TPN Discontinuation

Post Bowel Resection Clinical Case Study by:

Cody Steiner MSU Dietetic Intern

Overview

• Examine patient post reconstructive surgery

• Review patients outcome

• Determine best practice for TPN discontinuation

The Patient

• 52 year old female patient admitted for pelvic

sarcoma

• Resection of recurrent pelvic sarcoma, en bloc

ileocecal region, sigmoid colon and dome of the

bladder, extensive lysis of adhesion for

reestablishment of gastrointestinal continuity, and a

cystoscopy with ureteral stent placement

ADIME Charting: Assessment

• Ht: 60”

• Weights:

• 54.4kg - at admission

• 45.1kg - 15 days post admission

• Ideal Body Weight: 49kg

• % Ideal Body Weight:

• 110% - at admission

• 92% - 15 days post admission

• BMI: 22.7 at admission

Anthropometric

ADIME Charting: Assessment

• Metastatic pelvic cancer

• TPN dependence since 2011

• 100% TPN for > 3 years

• Venting gastric tube in place

• Chronic anemia

• Recurrent bacteremia and line sepsis

• Benign meningioma in 1990

• Invasive breast cancer of right breast

Past Medical History

Surgical Procedures

• Pelvic Sarcoma resection followed by

abdominal/pelvic radiation in 2010

• Small bowel to transverse colon

anastomosis in 2013

• Risk for malabsorption of fat

soluble vitamins, B12, and

fluids/electrolytes

ADIME Charting: Assessment

• Poor appetite and fear of eating

• Related to numerous years of TPN

• Surgeon note reports “adequate intake with some emesis” on prior to

discharge

• Weight loss of 9.3kg between admission and discharge

• 17% decrease - considered significant in 30 day period

Nutrition Focused Information

ADIME Charting: Assessment

• Estimated Nutritional Needs:

• Calories: 1640kcals (30kcals/kg)

• Admission weight used

• Based on Harris-Benedict with x1.5 stress factor for current cancer

• Protein: 65-81g (1.2-1.5g/kg)

• Related to current cancer and post resection

ADIME Charting: Diagnosis

PES 1: Altered gastrointestinal function related to

decreased functional intestine length as evidenced by

two resections of small bowel sarcoma and 5 years of

partial parenteral nutrition dependence including 3 years

of no enteral nutrition.

PES 2: Inadequate caloric intake related to abrupt

discontinuation of TPN as evidenced by a > 5%

weight loss in less than 1 month post

discontinuation.

ADIME Charting: Case Study

Intervention

• TPN was abruptly discontinued upon discharge

• No outpatient follow up or RD referral for diet counseling

scheduled

• Inpatient RD gave as much information/support as possible

• Signs of dehydration/malabsorption

• Moderate fat intake, increasing soluble fiber, frequent small

meals, decreasing fluid intake during meals

• Vitamins, minerals, and supplementation

Abrupt vs. Stepwise TPN

Discontinuation

• Abrupt vs. Stepwise discontinuation:

• Abrupt discontinuation

• Quickens increases of enteral intake

• Risk of weight loss

• Stepwise discontinuation

• Combines TPN and oral intake

• Adjusts as oral intake increases

• Delays adequate oral nutrition

Abrupt vs. Stepwise TPN

Discontinuation• Current research on gut atrophy after TPN dependence:

• Journal of Digestive Disease and Sciences

• Rat model - 8 days 100% TPN

• Significant (p<0.01) decreases in intestinal circumference,

villi diameter in the jejunum and ileum

• Nutrition Issues in Gastroenterology

• Great risk of malabsorption during adaptation phase

• Can last 2-3 years post resection

Abrupt vs. Stepwise TPN

Discontinuation• Three case studies by the International Life Sciences Institute

• Patient #1 adapted to abrupt discontinuation

• Required nocturnal enteral hydration

• Patient #2 discontinuation with nightly TPN

• Extremely short functioning length ~100cm

• Nocturnal TPN only to promote oral intake

• Patient #3 Stepwise TPN tapering planned

• 3 meals/day provided ~55% calories, TPN ~45%

ADIME Charting: Intervention

& Monitoring

• Patient needs diet counseling and weight monitoring in relation to reinitiating of oral

intake

• Stepwise TPN discontinuation should be utilized

• Begin with nightly TPN meeting 75% needs and decrease in relation to oral intake

• There should be little to no unintentional weight loss

• Weight and oral intake should be self monitored by patient at least x2 weekly and

changes reported to dietitian

• Any weight loss would trigger a reevaluation of diet and nutritional support

Conclusions

• Unfortunately unable to personally follow up with patient after

discharge

• Outpatient RD reported weight stabilized at 41kg (83.5%

IBW) with supplemental TPN reinitiated

Conclusions• Best evidence-based

research shows:

• Gut adaptation with abrupt discontinuation is possible

• Dependent on many factors

• Functional intestine length

• Other SBS treatments (medications, EN, etc.)

• Ability for oral intake

• Most effective treatment plan:

• A patient centered

approach!

• TPN discontinuation

dependent on not only

functional length, but

also patient’s readiness

for oral intake

• Diet adaptation, with

education and

monitoring, should also

be based on individual

needs

Q & A

Barrett, M., Demehri, F. R., Ives, G. C., Schaedig, K., Arnold, M. A., & Teitelbaum, D. H. (2017). Taking a STEP back: Assessing the outcomes of

multiple STEP procedures. Journal of Pediatric Surgery, 52(1), 69-73. doi:10.1016/j.jpedsurg.2016.10.024

Bodoky, Gyorgy, Antonio C. Campos, Zhong-Jin Yang, David C. Hitch, and Michael M. Meguid. "The comparative effects of abrupt vs. stepwise

discontinuation of TPN in rats." Physiology & Behavior 52.3 (1992): 591-95. Web. 15 Nov. 2016.

Carroll, Robert E., Enrico Benedetti, Joseph P. Schowalter, and Alan L. Buchman. "Management and Complications of Short Bowel Syndrome: An

Updated Review." Current Gastroenterology Reports 18.40 (2016): 1-13. Web.

Ekelund, Mikael, Elin Kristensson, Mats Ekelund, and Eva Ekblad. "Total Parenteral Nutrition Causes Circumferential Intestinal Atrophy, Remodeling of

the Intestinal Wall, and Redistribution of Eosinophils in the Rat Gastrointestinal Tract." SpringerLink. Kluwer Academic Publishers-Plenum Publishers,

28 Mar. 2007. Web. 03 Apr. 2017.

Nauth, Justin, Chih Wen Chang, Sohrab Mobarhan, Sherri Sparks, Margaret Borton, and Sheryl Svoboda. "A Therapeutic Approach to Wean Total

Parenteral Nutrition in the Management of Short Bowel Syndrome: Three Cases Using Nocturnal Enteral Rehydration." Nutrition Reviews 62.5 (2004):

221-31. Web. 3 Apr. 2017.

Parrish, C. R., & DiBaise, J. K. (2015). Short Bowel Syndrome in Adults – Part 5 Trophic Agents in the Treatment of Short Bowel Syndrome. Nutrition

Issues in Gastroenterology, 141st ser., 56-66. Retrieved March 28, 2017.

Seguy, D., et al. “Growth Hormone Enhances Fat-Free Mass and Glutamine Availability in Patients with Short-Bowel Syndrome: An Ancillary Double-

Blind, Randomized Crossover Study.” American Journal of Clinical Nutrition 100.3 (2014): 850–858. Web.

SUDAN, D, et al. “A Multidisciplinary Approach to the Treatment of Intestinal Failure.” Journal of Gastrointestinal Surgery 9.2 (2005): 165–177. Web.

Wu, Guo-Hao, Zhao-Han Wu, and Zhao-Guang Wu. “Effects of Bowel Rehabilitation and Combined Trophic Therapy on Intestinal Adaptation in Short

Bowel Patients.” World Journal of Gastroenterology 9.11 (2003): 2601–2604. Print.

References