COMPLICATIONS AND MONITORING DURING TPN

PRESENTOR:DR. RAJESH CHOUDHURI

PGT, DEPARTMENT OF ANAESTHESIOLOGY

MODERATOR: Dr. V. MAJUMDER, Asst. Prof AGMC & GBP HOSPITAL, AGARTALA

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.

Complications Of TPN

Mechanical

metabolic

infectious

MECHANICAL COMPLICATIONSAir embolism Pneumothorax HemothoraxCardiac tamponadeInjuries to arteries and veinsInjury to thoracic duct Brachial plexus injury

METABOLIC COMPLICATIONS• Early or nutrient related

Hyperglycemia Hypoglycemia HyperlipidemiaRrefeeding syndrome

• late or related to long term administration Hepatic dysfunctionSteatosis, steatohepatitis, lipidosis, cholestasis, cirrhosis Biliary complications: acalculous cholecystitis, Gb sludge,

cholelithiasisMetabolic bone disease: osteomalaacia, osteopenia

• Fluid overload• Hypo/hypernatremia• Hypercalcemia• Hypo/hyperkalemia

INFECTION : Catheter related sepsis is most common life threatening

complicationCauses: staph epidermidis and staph aureus,

enterococcus, candida, E coli, psuedomonas, klebsiella etc in immunocompromised pts

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).

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.

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

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.

• 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 if TPN interrupted for >

30 min. Endogenous and exogenous insulin are resposible. PREVENTION: Taper TPN before stopping (1/2 rate x 1-2 hours) ;Hang D10%.

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.

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 / Specialized AA 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

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.

MONITORINGClinical 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

MONITORINGLaboratory 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

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.

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.

REFERENCES• Complications and Monitoring – Guidelines on Parenteral

Nutrition, Chapter 11Komplikationen und Monitoring – Leitlinie

Parenterale Ernährung, Kapitel 11

• ASPEN Board of Directors and the Clinical Guidelines Task 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.