Complications, Monitoring, and Management of Nutrition Support
Enteral complications
Mechanical: tube clogging, displacement, aspiration. GI: diarrhea (often from medications, sorbitol, antibiotics, or formula osmolality), nausea, distension. Metabolic: refeeding syndrome, hyperglycemia, electrolyte shifts. Management includes flushing tubes, slowing rate, changing formula, and addressing medications.
Parenteral complications
Catheter-related: infection, thrombosis, pneumothorax at insertion. Metabolic: hyperglycemia, refeeding syndrome, electrolyte abnormalities, hepatic steatosis, gallbladder stasis, and bone disease with long-term use. Management includes catheter care, glycemic control, and monitoring labs.
Refeeding syndrome
High-risk patients: low BMI, minimal intake >5-10 days, chronic alcoholism, malabsorption, prolonged starvation. Signs: hypophosphatemia, hypokalemia, hypomagnesemia, fluid overload, arrhythmias. Management: start low, advance slowly, replace electrolytes aggressively, and monitor closely.
Monitoring principles
Regular weights, intake/output, electrolytes, glucose, renal and liver function, and physical exam. Recognize that diarrhea in EN is often multifactorial, not simply formula intolerance.
Worked rule of thumb
For a high-risk refeeding patient, start at 10-20 kcal/kg/day and advance over several days while checking phosphate, potassium, and magnesium at least daily initially; do not wait for symptoms to replace electrolytes.