Читать книгу Mount Sinai Expert Guides - Группа авторов - Страница 144

 Catheter infections remain the major infectious complication of parenteral nutrition. Common pathogens include Staphylococcus epidermidis, Candida, and S. aureus. For patients on TPN, an established catheter monitoring and maintenance protocol is essential. In patients with suspected infection, replacement of the central catheter at a different site is necessary.

 Hyperglycemia can occur as a result of increased parenteral carbohydrate availability along with concomitant insulin resistance. This can be avoided by gradual titration to the patient’s carbohydrate goal as well as regular glucose monitoring. Goal blood glucose should be between 140 and 180 mg/dL.

 Hypertriglyceridemia can occur as a result of lipids infusion, the underlying stress hormone production, and renal insufficiency. In severe cases (triglycerides >1000 mg/dL) this can lead to precipitation of acute pancreatitis. Lipids should be removed from TPN if the plasma triglyceride concentration exceeds 400 mg/dL.

 Hepatic steatosis and cholestasis are known complications of long‐term parenteral nutrition. More often seen in children, the exact etiology of fatty liver remains unclear. In the absence of enteral nutrition it is also common for development of cholestasis and biliary sludge. Early resumption of enteral feeding is the definitive treatment. Experimental use of ursodeoxycholic acid and cholecystokinin have shown mixed results.

 Refeeding syndrome can occur when TPN is introduced to patients who are severely malnourished. A rapid intracellular shift of potassium phosphorous and magnesium can precipitate rhabdomyolysis heart failure and cardiac arrhythmias. Careful monitoring and timely replacement of electrolytes can help avoid this complication.

 Intestinal mucosal atrophy can occur in the absence of enteral nutrition. There is risk for bacterial overgrowth and translocation of bacteria in the setting of mucosal denudation and impaired local immunity. The early initiation of trophic feeds helps reduce the risk of infection and translocation. The role of antibiotic agents such as neomycin to inhibit bacterial growth remains poorly defined.