate formation Inability to aspirate blood. Resistance to flushing; sluggish infusion. Tissue plasminogen activator (TPA) Urokinase , streptokinase, catheter change Proper catheter care Observe for inability to infuse

19. Complications of Parenteral Nutrition: Septic Cause S/S Treatment Prevention Monitoring Catheter-Related Sepsis : Improper technique in catheter insertion; infusion of contaminated solution; multiple-line violation and manipulation; skin colonization adjacent to catheter site; hematogenous seeding of catheter by bloodborne organisms from other distant infections Unexplained fever; chills; red, indurated area or purulent discharge around catheter site; positive catheter tip culture and positive blood culture to confirm infection Removal of catheter and replacement at another site and concurrent antibiotic therapy Strick adherence to aseptic technique during line insertion, line manipulation, and catheter care Monitor for signs and symptoms; assess for glucose intolerance as possible early warning sign of impending sepsis Table 17-5, Complications of Parenteral Nutrition, Infusion Nursing