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

  • pneumothorax
  • hemothorax
  • air embolism
  • arterial puncture
  • line malposition

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