43-year-old woman diagnosed with cervical cancer in 2007 and treated with brachytherapy and radiotherapy. After presenting with actinic sigmoiditis and intestinal obstruction at the end of 2009, she underwent a Hartman intestinal resection with the result of an unloading colostomy. At that time the patient weighed 41.5 kg, 165 cm (BMI = 15). During the subsequent period her weight fluctuated between 38 and 42 kg despite nutritional monitoring, and she was admitted five times, one of them for intrabadominal abscess and ureteroenteral fistula, for which a left nephrostomy was performed.
In November 2011 she underwent ileocaecal resection with laterolateral anastomosis due to intestinal fistula. In the postoperative period, she developed a coma secondary to imipenem, which led to admission to the ICU. He required parenteral nutritional support for 20 days.
In January 2012 he was admitted again for multifactorial grade III chronic renal failure and nutritional treatment with a renal protection diet was established. The clinical situation required new PN for 10 days due to incoercible vomiting and inability to eat orally.
In September 2012, she was readmitted due to a suprapubic fistula, starting PN again with the aim of renourishing the patient to face a new surgical intervention, at which time she had a BMI = 13 (37 kg, 169 cm). On the thirteenth day, after a weight gain of 4 kg, the patient developed an allergic condition that started with erythema and pruritus. Antibiotics were discontinued (9 days with meropenem) and treatment with corticosteroids and antihistamines was administered. The evolution continued to be torpid in the following hours, with oedema and difficulty breathing. At this point it was decided to discontinue PN, and an improvement in symptoms was observed. Given the essential need for preoperative nutrition, a protocol was drawn up for the reintroduction of PN:
1. Initiation of TPN with exclusive supply of amino acids, glucose and electrolytes, using a different source of amino acids to that of the previous preparation. Always start in the morning with close monitoring of the patient.
2. After 48 hours, if there have been no signs of recurrence of allergy, add increasing amounts of lipids to the parenteral diet over the next 72 hours.
3. In case of good tolerance, assess the need to add vitamins and trace elements to the mixture.
PN is restarted with good tolerance and without complications, providing complete PN with macro and micronutrients according to the patient's needs around the 4th day.
Following nutritional recovery, surgery was decided with poor postoperative evolution and the need for admission to the Intensive Care Unit due to the development of septic shock of abdominal origin and multi-organ failure, which ended in the patient's death.

