Reactive hypoglycemia

  • reactive hypoglycemia can occur 15-60 minutes after cessation of parenteral nutrition due to prolonged insulin response to caloric load
  • increased risk with
    • renal and liver disease
    • severe malnutrition
    • sepsis
    • hyperthyroidism
  • prevention strategies include
    • adequate oral intake to sustain blood glucose levels
    • if oral intake is not resumed, consider
      • infusion of 10% dextrose immediately after discontinuation of parenteral nutrition 
      • gradual tapering of parenteral solution for 1-2 hours

Hyperlipidemia

  • causes
    • excessive lipid load
    • impaired lipid clearance
      • obesity
      • diabetes
      • sepsis
      • pancreatitis
      • liver disease
      • renal failure
    • prolonged use of high-dose corticosteroids 
  • prevention and treatment
    • reduce dextrose load, especially with hypertriglyceridemia 
    • reduce lipid load; if hyperlipidemia is not corrected by reduced dextrose load
      • consider cycling lipid as 250 mL of 20% IV fat emulsion twice weekly if serum triglyceride > 400 mg/dL (4.5 mmol/L)
      • limit lipid infusion to < 0.12 g/kg/hour in critically ill patients or if impaired lipid clearance
  • goal serum triglyceride < 400 mg/dL (4.5 mmol/L) in adult patients on continuous TPN

Gastrointestinal complications

  • intestinal atrophy may result from
    • lack of stimulation from luminal nutrients
    • absent fuel source
    • impaired gastric hormonal response 
    • increased intestinal permeability and bacterial translocation
  • gastroparesis 
  • may be limited by gut stimulation from oral or enteral intake

Parenteral nutrition-associated liver disorders

  • hepatic steatosis
    • characterized by elevated serum aminotransferases and hepatomegaly
    • may occur within first few weeks of treatment
    • reversible with discontinuation of TPN
    • more common in adults
    • may be limited by reduction in carbohydrate load in patients with elevated LFTs
  • biliary complications
    • long-term TPN associated with cholecystitis and biliary sludge
    • may be prevented by oral or enteral intake 
  • cholestasis
    • typically occurs with long-term TPN
    • often chronic and irreversible, may lead to liver failure and death
    • more common in infants
    • prevention strategies include
      • initiation of enteral feeding and weaning of parenteral nutrition
      • avoiding overfeeding 
      • providing balanced source of energy
      • cyclic parenteral nutrition infusions
      • avoidance of sepsis
      • limiting manganese if long-term TPN used
    • ursodiol (ursodeoxycholic acid) reported effective for treatment


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