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Nutrition support in intubated critically ill adult patients: Parenteral nutrition

Nutrition support in intubated critically ill adult patients: Parenteral nutrition
Author:
David Seres, MD
Section Editor:
Polly E Parsons, MD
Deputy Editor:
Geraldine Finlay, MD
Literature review current through: Jan 2024.
This topic last updated: Jan 29, 2024.

INTRODUCTION — Parenteral nutrition (PN) support refers to the provision of calories (usually dextrose and lipids), amino acids, electrolytes, vitamins, minerals, trace elements, and fluids via a parenteral route.

Typical access used, formulations and their components, delivery, monitoring, and complications of PN are reviewed here. Issues surrounding enteral feeding as well as indications, contraindications, timing, and prescription of nutritional support in critically ill patients are discussed separately. (See "Nutrition support in intubated critically ill adult patients: Enteral nutrition" and "Nutrition support in intubated critically ill adult patients: Initial evaluation and prescription".)

INDICATIONS AND CONTRAINDICATIONS — The indications and contraindications for PN (table 1) are discussed elsewhere. (See "Nutrition support in intubated critically ill adult patients: Initial evaluation and prescription", section on 'Timing and type of nutrition'.)

The Institute for Safe Medication Practices (ISMP) has listed PN as a "high alert medication," in the same category of complexity and potential for error or harm as chemotherapy. Guidelines that describe safe practices for PN have been published by professional organizations [1-5]. These recommend that PN be prescribed by a multidisciplinary team of physicians, nutritionists, pharmacists, and nurses [1] since it is complicated and requires advanced knowledge about issues such as nutrient metabolism and solute compatibility [4,5].

ACCESS — When given for more than a few days, PN must be delivered via a central venous catheter (CVC; also called central PN [CPN]) because its high osmotic load is not tolerated by peripheral veins [6,7]. PN may be given via a peripheral vein if it is significantly more diluted (<900 milliosmole); this is termed peripheral PN (PPN). PPN is rarely indicated in the inpatient setting because of the ease of obtaining central access in the hospital. (See 'Peripheral parenteral nutrition' below.)

Device options – Central venous access devices (CVADs) are the access of choice for the delivery of PN. This includes a peripherally inserted central catheter (PICC) or a tunneled CVC (TCVC; also referred to as TICC; eg, Hickman catheter, Groshong catheter, or implanted infusion port), as well as CVCs that are often in place in critically ill patients (eg, subclavian, internal jugular, or femoral CVC).

Choosing a device – Choosing appropriate access should be individualized and depends upon duration of need for PN, local expertise, ability of the facility or individual to take care of the device, and presence of other risk factors for catheter-related blood stream infections (CRBSI; eg, previous sepsis with CVC in place). The American Society for Parenteral and Enteral Nutrition (ASPEN) has issued clinical guidelines to describe best practices in the selection and care of CVADs for the infusion of home PN in adult patients [8]. We use similar principles when selecting CVADs for hospitalized critically ill patients in whom PN is indicated.

Short-term administration (<30 days) – In general, we agree that for patients in whom short-term administration of PN is desirable or intended, PN delivered through a PICC is appropriate. As a less preferable alternative, PN may be administered through a subclavian, internal jugular, or femoral CVC if PN is only needed for very short periods (eg, transition to enteral nutrition is anticipated in the near future, such as a week or two) or if a PICC is not feasible or reasonable. The femoral site is least desirable due to an increased risk of CRBSIs [9]. (See 'Bloodstream infection' below.)

Long-term administration (≥30 days) – For long-term administration of PN, it is our practice to use PICCs preferentially because of the relative ease of insertion and removal compared with TCVC. ASPEN guidelines indicated a preference for a TCVC based upon expert opinion and observational studies that suggest infection rates may be lower with TCVC than other catheters [10-13]. However, one systematic review suggested that infection rates were similar when PN delivered through a PICC was compared with TCVC delivery (relative risk 0.4, 95% CI 0.19-0.83) [10].

When possible, we use a single lumen catheter dedicated to PN administration. If a multiple lumen CVC is used, one port should be dedicated solely for PN administration, even if previously used for other infusions before PN administration. For patients who have an existing CVC, a new CVC is not typically required unless there has been septicemia during the life of the existing line. In addition, catheter manipulations should be minimized.

Indications, insertion, and complications of CVCs are discussed separately. (See "Central venous catheters: Overview of complications and prevention in adults" and "Central venous access in adults: General principles" and "Catheter-related upper extremity venous thrombosis in adults".)

FORMULATIONS — PN is an admixture of solutions containing dextrose, amino acids, electrolytes, vitamins, minerals, and trace elements. Lipid emulsion may be infused separately or added to the mixture. When lipid is infused separately, the PN is referred to as "2-in-1." When lipid is mixed with the other ingredients, it is referred to as total nutrient admixture (TNA) or "3-in-1." TNA is recommended by ASPEN and preferred by us, although choosing among formulations is institution- and clinician-specific [14]. Noteworthy is that the minimum triglyceride concentration in TNA must be ≥2 percent (ie, 2 g/100 mL) or the emulsion becomes unstable.

PN may be custom-formulated in a hospital or compounding pharmacy or manufactured as a premixed solution. Use of one or the other is institution-dependent. (See 'Premixed solutions' below and 'Custom-made solutions' below.)

The exact composition and infusion rate are tailored to the nutritional and fluid needs of each patient and the estimated metabolic capacity for incorporation of the components, the details of which are discussed separately. (See "Nutrition support in intubated critically ill adult patients: Initial evaluation and prescription", section on 'Calculating calorie and protein requirements in adequately nourished patients'.)

Custom-made solutions — Many hospitals maintain sterile compounding pharmacy facilities to mix PN. In some regions, freestanding compounding pharmacies provide this function for multiple hospitals. Home infusion companies most often provide custom-made solutions. The advantage to this method is that most components of PN can be adjusted to an individual patient's needs (eg, macronutrients, electrolytes, trace elements, and to a lesser extent, vitamins).

Premixed solutions — Premixed solutions are commercially available ("off-the-shelf PN"). These have the advantage of not requiring specialty pharmacies for compounding since they are manufactured in large pharmaceutical settings. Their disadvantage is the diminished ability to customize the formula for an individual patient's needs.

Premixed solutions contain various combinations of dextrose, amino acids (with electrolytes), and lipids. Vitamins, minerals, and trace elements are generally added to this solution. While there are many variations in macro- and micronutrient contents that can be ordered (eg, high- and low-protein formulas and electrolyte-restricted formulas), keeping a large variety in stock can be cost-prohibitive and institutions using premixed PN generally choose a few commonly used formulations.

COMPOSITION

Dextrose — Dextrose-containing stock solutions are available in a variety of concentrations (40, 50, 70 percent), but 70 percent is most commonly used. The caloric contribution of dextrose in medical solutions is 3.4 kilocalories (kcal)/g of dextrose, which differs from dietary carbohydrate (4 kcal/g). The reason for the difference is that water contributes to the weight of the dextrose-hydrate that is used to prepare PN.

The percentage of calories that is contributed by dextrose is titrated according to individual factors, such as severity of illness, the caloric needs of the patient, and the underlying conditions. It is generally thought that dextrose dosage should not exceed 4 to 7 mg/kg/minute or 5 to 6 g/kg/dL.

The amount of dextrose given on the first day of PN administration should be half of the intended goal. This helps attenuate the potential for refeeding syndrome and hyperglycemia. Dextrose can be increased to goal if electrolytes and glucose levels are satisfactory on the second or subsequent day. (See "Nutrition support in intubated critically ill adult patients: Initial evaluation and prescription", section on 'Calculating calorie and protein requirements in adequately nourished patients'.)

Amino acids — Amino acid solutions contain most essential and nonessential amino acids. The amino acid stock solutions come in concentrations ranging from 5.5 to 15 percent, and the caloric contribution of amino acids is approximately 4 kcal/g.

The buffer most commonly used in amino acid solutions contains electrolytes in small quantities. It is occasionally necessary to use amino acid solutions with volume and electrolyte restriction (eg, for example in patients with kidney failure and hyperphosphatemia). These are usually 15 percent amino acid solutions and contain less sodium and acetate and are devoid of phosphate.

Enrichment of PN with a variety of specialized amino acids, such as branched chain amino acids has been studied, but there is insufficient evidence to warrant their routine use [15].

Lipids — Lipids are provided as an emulsion that may be infused separately (ie, 2-in-1 PN) or added to the mixture (ie, total nutrient admixture or "3-in-1"). We prefer the latter.

Lipids are a source of essential fatty acids (to prevent deficiency) and calories. The caloric contribution of a typical lipid emulsion is 10 kcal/g (or 2 kcal/mL in 20 percent emulsion) and 11 kcal/g or (1.1 kcal/mL in 10 percent emulsion). While dietary fat provides 9 kcal/g, parenteral lipids provide slightly more calories due to the contribution of calories from the emulsifiers used to create the lipid suspension for intravenous administration.

Lipid infusion rates should not exceed 0.11 g triglyceride/kg/minute. When infused separately from PN, both 10 and 20 percent emulsions can be infused via peripheral vein.

Because propofol is provided in a 10 percent fat emulsion, fat dosing in PN should be reduced accordingly.

In the United States, most lipid emulsion consists of long-chain omega-6 triglycerides derived from soybean and safflower oils. Mixtures of several types of lipids (eg, refined olive, soybean, and fish oil emulsions) have been approved and are also available for use in the US. However, randomized trials have not conclusively demonstrated any meaningful clinical benefit in association with any specific type of lipid emulsion in critically ill patients [16-20]. Similarly, while omega-3 fatty acid-enriched PN was associated with a lower risk of infection in one meta-analysis [21], trials in critically ill patients of omega-3 fatty acid supplementation in enteral feeds were not beneficial. Further trials are needed before we can recommend supplementation of PN with omega-3 fatty acids. (See "Nutrition support in intubated critically ill adult patients: Enteral nutrition", section on 'Extra supplements of no proven benefit'.)

Certain precautions should be taken when prescribing lipids. Patients may have allergies to some of the components, hyperlipidemias may be exacerbated, and some emulsions may be made unstable (see 'Formulations' above):

Allergy to eggs, soy, or fish – Intravenous fat emulsions should be given with care to patients with prior allergy to eggs, especially if severe. Egg phospholipid together with glycerin is used to emulsify the triglycerides in intravenous fat emulsions, and rare allergic cross-reactions have been reported.

Similarly, most intravenous fat emulsions contain soy oils, and rare allergies have been reported.

Finally, fat mixtures that contain fish oils are available, and may rarely cause allergic reactions when patients have allergies to fish.

Hypertriyglyceridemia/lipid disorders – Severe hypertriglyceridemia and other severe disorders of lipid metabolism are relative contraindications to lipid emulsion infusion (eg, serum triglycerides >1000 mg/dL due to pathologic hypertriglyceridemia, lipoid necrosis, acute pancreatitis accompanied by hypertriglyceridemia, disorders of fat metabolism). Monitoring for hypertriglyceridemia is discussed below. (See 'Metabolic effects' below.)

Electrolytes — Electrolytes are added to PN in amounts required to maintain normal serum levels.

Our usual practice for patients with no electrolyte abnormalities is to start PN at half normal salinity (ie, approximately 75 mEq sodium per liter). Sodium is divided approximately 30 to 40 percent as sodium acetate and the remainder as sodium chloride. Acetate is metabolized to bicarbonate, and higher amounts can be given to help correct acidosis.

Sodium phosphate is the preferred source for phosphate. A starting dose of 10 mmol/dL is reasonable. Potassium phosphate is available but often has higher aluminum contamination. Moreover, to avoid errors in dosing, we use one form of potassium.

Potassium may be given as chloride or acetate, but we generally only use the chloride salt except when high doses of acetate are required. We usually start with 30 to 40 mEq potassium per liter.

Calcium gluconate and magnesium chloride are usually started at 10 mEq per day.

Vitamins, minerals, and trace elements — Patients receiving PN must receive adequate vitamins and minerals to prevent deficiencies. For most patients, a unit dose of a standard multivitamin and multi-trace element solution added to the amino acid/dextrose/lipid admixture is sufficient to meet minimum daily requirements.

It is advisable that patients with cholestasis do not receive copper or manganese, as these are excreted in bile. A total bilirubin of 2 mg/dL is often used as a cutoff to restrict these, and it is often necessary to order the remaining trace elements individually. In this population, it is also reasonable to measure trace element levels periodically. Specific time intervals for monitoring are complex and can be found in published guidelines [3].

While there are also concerns about clearance of some vitamins in anephric patients (eg, vitamins A, B6, and B12), we do not restrict either vitamins or minerals in these patients but do monitor levels if patients are on PN for extended periods (eg, months).

Supplements of no benefit — It is not our practice to supplement vitamins and minerals above the recommended daily amounts unless a deficiency is documented or strongly suspected. It should be noted that a deficiency is not the same as a low level. Rather, a deficiency occurs only when a lack of a substance causes an undesired health outcome that is reversed or prevented by supplementation.

These trials are largely performed in patients on enteral feeding and are discussed separately. (See "Nutrition support in intubated critically ill adult patients: Enteral nutrition", section on 'Extra supplements of no proven benefit'.)

DELIVERY VOLUME AND RATE — Once the caloric and protein needs of a patient has been determined, PN is generally administered as a continuous infusion with the total volume initially administered over 24 hours. Calculating the caloric and protein needs of an individual patient is discussed separately. (See "Nutrition support in intubated critically ill adult patients: Initial evaluation and prescription", section on 'Calculating calorie and protein requirements in adequately nourished patients'.)

The daily volume of PN is tailored to the nutritional and fluid needs of each patient. While enteral feeding formulas may be as concentrated as 2 kilocalories (kcal)/mL, it is difficult to concentrate PN much more than 1.2 kcal/mL. PN may be highly diluted to provide extra volume to patients who require it (eg, high output enterocutaneous fistula), but lipid concentration must be maintained above 2 percent in total nutrient admixture or the emulsion becomes unstable. (See 'Lipids' above.)

In general, we start PN at half the daily requirements on day one and, if tolerated without uncontrolled hyperglycemia, precipitous change in electrolytes, or reaction to lipid, we proceed to the target goal on day two.

The prescription for PN is written daily since electrolyte needs and laboratory chemistries may vary daily.

MONITORING — Routine monitoring of PN includes measurement of fluid intake and output, as well as selected laboratory studies. The frequency of laboratory monitoring should be adjusted to the individual patient's acuity, stability, and risks for deficiencies. After initiation, our approach is the following:

Serum electrolytes, glucose, calcium, magnesium, and phosphate are measured daily until they are stable or more frequently if the patient is at high risk for or exhibiting signs of refeeding syndrome. Once stable, laboratory draw frequency is an individualized decision. In very stable hospitalized patients, we recommend (at minimum) weekly laboratory draws. (See "Anorexia nervosa in adults and adolescents: The refeeding syndrome".)

Aminotransferases and bilirubin are measured at least once each week for the first few weeks.

Triglyceride levels are also measured for the initial two to three days of PN, and if stable, then weekly for the subsequent few weeks and then monthly; if elevated, more frequent measurements are necessary. (See 'Metabolic effects' below.)

Trace elements, including iron, only need to be measured every three months (earlier if deficiency is suspected), which is not applicable to most intensive care unit patients receiving PN.

Additional monitoring may be needed after composition changes and treatment of specific deficiencies.

COMPLICATIONS — Patients who receive PN support are at risk for systemic infection, adverse metabolic effects, and complications related to venous access. Clinical practice guidelines, protocols, and oversight by multidisciplinary teams have been shown to reduce the complications and total cost of PN [1,22,23].

Bloodstream infection — Because central venous access is required to administer PN, patients are at increased risk of acquiring a bacterial or fungal bloodstream infection (approximately one episode per 100 inpatient PN days) [24].

Among patients receiving PN, factors associated with bloodstream infection include the following [25]:

Poor patient or hand hygiene and poor barrier precautions

Use of a central venous catheter that was placed under emergent circumstances

Severe illness

Long duration of central venous catheterization

It is unclear whether the PN itself is causal. In a meta-analysis of two randomized trials enrolling more than 6000 patients, in which patients who could receive enteral nutrition (EN) were randomized to EN or PN, there was no difference in any outcomes, including infections [26].

Evaluation and management of suspected catheter-related blood stream infections are the same as in patients with catheter-related infections due to other causes. These details are discussed separately. (See "Intravascular non-hemodialysis catheter-related infection: Clinical manifestations and diagnosis" and "Intravascular non-hemodialysis catheter-related infection: Treatment".)

Metabolic effects — PN is associated with metabolic complications, including hyperglycemia, serum electrolyte alterations, macro- or micronutrient excess or deficiency, refeeding syndrome [27], Wernicke encephalopathy [28], and hepatic dysfunction. Routine monitoring of serum glucose, electrolytes, and volume status may allow early detection of such complications. (See 'Monitoring' above.)

Hyperglycemia – Hyperglycemia is particularly common among patients who receive PN, perhaps twice the rate seen in patients receiving enteral feeding [29]. However, PN is not an indication for frequent point-of-care (ie, fingerstick) blood glucose monitoring in patients who are neither hyperglycemic nor diabetic.

We manage hyperglycemia using similar principles to those in all critically ill patients; in many instances, we add short-acting insulin to the PN solution and/or administer insulin subcutaneously. The target goals and management strategy used for hyperglycemia in critically ill patients are discussed in detail elsewhere. (See "Glycemic control in critically ill adult and pediatric patients", section on 'Insulin therapy administration'.)

Refeeding syndrome – Refeeding syndrome is a potentially fatal condition resulting from rapid changes in fluids and electrolytes when patients with malnutrition are given oral, enteral, or parenteral feedings (eg, individuals with anorexia or alcohol substance use disorder) [30]. Patients with ongoing electrolyte losses (eg, from diarrhea, vomiting, fistulas) are also at increased risk of refeeding syndrome. It is defined primarily by manifestations of severe hypophosphatemia, but hypokalemia and hypomagnesemia also occur.

Refeeding syndrome presentation and management are described in greater detail elsewhere. (See "Anorexia nervosa in adults and adolescents: The refeeding syndrome".)

Wernicke encephalopathy – Wernicke encephalopathy is more challenging to diagnose in critically ill patients but may present as oculomotor dysfunction and encephalopathy classically in patients with alcohol use disorder or anorexia. Wernicke encephalopathy presentation and management are described in greater detail elsewhere. (See "Wernicke encephalopathy".)

Hypertriglyceridemia – Hypertriglyceridemia or worsening of existing hypertriglyceridemia may result from the infusion of lipids. Concentrations up to 400 mg/dL are acceptable during therapy without altering the amount of lipids in PN [31].

When triglyceride concentrations rise above 400 mg/dL, we reduce the dose of lipid emulsion by reducing the frequency of administration (eg, two to three times per week as opposed to daily). It is also reasonable to decrease the proportion of calories provided by dextrose since excessive amounts of dextrose may also increase triglyceride levels.

Triglyceride levels >1000 mg/dL are a contraindication to lipid infusion [1,31].

Liver dysfunction – Liver dysfunction is not unusual. When elevations in aminotransferases or bilirubin occur, we decrease the lipid dosing and switch from soy-base to mixed-lipid emulsions, although data to support this practice is observational and guidelines allow for the use of any of the lipid emulsions currently available [26]. (See "Intestinal failure-associated liver disease in infants", section on 'Fish oil-based lipid emulsions'.)

Carnitine deficiency – Rarely, patients who have long-term fat malabsorption or are chronically dependent on PN develop carnitine deficiency, which is associated with liver dysfunction and myopathy. It is treated by adding 1 g per day of carnitine to the PN mixture. (See "Specific fatty acid oxidation disorders", section on 'Carnitine cycle defects' and "Metabolic myopathies caused by disorders of lipid and purine metabolism", section on 'Carnitine cycle disorders'.)

Venous access — PN requires venous access, which is associated with potential complications. Examples include bleeding, vascular injury, pneumothorax, venous thrombosis, arrhythmia, and air embolism. The complications of venous access for PN are not different from access for other purposes. Further details are described separately. (See "Central venous catheters: Overview of complications and prevention in adults" and "Catheter-related upper extremity venous thrombosis in adults" and "Air embolism".)

WEANING PARENTERAL NUTRITION — Guidelines suggest that when tolerance to enteral nutrition (EN) is evident, PN should be weaned and discontinued when >60 percent of the patients' needs are met enterally, although there are no data to support this practice [26]. Our practice is to wean PN proportionate to the amount of EN being delivered, thus meeting but not exceeding the daily goals.

PERIPHERAL PARENTERAL NUTRITION — Peripheral PN (PPN) is a form of PN that can be administered peripherally.

Access – PPN can be delivered for short periods through a peripheral intravenous catheter (eg, a few days). Although PPN has an osmolality lower than that of conventional PN, PPN is still quite hyperosmolar and irritating to the peripheral veins. Frequent replacement of intravenous access is usually necessary. We do not infuse PPN via midline catheters as we have seen late stenosis at the midline catheter tip location.

Indications – PPN is rarely prescribed because it can be used only for a limited time. To deliver adequate nutrients, either a large enough volume and/or a high fat formulation must be used, making it generally impractical as a form of long-term nutrition support.

PPN is useful when central access is delayed. In this circumstance, it can help to deliver calories sooner so that refeeding and glycemic control might be more quickly addressed once access is eventually achieved.

PPN is also used when central access needs to be temporarily removed and continued feeding is critical (eg, "line holiday" for treatment of bloodstream infection in a malnourished patient). In this circumstance, PPN is a bridge until the line is replaced. This approach is not necessary if the patient is adequately nourished.

Components – Calculations for PPN are the same as for central PN, with the exception that fat usually composes 50 to 60 percent of calories. This helps minimize volume while keeping osmolality low. Osmolality must not exceed 900 milliosmole/L. Calculators for estimating PN osmolality are available online if not built into the institution electronic order.

SHORTAGES — Shortages of individual components of PN are frequent and may impact the care of patients receiving it. The American Society of Parenteral and Enteral Nutrition recommendations for managing shortages relevant to components of PN can be accessed at the following site: http://www.nutritioncare.org/Professional_Resources/Drug_Shortages_Update/.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Nutrition support (parenteral and enteral nutrition) in adults".)

SUMMARY AND RECOMMENDATIONS

AccessParenteral nutrition (PN) provides calories and nutrients parenterally. PN should be delivered through a single dedicated lumen of a central venous catheter, preferably a peripherally inserted central catheter. As an alternative, infusion through a subclavian or internal jugular vein catheter is appropriate for short-term administration (<30 days). PN should be administered under the supervision of a multidisciplinary team of physicians, nutritionists, pharmacists, and nurses. (See 'Access' above.)

Formulations and composition – PN is an admixture of solutions containing dextrose, amino acids, electrolytes, vitamins, minerals, and trace elements. (See 'Formulations' above and 'Composition' above.)

PN may be manufactured in a premixed solution or custom-formulated in a hospital or compounding pharmacy. When lipid is infused separately, the PN is referred to as 2-in-1. When lipid is mixed with the other ingredients, it is referred to as total nutrient admixture (TNA) or 3-in-1. Choosing among formulations is institution- and clinician-specific, and practice varies. We suggest TNA rather than 2-in-1 formulations (Grade 2C). This preference is based upon convenience and also preferred by guideline groups. (See 'Formulations' above.)

The exact composition and infusion rate are tailored to the nutritional and fluid needs of each patient. Calculation of calorie and protein needs is discussed separately. (See "Nutrition support in intubated critically ill adult patients: Initial evaluation and prescription", section on 'Calculating calorie and protein requirements in adequately nourished patients'.)

Delivery – PN is generally administered as a continuous infusion with the total volume initially administered over 24 hours. In general, we start PN at half the daily requirements on day one and, if tolerated without uncontrolled hyperglycemia, precipitous change in electrolytes, or reaction to lipid, we proceed to the target goal on day two. (See 'Delivery volume and rate' above.)

Monitoring – Routine monitoring of PN includes measurement of fluid intake and output, as well as selected laboratory studies. For most patients, serum electrolytes, glucose, calcium, magnesium, and phosphate are measured daily until they are stable; aminotransferases and bilirubin are measured at least once each week for the first few weeks.

Triglyceride levels are also measured for the first two to three days of PN, and if stable, they are then measured weekly for a few weeks, then monthly. When concentrations rise above 400 mg/dL, we reduce the frequency of lipid administration (eg, two to three times per week); lipid infusion should be discontinued for triglyceride concentrations >1000 mg/dL. (See 'Monitoring' above.)

Complications – Patients who receive PN support are at risk for the following complications:

Infection – (See 'Bloodstream infection' above.)

Adverse metabolic effects including the following (see 'Metabolic effects' above):

-Hyperglycemia – (See "Glycemic control in critically ill adult and pediatric patients".)

-Refeeding syndrome – (See "Anorexia nervosa in adults and adolescents: The refeeding syndrome".)

-Wernicke encephalopathy – (See "Wernicke encephalopathy".)

-Liver dysfunction – (See "Approach to the patient with abnormal liver biochemical and function tests".)

Complications related to venous access (See "Vascular complications of central venous access and their management in adults".)

Peripheral PN (PPN) – Peripheral PN (PPN) can be delivered for short periods (eg, a few days) through a peripheral intravenous catheter. For patients in whom access is delayed or those who need a temporary central access "line holiday," PPN is an option. (See 'Peripheral parenteral nutrition' above.)

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  27. da Silva JSV, Seres DS, Sabino K, et al. ASPEN Consensus Recommendations for Refeeding Syndrome. Nutr Clin Pract 2020; 35:178.
  28. Mattioli S, Miglioli M, Montagna P, et al. Wernicke's encephalopathy during total parenteral nutrition: observation in one case. JPEN J Parenter Enteral Nutr 1988; 12:626.
  29. Petrov MS, Zagainov VE. Influence of enteral versus parenteral nutrition on blood glucose control in acute pancreatitis: a systematic review. Clin Nutr 2007; 26:514.
  30. Mehanna HM, Moledina J, Travis J. Refeeding syndrome: what it is, and how to prevent and treat it. BMJ 2008; 336:1495.
  31. Mirtallo JM, Ayers P, Boullata J, et al. ASPEN Lipid Injectable Emulsion Safety Recommendations, Part 1: Background and Adult Considerations. Nutr Clin Pract 2020; 35:769.
Topic 1626 Version 32.0

References

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