Fluids:

Hypervolemia (fluid overload)

Cardiac and renal diseases

Estimate fluid tolerance in high risk patients, maintain lower volume of fluid through slower rates of infusion, concentration of formulation (according to tolerance), and the use of fat emulsions to supply non-protein calories

Edema, low serum levels of electrolytes, albumin, and minerals

Restrict volume of TPN fluids; utilize fat emulsions to improve calorie levels without adding fluid load; diuretics

Hypovolemia

Gastrointestinal fluid losses; hyperosmolar infusion

Monitor for fluid balance and provide adequate fluids

Increased serum levels of electrolytes, glucose, albumin, minerals; hypotension

Increase fluid volume infusion

Electrolytes and Acid-Base Balance:

Refeeding syndrome

Moderately to severely malnourished patients, alcoholism, acute stress and body tissue depletion

Correct imbalances prior to initiation of TPN, assure the provision of adequate electrolytes during anabolism; start carbohydrate infusion slowly to prevent rapid shifts in electrolytes; monitor closely for signs and symptoms of refeeding syndrome

Low serum levels of potassium, phosphorus, magnesium; fluid overload with insulin-mediated retention of fluids and salt

Reduce infusion rate or concentration of carbohydrate and provide adequate electrolytes to accommodate acceleration electrolyte utilization during tissue growth

Sodium: high normal values: 135-145 mEq/L

Fluid restriction, dehydration, diabetes insipidus

Balance intake of fluids and carefully monitor for stability; encourage oral water intake if possible for reducing hypernatremia

Hypernatremia, thirst, irritability, spasticity, ataxia, seizures

Balance fluid volume; monitor for excess sodium intake; monitor blood sugar levels closely

Sodium: low

Normal values: 135-145 mEq/L

High fluid administration, fluid overload; hyperlipidemia, hyperproteinemia, gastrointestinal/ renal/skin losses, syndrome of inappropriate antidiuretic hormone (SIADH)

Balance fluid intake and monitor for stability

Hyponatremia; confusion, hypotension, lethargy, seizures, irritability, anorexia, nausea, vomiting, increased intracranial pressure, cerebral edema

Balance fluid volume; increase formula concentration; increase sodium content if at risk for seizures, check and treat causes of sodium loss and fluid retention

Chloride

Gastric decompression

Use acetate-balanced formulas

Hypochloremic metabolic alkalosis

Magnesium: low

Normal values: 1.5-2.0 mEq/L

Renal dysfunction, inadequate intake or absorption, parathyroid disease, drug/alcohol abuse

Anticipate additional needs in high-risk patients; monitor closely

Twitching and other neuromuscular hyperactivity, apathy and depression, Ventricular fibrillation and tachycardia

Identify and treat refeeding syndrome and underlying causes, increase magnesium intake

Magnesium: high

Normal values 1.5-2.0 mEq/L

Renal dysfunction, excess intake

Anticipate reduced needs in high-risk patients; monitor closely for intake and balance

Weakness, paralysis and respiratory depression, hypotension, sinus bradycardia

Monitor for renal function changes and limit intake

Potassium: low

Normal values: 3.5-5.0 mEq/L

Moderately to severely malnourished patients, potassium- losing medications, diarrhea, vomiting, metabolic alkalosis

Prevent refeeding syndrome by providing adequate potassium during feeding and avoiding overfeeding

Weakness, myalgias, cramps, paralytic ileus, bradyarrhythmias

Check and correct magnesium balance, increase potassium intake, treat underlying causes, identify and treat refeeding syndrome

Potassium: high

Normal values: 3.5-5.0 mEq/L

Renal dysfunction, metabolic acidosis, potassium-containing and sparing medications, insulin deficiency, chemotherapy, excessive potassium intake

Plan for reduced potassium needs in high risk patients; monitor closely and correct potassium status; treat underlying risk factors 

Hyperkalemia, muscle weakness, arrhythmias

Check and treat underlying causes, reduce potassium intake

Minerals:

Calcium: low

Normal values: 8.5-10.5 mg/dL (serum levels are usually normal at the expense of bone losses)

Pancreatitis, administration of high doses of phosphate salts; low albumin (half of calcium is albumin-bound)

Use phosphate and acetate-balanced formulas to prevent urinary losses of calcium; assure calcium replacement in formulations

Bone demineralization in adults; growth retardation in children

Calcium: high

Normal values: 8.5-10.5 mg/dL

Hyperparathyroidism, bone metastases, immobilization, excessive intake, interacting drugs and supplements (vitamin A, D, thiazides, lithium), dehydration

Adequate hydration, prevent vitamin A, D overdose

Anorexia, nausea/vomiting, constipation, thirst, kidney stones, bone calcification (metastatic)

Treat underlying cause, balance calcium intake, hydration

Iron: low

Normal values:

Men:75-175ug/L

Women 65-165

Child 50-120

Newborn 100-250

Malabsorption or the lack of oral iron intake with long-term parenteral nutrition

Assure adequate oral intake if possible, monitor closely for signs of deficiency

Iron-deficiency anemia

Intermittent parenteral infusion (separate from TPN that contains fat), or addition of iron to non-fat containing TPN formula at 25-100 mg 3x/week

Phosphorus: low

Normal values: 3.0-4.5 mg.dL

Alcoholism, reduced intake/balance, diabetic ketoacidosis, respiratory alkalosis, phosphate binding drugs, recovery from burns

Prevent refeeding syndrome, balance with caution in high-risk patients

Irritability, anxiety, confusion, respiratory failure, anorexia, nausea, hemolysis

Treat refeeding syndrome, treat underlying cause, slow increase in phosphate (balanced with calcium)

Phosphorus: high

Normal values:

3.0-4.5 mg/dL

Excessive intake, hypoparathyroidism, renal dysfunction, chemotherapy, rhabdomyosis

Balance phosphate carefully in high-risk patients

Hypocalcemia, calcium phosphate deposits in bone and soft tissues

Treat underlying cause, reduce intake, phosphate-binding drugs

Bone disease

Prolonged TPN, steroid use, imbalances in vitamin and mineral concentrations; prolonged high protein content of formulation; inadequate physical activity; metabolic acidosis

Adequate minerals, especially calcium, phosphorus, magnesium, and acetate; obtain urine calcium and magnesium and adjust formula to maintain a positive balance; promote physical activity and smoking cessation

Bone and back pain, loss of height, low scores on annual DEXA evaluation of bone mineral density,

Improve mobilization and activity levels, balance minerals, assure supportive treatment (balanced vitamin A, D, and sunlight exposure)

Vitamins

Vitamin K: low

indirectly measured thorugh prothrombin time;

Normal values for PT: 12-14 seconds; increased time suggests vitamin K deficiency

Long-term TPN without vitamin K

Assure adequate intake and intermittent therapy

Include vitamin K in formula as either 10 mg/week or 0.25-1 mg daily; or use subcutaneous injections of 10 mg/week

Folic acid, B12: low

Normal values:

200-1100pg/ml

Short bowel syndrome or other reason for malabsorption

Assure adequate intake, monitor for anemias

Macrocytic anemia

Intravenous B12

Carbohydrates:

Hyperglycemia

Normal values:

70-110 mg/dL <180 mg/dL on TPN

Diabetes, insulin resistance, stress

Avoid overfeeding, treat underlying

>180 mg/dL

Reduce dextrose load, include or increase insulin

Hypoglycemia (rare)

Transition period for cyclic feeding or feeding cessation

Taper rate slowly to allow the body to adjust to discontinued carbohydrate source

<40-60 mg/dL

Balance carbohydrate load and use gradual transition to discontinue or cycle TPN

Fats:

Essential fatty acid deficiency (EFAD)

Patients with fat malabsorption or on fat-free parenteral nutrition

Assure the routine provision of 1 g/kg/week of IV fat emulsion in long-term TPN patients, improve fat intake

Skin changes, impaired resistance to infection; impaired growth, visual, motor skills and cognitive development in children

Provide fat emulsions separate from or in formulation to meet EFA requirements

Hyperlipidemia

Normal values:

Triglycerides <200 mg/dL

Liver disease, diabetes, stress

Determine baseline triglyceride levels and provide fats in TPN regiment accordingly; >400 mg/dL may warrant limitation of fat infusion

Hyper-triglyceridemia >400 mg/dL

Levels above 500 mg/dL may require the withholding of fat emulsions; possible use of topical fats (soybean or safflower oil) to maintain some EFA stability

Gastrointestinal:

Cholestasis

Children on long-term PN without oral or enteral intake

Provide oral or enteral intake, if possible; avoid overfeeding; monitor and treat for sepsis

Elevated conjugated bilirubin, alkaline phosphatase

Initiate enteral/oral intake, decrease glucose load, treat sepsis, initiate cyclic feeding schedule, remove copper from formula

Intestinal atrophy

Patients with no oral or enteral intake of nutrients

Maintain oral/enteral intake, if possible; especially include water, protein/amino acids, and fiber where possible

Diarrhea, steatorrhea

Introduce small amounts of oral intake, if possible; especially include water, protein/amino acids, and fiber where possible