Management of Parenteral Nutrition in Hospitalized Adult Patients [Formula: see text]

[Clinical experience in patients with intestinal failure: a cohort study in a third referral hospital]

INTRODUCTION

intestinal failure (IF) is an organic failure classified into three types (I-III); it conditions inability to absorb nutrients and water, so parenteral nutrition (PN) is required.

OBJECTIVE

to evaluate the characteristics of hospitalized patients with IF, and their association with clinical and nutritional outcomes.

METHODS

historical cohort of hospitalized adults with IF and PN. Variables of the nutritional care process (screening, anthropometric, biochemical, clinical, nutritional), mortality and hospital stay were recorded.

RESULTS

six hundred and ninety-seven patients aged 56 (41-68) years, 327 women (46.8 %), with body mass index (BMI) 22.4 (18.3-25.9), were included.

DIAGNOSIS

577 patients with IF-I, 96 patients with IF-II, and 24 patients with IF-III. The most frequent causes were malignant neoplasms, IF-I (26.7 %) and surgical complications in IF-II (21.9 %) and IF-III (37.5 %). The most common pathophysiology in all types of IF was motility disorders (40.6 % in IF-I; 43.8 % in IF-II; 33.8 % in IF-III). The majority of patients had high nutritional risk (92.4 %) and refeeding syndrome (65.6 % high and very high). In acute IF (FI-I) compared to prolonged IF (If-II/IF-III) there is a higher BMI (p = 0.039), visceral fat (p = 0.041) and over-hydration (p = 0.014), but they have a smaller phase angle (p = 0.004), with a lower adequacy percentage than what is prescribed in relation to their energy expenditure (p < 0.001).

CONCLUSIONS

during the nutritional care process there are differences between the types of IF, which are relevant to optimize their multidisciplinary management and avoid related complications.

A Narrative Review: Analysis of Supplemental Parenteral Nutrition in Adults at the End of Life

"End of life" is a stage defined by the existence of an irreversible prognosis that ends with a person's death. One of the aspects of interest regarding end of life focuses on parenteral nutrition, which is usually administered in order to avoid malnutrition and associated complications. However, parenteral nutrition can be adapted to specific circumstances and evolve in its functionality through supplementation with certain nutrients that can have a beneficial effect. This narrative review aims to carry out a situation analysis of the role that could be adopted by supplemental parenteral nutrition in attenuating alterations typical of end of life and potential improvement in quality of life.

Finding the sweet spot: Managing parenteral nutrition-related glycemic complications in hospitalized adults

Parenteral nutrition (PN) remains an important aspect of treating hospitalized adult patients who are otherwise unable to achieve adequate nutrition intake. PN is highly individualized and requires careful adjustment of macronutrients and micronutrients to minimize complications. One frequent complication associated with PN involves blood glucose (BG) derangements including both hypoglycemia and hyperglycemia. PN-related glycemic complications are complex and multifactorial. Close BG monitoring is required for selecting and evaluating therapeutic interventions. BG goals for patients treated with PN may vary depending on patient-specific characteristics. Since dextrose provides the carbohydrate source in PN prescriptions, hyperglycemia may be expected, but nondextrose causes must also be considered. Insulin is a mainstay of therapy for managing glycemic complications related to PN, and the regimen chosen depends on patient-specific factors. However, insulin therapy also places the patient at an increased risk of hypoglycemia. Similarly, insulin is not the sole cause of hypoglycemia in these patients. The aim of this review is to describe the factors associated with dysglycemia during PN therapy and provide recommendations for minimizing and managing these complications, which is paramount to providing high-quality patient care and improving clinical outcomes.

Metabolic and nutritional aspects in continuous renal replacement therapy

Nutrition is one of the foundations for supporting and treating critically ill patients. Nutritional support provides calories, protein, electrolytes, vitamins, and trace elements via the enteral or parenteral route. Acute kidney injury (AKI) is a common and devastating problem in critically ill patients and has significant metabolic and nutritional consequences. Moreover, renal replacement therapy (RRT), whatever the modality used, also profoundly impacts metabolism. RRT and of the extracorporeal circuit impede 'effect the evaluation of a patient's energy requirements by clinicians. Substrates added and removed within the extracorporeal treatment are not always taken into consideration, making treatment even more challenging. Furthermore, evidence on nutritional support during continuous renal replacement therapy (CRRT) is scarce, and there are no clinical guidelines for nutrition adaptations during CRRT in critically ill patients. Most recommendations are based on expert opinions. This review discusses the complex interaction between nutritional support and CRRT and presents some milestones for nutritional support in critically ill patients on CRRT.

Impact of Continuous Veno-Venous HemoDiALYsis with Regional Citrate Anticoagulation on Non-NUTRItional Calorie Balance in Patients on the ICU-The NUTRI-DAY Study

Background: Malnutrition as well as overfeeding can have negative impacts on clinical outcomes in critically ill patients. Continuous veno-venous hemodialysis (CVVHD) with regional citrate anticoagulation (RCA) using trisodium citrate 4% (TSC) might play a role in nutrient disposition in patients in the ICU. Methods: In 33 consecutive patients on CVVHD with RCA, energy uptake or loss was calculated. Three macronutrients (lactate, glucose and citrate) were analyzed by taking prefilter blood and effluent samples. Results: Glucose and lactate clearance through CVVHD made up for a loss of 61 kcal/d (IQR 25−164 kcal/d) and 38 kcal/d (IQR 23−59 kcal/d), respectively. Two patients with hyperglycemic state (>350 mg/dL) lost around 600 kcal/d during CVVHD. Net post-filter citrate caloric delivery through RCA was 135 kcal/d (IQR: 124−144 kcal/d). Adding the three macronutrients, net caloric gain through CVVHD was 10 kcal/d (IQR: −63−75 kcal/d). Conclusion: In non-hyperglycemic patients on CVVHD with RCA, the metabolic contribution of the three macronutrients lactate, glucose and citrate is neglectable.

Caloric adequacy of parenteral nutrition and its influence on the clinical outcome of hospitalised patients

Background: The adaptation of Parenteral Nutrition (PN) to actual energy requirements of hospitalised patients is essential, since excessive and insufficient nutritional intake have been associated with poor clinical outcomes. Aim: To evaluate the adaptation of prescribed PN to the estimated nutritional requirements using three predictive equations and the influence of excessive/insufficient nutrient intake on patient clinical outcomes (nutritional parameters, metabolic and infectious complications). Methods: Prospective, observational study in hospitalised patients nutritionally assessed. Data was collected the first and fifth/sixth day of PN with clinical (infection, length of hospital stay), biochemical (visceral proteins, cholesterol, glucose, triglycerides, lymphocytes, CRP) and anthropometric parameters (skin folds, height, weight). Theoretical requirements were calculated using Harris-Benedict (HB), Mifflin-St Jeor (MF) and 25 Kcal/Kg/day formulas. The HB formula was used to compare estimated and provided requirements. Results: A total of 94 patients (mean: 72 ± 13.7 years old) were included with initial mean weight and height of 69.2 Kg and 162.8 cm, respectively (mean BMI: 26.1 Kg/m²). No statistically significant differences were found between the actual (1620 Kcal/day) and estimated caloric mean calculated with HB (1643 Kcal/day) and MF (1628 Kcal/day). When comparing with the caloric estimation, 31.9% of patients were underfed, while 14.9% were overfed. Intergroup analysis demonstrated significant variations in albumin, prealbumin, glucose, cholesterol, triglycerides and MUAC, with a significant increase of hyperglycaemia (+37.86; p < 0.05) and hypertriglyceridemia (+63.10; p < 0.05), being higher in overfed patients. Conclusion: In our study, inadequate nutrient intake was associated with a higher degree of hyperglycaemia and hypertriglyceridemia, without positive impact on anthropometric parameters.

Blood Sugar Targets in Surgical Intensive Care—Management and Special Considerations in Patients With Diabetes

BACKGROUND

30-80% of patients being treated in intensive care units in the perioperative period develop hyperglycemia. This stress hyperglycemia is induced and maintained by inflammatory-endocrine and iatrogenic stimuli and generally requires treatment. There is uncertainty regarding the optimal blood glucose targets for patients with diabetes mellitus.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed and Google Scholar.

RESULTS

Patients in intensive care with pre-existing diabetes do not benefit from blood sugar reduction to the same extent as metabolically healthy individuals, but they, too, are exposed to a clinically relevant risk of hypoglycemia. A therapeutic range from 4.4 to 6.1 mmol/L (79-110 mg/dL) cannot be justified for patients with diabetes mellitus. The primary therapeutic strategy in the perioperative setting should be to strictly avoid hypoglycemia. Neurotoxic effects and the promotion of wound-healing disturbances are among the adverse consequences of hyperglycemia. Meta-analyses have shown that an upper blood sugar limit of 10 mmol/L (180 mg/dL) is associated with better outcomes for diabetic patients than an upper limit of less than this value. The target range of 7.8-10 mmol/L (140-180 mg/dL) proposed by specialty societies for hospitalized patients with diabetes seems to be the best compromise at present for optimizing clinical outcomes while avoiding hypoglycemia. The method of choice for achieving this goal in intensive care medicine is the continuous intravenous administration of insulin, requirng standardized, high-quality monitoring conditions.

CONCLUSION

Optimal blood sugar control for diabetic patients in intensive care meets the dual objectives of avoiding hypoglycemia while keeping the blood glucose concentration under 10 mmol/L (180 mg/dL). Nutrition therapy in accordance with the relevant guidelines is an indispensable pre - requisite.

Short-Bowel Syndrome: Epidemiology, Hospitalization Trends, In-Hospital Mortality, and Healthcare Utilization

INTRODUCTION

Short-bowel syndrome (SBS) is a common cause of chronic intestinal failure and is associated with increased morbidity, mortality, poor quality of life, and an increased burden on healthcare costs.

METHODS

We used the US Nationwide Inpatient Sample database from 2005 to 2014. We identified adult SBS hospitalizations by using a combination of International Classification of Diseases, Ninth Revision, Clinical Modification codes. We studied the demographics of the patients with SBS and analyzed the trends in the number of hospitalizations, in-hospital mortality, and healthcare costs. We also identified the risk factors associated with in-hospital mortality.

RESULTS

A total of 53,040 SBS hospitalizations were identified. We found that SBS-related hospitalizations increased by 55% between 2005 (N = 4037) and 2014 (N = 6265). During this period, the in-hospital mortality decreased from 40 per 1000 to 29 per 1000 hospitalizations, resulting in an overall reduction of 27%. Higher mortality was noted in SBS patients with sepsis (6.7%), liver dysfunction (6.2%), severe malnutrition (6.0%), and metastatic cancer (5.4%). The overall mean length of stay (LOS) for SBS-related hospitalizations was 14.7 days, with a mean hospital cost of $34,130. We noted a steady decrease in the LOS, whereas the cost of care remained relatively stable.

CONCLUSIONS

The national burden of SBS-related hospitalizations continues to rise, and the mortality associated with SBS has substantially decreased. Older SBS patients with sepsis, liver dysfunction, severe malnutrition, and metastatic cancer had the highest risk of mortality. Healthcare utilization in SBS remains high. healthcare utilization; hospitalization trend; mortality; research and diseases; short-bowel syndrome.

New insights into intestinal failure-associated liver disease in adults: A comprehensive review of the literature

Intestinal failure-associated liver disease (IFALD) remains one of the most common and serious complications of parenteral nutrition (PN), causing a wide spectrum of hepatic manifestations from steatosis and mild cholestasis to portal hypertension and end-stage liver failure. The prevalence of IFALD depends on the diagnostic criteria and ranges from 4.3% to 65%. Moreover, many factors are shown to contribute to its development, including nutrient deficiencies, toxicity of PN, infections, and alterations of bile acid metabolism and gut microbiota. Prevention and management of IFALD aim at ameliorating or eliminating the risk factors associated with IFALD. The use of PN formulations with a lower ratio omega-6-to-omega-3 polyunsaturated fatty acids, cycle PN, optimization of enteral stimulation and prevention and early treatment of infections constitute the main therapeutic targets. However, failure of improvement and severe IFALD with end-stage liver failure should be considered as the indications of intestinal transplantation. The aim of this review is to provide an update of the epidemiology, pathophysiology, and diagnosis of IFALD in the adult population as well as to present a clinical approach of the therapeutic strategies of IFALD and present novel therapeutic targets.

High-protein compared with standard parenteral nutrition in palliative cancer care

Objectives

High-protein parenteral nutrition (PN) has been developed to counteract muscle loss in patients with cancer treated with PN. Nevertheless, it is not clear if high-protein PN is as safe as standard PN in patients with palliative cancer. Our primary aim was to compare the proportion of patients with elevated liver enzymes between high-protein and standard PN in patients with palliative cancer enrolled to Medical Home Care. Our secondary aim was to compare the two treatments with regard to weight and albumin levels during treatment.

Methods

Medical records from 2016 to 2018 were retrospectively reviewed to identify palliative cancer patients that had received PN for more than 3 weeks. Data on weight, height, albumin, liver enzymes, socioeconomic factors and dietitian consultations were collected at baseline and after 3–8 weeks of PN treatment. The odds of having elevated liver enzymes or having a maintained weight and/or stable albumin levels were calculated using logistic regression.

Results

20 patients treated with high-protein PN were compared with 104 patients treated with standard PN. Patients treated with high-protein PN had a significantly higher weight at follow-up compared with patients treated with standard PN (p<0.05). There was no significant difference in the proportion of patients with elevated liver enzymes (OR 0.20; 95% CI 0.02 to 1.86), or maintained weight and/or albumin levels (OR 1.62; 95% CI 0.46 to 5.76) between high-protein and standard PN.

Conclusion

High-protein PN was as safe, and at least as effective, as standard PN to patients with palliative cancer.

Magnesium: The overlooked electrolyte in blood cancers?

Magnesium is an important element that has essential roles in the regulation of cell growth, division, and differentiation. Mounting evidence in the literature suggests an association between hypomagnesemia and all-cause mortality. In addition, epidemiologic studies have demonstrated that a diet poor in magnesium increases the risk of developing cancer, highlighting its importance in the field of hematology and oncology. In solid malignancies, hypomagnesemia at diagnosis portends a worse prognosis. However, little is known about prognosis in patients with hypomagnesemia and blood cancers in general; lymphoma more specifically. Hypomagnesemia has been associated with a higher viral load of the Epstein Barr virus, a virus associated with a multitude of hematologic malignancies. The role of magnesium in the immune system has been further elucidated in studies of patients with a rare primary immunodeficiency known as XMEN disease (X-linked immunodeficiency with Magnesium defect, Epstein-Barr virus (EBV) infection, and Neoplasia disease). These patients have a mutation in the MAGT1 gene, which codes for a magnesium transporter. The mutation leads to impaired T cell activation and an increased risk of developing hematologic malignancies. In this review we discuss the relevance of magnesium as an electrolyte, current measurement techniques, and the known data related to cause and prognosis of blood cancers. The goal is to use these data to stimulate additional high-quality and well powered studies to further investigate the role of magnesium in preventing cancer and improving outcomes of patients with malignancy and concomitant magnesium deficiency.

Stability of high-dose thiamine in parenteral nutrition for treatment of patients with Wernicke's encephalopathy

BACKGROUND & AIMS

Wernicke's encephalopathy is associated mainly with malnourishment in alcohol-dependent patients but can be caused also by cancer, Crohn's disease, gastrointestinal surgery or prolonged parenteral nutrition (PN) without adequate supplementation of vitamins. The disorder, with a significant mortality rate of up to 20%, is often associated with the underlying disease and intensifies after administration of non-supplemented PN. Thus, it seems justified to add thiamine to PN admixtures prepared for parenterally fed patients. Due to the lack of data on the stability of thiamine in PN admixtures at concentrations exceeding 60 mg/L, we decided to determine the possibility of adding a high dose of thiamine (800 mg per bag, 320 mg/L) to PN admixtures in order to treat Wernicke's encephalopathy in malnourished patients.

METHODS

The study aimed to assess the stability of the physical properties of PN admixtures (pH, zeta potential, particle size) and to determine thiamine content using an HPLC method.

RESULTS

Thiamine was found to degrade regardless of the PN admixture composition and storage conditions. The highest decrease in thiamine content was observed at room temperature without light protection whereas the lowest at a temperature of 4 ± 1 °C with light protection.

CONCLUSIONS

The treatment of Wernicke's encephalopathy in parenterally fed patients is possible with the use of high thiamine doses (800 mg) added to PN admixtures without a decrease in the drug content above 10% within the first 24 h. It should be emphasized that thiamine as a photosensitive drug must be stored and administered under conditions ensuring light protection.

Parenteral Nutrition Drug Shortages: A Single-Center Experience With Rapid Process Change

Disruptions in the medication supply chain and consequent drug product shortages, including shortages of parenteral products used for parenteral nutrition (PN) compounding, have become an increasingly common occurrence. The amino acid solution shortage that resulted from the devastating impact of Hurricanes Maria and Irma on manufacturing facilities in Puerto Rico in 2017 necessitated a rapid, coordinated shift from use of compounded PN to commercial multichamber-bag PN (MCB-PN) at our hospitals. We describe our experience operationalizing this intervention via a framework that may be adapted for addressing other drug product shortages to promote rapid yet safe use of therapeutic alternatives.

Clinical Nutrition in Critical Care Medicine - Guideline of the German Society for Nutritional Medicine (DGEM)

PURPOSE

Enteral and parenteral nutrition of adult critically ill patients varies in terms of the route of nutrient delivery, the amount and composition of macro- and micronutrients, and the choice of specific, immune-modulating substrates. Variations of clinical nutrition may affect clinical outcomes. The present guideline provides clinicians with updated consensus-based recommendations for clinical nutrition in adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function.

METHODS

The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. According to the S2k-guideline classification, no systematic review of the available evidence was required to make recommendations, which, therefore, do not state evidence- or recommendation grades. Nevertheless, we considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of other societies. The liability of each recommendation was described linguistically. Each recommendation was finally validated and consented through a Delphi process.

RESULTS

In the introduction the guideline describes a) the pathophysiological consequences of critical illness possibly affecting metabolism and nutrition of critically ill patients, b) potential definitions for different disease phases during the course of illness, and c) methodological shortcomings of clinical trials on nutrition. Then, we make 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in critically ill patients. Among others, recommendations include the assessment of nutrition status, the indication for clinical nutrition, the timing and route of nutrient delivery, and the amount and composition of substrates (macro- and micronutrients); furthermore, we discuss distinctive aspects of nutrition therapy in obese critically ill patients and those treated with extracorporeal support devices.

CONCLUSION

The current guideline provides clinicians with up-to-date recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. The period of validity of the guideline is approximately fixed at five years (2018-2023).

Effect of Lipid Emulsion on Stability of Ampicillin in Total Parenteral Nutrition

Background: Ampicillin (AMP) is frequently administered parenterally in critically ill patients with meningitis or endocarditis. Many of them require parallel infusion of total parenteral nutrition (TPN) admixtures. The aim of the study was to determine the physicochemical stability of AMP in TPN admixtures. Methods: AMP was added to two formulations of TPN admixtures differing in the lipid emulsion (Lipofundin^® MCT/LCT 20% or LIPIDem^®). Samples were stored at 4 ± 1 °C with light protection, and at 25 ± 1 °C with and without light protection to assess the impact of temperature and light on formulation stability. Every 24 h the pH, zeta potential, mean droplet diameter (MDD) of a lipid emulsion, and AMP concentration using HPLC method were determined. The assessment of stability and compatibility of TPN admixtures with vitamins and trace elements was carried out immediately after preparation and after 24 h of storage. Results: The addition of AMP as well as vitamins and trace elements to the TPN admixtures did not affect their physical stability. An increase in the pH value of approx. 0.6 and reduction of zeta potential were observed. The MDD of the lipid emulsions was below the limit of 500 nm (dynamic light scattering (DLS) method) and no fat droplets greater than 525 nm were observed (light diffraction (LD) method). The content of AMP after the first 24 h was within the acceptable limit of 90% for TPN admixtures stored at 4 ± 1 °C and 25 ± 1 °C with light protection. Conclusions: The results showed that co-administration of AMP in the same bag with TPN admixture at the tested dose is possible when used ex tempore and with light protection.

Impact of Intravenous Lipid Emulsions Containing Fish Oil on Clinical Outcomes in Critically Ill Surgical Patients: A Literature Review

A fish oil (FO)-containing intravenous lipid emulsion (ILE; FO ILE) has been approved for use in the United States; however, similar formulations have been used throughout Europe and China in intensive care units since the 1990s. This literature review evaluates the evidence regarding the effectiveness of FO ILE on clinical outcomes in the critically ill surgical patient population. The review of available evidence demonstrates that ILEs containing FO lower triglyceride concentrations, inflammatory markers, and liver function enzymes, and improve morbidity and mortality outcomes in critically ill surgical patients.

Metabolic Support of the Patient on Continuous Renal Replacement Therapy

Continuous renal replacement therapy (CRRT) is the modality of choice in critically ill patients with hemodynamic instability requiring renal replacement therapy. The goal of this review is to discuss an overview of CRRT types, components, and important considerations for nutrition support provision. Evidence basis for guidelines and our recommendations are reviewed. Nutrition support-related implications include the possibility of calorie gain with citrate-based anticoagulation, calorie loss with glucose-free replacement fluids and dialysate, and significant amino acid losses in effluent. We challenge nutrition support clinicians to develop a keen understanding of the specific CRRT modalities that are employed in their intensive care units and to be able to determine how the CRRT prescription may impact a patient's nutrition support prescription.

Dispelling myths about intravenous fish oil-based lipid emulsions: a clinical perspective

PURPOSE OF REVIEW

Intravenous lipid emulsions (IVLEs) are an essential component of parenteral nutrition. With the recent incorporation of new lipid emulsions into the Canadian and American market, the clinician responsible for prescribing these lipids should be educated regarding the different fatty acid (FA) profiles of these lipids, as well as their metabolic and functional effects.

RECENT FINDINGS

New IVLEs contain a mix of soybean oil and olive oil, or a mix of soybean oil, coconut oil, olive oil and fish oil. These new lipid emulsions provide less essential fatty acids (FAs) (linoleic and alpha linolenic acids) than in pure soybean oil, yet incorporation of fish oil into an IVLE may decrease the amount of essential FAs required. Fish oil is a treatment for hypertriglyceridemia, and therefore, IVLEs that include fish oil may decrease serum triglycerides. Historical perspective is that fish oil can be associated with increased bleeding time. Evidence suggests that there is no association between fish oil and increased bleeding in patients, even those who are using anticoagulants. New IVLEs provide less vitamin K than soybean oil alone. Patients, or the parenteral nutrition solutions that include these new IVLEs should be supplemented with vitamin K.

SUMMARY

Canadian and American Guidelines for IVLEs were based on soybean oil. Current practice should be tailored to which IVLE is being prescribed.

Management of parenteral nutrition in critically ill patients

Artificial nutrition (AN) is necessary to meet the nutritional requirements of critically ill patients at nutrition risk because undernutrition determines a poorer prognosis in these patients. There is debate over which route of delivery of AN provides better outcomes and lesser complications. This review describes the management of parenteral nutrition (PN) in critically ill patients. The first aim is to discuss what should be done in order that the PN is safe. The second aim is to dispel “myths” about PN-related complications and show how prevention and monitoring are able to reach the goal of “near zero” PN complications. Finally, in this review is discussed the controversial issue of the route for delivering AN in critically ill patients. The fighting against PN complications should consider: (1) an appropriate blood glucose control; (2) the use of olive oil- and fish oil-based lipid emulsions alternative to soybean oil-based ones; (3) the adoption of insertion and care bundles for central venous access devices; and (4) the implementation of a policy of targeting “near zero” catheter-related bloodstream infections. Adopting all these strategies, the goal of “near zero” PN complications is achievable. If accurately managed, PN can be safely provided for most critically ill patients without expecting a relevant incidence of PN-related complications. Moreover, the use of protocols for the management of nutritional support and the presence of nutrition support teams may decrease PN-related complications. In conclusion, the key messages about the management of PN in critically ill patients are two. First, the dangers of PN-related complications have been exaggerated because complications are uncommon; moreover, infectious complications, as mechanical complications, are more properly catheter-related and not PN-related complications. Second, when enteral nutrition is not feasible or tolerated, PN is as effective and safe as enteral nutrition.