Team approaches that assess,
prescribe, monitor, and provide ongoing treatment are essential to successful
therapy. Both prevention efforts and early identification of complications are
important to achieve the best clinical outcomes.
Usage guidelines of parenteral
nutrition support in both institutional and outpatient settings have been
established and are modified as new information and research-based evidence
contributes to refined practice.
[8]
[9]
[10]
[11]
[12]
[13]
The prevention and prompt treatment for complications of TPN can significantly
reduce morbidity and mortality. Routine monitoring and trouble shooting of
medical conditions, parenteral solutions, and methods of administration are
essential to safety and efficacy in the homecare setting.
The most common complications of
parenteral nutrition are infections, followed by mechanical and metabolic
problems. Metabolic complications may occur in between 5-10% of adults receiving
the therapy. Fluid Overload, intolerances and toxic reactions, and deficiencies
of nutrients have all been documented and require care and treatment by
clinicians who are knowledgeable about the prevention, identification, and
treatment strategies for adverse metabolic effects.
Early complications are typically
preventable. Early complications may include volume overload, hyperglycemia,
acidosis and refeeding syndrome, with accompanying lower levels of potassium,
phosphate and magnesium. Later complications may include the exacerbation of
existing conditions and unanticipated long-term deficiencies of vitamins,
minerals and essential fatty acids. Fatty liver, cholestasis and metabolic bone
disease may be late complications
Careful monitoring of patients for
complications is essential for prevention and treatment efforts. Table 1 shows
some variables that should be monitored often during the initiation of TPN as
the desired rate and concentration of formulation is achieved. Once the patient
is stable, monitoring can occur less often. However, if the patient becomes
metabolically unstable, more frequent monitoring should resume.
Monitor |
Baseline |
Initial Frequency/Acute Patient |
Stabilized Frequency |
Weight |
X |
Daily |
Weekly or 2-3 times/week |
Electrolytes |
X |
Daily |
Monthly |
Blood urea nitrogen |
X |
Daily |
Monthly |
Calcium, phosphorus, magnesium |
|
Daily |
Monthly |
Glucose |
X |
Daily (more often if at high risk)
until stabilized <200 mg/dL |
2-3 times/week |
Triglycerides |
X |
Weekly |
Weekly |
Liver function tests |
X |
Biweekly |
Weekly |
Hemoglobin/hematocrit |
X |
Weekly |
|
Prothrombin Time, Partial
Thromboplastin Time |
X |
Weekly |
Weekly |
Clinical status |
X |
Daily |
Daily |
Catheter site |
X |
Daily |
Daily |
Temperature |
|
Daily |
Daily |
Input and output |
|
Daily |
Daily |
*Monitoring frequency
recommendations vary; see specific recommendations for institution or home care
agency
----------------------------
[8]
ASPEN. Administration of specialized nutrition support.
J Parenter Enteral Nutr. 2002;26(1 suppl):18SA-21SA.
[9]
ASPEN. Administration of specialized nutrition support - issues unique
to pediatrics. J Parenter Enteral Nutr. 2002;26(1 suppl):97SA-110SA.
[10]
Report on the guidelines on parenteral nutrition in infants, children
and adolescents. Clin Nutr. 2005;24(6):1105-1109.
[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. J Parenter Enteral Nutr. 2002;26(1 suppl):1SA-138SA.
[12]
Mirhosseini N, Fainsinger RL, Bacacos V.
Parenteral nutrition in advanced cancer: indications and clinical
practice guidelines. J Palliative Med. 2005;8(5):914-918.
[13]
Guidelines for management of home parenteral support in adult chronic
intestinal failure patients. Gastroenterology. 2006;130(2 suppl
1):S43-S51.