How to manage a TPN-dependent patient with short gut syndrome presenting with weakness and requiring line exchange, with a high risk of refeeding syndrome and a history of recurrent line infections and thromboembolic events?

Management Checklist for TPN-Dependent Short Bowel Syndrome Patient Requiring Line Exchange

Pre-Admission Risk Stratification

This patient is at extremely high risk for refeeding syndrome given 10-20 pound weight loss, prolonged nutritional deprivation, and low phosphate (0.64 mmol/L) at baseline. 1

Refeeding Syndrome Risk Assessment

• High-risk criteria present:
  • Significant recent weight loss (130 lbs from baseline 150-160 lbs = 13-19% loss) 2, 3
  • Baseline hypophosphatemia (0.64 mmol/L, normal >0.8 mmol/L) 4
  • Hypomagnesemia (0.69 mmol/L) 2
  • Prolonged inadequate nutritional intake 5
  • TPN-dependent status with recent interruption 1

Thromboembolism Risk Assessment

• Very high risk:
  • History of DVT/PE 1
  • TPN dependence (independent risk factor) 1
  • Declined anticoagulation due to prior severe GI bleeding 1
  • Dehydration risk with short bowel syndrome 1

Line Infection Risk Assessment

• High risk:
  • Multiple prior MSSA bacteremia episodes 1
  • Recurrent line infections documented 1
  • Requires specialized nursing care for line management 1

Initial Assessment Checklist (First 24 Hours)

History Components

• Nutritional history:

  • Duration of current weight loss and oral intake pattern 6, 7
  • Current TPN regimen details (volume, composition, frequency, duration) 1, 8
  • Stool/ostomy output volume (quantify in liters/day) 1, 6
  • Urine output volume 1
  • Thirst symptoms 1
  • Teduglutide 5mg SQ use and response 9

• Bowel anatomy documentation:

  • Exact residual small bowel length (measured along antimesenteric border) 6
  • Presence/absence of colon and continuity 6, 7
  • Type of anatomy: jejunostomy vs jejunocolonic vs jejuno-ileo-colic 6
  • Date of last bowel resection 1

• Line infection history:

  • Dates and organisms of prior bacteremias 1
  • Current line type, insertion date, and location 1
  • Signs of current line infection (fever, erythema, purulent drainage) 1

• Thrombosis history:

  • Details of prior DVT/PE (location, timing, treatment) 1
  • Reason for declining anticoagulation (severity of prior GI bleeding) 1
  • Current symptoms of thrombosis 1

Physical Examination Components

• Volume status assessment:

  • Orthostatic vital signs 6
  • Mucous membrane moisture 1
  • Skin turgor 1
  • JVP assessment 6
  • Peripheral edema (may indicate refeeding-related fluid retention) 4

• Nutritional status:

  • Current weight vs usual/ideal weight 1, 6
  • Mid-arm muscle circumference 6
  • Temporal wasting 6
  • Signs of micronutrient deficiency (glossitis, cheilosis, neuropathy) 7

• Line site examination:

  • Erythema, warmth, tenderness, purulent drainage 1
  • Tunnel tract examination 1
  • Line patency 1

• Neurological examination:

  • Mental status (confusion may indicate D-lactic acidosis or refeeding complications) 7, 4
  • Peripheral neuropathy (thiamine deficiency) 4, 5
  • Muscle weakness (hypophosphatemia, hypokalemia) 4, 10

Laboratory Monitoring Protocol

Day 0 (Admission):

• Comprehensive metabolic panel with phosphate, magnesium, calcium 1, 2
• CBC with differential 1
• Liver function tests 1
• Thiamine level 1, 4
• Vitamin B12, folate 7
• 25-OH vitamin D 7
• Prothrombin time/INR (baseline 1.8, monitor trend) 1
• Blood cultures if fever or line infection suspected 1
• Urinary sodium (target >20 mmol/L to confirm adequate sodium repletion) 6

Days 1-7 (Daily monitoring):

• Phosphate, magnesium, potassium, sodium (daily for first 7 days minimum) 1, 2, 3
• Glucose (every 6 hours initially) 1
• Calcium 1
• Daily weights 1, 6
• Fluid balance including stool/ostomy output 1, 6

Problem List with Management Priorities

1. HIGH RISK REFEEDING SYNDROME (HIGHEST PRIORITY)

Management protocol:

• Start TPN at 10 kcal/kg/day (approximately 590 kcal/day for 130 lb patient) 6, 5
• Increase by 2-4 kcal/kg/day if electrolytes stable 3
• Target 25-30 kcal/kg/day by day 5-7 6, 7

Mandatory supplementation before/concurrent with TPN restart:

• Thiamine 200-300 mg IV daily for 3 days, then 100 mg daily 1, 4, 5
• Vitamin B complex IV daily 5
• Multivitamin supplementation 5

Aggressive electrolyte replacement (start immediately, before TPN):

• Phosphate: Target >1.0 mmol/L; supplement 20-40 mmol IV over 12 hours if <0.65 mmol/L 2, 4, 10
• Magnesium: Target >0.85 mmol/L; supplement 8-16 mmol IV 2, 4
• Potassium: Target >4.0 mmol/L; supplement 40-80 mmol IV daily 2, 4

Critical monitoring:

• If phosphate drops below 0.5 mmol/L: STOP TPN temporarily, aggressive IV phosphate replacement, resume at lower rate when >0.65 mmol/L 10
• Monitor for cardiac arrhythmias (telemetry if phosphate <0.5 mmol/L) 4, 10
• Monitor for respiratory failure (hypophosphatemia-induced diaphragm weakness) 4

2. CENTRAL LINE EXCHANGE

Pre-procedure:

• Blood cultures if any signs of infection 1
• Ensure coagulation parameters acceptable (INR 1.8 is borderline but acceptable) 1

Procedure standards:

• Use tunneled central venous catheter (NOT PICC, NOT port) 1
• Tip placement in superior vena cava or right atrium confirmed by chest x-ray 1
• Full barrier precautions during insertion 1
• Chlorhexidine skin preparation 1

Post-procedure:

• Chest x-ray to confirm placement and rule out pneumothorax 1
• Specialized nursing team for ongoing catheter care 1

3. THROMBOEMBOLISM PROPHYLAXIS

Despite history of PE and contraindication to therapeutic anticoagulation:

• Consider prophylactic dose anticoagulation (enoxaparin 40 mg SC daily or heparin 5000 units SC TID) given extremely high risk 1
• Weigh risk vs benefit given prior severe GI bleeding 1
• Aggressive hydration to prevent dehydration (independent thrombosis risk factor) 1
• Sequential compression devices 1
• Early mobilization 1

4. DEHYDRATION MANAGEMENT

Fluid prescription:

• Calculate total fluid needs: baseline requirements + stool/ostomy losses + 1L for urine output 1
• Use glucose-electrolyte oral rehydration solution (90-120 mEq/L sodium) if tolerating PO 1, 6, 7
• Avoid hypotonic fluids (water, tea, coffee) which increase ostomy output 1
• Parenteral fluids as needed to maintain urine output >1L/day 1

Monitoring:

• Daily weights (target stable or gradual increase) 1, 6
• Urine output >1L/day 1
• Urinary sodium >20 mmol/L 6

5. GASTRIC HYPERSECRETION

Continue current regimen:

• Rabeprazole 20 mg PO daily (already prescribed) 1, 6, 7
• Continue for minimum 6 months post-resection 6, 7

6. MICRONUTRIENT DEFICIENCIES

Immediate supplementation:

• Continue cholecalciferol 10,000 units daily 7
• Add fat-soluble vitamins A, E, K if not already supplemented 7
• Zinc supplementation (increased losses with high ostomy output) 1
• Monitor and replace vitamin B12, folate based on levels 7

7. TEDUGLUTIDE CONTINUATION

Management:

• Continue teduglutide 5 mg SQ daily during hospitalization 9
• This GLP-2 analog promotes intestinal adaptation and may reduce PN requirements over time 9
• Monitor for response (reduced PN volume requirements) 9

8. ANEMIA

Assessment:

• Hemoglobin 93-97 g/L (mild anemia) 1
• Check iron studies, B12, folate 7
• Consider chronic disease vs nutritional deficiency 7

Daily Monitoring Checklist (Days 1-7)

Every morning:

• Weight 1, 6
• Vital signs including orthostatics 6
• Stool/ostomy output volume (24-hour total) 1, 6
• Urine output volume 1
• Mental status assessment 7, 4

Laboratory (daily for 7 days):

• Phosphate, magnesium, potassium, sodium 1, 2, 3
• Glucose 1
• Calcium 1

Clinical assessment:

• Signs of fluid overload (peripheral edema, crackles) 4
• Cardiac rhythm abnormalities 4, 10
• Muscle weakness 4, 10
• Confusion or altered mental status 7, 4
• Line site examination 1

Discharge Planning Criteria

Patient ready for discharge when:

• Electrolytes stable for 48 hours on current TPN regimen 1, 8
• No signs of refeeding syndrome 3
• New line functioning without complications 1
• Patient/caregiver demonstrates competency in line care 1
• Outpatient nutrition clinic follow-up arranged 1
• Home TPN prescription finalized and coordinated with home infusion company 1

Expected length of stay: 7-10 days as anticipated 1