What would you do? ...stop TPN or not

Specialties MICU

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Specializes in Critical Care- Medical ICU.

Situation.... I had a patient admitted to me quite unstable from the floor, needed to be intubated and had a MAP around 45. Resp acidosis and probable sepsis/ septic shock. Needed to be started on several drips and needed blood cultures X2 and a few antibiotics hung. The only access she had was a double lumen PICC, with TPN already infusing into one. I need to hang all of these pretty much at the same time because the drips needed to be started immediately and there were 3 stat antibiotics ordered (on our unit we have a very strict policy regarding having blood cultures drawn and all antibiotics ordered given within one hour of admission.) So I only had 1 available port, and there were some incompatibility issues. Nobody was able to get another IV in her, even with an ultrasound. I requested another line but it would have been way too late by the time it was placed anyways.

Well, I ended up late on one abx, so I'm sure I will be hearing about it from our pharmacist some time. But I went with my preceptors judgement and just hung it after something else was done. The antibiotic was the least important of everything I needed to give.

But my question to you guys is, I know you arent really supposed to stop TPN, but is it ok to stop TPN for a short period of time if you absolutely had to? Like say for 30 min to run something else in really fast? & if so, how long can it be off before you would be concerned about a risk of hypoglycemia?

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We barely ever see TPN so I'll default to the more experienced nurses. But it sounds like you did right. Our sepsis protocol says we do cultures and abx in under an hour. Doesn't matter if you have all 3 abx completed, as long as they were started in under an hour. So it sounds like you did just fine judging by our standards.

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Specializes in MICU, SICU, CICU.

I probably would have stopped the TPN. Usually if my docs are worried about sepsis, they would d/c it until we had negative blood cultures. Otherwise I probably would have gotten the doc intubating to drop a TLC in the IJ or subclavian while they were in the unit.

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You really have no choice except to stop the TPN and monitor for hypoglycemia. When you get a new triple lumen you can restart it if they want it to keep running. BTW, once you use the TPN port for something else, you can't restart TPN on that port anyway, because TPN has to run through a dedicated, TPN-only port.

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Specializes in Critical Care- Medical ICU.

Yes, that was one of my concerns as well because I knew I had been taught that TPN needs a dedicated line. I hate double lumens period. If you are gonna go through the trouble of putting in a line, might as well make it a triple lumen!!!

Our ICU team is good about using only triple or even quad lumen lines, but I guess things are different on the regular floor when they arent expecting to have to run a gazillion drips.

Thanks to all for your answers so far! ..... Being a new ICU nurse is hard :(

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I think you did the right thing. It was a peri-arrest situation so your priorities are Airway, Breathing, Circulation. ABC...not TPN. That can wait.

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Specializes in CCT.

Would have stopped the TPN, and have been paging a physician to get a central line ASAP. I get VERY suspicious of line sepsis in the patient with undifferentiated sepsis and TPN through a PICC.

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Specializes in ER/ICU/STICU.

I agree with others. Stop TPN and get the meds in and just monitor for hypoglycemia and maybe get an order to hang D5NS, but my guess is if this patient is septic and has been on TPN then they most likely are going to be hyperglycemic. Once the patient is settled and has everything running then have the doc drop another central line, which they should already be doing and at least getting set up to do. Hopefully the patient is already tubed so it would be a little easier for the doc to put in the central line.

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Specializes in NICU.

Did the TPN have insulin in it? Not all TPN does.

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Specializes in ICU.

If you have an emergent newly admitted patient going into septic shock, very hypotensive and trending downwards, the TPN is the least of your worries. As others have said, the course of action would be to cease the TPN (and aspirate and flush the lumen); administer the other orders; continue to monitor her BSL and if necessary hang a bag of dextrose. In septic shock, it is extremely important to get the antibiotics up ASAP. Your preceptor gave you the correct guidance.

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Specializes in PICU, SICU.

we stop tpn occasionaly for access issues your course of action was standard on our unit including the post about the D5 also know how fast you can givethe abx, some can be given in 15 minutes. Check with pharmacy and you might be surprised, however the mycins youll just have to wait

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I'm still in nursing school, but I want to work in ICU when I graduate. If it was my patient, I think I would've stopped TPN and done glucose levels from time to time to monitor for hypoglycemia. If the patient is septic, hypotensive, and in a downward spiral, the TPN is the least of your worries. At the time, the priority was to start antibiotics to treat massive infection, increase BP to a more normal, and safe, range and maintain it there, get the patient intubated, and try to stabilize the patient's overall condition. If you continue the TPN and don't give the essential medications, the patient could very well die; and if the patient dies, well, then, TPN isn't really an issue at all now is it? If the glucose dropped and the patient became hypoglycemic after stopping TPN, you could always hang a bag of dextrose, increase the frequency of your glucose checks, and titrate the bag of dextrose to maintain a normal glucose level until you had a free port to start the TPN back again.

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