Parenteral nutrition (PN) can result in numerous complications if not carefully monitored. Mechanical complications include injuries from catheters. Metabolic complications involve issues like hyperglycemia, hepatic dysfunction, and refeeding syndrome. Infections from catheters are also common. Close monitoring of patients on PN is necessary to check for metabolic and clinical issues and manage complications. Careful attention to nutrient levels and other medical factors can help reduce risks.

1. COMPLICATIONS AND MONITORING DURING TPN
PRESENTOR:DR. RAJESH CHOUDHURI
PGT, DEPARTMENT OF ANAESTHESIOLOGY
MODERATOR: Dr. V. MAJUMDER, Asst. Prof
AGMC & GBP HOSPITAL, AGARTALA

2. INTRODUCTION
•Parenteral Nutrition (PN) is beneficial and life-saving
in a variety of clinical conditions, but can also result in
numerous, potentially serious, side-effects .
•The risk of PN complications can be minimised by
carefully monitoring patients and the use of nutrition
support teams particularly Working group during
long-term PN.

3. Complications
OfTPN
Mechanical
metabolicinfectious

4. MECHANICAL COMPLICATIONS
Air embolism
 Pneumothorax
 Hemothorax
Cardiac tamponade
Injuries to arteries and veins
Injury to thoracic duct
Brachial plexus injury

5. METABOLIC COMPLICATIONS
• Early or nutrient related
 Hyperglycemia
 Hypoglycemia
 Hyperlipidemia
Rrefeeding syndrome
• late or related to long term administration
 Hepatic dysfunction
Steatosis, steatohepatitis, lipidosis, cholestasis, cirrhosis
 Biliary complications: acalculous cholecystitis,Gb sludge, cholelithiasis
Metabolic bone disease: osteomalaacia, osteopenia

6. • Fluid overload
• Hypo/hypernatremia
• Hypercalcemia
• Hypo/hyperkalemia
INFECTION :
 Catheter related sepsis is most common life threatening complication
Causes: staph epidermidis and staph aureus, enterococcus, candida, E
coli, psuedomonas, klebsiella etc in immunocompromised pts

7. REFEEDING SYNDROME
• Initiation of refeeding in patients suffering from severe
malnutrition may result in severe adverse effects.
• Usually occurs during the first few days after initiating refeeding.
• Among the several complications are:
-Vitamin B1 deficiency and acute beriberi,
- Volume overload with oedema, cardiac insufficiency and
lung oedema.
- Electrolyte disorders including hypophosphataemia,
hypokalemia and hypomagnesaemia,
-Arrhythmia (bradycardia, ventricular tachyarrhythmia)
- Glucose intolerance (hyperglycaemia, glucosuria,
dehydration and hyperosmolar coma).

8. HYPERGLYCAEMIA
• Found in up to 50% of PN patients.
• Important predictors: insulin resistance or diabetes mellitus,
severity of the underlying illness, concomitant steroid therapy, and
the amount of glucose provided.
• Normoglycaemia (approximately 80–145 mg/dL) should be aimed for
in critically ill patients.
• In extreme cases PN can result in a hyperosmolar, hyperglycaemic
non-ketotic coma. The risk of infectious complications is increased.
• MONITORING & PREVENTION: Blood glucose should be monitored
frequently .
The maximum glucose intake should not exceed 3–
4mg/kg/min.

9. HYPERTRIGLYCERIDEMIA
• Found in approximately 25–50% of PN patients.
• Depends on the presence of accompanying hyperglycaemia,
simultaneous renal insufficiency, steroid administration, extent of
the illness and the amount of lipids infused .
• Severe hypertriglyceridemia ( particularly >5000 mg/dL ) can induce
acute pancreatitis.
• Aim for plasma triglyceride concentrations below 400 mg/dL (4.6
mmol/L) during PN infusion.
• MONITORING & PREVENTION: Regular monitoring of plasma triglyceride
concentrations.
Above-mentioned causative factors should be corrected.
Heparin activates lipoprotein lipase and hence can lower blood triglyceride
levels

10. HEPATIC COMPLICATIONS
• May occur in 15–40% of patients after long-term PN.
• Fatty liver, non-alcoholic fatty liver disease and intrahepatic
cholestasis as well as cholecystitis and cholelithiasis.
• Biliary complications occur frequently – after 6 weeks of therapy, up
to 100% of patients have sludge in the gallbladder.
 Particularly frequent in paediatric patients.
• MONITORING & PREVENTION: Liver function tests should be monitored
periodically. -
Ursodeoxycholic acid may be tried in cholestatic liver disease.
-Establishing at least a minimal enteral food intake .
- Potentially hepatotoxic substances (drugs) should be avoided whenever
possible.

11. • INTESTINAL COMPLICATIONS :
• Glutamine-free total PN does not result in a significant loss of structural
integrity of the intestinal mucosa in patients who are not severely
malnourished.
• A discrete loss of function with reduced enzyme activity may be seen.
• Limited nutrient absorption and increased intestinal permeability in intensive
care patients .
• Prevention is to provide a minimal enteral nutrition supply to avoid or
minimize this risk.
• REBOUND HYPOGLYCEMIA : May occur ifTPN interrupted for > 30 min.
Endogenous and exogenous insulin are resposible.
PREVENTION:TaperTPN before stopping (1/2 rate x 1-2 hours) ;Hang D10%.

12. METABOLIC BONE DISEASE
• Bone demineralisation and osteoporosis may occur.
• Reported prevalence ranging from rare cases to up to 40% of
patients with long-term PN.
• Linked to supoptimal calcium, phosphate and vitamin D intakes,
lack of physical activity, lack of light exposure with poor vitamin D
status, and side-effects of other therapies (e.g. heparin, steroids).
• Therapeutic measures involve approaching adequate substrate
intakes as well as preventing other risks.
• Bisphosphonates may be used for treating low bone density
associated with PN.

13. OTHER METABOLIC COMPLICATIONS
• Electrolyte imbalance, mineral imbalance, acid-base imbalance,
toxicity of contaminants of the parenteral solution.
• CO2 Retention :Occurs in pts with resp. dz. (ie. COPD)
Occurs with overfeeding ,especially if primary source of calories
dextrose
• Prevention: Feed per nutritional assessment, Provide mixed substrate.
• Azotemia :Occurs in pts with renal failure
• Prevention: restrict protein -ARF: 0.5-0.8gm/kg/d CRF: 0.8-1 gm/kg/d
Dialysis / SpecializedAA formulations??
• Hyperammonemia and Hepatic Encephalopathy (HE): Occurs in pts with liver failure.
Restrict protein as necessary ie. 0.5 gm/kg/d. Treat HE with lactulose or antibiotic
enemas

14. CATHETER-RELATED COMPLICATIONS
CATHETER SEPSIS: localized or systemic (skin portal, malnutrion, poor
immunity).
CCC BY: fever, chills, ±drainage around the catheter entrance site,
Leukocytosis, +ve cultures (blood & catheter tip).
TREATMENT:1- exclusion of other causes of fever
2- short course of anti-bacterial and antifungal therapy (acc. to
C&S) .
3- Catheter removal may be required.
PREVENTION:Only i.v. nutrition solutions are administered through the catheter, no
blood may be withdrawn from the catheter.
Catheter disinfection and redressing 2 to 3 times weekly.
The entrance site is inspected for signs of infection and if present, culture is
taken or the catheter is removed.

15. MONITORING
Clinical Data Monitored Daily
General sense of well-being
Strength as evidenced in getting out of bed, walking, resistance exercise as
appropriate
Vital signs including temperature, blood pressure, pulse, and respiratory rate
Fluid balance: weight at least several times weekly, fluid intake (parenteral and
enteral) vs. fluid output (urine, stool, gastric drainage, wound, ostomy)
Parenteral nutrition delivery equipment: tubing, pump, filter, catheter,
dressing
Nutrient solution composition

16. MONITORING
Laboratory Daily
Finger-stick glucose Three times daily until stable
Blood glucose, Na, K, Cl, HCO3, BUN Daily until stable and fully
advanced, then twice weekly
Serum creatinine, albumin, PO4, Ca,
Mg, Hb/Hct, WBC
Baseline, then twice weekly
INR Baseline, then weekly
Micronutrient tests As indicated

17. SPECIAL CONSIDERATIOS
• The requirement for total PN therapy should be regularly reevaluated…. to
explore whether it might be complemented or replaced by enteral or oral
feeding.
• Changes in the clinical state and level of activity may require a periodic
recalculation of energy requirements.
• Special monitoring measures in long-term PN patients: The metabolic
determinants of bone metabolism should be monitored.
Markers of intermediary, electrolyte and trace element
metabolism require regular checks.
Monitoring of bone density by dual energy X-ray
absorptiometry (DEXA) or peripheral quantitative computer tomography
(pqCT) is recommended.

18. SPECIAL CONSIDERATIOS
• Measures to prevent the refeeding syndrome: Severely malnourished
patients, in whom PN is provided after a long period of fasting, need to be
strictly monitored.
Water balance, cardiovascular function and serum electrolytes
should be carefully monitored.
Sufficient thiamine intake should be established prior to PN.
During the first week of PN, fluid intake should be limited to
approximately 800 ml/day plus compensation for insensible losses.
Daily monitoring of body weight.
The amount of carbohydrates administered daily should not
exceed 2–3 g/kgbody weight/day.

19. REFERENCES
• Complications and Monitoring – Guidelines on Parenteral Nutrition,
Chapter 11
Komplikationen und Monitoring – Leitlinie Parenterale Ernährung, Kapitel 11
• ASPEN Board of Directors and the Clinical GuidelinesTask Force.
Guidelines for the use of parenteral and enteral nutrition in adult and
pediatric patients. JPEN J Parenter Enteral Nutr. 2002;26(1
Suppl):1SA-138SA.