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

[IheartICUnursing]

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?

[PICC ACE]

Stop the TPN,resuscitate the pt. No big deal. General rule of thumb is that if you have to stop TPN for whatever reason,start D10% at the same rate as the TPN. Watch blood sugars and treat them as needed--if there was loads of insulin in the TPN,they could go up. And with running pressors and being septic-ish,the BG's are going to go wild anyway.

Does your hospital's TPN orders include standing orders for what to do if TPN has to come off? My former hospital had the D10% and blood sugar checks as part of the basic TPN order set.

Z.

[RW23RN, BSN, RN]

Actually, literature for sepsis says that antibiotics given within the first hour of diagnosis is critical. That's why there are strict rules in your unit. Its fast becoming a national standard as much as the "golden hour" for MI and strokes. Many antibiotics are compatible with TPN, althought you would need to check your hospital policy on this and hypoglycemia is not likely to occur as quickly as you would think and is easily corrected with D50. You want the patients blood sugar on the low side of normal anyways as all that excess sugar is just food for the bacteria causing the sepsis. Several pressors are compatible, several antibiotics are compatible-I agree, double lumens are a waste of time! Part of the sepsis protocol at my last unit included central line placement within an hour as well-and usually if we needed more lines we could have the docs place them. If you can't get a PIV and really need a line, you may need to consider an EJ or an IO until you can get further access. I'd find out what your facility's policy is on those too.

[CCL RN, RN]

. The antibiotic was the least important of everything I needed to give.

quite the opposite. The Abx was the *most* Important thing to give....