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Guidelinesonparenteral Nutrition, Chapter 11 Special Issue OPEN ACCESS Review Article Complications and Monitoring – Guidelines on Parenteral Nutrition, Chapter 11 Komplikationen und Monitoring – Leitlinie Parenterale Ernährung, Kapitel 11 Abstract Compared to enteral or hypocaloric oral nutrition, the use of PN (par- W. H. Hartl1 enteral nutrition) is not associated with increased mortality, overall K. W. Jauch1 frequency of complications, or longer length of hospital stay (LOS). The 2 risk of PN complications (e.g. refeeding-syndrome, hyperglycaemia, K. Parhofer bone demineralisation, catheter infections) can be minimised by carefully P. Rittler1 monitoring patients and the use of nutrition support teams particularly Working group for during long-term PN. Occuring complications are e.g. the refeeding- syndrome in patients suffering from severe malnutrition with the initi- developing the ation of refeeding or metabolic, hypertriglyceridemia, hyperglycaemia, guidelines for osteomalacia and osteoporosis, and hepatic complications including parenteral nutrition of fatty liver, non-alcoholic fatty liver disease, cholestasis, cholecystitis, The German and cholelithiasis. Efficient monitoring in all types of PN can result in Association for reduced PN-associated complications and reduced costs. Water and electrolyte balance, blood sugar, and cardiovascular function should Nutritional Medicine regularly be monitored during PN. Regular checks of serum electrolytes and triglycerides as well as additional monitoring measures are neces- 1 Dept. Surgery Grosshadern, sary in patients with altered renal function, electrolyte-free substrate University Hospital, Munich, intake, lipid infusions, and in intensive care patients. The metabolic Germany monitoring of patients under long-term PN should be carried out accord- 2 Dept. Medicine II, University ing to standardised procedures. Monitoring metabolic determinants of of Munich, Germany bone metabolism is particularly important in patients receiving long- term PN. Markers of intermediary, electrolyte and trace element meta- bolism require regular checks. Keywords: refeeding syndrome, hyperglycaemia, hypertriglyceridemia, liver disease, catheter infection Zusammenfassung Im Vergleich zu einer enteralen bzw. hypokalorisch oralen Ernährung ist die PE (parenterale Ernährung) nicht mit einer erhöhten Letalität, Komplikationshäufigkeit insgesamt und Krankenhausverweildauer verbunden. Das Risiko durch PE verursachter Komplikationen (wie z.B. Refeeding-Syndrom, Hyperglykämie, Knochendemineralisierung, Kathe- terinfektionen) kann durch eine sorgfältige Überwachung des Patienten und durch den Einsatz von Ernährungsteams, besonders während einer Langzeit-PE, minimiert werden. Auftretende Komplikationen sind z.B. das Refeeding-Syndrom bei Patienten mit ausgeprägter Mangelernäh- rung, bei denen eine erneute Ernährung begonnen wird. Weitere schwere Nebenwirkungen können metabolische und hepatische Kom- plikationen sein, wie eine Hypertriglyzeridämie, Hyperglykämie, Fettleber, Steatohepatitis, Cholestase, Cholezystitis, Cholelithiasis sowie Osteo- malazie und Osteoporose. Die Effizienzkontrolle bei jeder Art von PE kann zur Reduktion von PE-assoziierten Komplikationen und zur Kos- tensenkung führen. Unter PE sollte Wasser,- Elektrolyt- und Zuckerhaus- halt sowie die kardiozirkuläre Funktion engmaschig überwacht werden. Regelmäßige Kontrollen der Serumelektrolyte und der Triglyzeride sind GMS German Medical Science 2009, Vol. 7, ISSN 1612-3174 1/12 Hartl et al.: Complications and Monitoring – Guidelines on Parenteral ... unter PE erforderlich sowie zusätzliche Überwachungsmaßnahmen bei Patienten mit Nierenfunktionsstörungen, bei elektrolytfreier Substratzu- fuhr, Fettinfusion bzw. bei Intensivpatienten. Das metabolische Monito- ring von Patienten unter längerfristiger PE sollte nach standardisierten Schemata erfolgen. Unter Langzeit-PE sind zusätzlich die metabolischen Determinanten des Knochenstoffwechsels überwachungspflichtig. Va- riablen des Intermediär-, Elektrolyt- und Spurenelementstoffwechsels bedürfen einer Kontrolle in regelmäßigen Abständen. Schlüsselwörter: Refeeding-Syndrom, Hyperglykämie, Hypertriglyzeridämie, Hepatopathie, Katheterinfektion Complications Commentary Preliminary remarks and general Benefits and side effects of PN have been the subject of information extensive literature analyses and intensive scientific dis- cussions. The most extensive meta analysis on this topic Parenteral Nutrition (PN) is beneficial and life-saving in was presented by Koretz and co-workers in 2001 [3]. a variety of clinical conditions, but can also result in nu- Eighty-two randomised controlled studies were evaluated merous, potentially serious, side-effects [1], [2]. The risk in which parenterally nourished patients received intra- of such complications can be minimised by carefully venous fluids with a mixture of amino acids and at least monitoring patients and the use of nutrition support 10 kcal/kg body weight per day of non-protein calories. teams. Control patients were either not given intravenous nutri- One of the most dramatic side effects of PN is the so- tion at all (only spontaneous oral food intake) or received called refeeding syndrome, which can occur in severely up to 5% glucose solutions intravenously as basal fluid malnourished patients who are receiving aggressive PN. intake. PN did not significantly change either mortality or In addition, hyperglycaemia can occur due to parenteral morbidity (overall rate of complications) compared to the carbohydrate intake in diabetic patients, in response to control group. There was, however, a significant increase postaggression metabolism or the systemic inflammatory in infectious complications (+5%) with PN, which caused response syndrome (SIRS), or due to systemic steroid one additional infection per 20 PN treated patients. A therapy. In extreme cases PN can result in a hyperosmol- subgroup analysis revealed that this side-effect occurred ar, hyperglycaemic non-ketotic coma. mainly in tumour patients receiving oncologic therapy. In When suddenly discontinuing parenteral intake, rebound other subgroups, for example perioperative patients, the hypoglycaemia, although rare, may occur. Abnormalities infection frequency was not increased. The overall LOS in the acid-base-balance can occur due to PN and may with PN was not increased despite the increased inci- result in significant electrolyte shifts. Hypertriglyceridemia dence of infection. with dyslipoproteinaemia may occur. High carbohydrate A further meta-analysis on the frequency of complications intakes may result in excessive carbondioxide production. was published by Braunschweig and co-workers [4]. The Hepatic complications of PN include steatosis (fatty liver) inclusion criteria varied from those of Koretz's analysis and cholestasis. Special complications like metabolic in that only those studies were considered where the bone disease wih bone demineralisation and osteoporosis calorie intake with PN either met or exceeded energy re- may occur in patients receiving long-term PN. In all forms quirements. Some 27 studies, with a total of 1829 pa- of PN there is an imminent risk of infectious complica- tients, were identified comparing PN with appropriate tions. Finally, intestinal side-effects (mucosal atrophy, enteral intake. This analysis showed that infectious increased translocation of micro organisms and their complication incidence increased significantly when pa- toxins) may also occur. tients received PN relative to patients in the control group who received either isocaloric enteral nutrition or oral Relevance of complications in short-term nutrition. Mortality was unaffected by PN. Malnourished patients receiving PN had a lower infection frequency and PN with respect to patient outcome a significantly lower mortality than those receiving only oral food intake. The increased infectious morbidity is • Compared to enteral or hypocaloric oral nutrition, total likely due to the relatively high amounts of carbohydrates PN is not associated with increased mortality, overall administered parenterally in some of the older studies frequency of complications, or longer length of hospital included in the analysis. The hyperglycaemic episodes stay (LOS) (I). that must be expected with high dosage of parenteral supply are a well-known complication of PN. The incidence of hyperglycaemia is evidently higher even with normocal- GMS German Medical Science 2009, Vol. 7, ISSN 1612-3174 2/12 Hartl et al.: Complications and Monitoring – Guidelines on Parenteral ... oric PN intake as compared to enteral or oral food intake Refeeding syndrome [4]. Persistent hyperglycaemia and associated immunosup- • Initiation of refeeding in patients suffering from severe pression are considered causal factors for a poor patient malnutrition may result in severe adverse effects, the outcome [5], which would explain the better results of so-called refeeding syndrome (III). the meta-analysis by Koretz and co-workers who included in their meta-analysis studies with a minimum daily energy Commentary intake of approx. 15 kcal/kg body weight. The frequency of infectious complications is probably reduced with a Refeeding syndrome is especially prevalent in severely low substrate intake and hence a low incidence of hyper- malnourished patients and usually occurs during the first glycaemia. few days after initiating refeeding [14]. The exact inci- The known complications of PN caused a fierce contro- dence is not known give a considerable heterogeneity of versy in 2003 on
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