PN complications can be broken up into 3 categories:

1. Metabolic complications.

2. Catheter-related (mechanical) complications.

3. Infection-related complications (sepsis).

The complications can also be considered short-term or long-term.

Common Short-Term Complications:

• Volume overload

• Hyperglycemia (high blood sugar) or Hypoglycemia (low blood sugar)

• Refeeding Syndrome (hypophosphatemia (low phosphorous), hypomagnesemia (low magnesium), hypokalemia (low potassium)

• Other electrolyte imbalances

Common Long-Term Complications

• Hepatic cholestasis (impaired bile formation or flow)

• Hepatic steatosis. (fatty liver)

• Cirrhosis and End-Stage Liver Disease

PN contains large amounts of glucose. This places individuals on PN at risk of developing hyperglycemia (too much glucose in the blood) or hypoglycemia (too little glucose in the blood).

Hyperglycemia (High Blood Sugar)

• Can result from the high amount of glucose infused over a short period

• Generally, you will be required to use a urine dipstick test or glucose monitor to assess the levels of glucose (sugar) in your blood to determine if the level is too high.

• Treatment: Your team may choose to add insulin to your PN or require you to give yourself insulin. Insulin is the hormone in your body that regulates sugar levels, signaling to cells to take in the glucose and store energy for later use.

Hypoglycemia (Low Blood Sugar)

• This is when your blood sugar is too low.

• This can occur when your PN is stopped too abruptly.

• Signs and Symptoms of Hypoglycemia

  • Feeling shaky

  • Sweating, clamminess

  • Confusion

  • Fast heartbeat

  • Feeling lightheaded or dizzy

• If you are having trouble with hypoglycemia, your team may choose to place your PN regimen on a taper schedule.

  • This means that the infusion starts off slowly over the first hour or two of your infusion, gradually increasing the infusion until it reaches full speed.

  • The hour or two before your PN cycle is going to end, you may also need to taper-down.

  • The tapers make it so your body is not shocked by massive amounts of glucose, which could cause the release of too much insulin, resulting in low blood sugar (hypoglycemia).

Refeeding syndrome can occur upon initiation of PN if an individual is severely malnourished.

When the body is in the starved state without carbohydrates, it uses protein and fat stores for energy. When PN is introduced and initiates carbohydrate metabolism, insulin production increases. This causes a movement of electrolytes into cells, particularly phosphate, leading to serious electrolyte and fluid disturbances in the body.

It is a very serious situation and can be life-threatening if not treated. Fluid can shift into the lungs which causes serious breathing difficulties.

A hallmark of refeeding syndrome is hypophosphatemia (low phosphate levels), but concentrations of many electrolytes, such as potassium and magnesium, can become low.

Parenteral Nutrition Associated Liver Disease (PNALD) refers to liver dysfunction that results from the use of parenteral nutrition (PN) in individuals with a nonfunctioning intestine (intestinal failure).

There are three main types of PNALD:

1. Steatosis (fatty liver): This is a benign condition but can progress to fibrosis and cirrhosis. Cirrhosis is scarring of the liver and is generally permanent. The portions of the liver that become cirrhotic are no longer functional.

2. Cholestasis: This is when the flow of bile from your liver is reduced or blocked.

3. Cholelithiasis (gallstones or gallbladder sludge): Commonly seen in short bowel patients on PN due to reduced concentration of bile acids from altered intestinal-liver (enterohepatic) circulation. Also, with limited oral intake, the gallbladder contracts less, leading to more concentrated bile and increased risk for developing stones.

Steatosis and cholestasis can progress to end-stage liver disease and cirrhosis (scarring of the liver, no longer functional).

Factors affecting PNALD:

• Long-term PN use, more prolonged use = higher risk

• Infusion of high amounts of lipids or dextrose = higher risk

• Type of lipid emulsion, SMOFlipid®, and Omegaven® is shown to have better outcomes

Diagnosis: Diagnosis is based on bloodwork which assesses liver function tests such as alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP). bilirubin). A liver or gallbladder ultrasound may be used to visualize the liver or look for stones. Either a magnetic resonance elastogram or an ultrasound elastogram may be performed to assess for the presence of fibrosis (scarring). The gold standard is a liver biopsy to assess for fibrosis and cirrhosis.

Treatment: The best option is to get you off of PN. If this is not possible, your team may be able to make adjustments to your PN solution, such as decreasing the amount of glucose or lipids. Also, your team may recommend the use of a different lipid formulation (see SMOFlipid® and Omegaven® for more information). If you have progressed to end-stage liver disease, a liver or multivisceral transplant may be recommended.

Parenteral Nutrition Associated Liver Disease (PNALD) refers to liver dysfunction that results from the use of parenteral nutrition (PN) in indivduals with a nonfunctioning intestine (intestinal failure).

Risk factors for development of PNALD in a child includes:

• Premature birth

• Disruption of the intestinal-liver (enterohepatic) circulation of bile acids

• Slow intestinal motility resulting in bacterial overgrowth

• High parenteral protein, fat, and/or energy intake

• Frequent line infections

• Absence of oral feeds (inc. risk for biliary sludge)

• Continuous PN infusion can lead to too much insulin in the blood and is accosiated with cholestatic liver disease in children

What are the possible forms of PNALD?

1. Steatosis (more common in adults): his is a benign condition but can progress to fibrosis and cirrhosis. Cirrhosis is scarring of the liver and is generally permanent. The portions of the liver that become cirrhotic are no longer functional.

2. Cholestasis (common in children): This is when the flow of bile from your child's liver is reduced or blocked.

3. Cholelithiasis (gallstones, gallbladder sludge): Commonly seen in short bowel patients on PN due to reduced concentration of bile acids from altered intestinal-liver (enterohepatic) circulation. Also, with limited oral intake, the gallbladder contracts less, leading to more concentrated bile and increased risk for developing stones.

Diagnosis: Diagnosis is based on bloodwork which assesses liver function tests such as alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP). bilirubin). A liver or gallbladder ultrasound may be used to visualize the liver or look for stones. Either a magnetic resonance elastogram or an ultrasound elastogram may be performed to assess for the presence of fibrosis (scarring). The gold standard is a liver biopsy to assess for fibrosis and cirrhosis, but often this is not performed in a young child.

Treatment: The best option is to get your child off of PN. If this is not possible, your child's team may be able to make adjustments to their PN solution, such as decreasing the amount of glucose or lipids. Also, your child's team may recommend the use of a different lipid formulation (see SMOFlipid® and Omegaven® for more information). If your child has progressed to end-stage liver disease, a liver or multivisceral transplant may be recommended.

Central Venous Catheter Thrombosis (CVT) occurs when a blood clot forms in a central line (the line that goes into your (or your child's) vein for infusing PN).

You (or your child) can also have an occlusion in the central line from blood, a medication, or PN fluid precipitate (such as a lipid component).

Signs and Symptoms:

• Facial swelling

• Swelling of the arm on the same side of the body as the catheter

• Distended neck veins

If you are caring for a child, you should look for:

• Any distress or breathlessness while infusing

• Swelling in the neck or limbs

• Stiffness or difficulty when flushing the line

• Fluid coming out around the exit site of the line

How to help prevent this from happening?

• Flush with 0.9% NS after every use of the line

• If you do not use the line on a regular basis, flush the line at least once per week

• If you start to feel your line becoming difficult to push, consult your team so they can get you a special solution a nurse can place in your line to help it flow better

Diagnosis: Your team may or may not choose to order a test to assess for a blood clot depending on the situation. If a test is ordered, it may be a venogram, MRI angiography, or Doppler ultrasound. All of these tests are able to view the flow of blood through your blood vessels.

Treatment: Treatment will depend on the severity of your clot. In some cases, an anti-thrombolytic agent can be used. These medications are 'clot busters' and are placed directly into your line to break-up the clot. You may also be placed on some form of anticoagulation or blood thinner to help prevent future clots. In some cases, the central line must be removed and replaced.

Infection is one of the most common complications associated with PN use. Aseptic (sterile) technique is essential when setting up PN and doing anything with your (or your child's) central line.

The most common organisms that lead to central line infections include:

• Gram-positive organisms

• Coagulase-negative staphylococci

• Staphylococcus aureus

Signs and Symptoms: (oftentimes correlates with PN infusion)

• Fever

• Chills

• Muscle aches and pains

• Fatigue and lethargy

Diagnosis: Diagnosis is usually based on blood cultures. Blood cultures can take days to come back, so your (or your child's) team will often initiate a broad-spectrum course of antibiotics if there is clinical suspicion of a bloodstream infection.

Treatment: Your team will determine the best antibiotic and antimicrobial treatment for you. Depending on the organism causing the infection often determines if your line will need to be removed and replaced. For example, if you have a fungal infection, gram-negative bacilli, valvular heart disease, multiple organisms, or endocarditis, the line is usually removed. Each case is individualized, and your team will determine the best course for you.

Prevention:

• Wash your hands before and after handling your PN or CVC.

• Always scrub your catheter hubs for 15 seconds before and after each use.

• Always cover your central line when taking a shower or getting wet.

• Never let the tip of your PN tubing touch anything other than the connection with your catheter.

• Perform cap changes about every 3 days.

• When your catheter is not in use, be sure it is covered with a cap.

• Remain completely sterile (completely free from bacteria) while doing dressing changes.