Editing Artificial nutrition (section)

=== '''Complications''' ===

** Related to nutrient deficiency
*** Refeeding syndrome
**** Severe fluid and electrolyte shifts in malnourished patients undergoing refeeding
**** Results in low phosphate, magnesium and calcium
**** Need to replace phosphate and magnesium and increase TPN rate slowly
****
*** Chronic deficiency syndromes
** Related to overfeeding
*** Excess glucose: hyperglycaemia (may need insulin infusion), hyperosomolar dehydration, hepatic steatosis, hypercapnia, increased sympathetic activity, electrolyte abnormalities
*** Excess fat: hypercholesterolaemia/hypertriglyceridaemia
**** Consider whether propofol is being used - also has a high lipid content - reducing it can help with triglyceride levels
**** Alternatively, some lipid-free emulsions are available
*** Excess amino acids
** Fluid overload
** Deranged LFTs
*** Intra-hepatic cholestasis
*** Hepatic steatosis
*** Hepatomegaly 
*** Sometimes need to reduce fat content of TPN in this setting
*** For more discussion on what to do about LFT derangements with TPN, see the 'LFTs' page under Periop medicine
** Catheter-related blood-stream infection
*** Prevent by choosing the right site (avoid femoral), hand hygiene, alcohol-based chlorhex skin prep, maximum barrier precautions, catheter-care guidelines
*** Suspect CLABSI with low-grade fever for a few days, then spiking fever and rigors. Take cultures from the line and also somewhere else. Culture tip when removing CVC. Will need 24-48 hours of adequate Abx coverage before reinserting central line.
*** Ideally, whenever line infection is suspected, you would remove the line and culture the tip. However if this is going to create problems, a compromise would be to just culture the line.
** Blocked line
*** Flush with saline
*** Occasionally alteplase/urokinase are used
** Central venous thrombosis
*** As per topic under 'vascular'