-----Original Message-----
From: Stranz, Marc
[mailto:[EMAIL PROTECTED]
Sent: Wednesday, June 21, 2006
2:08 PM
To: 'Galloway, Margy';
[EMAIL PROTECTED]
Subject: RE: TPN guidelines
It is unlikely that most patients
will react badly to sudden PN discontinuation. Those receiving
supplemental insulin for the dextrose load would be at greatest risk
Nirula R, Yamada K, Waxman K. The effect of abrupt cessation of
total parenteral nutrition on serum glucose: a randomized trial. Am Surg. 2000
Sep;66(9):866-9
The common clinical practice of gradually tapering total parenteral nutrition
(TPN) to prevent hypoglycemia may be unnecessary. This randomized prospective
study assessed the blood glucose profiles of patients whose TPN was abruptly
discontinued in comparison with those whose TPN was gradually tapered to
determine whether abrupt cessation can be performed safely. Patients were
randomized into the abrupt cessation or the tapered protocol. A symptomatic
hypoglycemic questionnaire was administered at regular intervals. Fingerstick
glucose sampling was performed at 30-minute intervals and compared
prospectively. From October 1996 through July 1997, 21 patients receiving TPN consented
to participate in this study. Inclusion criteria included 1) duration of TPN
infusion >24 hours, 2) age >18 years, and 3) establishment of enteral
feeding at the time of TPN discontinuation. Patients had a baseline blood
glucose level followed by repeat glucose measurements at 30-minute intervals
until 90 minutes after TPN was completely discontinued in the tapered group and
120 minutes after cessation in the abrupt group. The rate of TPN tapering was
in 25 per cent increments over 90-minute intervals. Ten patients were
randomized into the tapered group and 11 patients in the abrupt group. None of
the patients developed symptomatic hypoglycemia. There was no difference
between the lowest blood glucose in the abrupt group in comparison with that of
the tapered group (108.6+/-11.5 vs 108.2+/-9.8 respectively; P = 0.98). No
patient had a significant change in hypoglycemia questionnaire score. There was
no significant difference in age, duration of TPN, steroid use, or enteral
caloric intake between the two groups. We conclude that there was no
symptomatic hypoglycemia, and glucose profiles returned to a similar baseline
level in those whose TPN was abruptly stopped when compared with those in the
tapered group. These data demonstrate that patients receiving TPN can have
parenteral nutrition abruptly stopped without the development of significant
hypoglycemia.
Eisenberg
PG, Gianino S, Clutter WE, Fleshman JW.
Abrupt discontinuation of
cycled parenteral nutrition is safe.
Dis Colon Rectum. 1995 Sep;38(9):933-9.
PMID: 7656740 [PubMed - indexed for MEDLINE]
Krzywda
EA, Andris DA, Whipple JK, Street CC, Ausman RK, Schulte WJ, Quebbeman EJ.
Glucose response to
abrupt initiation and discontinuation of total parenteral nutrition.
JPEN J Parenter Enteral Nutr. 1993 Jan-Feb;17(1):64-7.
PMID: 8437327 [PubMed - indexed for MEDLINE]
Bendorf
K, Friesen CA, Roberts CC.
Glucose response to
discontinuation of parenteral nutrition in patients less than 3 years of age.
JPEN J Parenter Enteral Nutr. 1996
Mar-Apr;20(2):120-2.
PMID: 8676529 [PubMed - indexed for MEDLINE]
-----Original Message-----
From: [EMAIL PROTECTED]
[mailto:[EMAIL PROTECTED] On
Behalf Of Galloway, Margy
Sent: Tuesday, June 20, 2006 6:18
PM
To: [EMAIL PROTECTED]
Subject: TPN guidelines
I need some assistance with writing
a policy to cover patients who are on TPN and the central line
is accidentally removed. Our
current policy (which dates back to 1998) states that 10% Dextrose must
be started with in 10 minutes.
We all know we shouldn't give D10W through a PIV. The INS "blue
book" states in the "unstressed patient, rapid tapering can be
accomplished by reducing the rate by 50% during the first hour and by 50%
during the second hour.". The blue book also talks about using D5W
instead of D10W.
At conference I heard someone talk
about doing hourly blood sugars and only start fluids if the patient shows
signs of trouble when the catheter was accidentally removed. What do you
have in your policy concerning accidental catheter removal? Any
literature that addresses this issue?
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