DEPATMENT OF INTENSIVE

CARE MEDICINE

Nutritional Therapy Complications

and Management in ICU

September 2023

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Nutritional Therapy Complications and Management
Nutrition is the basic part of treating almost every patient’s specifically critically ill patients in
ICU in order to increase survival and fighting different type of chronic and acute disorders. Even
if supporting patients with variety of nutritional supplement have benefits without adequate
knowledge and inappropriate administration can have several complications including death.

Oral
Oral supplementation may be necessary for patients who can eat and have normal digestion and
absorption but cannot consume enough regular foods to meet caloric and protein needs. Patients
with mild-to-moderate anorexia, burns, or trauma sometimes fall into this category.

Oral feeding have the lowest risk of having complication as compared to the tube and parenteral
feeding however studies have been suggested complications due to oral complications including

Aspiration

Chocking

Tooth decay

Enteral feeding access complications

Enteral nutrition or tube feedings are used for patients who have at least some digestive and
absorptive capability but are unable or unwilling to consume enough by mouth. When possible,
the enteral route is the preferred method of feeding over total parenteral nutrition (TPN). The
proposed advantages of enteral nutrition over TPN include lower cost, better maintenance of gut
integrity, and decreased infection and hospital length of stay.

The gastrointestinal (GI) tract plays an important role in maintaining immunologic defenses,
which is why nutrition by the enteral route is thought to be more physiologically beneficial than
TPN. Some of the barriers to infection in the GI tract include neutrophils; the normal acidic
gastric pH; motility, which limits GI tract colonization by pathogenic bacteria; the normal gut
microflora, which inhibit growth of or destroy some pathogenic organisms; rapid desquamation

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and regeneration of intestinal epithelial cells; the layer of mucus secreted by GI tract cells, and
bile, which detoxifies endotoxin in the intestine and delivers immunoglobulin A (IgA) to the
intestine.

Gastrointestinal complications

Nausea and vomiting

Approximately 20% of patients receiving enteral tube feedings experience nausea and vomiting.
Vomiting increases the risk of aspiration. Causes are multi factorial but delayed gastric emptying
is the most common problem.

If delayed gastric emptying is suspected, reducing narcotic medications, switching to a low-fat

formula, administering the feeding solution at room temperature, reducing the rate of
administration, and administering a pro motility agent.

In case of distention, check gastric residuals before the next bolus feeding, or every four hours
for continuous feeding. If gastric residuals are low yet nausea persists, consider antiemetic
medications.

Diarrhea

Diarrhea is common in tube fed patients, occurring in 2% to 63% of patients depending on how it
is defined. If clinically significant diarrhea develops during enteral tube feeding, we use the
following options:

 Add fiber, e.g., psyllium

 Consider an enteral formula with fiber
 Change the formula
 Use an anti diarrheal agent

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Constipation

Constipation can result from inactivity, decreased bowel motility, decreased fluid intake,
impaction, or lack of dietary fiber. Poor bowel motility and dehydration may lead to impaction
and abdominal distension. A standard abdominal x-ray is often effective for diagnosis and will
clearly differentiate constipation from bowel obstructions.

Constipation usually is improved through adequate hydration and use of fiber-containing

formulas, stool softeners, or bowel stimulants.

Malabsorption

Malabsorption is defined as impaired absorption of one or more nutrients. Clinical

manifestations include unexplained weight loss, steatorrhea, diarrhea, anemia, tetany, bone pain,
bleeding, neuropath, glossitis, or edema.

Causes of malabsorption are many and include gluten sensitive enteropathy, Crohn's disease,
diverticular disease, radiation enteritis, enteric fistuals, HIV, pancreatic insufficiency, and short
bowel syndrome. Knowledge of the patient's history and selection of an appropriate enteral
product should help reduce or prevent malabsorption. However, depending upon the extent of
disease, parenteral nutrition may be necessary.

Mechanical complications

Aspiration

Pulmonary aspiration is an extremely serious complication of enteral feeding and can be life-
threatening in malnourished patients.

The incidence of clinically significant aspiration pneumonia is 1% to 4%. Symptoms of

aspiriation include dyspnea, tachypnea, wheezing, rales, tachycardia, agitation, and cyanosis.

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Aspiration of small amounts of formula may not cause immediate symtoms, but a fever later may
suggest development of aspiration pneumonia.

Risk factors for aspiration include:

 Decreased level of consciousness

 Diminished gag reflex
 Neurologic injury
 Incompetent LES
 GI reflux
 Supine position
 Use of large-bore feeding tubes
 Large gastric residuals

Use of small-bowel feeding tubes, promotility agents, periodic assessment of gastric residuals,
and keeping the head of the bed elevated may reduce the risk of aspiration.

Tube malposition

Complications may arise during the placement of a feeding tube or simply from the presence of
one. Feeding tube placement can cause bleeding, tracheal or parenchymal perforation, and GI
tract perforation. Using appropriate post-placement monitoring (Auscultation and X-ray) should
minimize these complications.

Presence of the feeding tube itself may cause upper and lower airway complications, aggravation
of esophageal varices, cellulitis, necrotizing fasciitis, fistulas, and wound infection. Use of a
small-bore feeding tube and very attentive nursing care can minimize many of these
complications.

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Tube clogging

Tube clogging is more likely with intact protein products and viscous products. Most clogs can
be prevented by routine flusing of the feeding tube, use of clean technique to minimize formula
contamination, and extreme care when administering medications via the feeding tube.

The recommended first line method to unclog a tube is to instill warm water using slight manual
pressure. If this fails, a pancrelipase and sodium bicarbonate solution may be instilled in order to
"digest" the clog.

Metabolic complications

Metabolic complications of enteral nutrition are similar to those that occur during PN, although
the incidence and severity may be less. Careful monitoring can minimize or prevent metabolic
complications.

Hyponatremia, hypernatremia, dehydration, hyperglycemia, hypoglycemia, hypokalemia and

hyperkalemia are the most common complications resulted from malnutrition and overfeeding.
The managements for those metabolic complications are managed accordingly through selective
and appropriate supplement accordingly

Re-feeding syndrome

Refeeding of severely malnourished patients may result in "refeeding syndrome" in which there
are acute decreases in circulating levels of potassium, magnesium, and phosphate. The sequelae
of refeeding syndrome adversely affect nearly every organ system and include cardiac
dysrhythmias, heart failure, acute respiratory failure, coma, paralysis, nephropathy, and liver
dysfunction.

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The primary cause of the metabolic response to refeeding is the shift from stored body fat to
carbohydrate as the primary fuel source. Serum insulin levels rise, causing intracellular
movement of electrolytes for use in metabolism.

The best option when initiating nutritional support is to "start low and go slow".
Recommendations to reduce the risk of refeeding syndrome include:

 Recognize patients at risk

o Anorexia nervosa
o Classic kwashiorkor or marasmus
o Chronic malnutrition
o Chronic alcoholism
o Prolonged fasting
o Prolonged IV hydration
o Significant stress and depletion
 Correct electrolyte abnormalities before starting nutritional support
 Administer volume and energy slowly
 Monitor pulse, I/O, electrolytes closely
 Provide appropriate vitamin supplementation
 Avoid overfeeding

Total Parenteral Nutrition (TPN) Complications

Parenteral nutrition means feeding intravenously (through a vein). "Parenteral" means "outside of the
digestive tract." Whereas enteral nutrition is delivered through a tube to stomach or the small intestine,
parenteral nutrition bypasses entire digestive system, from mouth to anus. Certain medical conditions may
require parenteral nutrition for a short or longer time. Some patients need it to supplement their diet, and
some need to get all of their calories intravenously.

Parenteral nutrition can be partial or total.

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  Partial parenteral nutrition (PPN) is parenteral nutrition given to supplement other kinds of
feeding. If the patient is eating but still have malnutrition, parenteral nutrition help the patient to
replace missing elements in diet or give additional calories.
 Total parenteral nutrition (TPN) is complete nutrition delivered intravenously to patients who
can’t use their digestive systems at all. TPN might be required when certain conditions impair
ability to process food and absorb nutrients through digestive tract.

Sometimes parenteral nutrition is classified by the type of vein that is used to deliver the
nutrition.

Total parenteral nutrition (TPN) is a feeding method that omits the gastrointestinal tract. Most of
the body’s nutritional requirements are met by a specific formula that is administered
intravenously. This technique is utilized when a person cannot receive feedings or fluids orally.
A patient may require TPN permanently or temporarily, depending on the illness.

Poor aseptic techniques and poor maintenance of TPN central lines can lead to severe TPN
complications. It has been reported that about 5% to 10% of patients receiving total parenteral
nutrition (TPN) have experienced adverse side effects and long-term complications associated
with central venous access (central lines) or TPN itself.

Catheter-associated TPN Complications

Catheter insertions are necessary for TPN feedings and may lead to catheter-related problems.
Two complications that most frequently arise are infections and catheter occlusions. However,
these complications can be avoided by keeping the lines clean and using the catheter only for
TPN.

Other complications may include poor aseptic technique, contamination around the insertion
area, and poor maintenance of central lines. Complications with central venous access affect 5%
to 10% of individuals receiving TPN. The most frequent and potentially lethal catheter-
associated complications experienced by patients during TPN nutritional support include acute

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sepsis (bloodstream infection) and localized skin infections at the insertion or exit point of the
catheter.

Amateur insertion of catheters in the veins can result in air embolisms , pneumothorax (a
condition in which lungs collapse when the tip of a catheter enters into the pleural cavity), and
thrombosis (blockage of a vein due to blood clots or injury). According to TPN guidelines,
practicing aseptic techniques of insertion or removal of the catheter can help avoid catheter-
associated complications.

Metabolic Abnormalities

Approximately 90% of patients receiving TPN administration experience metabolic

complications, specifically glucose abnormalities. Metabolic complications can be controlled by
monitoring electrolytes, blood glucose levels, and insulin levels.

Metabolic complications may arise due to rapid infusion of nutrients after a recent malnourished
state. Some of the major metabolic abnormalities include hypoglycemia (which happens due to
TPN discontinuation) or hyperglycemia and refeeding syndrome (severely malnourished patients
experience this syndrome usually within 24 to 48 hours when TPN infusion results in metabolic
and hormonal changes characterized by electrolytes shift.) When starting TPN in previously
malnourished patients, refeeding syndrome is caused by abrupt changes in fluid and electrolyte
levels. Refeeding syndrome patients typically have low levels of phosphate, magnesium, and
potassium. These symptoms may become exacerbated with TPN, largely caused by low levels of
phosphate, leading to respiratory failure, convulsions, delirium, and death. It can also decrease
cardiac contractility.

Hepatic Complications

Total parenteral nutrition can result in a plethora of hepatic complications. Some of the hepatic
complications include hepatic steatosis, gallbladder and bile duct damage, and cholestasis. The
most serious consequence can lead to progressive fibrosis and cirrhosis, which is the most

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notable concern in long-term use of TPN in both adults and pediatric patients. Long-term TPN
use can lead to low birth weight, sepsis, short bowel syndrome, and prematurity.

Hepatic complications are more prevalent in infants with immature liver but can occur at any
age, affecting 15% to 40% of patients receiving total parenteral nutrition (TPN) infusion. Hepatic
complications include liver dysfunction, increased ammonia levels, and painful hepatomegaly.

 Liver dysfunction commonly occurs due to an increased ratio of bilirubin and alkaline
phosphatase, resulting in inflammation, cholestasis, and progressive fibrosis.
 Increased ammonia levels and painful hepatomegaly result in fat accumulation, feeling of
 Twitching, seizures, and lethargy.

Metabolic bone disease is a problem that can arise in long-term TPN use. Approximately 40% of
the patient’s receiving long-term TPN infusion experience metabolic bone diseases such as
osteomalacia and osteoporosis. This can lead to a decrease in quality of life due to bone pain,
fractures, and limited mobility. The reported causes of these bone diseases can be due to:

 Less exposure to sunlight (low vitamin D intake)

 Lack of physical activity
 Side effects of other therapies such as heparin and steroids
 Suboptimal intake of calcium, phosphate, and vitamin D

It has been demonstrated that intravenous pamidronate improves the bone mineral density of
patients receiving TPN at home

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Reference

1. Cleveland clinic,2022, http//:my.clavelandclinic.org/health/treatment

2. Amanda H. and Paul F., 2017, www.myamericannurse.com/enteral-feeding-indication-

complication

3. Lubos S. and Maria E., Baics in clinical nutrition: complications of parentral nutrition 2009,
www.clinicalnutritionespen.com

4. Dr. Martina M., Total parentral nutrition, 2022, www.ameripharmaspeciality.com/total-

patentral-nutrition-tpn-complications

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