Initiation, Advancement, and Acute Complications of Parenteral Nutrition


successful glycemic control, effective insulin therapy is just as import- ant as the PN prescription. Insulin therapy options and recommen- dations for patients receiving PN are listed in Box 4.2 on page 62 and include regular human insulin added to PN, correctional scale insulin, and a continuous insulin infusion.14,18-21,24


EXPERT INSIGHT


Glycemic control is imperative in patients receiving PN. The clinician should review institutional protocols and/or order sets regarding correctional scale insulin and continuous insulin infusions to become familiar with how glucose is managed.


Patients with type 1 diabetes have an absolute requirement for exog-


enous insulin for survival. Therefore, it is essential that these patients receive appropriate basal insulin therapy in most situations, including during nil per os (NPO) status and with the initiation of PN.


Hypertriglyceridemia


The addition of ILE to PN formulations is common. ILE is an excellent source of energy and can be a key source of essential fatty acids depend- ing on the type of ILE used. However, ILE can lead to complications, par- ticularly when hypertriglyceridemia is present or when lipids are infused in excessive amounts or too quickly. Hypertriglyceridemia is defined as a serum triglyceride level greater


than 150 mg/ dL and can develop secondary to receiving PN therapy containing ILE. However, while receiving PN, a triglyceride level less than 400 mg/ dL is considered acceptable.25


glycerides greater than 1,000 mg/ dL may result in pancreatitis.26,27


Although rare, serum tri- The


cause of PN-associated hypertriglyceridemia is typically excessive lipid infusion along with inadequate plasma lipid clearance or a decrease in lipoprotein lipase activity.26


Lipid-containing medications, such as


propofol (a sedative often used in patients who are critically ill; contains 10% ILE) and clevidipine (an antihypertensive; contains 20% ILE), can contribute to hypertriglyceridemia.26 for hypertriglyceridemia.4,26,28


Box 4.3 on page 63 lists risk factors


61


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