Metabolic and catheter complications of parenteral nutrition

Abstract

Since its introduction in the 1960s, total parenteral nutrition (TPN) has played a vital role in improving clinical outcomes for patients with acute and chronic illnesses. The evolution of TPN solutions and vascular access techniques, combined with an increased awareness and better understanding of the physiology of TPN, have improved the safety of this therapy. Nevertheless, complications are not uncommon and can be life threatening. This article provides an updated review on the metabolic and catheter complications associated with TPN.

Management of Parenteral Nutrition in Hospitalized Adult Patients

“…Administering excess calories may be one of the main contributing factors to development of both steatosis and cholestasis 96 , 97 . Excess carbohydrate can lead to hyperinsulinemia, stimulating lipogenesis and inhibiting beta oxidation of fatty acids 98 , 99 .…”

“…Another contributing factor to liver injury is the lack of enteral nutrition, which significantly disrupts the normal gastrointestinal flora and leads to mucosal atrophy and impaired immunity 104 . This may favor endotoxin absorption, leading to macrophage‐mediated and cytokine‐mediated inflammation and injury to the liver 97 . Thus, in addition to avoiding PN overfeeding, enteral nutrition should be initiated as soon as feasible.…”

“…Complications include placement‐related events (pneumothorax, arterial cannulation, and line malposition), infection, thrombosis, and thrombophlebitis, as well as rare complications such as pericardial tamponade, cardiac perforation, and even death 105 . ‐ 109 Estimates of the incidence of complications vary from 1.5–4.9 per 1000 catheter days, depending on the patient population, severity of illness, and the type of catheter 97 , 109 , 110 …”

“…Catheter‐related venous thrombosis (CRVT) can be seen in 3.9% of patients with PICC, with some variation based on clinical setting and operator 129 . Although the true incidence is difficult to ascertain, as many can be asymptomatic, the rates appear to be even higher under certain conditions, such as malignancy and hemodialysis 97 . The use of anticoagulation to prevent CRVT is controversial because some studies revealed no benefit, whereas others showed benefit only in high‐risk patients, such as those with malignancy 130 , 131 .…”

“…Guidelines state that there is no evidence to support the use of anticoagulation prophylaxis against CRVT without significant risk factors, such as family or personal history of coagulopathy, malignancy, or chronic inflammatory disorder 110 . Anticoagulation therapy is supported in symptomatic cases on the basis of a possible reduction in thromboembolism events, although the data are not definitive 97 , 110 …”