Complication	Comments	Potential prevention/treatment
Biliary diseases	Long-term PN has been associated with higher risk of acalculous and calculous cholecystitis; acalculous cholecystitis has been reported in approximately 4 percent of patients receiving PN for more than three months46	Oral or enteral intake can prevent cholecystitis and should be given as soon as feasible and in the smallest amount possible; daily cholecystokinin injections may reduce biliary stasis
Bone disease	Osteoporosis and osteomalacia are common with long-term PN and have an estimated prevalence of 40 to 100 percent	Encourage regular exercise; supplement PN with calcium; give vitamin D to correct deficiency; monitor serum 25-hydroxyvitamin D level; bisphosphonates have been used48
	Etiology is poorly understood; aluminum in the PN formula, vitamin D deficiency or excess, vitamin K deficiency, mineral deficiencies (calcium, phosphorus, magnesium), concomitant disease (e.g., inflammatory bowel disease), and medications (e.g., corticosteroids) have been implicated47
Catheter-related infections	Patients on PN have a fourfold higher risk of line infection compared with patients on other intravenous fluids, or about five cases per 1,000 catheter-days	Prevention and treatment of venous catheter– associated infections in accordance with Centers for Disease Control and Prevention guidelines42
	Mortality is estimated to be 12 to 25 percent for each infection41
Central venous access complications	Pneumothorax, arterial puncture, brachial plexus lesions, or line malposition occurs in 1 to 4 percent of central line placements40	Improved training and imaging guidance may decrease these complications40
Electrolyte imbalances (sodium, potassium, magnesium, phosphorus)	These imbalances are common but can be prevented with adequate monitoring	Adjust free water (sodium); avoid, monitor, and manage refeeding syndrome
Hyperglycemia	Most common cause is excessive dextrose infusion; others at risk include critically ill patients; patients with sepsis, diabetes mellitus, acute pancreatitis, or prematurity; and patients taking corticosteroids	Dextrose should not exceed 4 to 5 mg per kg per minute in adults or age-appropriate dosages in infants and children
		Glucose levels should be monitored every six hours until stable rate of PN infusion and stable blood glucose levels are reached
		Basal insulin can be added to PN formula (regular insulin only)
Hyperlipidemia	Caused by excess lipids or dextrose in the PN formula; diabetes, sepsis, pancreatitis, liver disease, and prematurity predispose to hypertriglyceridemia because of decreased lipid clearance	Dextrose should be reduced first, followed by lipids if hyperlipidemia not corrected
		Lipid infusion should not exceed 0.12 g per kg per hour in critically ill patients or those with impaired lipid clearance; in infants and children, age-appropriate lipid infusion rate should be followed, given over 24 hours
		Serum triglyceride levels should be monitored and daily fat infusion stopped if concentration exceeds 400 mg per dL(4.52 mmol per L)11
Liver diseases	Hepatic steatosis predominately in adults, cholestasis predominantly in infants and children; end-stage liver disease develops in one-half of adults and children who receive continuous long-term PN44	Hepatic steatosis: avoid overfeeding, especially dextrose
		Cholestasis: initiate even minimal EN as soon as feasible, avoid sepsis and overfeeding, use cysteine- and taurine-containing amino acid formulations in infants, use ursodeoxycholic acid, avoid hepatotoxic medications45
Thrombosis	Risk factors: underlying disease (e.g., cancer), type and location of the catheter; peripherally inserted central catheter lines appear to be associated with higher rate of clinically evident thrombophlebitis43	Central venous thrombosis should be treated with anticoagulation therapy unless contraindicated; prophylactic anticoagulation should be considered for patients with hypercoagulation or at high risk of catheter-related venous thrombosis42