Common Complications Associated with Parenteral Nutrition in Adults

Common Complications 

Associated with 

Parenteral Nutrition in Adults 

Ginger Langley, Pharm.D., BCNSP 

The University of Texas M.D. Anderson Cancer Center 

Houston, Texas

• 57-year-old female with metastatic breast 

cancer and carcinomatosis 

• Chief complaint of increasing abdominal pain 

and persistent nausea and vomiting 

• 25 pound weight loss in 2 months 

• TPN initiated for surgical exploration

• 48-year-old male Type 2 diabetic 

s/p allogeneic bone marrow transplant 

• TPN initiated secondary to severe GVHD 

• ICU admission further complicated by 

diffuse alveolar hemorrhage 

• Methylprednisolone 500mg IV daily x 3 days

• 38-year-old female with gastric outlet 

obstruction discharged on HPN 

• Discharge TPN formula includes 3 mL 

of M.T.E.-5 

• M.T.E.-5 Concentrated substituted for 

M.T.E.-5 to prepare for expected 3 month 

supply shortage of M.T.E.-5

Complications of 

Parenteral Nutrition 

Mechanical 

Infectious 

Metabolic

Fluid and Electrolyte 

Imbalances 

Glucose 

Intolerance 

Micronutrient 

Deficiencies 

Metabolic 

Complications 

Hepatic 

Steatosis 

Essential Fatty Acid 

Deficiency 

Metabolic 

Bone Disease

Refeeding Syndrome 

• Severe electrolyte and fluid shifts associated 

with metabolic abnormalities in malnouished 

patients undergoing feeding 

• Potentially lethal condition 

• Hypophosphatemia no longer considered the 

predominant feature


Clinical Features 

• Hypophosphatemia 

• Hypokalemia 

• Hypomagnesemia 

• Body fluid disturbances 

• Vitamin deficiency 

• Abnormalities in glucose metabolism

High-risk Patient Populations 

Kwashiorkor or marasmus 

Anorexia nervosa 

Chronic malnutrition 

Chronic alcoholism 

Prolonged fasting 

Duodenal switch operation for obesity 

Hunger strikers 

Oncology patients 

Postoperative patients

Starvation/Malnutrition 

Gluconeogenesis 

Protein Catabolism 

Weight Loss 

Refeeding 

Syndrome 

Water/Vitamin/Mineral 

Depletion 

Thiamine Utilization 

Refeeding 

PO 4 

PO 4 Mg 

++ 

Glucose 

K + 

Anabolism 

Pancreatic Insulin Release

Refeeding Syndrome Clinical Manifestations 

Phosphorus 

Potassium 

Magnesium 

Cardiac 

X 

X 

X 

GI 

X 

X 

Hematologic 

X 

Hepatic 

X 

Neuromuscular 

X 

X 

X 

Respiratory 

X


Clinical Manifestations 

• Weight gain 

– Total body water 

– Extracellular fluid volume 

• Hyperglycemia 

– Osmotic diuresis 

– Dehydration 

– Hypotension

• 57-year-old female with metastatic breast 

cancer and carcinomatosis 

• Chief complaint of increasing abdominal pain 

and persistent nausea and vomiting 

• 25 pound weight loss in 2 months 

• TPN initiated for surgical exploration


Prevention and Management 

• Perform thorough nutritional assessment 

• Identify and correct electrolyte disorders 

prior to initiation of parenteral nutrition 

• Start low and go slow with calories

Hyperglycemia 

• Well-known complication of parenteral 

nutrition with serious consequences 

• Strong correlation with rate of glucose 

infusion in TPN 

• Adversely effects clinical outcome during 

short-term hospitalization

Development of Hyperglycemia 

Insulin Deficiency 

Preexisting DM 

Elderly 

Pancreatitis 

Excessive Dextrose 

Administration 

Insulin Resistance 

Catecholamine infusions 

Corticosteroids 

Obesity 

Sepsis 

Uremia 

Cirrhosis

Hyperglycemia 

↑ INSULIN 

↑ Na & Water Reabsorption 

in proximal & distal tubule

Hyperglycemia 

↑ K Cellular Uptake 

Hypokalemia 

↑ INSULIN 



Hyperglycemia 

↑ Intracellular Phosphate Shift 

Hypophosphatemia 


Hypokalemia 

↑ INSULIN 



Hyperglycemia 

↑ Intracellular Phosphate Shift 

Hypophosphatemia 


Hypokalemia 

↑ INSULIN 

↑ Phosphate 

Reabsorption in 

proximal tubule 



Consequences of Hyperglycemia 

• Enhanced proteolysis 

• Decreased immune function 

• Increased infections 

• Poor wound healing 

• Osmotic diuresis 

• Electrolyte disorders (pseudohyponatremia)

Who’s at risk for hyperglycemia 

• Obesity 

• Diabetes mellitus 

• Acute & chronic pancreatitis 

• Corticosteroid-dependent patients 

• SIRS & Sepsis 

• Drug-induced

• 48-year-old male Type 2 diabetic 

s/p allogeneic BMT 

• TPN initiated secondary to severe GVHD 

• ICU admission further complicated by 

diffuse alveolar hemorrhage 

• Methylprednisolone 500mg IV daily x 3 days

Hyperglycemia 


• Identify and remove offending agents 

• Provide dextrose at appropriate rate 

– ≤ 4 mg/kg/min 

– Decrease TPN rate 

• Administer more calories as fat 

• Add insulin to TPN 

– 1 unit/10g dextrose for nondiabetics 

– 1 unit/ 5g dextrose for diabetics

Micronutrient Abnormalities 

• Zinc deficiency 

• Copper deficiency 

• Selenium deficiency 

• Chromium deficiency 

• Manganese intoxication

Zinc Deficiency 

• Risk factors 

– Hypercatabolism 

– Excessive diarrhea 

• Requirement 

– Normal stool losses: 6 mg/day 

– Short bowel syndrome: 12 – 20 mg/day 

• Presents as perioral postural rash, alopecia, 

darkening of skin creases, and neuritis

Copper Deficiency 

• Excessive diarrhea is a risk factor 

• Presents as microcytic anemia often 

mistaken for pyridoxine deficiency 

• Administer up to 2mg/day of copper as 

sulfate salt in deficient states 

• Liver disease reduces biliary excretion 

and lowers requirement

Selenium Deficiency 

• Clinical manifestations are rarely seen 

• Requirements during parenteral nutrition 

– Adults: 50 – 60 mcg/day 

– Children: 1 – 4 mcg/kg/day 

• Symptoms: skeletal myalgias and 

myopathy, hair depigmentation, nail 

streaking, and dilated cardiomyopathy

Chromium Deficiency 

• Patients on long-term TPN with little or 

no oral intake at highest risk 

• Requirements 

– Daily: 15 – 20 mcg/day 

– Deficiency: 150 mcg/day for several days 

• Manifestations: difficult blood glucose 

control, peripheral neuropathy, and 

encephalopathy

Manganese Intoxication 

• Patients with significant hepatobiliary disease 

at highest risk 

• Clinical presentation 

– Parkinsonian-like symptoms 

• Muscular weakness, stiffness 

• Tremors, ataxia, abnormal gait 

– Psychological changes 

• Mental irritability, headaches 

• Nervousness, compulsive actions, hallucinations


• Clinical symptom severity depends on 

– Parenteral dose 

– Duration of therapy 

– Extent of liver disease 

–Age 

• Adult requirements 

– Acute setting: 0.15 – 0.8 mg/day 

– Long-term setting: 0.1 – 0.3 mg/day

• 38-year-old female with gastric outlet 

obstruction discharged on HPN 

• Discharge TPN formula includes 3 mL 

of M.T.E.-5 

• M.T.E.-5 Concentrated substituted for 

M.T.E.-5 to prepare for expected 3 month 

supply shortage of M.T.E.-5



• Remove supplemental manganese from 

parenteral solutions in patients with liver 

disease 

• Avoid using trace-element concentrate in 

long-term adult patients 

• Supplement micronutrient deficiencies with 

single-entity products 

• Monitor blood manganese levels in long-term 

HPN patients

Summary 

• Most complications associated with 

parenteral nutrition are easily prevented or 

treated due to advances in modern medicine. 

• Nonetheless, hyperglycemia and catheterrelated 

sepsis still occur. 

• Early identification of severely malnourished 

patients and appropriate monitoring regimens 

are critical in reducing complications 

associated with parenteral nutrition.

Adults - Common Complications Associated with Parenteral Nutrition 

Ginger Langley PharmD 

The University of Texas M.D. Anderson Cancer Center 

Houston, TX 

Learning Objectives 

Upon completion of this session, the participant will be able to: 

1. Identify the risk factors and clinical features of the refeeding syndrome. 

2. Describe methods to prevent and manage hyperglycemia associated with parenteral nutrition. 

3. Discuss micronutrient abnormalities associated with acute and chronic parenteral nutrition. 

I. Complications of Parenteral Nutrition 

A. Mechanical 

B. Infectious 

C. Metabolic 

II. 


A. Clinical features 

B. High-risk patient populations 

C. Prevention and management 

III. Hyperglycemia 

A. Etiologies 

B. Adverse effects 

C. Prevention and management 

IV. Micronutrient Abnormalities 

A. Zinc deficiency 

B. Copper deficiency 

C. Selenium deficiency 

D. Chromium deficiency 

E. Manganese intoxication 

Self-Assessment Questions 

1. All of the following electrolyte abnormalities are present with the refeeding syndrome except: 

a. Hypokalemia 

b. Hypophosphatemia 

c. Hypomagnesemia 

d. Hypouricemia 

2. Hyperglycemia secondary to initiation of TPN in most patients can be managed by adding 0.1 units 

of insulin to the TPN for every gram of dextrose. 

a. True 

b. False 

3. All of the following are risk factors for the development of manganese intoxication except: 

a. Age 

b. Hepatobiliary disease 

c. High-dose parenteral manganese supplementation 

d. Renal failure

References 


1. Solomon SM, Kirby DF. The refeeding syndrome: A review. JPEN 1990; 14:90-97. 

2. Crook MA, Hally V, Panteli JV. The importance of the refeeding syndrome. Nutrition 2001;17:632-637. 

3. Brooks MJ, Melnik G. The refeeding syndrome: An approach to understanding its complications and preventing its 

occurrence. Pharmacotherapy 1995;15:713-726. 

Hyperglycemia 

1. McMahon M, Manji N, Driscoll DF, et al. Parenteral nutrition in patients with diabetes mellitus: Theoretical and 

practical considerations. JPEN 1989;13:196-204. 

2. McMahon MM. Management of hyperglycemia in hospitalized patients receiving parenteral nutrition. NCP 

1997;12:35-41. 

3. Schloerb PR, Henning JF. Patterns and problems of adult total parenteral nutrition use in US academic medical 

centers. Arch Surg 1998;133:7-12. 

4. Montori VM, Bistrian BR, McMahon MM. Hyperglycemia in acutely ill patients. JAMA 2002;288:2167-2169. 

Micronutrient Abnormalities 

1. Sudhakar M, Kirby DF. Micronutrient and trace element monitoring in adult nutrition support. NCP 2000;15:120- 

126. 

2. Baumgartner TG. Trace elements in clinical nutrition. NCP 1993;8:251-263. 

3. McClain CJ. Trace metal abnormalities in adults during hyperalimentation. JPEN 1981;5:424-429. 

4. Dickerson RN. Manganese intoxication and parenteral nutrition. Nutrition 2001;17:689-693. 

Answers to Self-Assessment Questions, Rationale and References 

1. The correct answer is d. Hypouricemia. 

Main pathophysiologic features of the refeeding syndrome are: abnormalities of fluid balance, 

abnormalities of glucose metabolism, vitamin deficiency, hypophosphatemia, hypomagnesemia, 

and hypokalemia. 

Nutrition 2001;17:632-637. 

2. The correct answer is a. True. 

Most diabetic patients need supplemental insulin when glucose is infused. For patients previously 

treated with insulin or oral agents or for patients with a fasting glucose greater than 180 to 200 

mg/dL, a basal amount of Human Regular insulin is added to dextrose-containing PN solutions. 

Insulin at 0.1 unit per gram of dextrose is our starting point. 

NCP 1997;12:35-41. 

3. The correct answer is d. Renal failure. 

Manganese is eliminated predominantly through the hepatobiliary system. The literature suggests 

that the presence of hypermanganesemia and the clinical symptoms from manganese toxicity 

depend on the dose of parenteral manganese, duration of use, and the presence of significant liver 

disease. Others have suggested age as risk factor for development of toxicity, with infants, 

children, and older adults being more susceptible to manganese toxicity. 

Nutrition 2001;17:689-693.

Common Complications Associated with Parenteral Nutrition in Adults

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