Complications of Parenteral Nutrition

Technical complications One of the more common and serious complications associated with long-term parenteral feeding is sepsis secondary to contamination of the central venous catheter. Contamination of solutions should be considered but is rare when proper pharmacy protocols have been followed. This problem occurs more frequently in patients with systemic sepsis and in many cases is due to hematogenous seeding of the catheter with bacteria. One of the earliest signs of systemic sepsis may be the sudden development of glucose intolerance (with or without temperature increase) in a patient who previously has been maintained on par-enteral alimentation without difficulty. When this occurs or if high fever (>38.5 °C) develops without obvious cause, a diligent search for a potential septic focus is indicated. Other causes of fever should also be investigated. If fever persists, the infusion catheter should be removed and cultured. If the catheter is the cause of fever, removal of the infectious source is usually followed by rapid defervescence. Some centers are replacing catheters considered at low risk for infection over a guidewire. Should evidence of infection persist for 24-48 h without a definable source, the catheter should be replaced in the opposite subclavian vein or into one of the internal jugular veins and the infusion restarted. It is prudent to delay reinserting the catheter by 12-24 h, especially if bacteremia is present.

Other complications related to catheter placement include the development of pneumothorax, hemothorax, hydrothorax, subclavian artery injury, thoracic duct injury, cardiac arrhythmia, air embolism, catheter embolism, and cardiac perforation with tamponade. All these complications may be avoided by strict adherence to proper techniques. The use of multilumen catheters may be associated with a slightly increased risk of infection. This is most likely associated with greater catheter manipulation and intensive use. Catheter infections are highest when catheters are placed in the femoral vein, lower when placed in the jugular vein, and lowest when placed in the subclavian vein. When catheters are indwelling for less than 3 days, infection risks are negligible. If indwelling time is 3-7 days, the infection risk is 3-5%, and an indwelling time of more than 7 days is associated with a catheter infection risk of 5-10%.

Metabolic complications Hyperglycemia may develop with normal rates of infusion in patients with impaired glucose tolerance or in any patient if the hypertonic solutions are administered too rapidly. This is a particularly common complication in latent diabetics and in patients subjected to severe surgical stress or trauma. Treatment of the condition consists of volume replacement with correction of electrolyte abnormalities and the administration of insulin. This complication can be avoided with careful attention to daily fluid balance and frequent monitoring of blood sugar levels and serum electrolytes.

Increasing experience has emphasized the importance of not 'overfeeding' the parenterally nourished patient. This is particularly true of the depleted patient in whom excess calorie infusion may result in carbon dioxide retention and respiratory insufficiency. In addition, excess feeding has also been related to the development of hepatic steatosis or marked glycogen deposition in selected patients. Cholestasis and formation of gallstones are common in patients receiving long-term parenteral nutrition. Mild but transient abnormalities of serum transaminase, alkaline phosphatase, and bilirubin may occur in many parenterally nourished patients. Failure of the liver enzymes to plateau or return to normal over 7-14 days should suggest another etiology.

Intestinal atrophy Lack of intestinal stimulation is associated with intestinal mucosal atrophy, diminished villous height, bacterial overgrowth, reduced lymphoid tissue size, reduced IgA production, and impaired gut immunity. The full clinical implications of these changes are not well realized, although bacterial translocation has been demonstrated in animal models. The most efficacious method to prevent these changes is to provide nutrients enterally. In patients requiring full parenteral nutrition, it may be feasible to infuse small amounts of trophic feedings via the gastrointestinal tract.

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