Page 426 - Nutrition Essentials for Nursing Practice

414 U N I T 3 Nutrition in Clinical Practice

Refeeding Syndrome: better” and overfeeding was common practice (Koretz, 2007). At that time, PN was
a potentially fatal called “hyperalimentation”—literally excessive nourishment. It is now recognized that
complication that overfeeding, particularly overfeeding carbohydrates, in nutritionally debilitated patients can
occurs from an abrupt lead to a life-threatening complication known as the refeeding syndrome (see Chapter 16).
change from a catabolic The practice of overfeeding has been replaced with a more conservative, lower-in-calories
state to an anabolic approach.
state and an increase
in insulin caused by a Because PN is expensive, requires constant monitoring, and has potential infectious,
dramatic increase in metabolic, and mechanical complications (Box 15.5), it should be used only when an enter-
calories. al intake is inadequate or contraindicated and when the duration of nutritional support is
expected to be 7 days or more (McClave et al., 2009). Current guidelines for the provi-
sion and assessment of nutrition support therapy in the adult critically ill patient from the
American Society for Parenteral and Enteral Nutrition state that in patients who were previ-
ously healthy and well nourished prior to critical illness, the use of PN should be reserved
and initiated only after the first 7 days of hospitalization when EN is not feasible (McClave
et al., 2009). Two meta-analyses that compared the use of PN and no nutrition support in
this population found that no nutrition therapy was associated with lower infectious mor-
tality and a trend toward fewer overall complications than was the use of PN. After the first
14 days of hospitalization, the reverse is true: withholding nutrition therapy is associated
with higher mortality and longer length of stay than PN. In patients who have evidence
of protein–calorie malnutrition on admission, it is appropriate to initiate PN as soon as

Box 15.5 POTENTIAL COMPLICATIONS OF TOTAL PARENTERAL NUTRITION

Infection and Sepsis Related to Altered acid–base balance
Catheter contamination during insertion Elevated liver enzymes
Long-term indwelling catheter Fluid overload
Catheter seeding from bloodborne or
Mechanical Complications Related to
distant infection Catheterization
Contaminated solution Catheter misplacement
Hemothorax (blood in the chest)
Mechanical Complications Pneumothorax (air or gas in the chest)
Dehydration; hypovolemia Hydrothorax (fluid in the chest)
Bone demineralization Hemomediastinum (blood in the
Hyperglycemia
Rebound hypoglycemia mediastinal spaces)
Hyperosmolar, hyperglycemic, nonketotic Subcutaneous emphysema
Hematoma
coma Arterial puncture
Azotemia Myocardial perforation
Electrolyte disturbances Catheter embolism
Cardiac dysrhythmia
Hypocalcemia Air embolism
Hypophosphatemia, hyperphosphatemia Endocarditis
Hypokalemia Nerve damage at the insertion site
Hypomagnesemia Laceration of lymphatic duct
High serum ammonia levels Chylothorax
Deficiencies of Lymphatic fistula
Essential fatty acids Thrombosis
Trace elements
Vitamins and minerals