Manual of Clinical Nutrition

Parenteral Nutrition

Manual of Clinical Nutrition Management III- 97 Copyright © 2013 Compass Group, Inc.

Complication Causes Symptoms Treatments

Hypocalcemia Hypoalbuminemia

Inadequate vitamin D

intake

Hypoparathyroidism

Inadequate Ca intake

Increased

gastrointestinal

losses

Inadequate

phosphorus intake

High protein dose

Metabolic acidosis

Paresthesias

Tetany

Muscular cramping/

spasms

Increase Ca2+ in PN. (Use caution and

follow protocols to avoid Ca2+–

phosphorus precipitation. Evaluate

ionized calcium level or adjusted total

serum Ca2+ if hypoalbuminemic prior

to increasing Ca2+ in PN.)

Ensure adequate phosphorus (20 to 40

mmol) in PN (1,3).

Evaluate protein (>2 g/kg per day

associated with increased urinary

excretion of calcium) (1).

Ensure adequate acetate and Mg in PN(1).

For critically ill patients or patients with

hypoalbuminemia it is preferable to

evaluate ionized calcium levels.

Ionized calcium is unaffected by

changes in serum albumin levels and

provides a more accurate assessment

of calcium status in critically ill and

patients receiving specialized

nutrition support (9).

Hypercalcemia Excessive vitamin D

administration

Prolonged

immobilization

Stress

Hyperparathyroidism

Malignancy

Thirst

Polyuria

Decreased appetite

Nausea

Vomiting

Itching

Muscle weakness

Evaluate Ca2+ in PN.

Ensure adequate hydration.

Provide intravenous hydration using

0.9% sodium chloride at 200 to 300

mL/hour when calcium >13 mg/dL (8).

After adequate hydration, furosemide

can be used to increase renal calcium

excretion (8).

Hypertriglyceridemia Overfeeding with

dextrose

Rapid administration

of IVFE >110 mg/kg

per hour (1)

Intravenous infusion

of propofol

(Diprivan), which

has the same lipid

content as IVFE

providing 1.1

kcal/mL (11)

Triglyceride level >400

mg/dL (1,3,10)

Impaired immune

response

Pancreatitis (risk occurs

when the triglyceride

level exceeds 1000

mg/dL) (1)

Reduce dose or lengthen the IVFE

infusion time (1).

Provide <30% of energy from IVFE, or

provide 1 g/kg per day and infuse

slowly (no less than 8 to 10 hours)

(1,4).

Avoid excessive dextrose administration.

References

1. Kumpf VJ, Gervasio J. Complications of parenteral nutrition. In: Mueller CM, ed. The A.S.P.E.N. Adult Nutrition Support Core Curriculum. 2nd
   ed. Silver Spring, Md: American Society of Enteral and Parenteral Nutrition; 2012: 284-297.


2. Critical Illness Evidence-Based Nutrition Practice Guideline. Academy of Nutrition and Dietetics Evidence Analysis Library. Academy of
   Nutrition and Dietetics; 2012. Available at: http://www.andevidencelibrary.com. Accessed January 16, 2013.


3. Task Force for the Revision of Safe Practices for Parenteral Nutrition. Safe practices for parenteral nutrition. J Parenter Enteral Nutr.
   2004;28(6 suppl):S 39 - S70.


4. McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, Ochoa JB, Napolitano L, Cresci G; A.S.P.E.N. Board of Directors;
   American College of Critical Care Medicine. Guidelines for the provision and assessment of nutrition support therapy in the adult
   critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A. S. P. E. N.). J
   Parenter Enteral Nutr. 2009;33:277-316.


5. Glycemic targets in hospitalized patients. Standards of medical care in diabetes—2013. Diabetes Care. 2013;36 (suppl 1): S46-S48.


6. Newton L, Garvey T. Nutritional and Medical Management of Diabetes Mellitus in Hospitalized Patients. In: Mueller CM, ed. The A.S.P
   E.N. Adult Nutrition Support Core Curriculum. 2nd ed. Silver Spring, Md: American Society of Enteral and Parenteral Nutrition; 2012:
   580 - 602.


7. Garber AJ, Moghissi ES, Bransome ED Jr, Clark NG, Clement S, Cobin RH, Furnary AP, Hirsch IB, Levy P, Roberts R, Van den Berghe G,