# Situation: A 63-year-old man is in the surgical intensive care unit after a major bowel resection. He receives parenteral nutrition (PN) by infusion pump through a central venous catheter and intermittent hemodialysis (HD) through a tunneled dialysis catheter for kidney failure. The PN infusion stopped for 2 hours because of an occlusion alarm and is now 160 mL behind schedule. The nurse restarts it at the prescribed rate and does not increase the rate to make up the volume. What is the reason?

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> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 63-year-old man is in the surgical intensive care unit after a major bowel resection. He receives parenteral nutrition (PN) by infusion pump through a central venous catheter and intermittent hemodialysis (HD) through a tunneled dialysis catheter for kidney failure.

The PN infusion stopped for 2 hours because of an occlusion alarm and is now 160 mL behind schedule. The nurse restarts it at the prescribed rate and does not increase the rate to make up the volume. What is the reason?

## 보기

1. The lipid emulsion separates when run at higher rates
2. The added dextrose load can cause marked hyperglycemia **✔ 정답**
3. Higher rates raise the risk of catheter-related infection
4. Infusion pumps lock out rates above the prescribed setting

**정답: 2**

## 해설

Parenteral nutrition is a concentrated dextrose solution. Running it faster to catch up delivers a sudden glucose load that can cause marked hyperglycemia, as well as fluid overload. The nurse resumes the prescribed rate and reports the shortfall.

## 심화 해설

Core rationale

Parenteral nutrition is a hyperosmolar admixture that delivers a large amount of dextrose per unit volume. When the infusion falls behind because of an occlusion, the immediate clinical concern is not the catheter itself but the metabolic response to a sudden increase in glucose delivery. Rapid infusion of PN to “catch up” the missing volume delivers an unplanned glucose load that can produce marked hyperglycemia and osmotic diuresis, and may also contribute to fluid overload. For a patient with kidney failure receiving intermittent hemodialysis, glucose disposal is already impaired, and hyperglycemia can worsen fluid shifts, electrolyte disturbances, and hemodynamic instability.

Key point! The correct nursing action is to restart the infusion at the prescribed rate and document the volume deficit. The missing volume is reported to the provider so that the daily nutrition and fluid plan can be adjusted, rather than corrected by speeding up the pump.

Why the other options are incorrect

| Option | Why it is not the best answer |
| --- | --- |
| 1. Lipid emulsion separates at higher rates | Lipid separation is a stability issue related to the PN admixture itself, not primarily to the infusion rate. If the PN contains lipid, separation is a concern with incompatible additives or prolonged standing, not with temporarily increasing the rate. |
| 3. Higher rates raise catheter-related infection risk | Infection risk is related to line manipulation, hub contamination, and duration of catheter use. Increasing the infusion rate through an existing closed system does not directly introduce microorganisms. |
| 4. Pumps lock out rates above the prescribed setting | Infusion pumps can be reprogrammed within safety limits. The reason for not increasing the rate is clinical safety related to glucose and fluid load, not a mechanical lockout. |

Deeper clinical context

PN solutions typically contain 10–25% dextrose, making them highly concentrated. Even a modest increase in infusion rate can raise the glucose infusion rate substantially. In a patient with acute kidney failure, insulin resistance and reduced renal gluconeogenesis regulation increase the risk of severe hyperglycemia when a dextrose load is delivered too quickly. Hyperglycemia in critically ill patients is associated with poor wound healing, increased infection risk, and osmotic fluid shifts that complicate hemodialysis.

The occlusion alarm itself is a separate problem. Watch out! Occlusion of a central venous catheter during PN can be caused by precipitate, thrombus, or mechanical obstruction. The nurse must assess for kinks, clamped tubing, or precipitate formation, but the immediate priority after resolving the alarm is safe resumption of the prescribed rate, not volume replacement.

For a patient receiving intermittent hemodialysis, fluid balance is tightly managed. Rapidly infusing the missed PN volume would add both glucose and fluid, potentially causing hypervolemia before the next dialysis session. The prescribed PN rate is calculated to meet nutritional needs while respecting the patient’s fluid restriction and metabolic capacity. Any deviation must be reported so the interdisciplinary team can decide whether to adjust the next PN bag or dialysis plan.

Nursing priority in this situation

The sequence of care is: assess the catheter and tubing for the cause of occlusion, restart PN at the prescribed rate, monitor blood glucose closely, and document the volume deficit. The nurse does not attempt to compensate for lost time by increasing the rate, because the primary risk is hyperglycemia from the concentrated dextrose load, compounded by fluid overload in a patient with kidney failure.

## 임상 시나리오

PN Catch-Up Infusion SafetyWhy you never speed up parenteral nutrition
Parenteral nutrition is a hyperosmolar dextrose solution. Infusing it faster to make up lost volume delivers a sudden glucose load that can cause marked hyperglycemia and fluid overload.

The safe action is to restart at the prescribed rate, document the volume deficit, and report the shortfall to the provider for adjustment of the daily nutrition and fluid plan.

CautionIn kidney failure with intermittent hemodialysis, glucose disposal is impaired. Rapid PN infusion can worsen electrolyte shifts and hemodynamic instability.

## 핵심 개념

- **Parenteral nutrition** — A hyperosmolar intravenous admixture containing concentrated dextrose, amino acids, lipids, electrolytes, and micronutrients.
- **Hyperglycemia** — Elevated blood glucose; a key risk when PN is infused too rapidly due to sudden dextrose delivery.
- **Osmotic diuresis** — Increased urine output caused by excretion of osmotically active substances such as glucose, leading to fluid and electrolyte loss.
- **Occlusion alarm** — Pump alarm indicating blocked flow in the infusion system, which can interrupt PN delivery.
- **Fluid overload** — Excess intravascular volume, a risk when PN is infused rapidly, especially in kidney failure.

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