Blood glucose determinations (accu-chekR) should be done before each rate increase. If the blood glucose is greater than 200, continue at the same rate for another 4 hours, check again and if still high, consider insulin therapy. If patient is diabetic; see section on TPN in various disease states.
2. Cessation - patient can be weaned from TPN rapidly. Decrease the rate by 1/2 every 2 hours until the rate is less than 50 ml/hr, then discontinue.
3. Cyclic TPN administration - Cycling is a procedure used especially in the outpatient setting to free the patient from being attached to an IV and allow for ambulation. There are no specific written guidelines on how to convert patients to cyclic TPN although the following information is generally considered to be helpful. The patient must be stabilized on the 24 hour schedule. The maximum hourly rate tolerated for a TPN is usually about 200 ml/hr. Advance to the final time period slowly by subtracting 2-4 hour blocks of time from the total daily infusion time. It will take several days to reach the final infusion time. Monitor vital signs, input and output, and glucose with accuchecks carefully during the change over period as the patient may require additional time to adjust to new regimen.
To convert a patient from a 24 hour TPN to cyclic TPN the following is suggested:
Total daily TPN volume/(Total hours to deliver TPN - 1) = Final cyclic TPN rate
Fluid volume and infusion rates
FLUID VOLUME/24 HOURS INFUSION RATE
1000 ml 42 ml/hr
1200 ml 50 ml/hr
1800 ml 75 ml/hr
2000 ml 83 ml/hr
2400 ml 100 ml/hr
3000 ml 125 ml/hr
3600 ml 150 ml/hr
Recommended only if the patient's additive profile is compatible with 3-in-1 mixing. Pharmacists will verify compatibility and will contact the physician if there are problems. Patients who show a rapid elevation of triglycerides to greater than>400 mg/dL upon fat emulsion infusion would NOT be candidates for 24 hour 3-in-1 admixtures.