The Effect of Acute Discontinuation of Total Parenteral Nutrition

Abstract

The present study was undertaken to assess the impact of acute discontinuation (AD) of total parenteral nutrition (TPN) on serum glucose, insulin, and glucagon levels and on the generation of symptomatic hypoglycemia. Fifty studies were performed in 48 patients. In none of the 30 studies of 1 hour duration nor in the 20 studies of 8 hours duration was there a single episode of symptomatic hypoglycemia. One patient had a glucose below normal (60 mg/dl) during the first hour after AD. Glucose and insulin concentrations were elevated at the start of TPN discontinuation but returned to normal values within 60 minutes and remained there during the successive 7 hours of study. Although glucagon levels were slightly elevated at zero time, no significant decrease occurred. There was no evidence for counter-regulation based on the patterns of glucose and hormone levels. With some restrictions, acute discontinuation is a safe, rapid method of ending a prolonged TPN infusion.

Metabolic Effects of Cyclic Parenteral Nutrition Infusion in Adults and Children

“…A number of before–after studies demonstrated a rapid increase in serum insulin concentrations upon PN infusion initiation, with a rapid decrease following discontinuation (N = 4‐48). 5 , 16 , 17 , 20 Two of these studies demonstrated similar circulating glucagon, cortisol, and growth hormone concentrations between patients receiving cyclic and continuous PN infusion (N = 10, 48, respectively). 5 , 20 In a randomized parallel‐group study of 16 traumatized or infected mechanically ventilated patients, urinary epinephrine, norepinephrine, and cortisol excretion rates were similar between patients given cyclic and continuous infusion, although circulating cortisol concentrations were elevated relative to baseline during infusion of cyclic regimens 11 .…”

“… 5 , 16 , 17 , 20 Two of these studies demonstrated similar circulating glucagon, cortisol, and growth hormone concentrations between patients receiving cyclic and continuous PN infusion (N = 10, 48, respectively). 5 , 20 In a randomized parallel‐group study of 16 traumatized or infected mechanically ventilated patients, urinary epinephrine, norepinephrine, and cortisol excretion rates were similar between patients given cyclic and continuous infusion, although circulating cortisol concentrations were elevated relative to baseline during infusion of cyclic regimens 11 . One small study demonstrated circadian rhythms of serum levels of total proteins, total cholesterol, high‐ and low‐density lipoproteins, triglycerides, free fatty acids, and apolipoproteins A and B during cyclic PN (N = 6) 21 …”

Response of Dogs to Short‐term Infusions of Carbohydrate‐ or Lipid‐based Parenteral Nutrition

“…Moreover, hyperinsulinemia during the infusions did not induce clinically apparent hypoglycemia following the discontinuation of the infusions after 10 h. This could be different in patients with markedly impaired glucose tolerance. Thus, in children <3 years old, a high frequency of hypoglycemia was reported after abrupt cessation of infusions (Bendorf et al., 1996), while no major clinical or biochemical problems were confirmed in adults (Wagmann et al., 1986; Krzywda et al., 1993; Eisenberg et al., 1995). In diseased dogs discontinuation of PN infusion seems to be feasible even with severe illness without significant hypoglycemia (Farlopulos et al., 1997).…”

Maintaining Normal Blood Glucose Concentrations With Total Parenteral Nutrition: Is It Necessary to Taper Total Parenteral Nutrition?

“…This elevated insulin level may cause hypoglycemia when TPN is discontinued abruptly. 7 Symptoms of hypoglycemia include diaphoresis, trembling, feelings of warmth, anxiety, nausea, dizziness, hunger, tingling, confusion or difficulty in thinking, palpitations, headache, weakness, inability to concentrate, blurred vision, and loss of consciousness. 8 Hypoglycemia is a major clinical concern because it may ultimately lead to seizures.…”