Hypoglycemia in ICU Patients with High Output Fistula

Pathophysiology and Clinical Presentation

The American Society for Parenteral and Enteral Nutrition recommends that TPN be discontinued to administer blood products through a separate line to prevent complications, and in this case, TPN was discontinued to administer 2 units of PRBCs through the same line 1
The development of coma in an ICU patient with high output fistula 2 hours after TPN discontinuation indicates an acute metabolic derangement, with hypoglycemia being a likely cause 2

The American Diabetes Association recommends that immediate blood glucose measurement is essential in any patient who becomes comatose after TPN discontinuation, and treatment involves prompt administration of intravenous glucose (D50W) followed by continuous glucose infusion until TPN can be safely restarted 3
The American Society for Parenteral and Enteral Nutrition suggests that prevention strategies include never abruptly discontinuing TPN in dependent patients, providing alternative glucose sources or tapering the rate gradually if TPN must be interrupted, and using separate dedicated lines for blood product administration in TPN-dependent patients 3

The Society of Critical Care Medicine recommends that electrolyte abnormalities are common in ICU patients, especially those with high output fistulas, and should be closely monitored, with regular monitoring of serum glucose levels being essential when TPN is interrupted for any reason 4
The American Society for Parenteral and Enteral Nutrition advises that patients with high output fistulas require vigilant monitoring of all electrolytes, particularly potassium, phosphate, and magnesium 1