Chapter 8: IV Therapy
8.12 Parenteral Nutrition (PN)
Critical Thinking Exercises: Questions, Answers, and Sources / References
- Describe refeeding syndrome and state one method to reduce the risk of refeeding syndrome.
Answer: Refeeding syndrome is caused by rapid refeeding after a period of malnutrition. It can result in metabolic and hormonal changes, and it is characterized by electrolyte shifts (decreased phosphate, magnesium, and potassium in serum levels) that may lead to widespread cellular dysfunction. Phosphorus, potassium, magnesium, glucose, vitamin, sodium, nitrogen, and fluid imbalances can be life-threatening.
High-risk patients include the chronically undernourished and those with little intake for more than 10 days. Patients with dysphagia are at higher risk.
The syndrome usually occurs 24 to 48 hours after refeeding has started. The shift of water, glucose, potassium, phosphate, and magnesium back into the cells may lead to muscle weakness, respiratory failure, paralysis, coma, cranial nerve palsies, and rebound hypoglycemia.
Interventions: PN infusion rate should be based on the severity of undernourishment for moderate- to high-risk patients. PN should be initiated slowly and titrated up for four to seven days. All patients require close monitoring of electrolytes (daily for one week, then usually three times/week). Always follow agency policy. Blood work may be more frequent depending on the severity of the malnourishment.
Copied from Anderson, R. (2018). Clinical Procedures for Safer Patient Care – Thompson Rivers University Edition. Adapted from Clinical Procedures for Safer Patient Care by G. R. Doyle and J. A. McCutcheon. Chapter 11 Parenteral Nutrition. https://pressbooks.bccampus.ca/clinicalproceduresforsaferpatientcaretrubscn/chapter/8-12-parenteral-nutrition-pn/
Sources:
Chowdary, K. V. R., & Reddy, P. N. (2010). Parenteral nutrition: Revisited. Indian Journal of Anaethestic, 54(2), 95-103. doi: 10.4103/0019-5049.63637.
Mehanna, H., Nankivell, P. C., Moledina, J., & Travis, J. (2009). Refeeding syndrome — awareness, prevention and management. Head and Neck Oncology, 1(4). https://doi.org/10.1186/1758-3284-1-4.
O’Connor, A., Hanly, A. M., Francis, E., Keane, N., & McNamara, D. (2013). Catheter associated blood stream infections in patient receiving parenteral nutrition: A prospective study of 850 patients. Journal of Clinical Medical Research, 5(1),18-21. https://dx.doi.org/10.4021%2Fjocmr1032w.
Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed). St. Louis, MO: Elsevier-Mosby.
- A patient receiving PN for the past 48 hours has developed malaise and hypotension. What potential complication are these signs and symptoms related to?
Answer:
Rule out potential hypoglycemia if PN solution contains insulin. Assess blood glucose.
Consider possible PN specific potential complications such as those in the following table:
| Complication | Rationale and Interventions |
| Cathet