If you read through the trials and reports, you will find that some patients do experience hypoglycemic symptoms after sudden discontinuation. Before the trials, there were no blood glucose data to help define what was seen, and numerous protocols were created. With data, it appears that the majority of patients with symptoms do not have dangerously low blood glucose levels - maybe in the 60 range. Given that symptoms relate to the rate of blood glucose change as well as the absolute blood glucose level, the intervention may be unnecessary, if the situation is understood. It may also mean that an intervention need not be drastic, but should probably be immediate since the reactions seem to occur within the first hour and be self-mitigating after that.
Note in the peds article I included, the frequency of hypoglycemia in those less than 3 yoa was significant - 50% dropped to <40 mg/dl. Abrupt discontinuation was not a good idea in the very young.
I am talking about stable adults, not on insulin to compensate for PN-induced hyperglycemia, etc.. What you do has to apply to the situation - I simply suggest you consider that abrupt discontinuation of PN is not always the critical event it is sometimes thought to be.
Just my opinion.. over it now..
marc
-----Original Message-----
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]] On Behalf Of Raye Dillon
Sent: Saturday, June 24, 2006 10:05 AM
To: [EMAIL PROTECTED]
Subject: RE: TPN guidelines
just out of curiosity were there actual studies that indicated TPN
should be tapered or was it a "theoretical" concern.
>>> "Stranz, Marc" <[EMAIL PROTECTED]> 06/21/06 2:07 PM >>>
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
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=A
bstract&list_uids=7656740&query_hl=3&itool=pubmed_docsum> 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
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=A
bstract&list_uids=8437327&query_hl=3&itool=pubmed_docsum> 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
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=A
bstract&list_uids=8676529&query_hl=3&itool=pubmed_docsum> 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]
marc
-----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
Colleagues,
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?
Thanks for your help.
Margy Galloway
Saint Luke's Health System Confidentiality Notice:
The information contained in this e-mail transmission is confidential
information, proprietary to the sender and legally protected. Its
purpose is
intended for the sole use of the individual(s) or entity named in the
message header. If you are not the intended recipient, you are hereby
notified that any dissemination, copying or taking any action in
reliance on
the contents of this information is strictly prohibited. If you
received
this message in error, please notify the sender of the error and delete
this
message and any attachments.
Kansas City's newest health care campus, Saint Luke's East-Lee's
Summit, is
now open. Go to saintlukeshealthsystem.org to learn more.
