Mechanical complications
- catheter or venous thrombosis
- incidence varies (3.9% with peripherally inserted central catheters (PICC) to 38% with hemodialysis)
- prophylactic heparin does not significantly reduce risk of thrombosis
- PICC associated with higher rates of thrombophlebitis and difficulty of insertion compared with standard subclavian catheters.
- catheter occlusion
- more common with PICC than non-PICC increased risk with addition of syrups, medications with low pH, or oleaginous liquid medication
- treatments include
- 70% ethanol may clear lipid-related occlusion
- 0.1-N sodium hydroxide for mineral or drug occlusion
- issue plasminogen activator (tPA) for thrombus-related obstruction
- catheter-related infection (higher risk than enteral nutrition or IV dextrose)
- catheter dislodgement or fracture (rare)
Central vascular access complications
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Compatibility issues
- formation of precipitates (calcium gluconate may decrease risk)
- if high-dose vitamin C (up to 2,000 mg per day) needed, use separate infusion
- many medications not compatible with 3-in-1 parenteral nutrition solutions
Stability (degradation of nutritional components over time)
- not typically seen in acute care settings due to daily compounding of solutions
- more commonly seen in home care settings with bulk home delivery of solutions
- avoid degradation by adding vitamins just prior to infusions
Hyperglycemia
- primary cause is excess dextrose infusion
- balanced regimen should include 50%-60% of total calories from dextrose (infusion 4-5 mg/kg/minute optimal)
- critically ill patients at increased risk
- advance dextrose concentration slowly to meet caloric goal with insulin adjustments per blood glucose levels
- consider using IV insulin drip instead of sliding scale in ICU
