What are the common complications of Total Parenteral Nutrition (TPN)?

Common Complications of Total Parenteral Nutrition (TPN)

Catheter-related bloodstream infections are the most common and serious complications of TPN, causing significant morbidity and mortality, especially in patients with intestinal failure. 1

Catheter-Related Complications

• Central line-associated bloodstream infections occur at rates of 3.8-11.3 infections per 1000 catheter days in pediatric patients and between 0.34-3.94 episodes per catheter year in home TPN patients 1
• Major pathogens causing catheter infections include Gram-positive coagulase-negative or positive staphylococci, Gram-negative bacteria, fungi, or polymicrobial flora 1
• Venous thrombosis is another significant catheter-related complication that can lead to loss of vascular access sites, which may eventually necessitate intestinal transplantation 1
• Catheter-related sepsis is a potentially life-threatening complication that requires immediate medical attention with blood cultures and appropriate antibiotic therapy 2

Metabolic Complications

• Hyperglycemia is one of the most common metabolic complications, occurring in approximately 36.5% of TPN patients 3
• Hypoglycemia can occur, especially when TPN is abruptly discontinued 4
• Electrolyte imbalances are particularly challenging in patients with renal failure and require daily monitoring of sodium, potassium, and phosphorus 1
• Refeeding syndrome can occur in malnourished patients starting TPN, characterized by severe electrolyte shifts and potentially life-threatening complications 1, 4
• Acid-base disturbances may develop during TPN administration 4

Hepatobiliary Complications

• TPN-associated liver disease is a serious complication that can progress to end-stage liver disease requiring combined intestinal-liver transplantation 1
• Liver function abnormalities occur in approximately 25% of patients on TPN 3
• Risk factors for TPN-associated liver disease include:
  • Pure soybean-based lipid emulsions 1
  • Excessive dextrose administration 1
  • Fatty acid deficiency 1
  • Lack of enteral nutrition 1, 5
• Strategies to reduce liver complications include:
  • Maximizing enteral intake whenever possible 1, 5
  • Cycling TPN infusion rather than continuous administration 1
  • Using mixed lipid emulsions instead of pure soybean-based solutions 1
  • Considering ursodeoxycholic acid in the presence of cholestasis 1

Bone Disease

• Metabolic bone disease is a recognized complication of long-term TPN 1, 4
• Regular assessment of bone mineralization is recommended for patients on long-term TPN 1
• Monitoring should include measurements of urinary calcium, plasma calcium, phosphorus, parathyroid hormone, 25-OH vitamin D concentrations, and serum alkaline phosphatase activity 1

Other Complications

• Aluminum toxicity can occur with long-term TPN, requiring ingredients with the lowest amount of aluminum for preparation of parenteral nutrition solutions 1
• Fluid overload can occur, particularly in patients with compromised cardiac or renal function 1, 6
• Hyperlipidemia may develop, especially with excessive lipid administration 4, 7
• Hypercapnia can result from excessive carbohydrate administration 4

Prevention Strategies

• A nutrition support team is recommended to minimize complications through adherence to management protocols, particularly catheter care 1
• The core nutrition support team should include a physician, nutrition nurse specialist, senior dietician, and senior clinical pharmacist 1
• Proper validation of TPN formulations by a licensed manufacturer or qualified institution is essential 1
• Multi-layer bags impermeable to oxygen and light protection for both bags and administration sets are recommended 1
• TPN should be administered via a central line with its tip positioned in the superior vena cava or inferior vena cava 1
• Cycling TPN to overnight infusion should be implemented as soon as metabolically feasible 1
• Replacing one-third of TPN glucose calories with fat leads to better glucose tolerance and fewer hepatic complications 7
• Early enteral feeding, even in minimal amounts, may prevent many metabolic complications associated with TPN 5

When to Consider Intestinal Transplantation

• Intestinal transplantation should be considered when life-threatening complications of TPN occur, including:
  • Progressive liver disease 1
  • Loss of vascular access 1
  • Recurrent or life-threatening central line sepsis 1
  • Inability to maintain adequate hydration/nutrition despite TPN 1