The introduction of a nutrition clinical nurse specialist results in a reduction in the rate of catheter sepsis

Clinical nurse specialists in nutrition: A systematic review of roles and clinical experiences

BACKGROUND/SCOPE

The Clinical Nurse Specialist in Nutrition is a professional capable of providing specialist clinical assistance and leadership-related clinical nutrition. To date, although their role has already been identified, there is still uncertainty about how this figure can actually fit into the various global health systems. The purpose of this review is to clarify and define the role of this professional aimed at analysing clinical experiences and data from nutrition scientific societies.

METHODOLOGY

A systematic literature review was conducted using the Prisma Statement in the Cochrane Library databases and subsequently in PubMed, Embase, CINAHL, Scopus and Web of Science. In addition, a manual search of studies published in Google Scholar was conducted for the analysis of 'grey literature'. Out of 2,348 identified records, 21 studies were included in the present review.

RESULTS

The development of specific training, certification and qualification protection courses is contributing to the development of this professional in various hospital and community clinical contexts. The clinical experiences identified have shown that this figure is able to provide specialist assistance by offering high levels of safety, efficacy and quality of the care provided.

CONCLUSIONS/ IMPLICATIONS FOR NURSING

The implementation of nurse nutrition specialist, to date, is still limited at the global level, and training programmes coordinated between scientific societies and nursing universities could be the basis for the development of this specialization in countries where today this figure is not yet present.

Identifying the nutrition support nurses' tasks using importance-performance analysis in Korea: a descriptive study

PURPOSE

Nutrition support nurse is a member of a nutrition support team and is a health care professional who takes a significant part in all aspects of nutritional care. This study aims to investigate ways to improve the quality of tasks performed by nutrition support nurses through survey questionnaires in Korea.

METHODS

An online survey was conducted between October 12 and November 31, 2018. The questionnaire consists of 36 items categorized into 5 subscales: nutrition-focused support care, education and counseling, consultation and coordination, research and quality improvement, and leadership. The importance-performance analysis method was used to confirm the relationship between the importance and performance of nutrition support nurses' tasks.

RESULTS

A total of 101 nutrition support nurses participated in this survey. The importance (5.56±0.78) and performance (4.50±1.06) of nutrition support nurses' tasks showed a significant difference (t=11.27, P<0.001). Education, counseling/consultation, and participation in developing their processes and guidelines were identified as low-performance activities compared with their importance.

CONCLUSION

To intervene nutrition support effectively, nutrition support nurses should have the qualification or competency through the education program based on their practice. Improved awareness of nutrition support nurses participating in research and quality improvement activity for role development is required.

Recent nanoengineered diagnostic and therapeutic advancements in management of Sepsis

COVID-19 acquired symptoms have affected the worldwide population and increased the load of Intensive care unit (ICU) patient admissions. A large number of patients admitted to ICU end with a deadly fate of mortality. A high mortality rate of patients was reported with hospital-acquired septic shock that leads to multiple organ failures and ultimately ends with death. The patients who overcome this septic shock suffer from morbidity that also affects their caretakers. To overcome these situations, scientists are exploring progressive theragnostic techniques with advanced techniques based on biosensors, biomarkers, biozymes, vesicles, and others. These advanced techniques pave the novel way for early detection of sepsis-associated symptoms and timely treatment with appropriate antibiotics and immunomodulators and prevent the undue effect on other parts of the body. There are other techniques like externally modulated electric-based devices working on the principle of piezoelectric mechanism that not only sense the endotoxin levels but also target them with a loaded antibiotic to neutralize the onset of inflammatory response. Recently researchers have developed a lipopolysaccharide (LPS) neutralizing cartridge that not only senses the LPS but also appropriately neutralizes with dual mechanistic insights of antibiotic and anti-inflammatory effects. This review will highlight recent developments in the new nanotechnology-based approaches for the diagnosis and therapeutics of sepsis that is responsible for the high number of deaths of patients suffering from this critical disease.

Exploring the role of the nutrition nurse specialist in an intestinal failure tertiary referral centre

The role of the nutrition nurse specialist (NNS) is diverse and is usually integral to a wider, multidisciplinary nutrition support team (NST). Practice frameworks have been developed to identify competencies within the NNS role. A mind-mapping technique was used with the NNS team and the wider NST to explore the role of the NNS in the authors' intestinal failure tertiary referral centre. The results of this were further compared with the published competency frameworks. The mind maps from the NNS team and NST demonstrated commonality. It was encouraging to see that colleagues seem to have a similar understanding of the NNS role and contribution to the wider service. Published competency frameworks did not entirely reflect the expanded scope of practice that is undertaken within this particular team. It is important for clinical nurse specialist teams to evaluate their role and service provision and to compare this against published competency frameworks.

The Role of Nurse in the Multidisciplinary Management of Cancer Cachexia

Cancer cachexia is a complex syndrome for which multidisciplinary management through collaboration has the potential to improve patient outcomes and efficiency of care, through the integration of nursing into practice. These authors conducted a literature review of PubMed, EBSCO, OVID, and ProQuest for publications on the roles and responsibilities of nurses who are working in multidisciplinary teams for the management of cancer cachexia. We limited our search parameters for the literature review such that: (1) the included papers were published in the English language from January 2000 to February 2021 and (2) the included papers featured an adult patient population. Based on this review, cancer cachexia can be characterized as an involuntary loss of body weight that is combined with a dysregulation in the control of energy homeostasis and protein loss, which leads to poor clinical outcomes in patients. Cancer cachexia has been recognized as having multidimensional etiologies that are related to the nutritional and metabolic systems, as well as other physical and physiological systems, and to symptoms that manifest concurrently to the cachexia. While the clinical identification and taxonomic classification of cancer cachexia are usually associated with an observable degree of weight loss and muscular atrophy in a patient, clinical evidence of inflammation and related symptoms should be considered (in addition to the weight loss and muscular atrophy) in the diagnosis and evaluation of cancer cachexia, as will be argued in this paper. Early diagnosis, appropriate clinical assessment, and evaluation of cancer cachexia are crucial to predicting the onset of the condition and managing its symptoms when it occurs. Various tools have been developed for the clinical evaluation and diagnosis of cancer cachexia which reflect the multitudinous manifestations of the condition. Due to the diversity of its manifestations, multimodal therapy has gained popularity for the management of cancer cachexia. Multimodal therapy includes combined pharmacologic intervention, nutrition supplements, nutritional consultation, physical exercise, and symptom control. As these authors will demonstrate in this paper, this mode of multidisciplinary team management is increasingly supported by scientific evidence and as such, can be seen as essential for high-quality cancer cachexia management. Nursing plays an important role in the multidisciplinary care team model for cancer cachexia management, as nurses are well situated to perform screening, referral, coordination, nutritional consultation, physical exercise consultation, direct nutritional nursing, psychosocial support, symptom control, and hospice care. However, an increased focus on education, skills training, and tool development (as well as adoption of tools) on the part of nurses and other multidisciplinary team members is required to meet the goal of efficient care and improved outcomes for patients with cancer cachexia. These authors demonstrate that increasing roles and responsibilities for nurses in the management of cancer cachexia is a valuable area to explore in the literature and to implement in clinical practice. Our review aims to summarize the etiology and epidemiology, mechanisms-of-action, and multitudinous manifestations of cancer cachexia, the therapies that are used in cancer cachexia care and the management approaches by which this care is organized. Finally, these authors emphasize nurses' responsibilities in this mode of cancer cachexia multidisciplinary team management, which represents a fruitful benefit both in the research literature and in clinical settings.

Systematic review with meta-analysis: effects of implementing a nutrition support team for in-hospital parenteral nutrition

BACKGROUND

Nutrition support teams (NST) may improve parenteral nutrition (PN) outcomes. No previous systematic review has provided conclusive data on catheter-related infection (CRI) occurrence after NST introduction, nor have previous studies performed meta-analysis or graded the evidence.

AIMS

To systematically evaluate the effects of implementing an NST for hospitalised adults on PN and compare these with standard care.

METHODS

This was a systematic review and meta-analysis, pre-registered in PROSPERO (CRD42020218094). On November 24, 2020, PubMed, Web of science, Scopus, Embase, Cochrane Library, and Clinical Key were searched. Clinical trials and observational studies with a standard care comparator were included. Primary outcome was relative reduction in CRI rate. A random-effects meta-analysis was used to estimate effects, and evidence was rated using Cochrane and GRADE methodologies.

RESULTS

Twenty-seven studies with 8166 patients were included. Across 10 studies, NST introduction reduced the CRI rate (IRR = 0.32, 95% CI: 0.19-0.53) with -8 (95% CI: -12 to -5) episodes per 1000 catheter days compared with standard care. Hypophosphataemia occurred less frequently (IRD = -12%, 95% CI: -24% to -1%) and 30-day mortality decreased (IRD = -6%, 95% CI: -11% to -1%). Inappropriate PN use decreased, both judged by indication (IRD = -18%, 95% CI: -28% to -9%) and duration (IRD = -21%, 95% CI: -33% to -9%). Evidence was rated very low to moderate.

CONCLUSIONS

This study documents the clinical impact of introducing an NST, with moderate-grade evidence for the reduction of CRI occurrence compared with standard care. Further, NST introduction significantly reduced metabolic complications, mortality, and inappropriate PN use.

Nutrition Support Teams: A Systematic Review

BACKGROUND

The concept of a nutrition support team (NST) was first introduced at the end of the 20th century in the US and Europe. Expected benefits include reduced (inappropriate) prescription of (par)enteral nutrition; however, to the authors' knowledge, no recent review has assessed the effectiveness of NSTs. Therefore, this systematic review evaluated the effectiveness of NSTs with respect to the prevalence of adult patients receiving (par)enteral nutrition.

METHODS

Five literature databases were searched and completed by citing searches. Studies on NSTs that were published between 2000 and 2018 in Western countries, applied a comparative design, and contained at least outcome data on the prevalence of (par)enteral nutrition were included. Analyses were mainly descriptive because of high heterogeneity that prevented meta-analyses.

RESULTS

The 27 included studies mainly originated from the UK and US. Only 1 of the included studies was a randomized trial; the other studies had a pre-post design (n = 17) or compared groups in a nonrandomized way. All but 2 studies were performed in acute care hospitals, and 5 studies focused only on intensive care patients. There was conflicting evidence of whether NSTs lead to reduction or increase in patients starting parenteral nutrition (PN); however, weak evidence suggested that NSTs might lead to an increase in the ratio of enteral nutrition to PN use and might decrease inappropriate PN use.

CONCLUSION

Although almost all studies concluded in favor of NSTs, the evidence base is weak and insufficient because of a lack of well-designed studies and successful outcomes.

Diagnosis and management of catheter-related bloodstream infections in patients on home parenteral nutrition

Catheter-related bloodstream infections (CRBSIs) commonly arise from a parenteral nutrition catheter hub. A target for a Nutrition Support Team is to have a CRBSI rate of less than 1 per 1000. The diagnosis of CRBSI is suspected clinically by a temperature shortly after setting up a feed, general malaise or raised blood inflammatory markers. It is confirmed by qualitative and quantitative blood cultures from the catheter and peripherally. Treatment of inpatients may involve central venous catheter removal and antibiotics for patients needing short-term parenteral nutrition, but catheter salvage is generally recommended for patients needing long-term parenteral nutrition, where appropriate.

Challenges and Perspectives in Nutritional Counselling and Nursing: A Narrative Review

Nutritional counselling has been recognised as the first line approach in the management of numerous chronic diseases. Though usually carried out by dietitians, nutritional counselling may be used by nurses, or other healthcare professionals to improve nutritional status and meet healthcare goals. Healthcare professionals require training and education to facilitate a patient centred approach to effective counselling. Advances in digital technology have the potential to improve access to nutritional counselling for some patients such as those in primary care. However, caution is required to ensure that valuable interpersonal relationships are not lost, as these form the cornerstone of effective nutritional counselling. The aim of this narrative review is to explore aspects of effective nutritional counselling, including advances in e-counselling and areas where nursing input in nutritional counselling might enhance overall nutritional care.

Intestinal failure: a review

Intestinal failure (IF) is the inability of the gut to absorb necessary water, macronutrients (carbohydrate, protein, and fat), micronutrients, and electrolytes sufficient to sustain life and requiring intravenous supplementation or replacement. Acute IF (types 1 and 2) is the initial phase of the illness and may last for weeks to a few months, and chronic IF (type 3) from months to years. The challenge of caring for patients with IF is not merely the management of the underlying condition leading to IF or the correct provision of appropriate nutrition or both but also the prevention of complications, whether thromboembolic phenomenon (for example, venous occlusion), central venous catheter-related bloodstream infection, IF-associated liver disease, or metabolic bone disease. This review looks at recent questions regarding chronic IF (type 3), its diagnosis and management, the role of the multidisciplinary team, and novel therapies, including hormonal treatment for short bowel syndrome but also surgical options for intestinal lengthening and intestinal transplant.

UK practice in the prevention of central venous catheter-associated thrombosis in adults on home parenteral nutrition

BACKGROUND

Maintaining central access is imperative for the delivery of home parenteral nutrition (HPN) in those with intestinal failure. Methods to reduce central venous catheter infection are well recognised; however, the prevention of line thrombosis is less well studied.

METHODS

This paper reviews the current evidence and reports a survey of current practice within the UK. Using an electronic survey, respondents were asked to detail their use of anticoagulation in different patient groups and the type of anticoagulation used.

RESULTS

41 replies were received from 31 centres. Only one responder used low-dose warfarin routinely; 80% however anticoagulated those with a previous line thrombosis and 65% anticoagulated those that had any deep vein thrombosis or pulmonary embolus. The most commonly used anticoagulant was dose-adjusted warfarin aiming for an international normalised ratio of 2-3.

CONCLUSIONS

The evidence from the current literature in both HPN and the wider field is that there is no clear evidence that anticoagulation is either beneficial or harmful in the prevention of line thrombosis. This survey suggested that practice is varied across the UK likely reflecting the lack of evidence within the current literature.

ESPEN guidelines on chronic intestinal failure in adults

BACKGROUND & AIMS

Chronic Intestinal Failure (CIF) is the long-lasting reduction of gut function, below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth. CIF is the rarest organ failure. Home parenteral nutrition (HPN) is the primary treatment for CIF. No guidelines (GLs) have been developed that address the global management of CIF. These GLs have been devised to generate comprehensive recommendations for safe and effective management of adult patients with CIF.

METHODS

The GLs were developed by the Home Artificial Nutrition & Chronic Intestinal Failure Special Interest Group of ESPEN. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds, and accepted in an online survey of ESPEN members.

RESULTS

The following topics were addressed: management of HPN; parenteral nutrition formulation; intestinal rehabilitation, medical therapies, and non-transplant surgery, for short bowel syndrome, chronic intestinal pseudo-obstruction, and radiation enteritis; intestinal transplantation; prevention/treatment of CVC-related infection, CVC-related occlusion/thrombosis; intestinal failure-associated liver disease, gallbladder sludge and stones, renal failure and metabolic bone disease. Literature search provided 623 full papers. Only 12% were controlled studies or meta-analyses. A total of 112 recommendations are given: grade of evidence, very low for 51%, low for 39%, moderate for 8%, and high for 2%; strength of recommendation: strong for 63%, weak for 37%.

CONCLUSIONS

CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for both the underlying gastrointestinal disease and to provide HPN support. The rarity of the condition impairs the development of RCTs. As a consequence, most of the recommendations have a low or very low grade of evidence. However, two-thirds of the recommendations are considered strong. Specialized management and organization underpin these recommendations.

Quality and safety impact on the provision of parenteral nutrition through introduction of a nutrition support team

BACKGROUND/OBJECTIVES

Parenteral nutrition (PN) should be provided to the malnourished patient if enteral feeding is insufficient or unsafe. A nutrition support team (NST) may improve PN services. We compared the use and complications of hospital PN before and after the implementation of an NST.

SUBJECTS/METHODS

All inpatients referred for PN outside of the intensive care unit and the intestinal failure unit were prospectively included from 2009 to 2012. The NST was introduced in 2010. Quality improvement methodology was applied.

RESULTS

In 2009, a mean of 16 (limits of normal variation 4-28) patients were referred for PN each month. After introduction of the NST, this rose to 26 (10-42) referrals per month. The percentage of referrals where PN was not initiated increased from 5.3% in 2009 to 10.1% in 2012 (P=0.03). This increase was restricted to teams that infrequently referred for PN, and enteral nutrition could replace PN in 31 of 51 patients (61%) as compared with 8 of 32 (25%) patients referred from teams that frequently referred for PN (P=0.001). The frequency of PN started owing to an insufficient oral or enteral intake decreased from 11% to 3% (P=0.01). The catheter-related bloodstream infection rate dropped from 6.7 to 0.7 episodes per 1000 catheter days (P<0.001).

CONCLUSIONS

Introduction of an NST increased both the total PN use and the percentage of referrals where enteral nutrition could replace PN. Medical specialty influenced the referral pattern and the likelihood that a referral resulted in PN being initiated. Safety of PN catheters improved significantly following NST introduction.

Central Venous Catheter Salvage in Home Parenteral Nutrition Catheter-Related Bloodstream Infections: Long-Term Safety and Efficacy Data

BACKGROUND

Catheter-related bloodstream infections (CRBSIs) are a serious complication in the provision of home parenteral nutrition (HPN). Antibiotic salvage of central venous catheters (CVCs) in CRBSI is recommended; however, this is based on limited reports. We assessed the efficacy of antibiotic salvage of CRBSIs in HPN patients.

MATERIALS AND METHODS

All confirmed CRBSIs occurring in patients receiving HPN in a national intestinal failure unit (IFU), between 1993 and 2011, were analyzed. A standardized protocol involving antibiotic and urokinase CVC locks and systemic antibiotics was used.

RESULTS

In total, 588 patients were identified with a total of 2134 HPN years, and 297 CRBSIs occurred in 137 patients (65 single and 72 multiple CRBSIs). The overall rate of CRBSI in all patients was 0.38 per 1000 catheter days. Most (87.9%) infections were attributable to a single microorganism. In total, 72.5% (180/248) of CRBSIs were salvaged when attempted (coagulase-negative staphylococcus, 79.8% [103/129], Staphylococcus aureus, 56.7% [17/30]; polymicrobial infections, 67.7% [21/30]; and miscellaneous, 66.1% [39/59]). CVC salvage was not attempted in 49 episodes because of life-threatening sepsis (n = 18), fungal infection (n = 7), catheter problems (n = 20), and CVC tunnel infection (n = 4). Overall, the CVC was removed in 33.7% (100/297) of cases. There were 5 deaths in patients admitted to the IFU for management of the CRBSI (2 severe sepsis at presentation, 3 metastatic infection).

CONCLUSIONS

This is the largest reported series of catheter salvage in CRBSIs and demonstrates successful catheter salvage in most cases when using a standardized protocol.

Vertebral osteomyelitis: an under-recognized infectious complication in patients on home parenteral nutrition

Background

Patients on home parenteral nutrition (HPN) are at high risk of central venous catheter sepsis (CVCS). CVCS can be associated with distant bacterial seeding. However, few cases of vertebral osteomyelitis (VO) related to HPN have been reported. For this reason, we made the hypothesis that the incidence of VO in patients on HPN is probably higher than what is reported. The goal of this study was to evaluate the incidence of infectious complications, and more specifically, the incidence of VO in patients on HPN.

Methods

A retrospective study of all patients receiving HPN from 2001 to 2006 was conducted. Patients who received HPN for < 1 month were excluded. Infectious complications and, more specifically, cases of VO were searched.

Results

Thirty-one patients received HPN and were included in the analysis. Forty-four infectious complications occurred (1.302/1,000 CVC-days). The most frequent infectious complication was urinary tract infection (25 cases; 0.740/1,000 CVC-days). Seven CVCS occurred in five different patients (0.207/1,000 CVC-days). In patients with CVCS, 42.9% (three cases) developed a secondary VO. No predictive factors for the development of VO could be identified in univariate analysis.

Conclusion

We report a very low rate of infectious complications and an even lower rate of CVCS in patients on HPN. However, we report that 42.9% of our cases of CVCS developed a secondary VO. Consequently, VO must be part of the differential diagnosis among patients with HPN who complain of back pain.

Interventions to improve professional adherence to guidelines for prevention of device-related infections

BACKGROUND

Healthcare-associated infections (HAIs) are a major threat to patient safety, and are associated with mortality rates varying from 5% to 35%. Important risk factors associated with HAIs are the use of invasive medical devices (e.g. central lines, urinary catheters and mechanical ventilators), and poor staff adherence to infection prevention practices during insertion and care for the devices when in place. There are specific risk profiles for each device, but in general, the breakdown of aseptic technique during insertion and care for the device, as well as the duration of device use, are important factors for the development of these serious and costly infections.

OBJECTIVES

To assess the effectiveness of different interventions, alone or in combination, which target healthcare professionals or healthcare organisations to improve professional adherence to infection control guidelines on device-related infection rates and measures of adherence.

SEARCH METHODS

We searched the following electronic databases for primary studies up to June 2012: the Cochrane Effective Paractice and Organisation of Care (EPOC) Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL. We searched reference lists and contacted authors of included studies. We also searched the Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effectiveness (DARE) for related reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies that complied with the Cochrane EPOC Group methodological criteria, and that evaluated interventions to improve professional adherence to guidelines for the prevention of device-related infections.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane EPOC 'Risk of bias' tool. We contacted authors of original papers to obtain missing information.

MAIN RESULTS

We included 13 studies: one cluster randomised controlled trial (CRCT) and 12 ITS studies, involving 40 hospitals, 51 intensive care units (ICUs), 27 wards, and more than 3504 patients and 1406 healthcare professionals. Six of the included studies targeted adherence to guidelines to prevent central line-associated blood stream infections (CLABSIs); another six studies targeted adherence to guidelines to prevent ventilator-associated pneumonia (VAP), and one study focused on interventions to improve urinary catheter practices. We judged all included studies to be at moderate or high risk of bias.The largest median effect on rates of VAP was found at nine months follow-up with a decrease of 7.36 (-10.82 to 3.14) cases per 1000 ventilator days (five studies and 15 sites). The one included cluster randomised controlled trial (CRCT) observed, improved urinary catheter practices five weeks after the intervention (absolute difference 12.2 percentage points), however, the statistical significance of this is unknown given a unit of analysis error. It is worth noting that N = 6 interventions that did result in significantly decreased infection rates involved more than one active intervention, which in some cases, was repeatedly administered over time, and further, that one intervention involving specialised oral care personnel showed the largest step change (-22.9 cases per 1000 ventilator days (standard error (SE) 4.0), and also the largest slope change (-6.45 cases per 1000 ventilator days (SE 1.42, P = 0.002)) among the included studies. We attempted to combine the results for studies targeting the same indwelling medical device (central line catheters or mechanical ventilators) and reporting the same outcomes (CLABSI and VAP rate) in two separate meta-analyses, but due to very high statistical heterogeneity among included studies (I(2) up to 97%), we did not retain these analyses. Six of the included studies reported post-intervention adherence scores ranging from 14% to 98%. The effect on rates of infection were mixed and the effect sizes were small, with the largest median effect for the change in level (interquartile range (IQR)) for the six CLABSI studies being observed at three months follow-up was a decrease of 0.6 (-2.74 to 0.28) cases per 1000 central line days (six studies and 36 sites). This change was not sustained over longer follow-up times.

AUTHORS' CONCLUSIONS

The low to very low quality of the evidence of studies included in this review provides insufficient evidence to determine with certainty which interventions are most effective in changing professional behaviour and in what contexts. However, interventions that may be worth further study are educational interventions involving more than one active element and that are repeatedly administered over time, and interventions employing specialised personnel, who are focused on an aspect of care that is supported by evidence e.g. dentists/dental auxiliaries performing oral care for VAP prevention.

Review article: the management of long-term parenteral nutrition

BACKGROUND

Home parenteral nutrition (HPN) is currently the management of choice for patients with chronic intestinal failure.

AIM

To summarise the major issues in delivering long-term parenteral nutrition (>3 months) and assess outcome as per complications, mortality and quality of life. To assess the evidence for the therapeutic use of trophic factors such as teduglutide and to review evolving therapeutic options in the treatment of chronic intestinal failure.

METHODS

A literature search using PubMed and MEDLINE databases was performed.

RESULTS

Safe delivery of HPN relies upon individualised formulations of parenteral nutrition administered via carefully maintained central venous catheters by trained patients or carers, supported by a skilled multidisciplinary team. Early diagnosis and treatment of complications including catheter-associated blood stream infection (reported incidence 0.14-0.83 episodes/patient-year on HPN) and central venous thrombosis (reported incidence 0.03 episodes/patient-year) is important to minimise mortality and morbidity. There is a significant variation in the reported incidence of both hepatobiliary complications (19-75%) and advanced liver disease (0-50%). Five-year survival rates in large centres are reported between 60% and 78% with survival primarily related to underlying diagnosis. Long-term survival remains higher on HPN than with intestinal transplantation. The role of intestinal lengthening procedures is yet to be validated in adults.

CONCLUSIONS

Home parenteral nutrition delivered by skilled nutrition teams has low incidences of catheter-related complications. Most deaths relate to the underlying disease. Therapies such as teduglutide and small bowel transplantation appear promising, but home parenteral nutrition appears likely to remain the bedrock of management in the near term.

Central venous catheter infections and antibiotic therapy during long-term home parenteral nutrition: an 11-year follow-up study

BACKGROUND

Catheter-related bloodstream infections are a serious and common complication in patients receiving home parenteral nutrition (HPN).

METHODS

Prevalence of infections, type of agents, and effectiveness of antibiotic therapy were evaluated in 296 patients (133 males, 163 females; mean age 58.2 +/- 13.5 years) receiving HPN for at least 3 months, from January 1995 to December 2006. Patients underwent 99,969 (331 +/- 552; minimum 91, maximum 4353) days of catheterization, corresponding to 93,236 (311 +/- 489; minimum 52, maximum 4353) days of HPN.

RESULTS

Fifty-two patients (24 males and 28 females; 35 oncological and 17 nononcological) were diagnosed with 169 infections. The overall corresponding infection rate was 2.0 per 1000 days of catheterization, with a progressive, regular decrease with time. In 30 cases, immediate central venous catheter removal was necessary. Infections were eradicated in 103 of 139 (74%) cases. As to the most common causative agent, 86 (51%) infections were due to Staphylococcus epidermidis. Of these, 64 were treated from 1995 to 2004, 57 of them (89%) successfully; 22 were treated from 2005 onward, only 7 of them (32%) successfully.

CONCLUSIONS

Although the global infection rate has progressively decreased over the years, S epidermidis has shown an alarming increase in resistance to antibiotic treatment in the last 2 years, suggesting the need for strategies to prevent central venous catheter infection.

Racial and geographic disparities in the use of parenteral nutrition among inflammatory bowel disease inpatients diagnosed with malnutrition in the United States

BACKGROUND

Racial disparities have been described in the use of a diverse spectrum of surgical procedures. The objectives of this study are to determine whether disparities also exist for the use of parenteral nutrition (PN) in inflammatory bowel disease (IBD).

METHODS

The U.S. Nationwide Inpatient Sample between 1998 and 2003 is analyzed to determine PN use among IBD inpatients diagnosed with protein-calorie malnutrition and assess whether use patterns differ by race and geographical region.

RESULTS

The proportion of African American IBD admissions with protein-calorie malnutrition who receive PN is significantly lower than that in whites (19.9% vs 28.1%, P = .001), whereas there is no difference between Hispanics and non-Hispanic whites. After adjustment for gender, comorbidity, health insurance status, geographic region, and median neighborhood income, African Americans remain less likely than whites to receive PN (odds ratio [OR] 0.67; 95% confidence interval [CI], 0.50-0.89), whereas the difference between Hispanics and non-Hispanic whites is marginally significant (OR 0.65; 95% CI, 0.41-1.04). PN use varies geographically, with highest rates in the Northeast (44.3%) and lowest in the Midwest (17.3%). Uninsured patients are less than half as likely to receive PN as those with insurance (OR 0.46; 95% CI, 0.31-0.69). Compared with whites, Hispanics experience a longer time interval between admission and initiation of PN (3.5 vs 4.8 days, P = .02) and have higher rates of catheter-related complications (5.1% vs 12.2%, P = .04).

CONCLUSIONS

Among IBD inpatients with clinically diagnosable malnutrition, PN use is lower among African Americans compared with whites. The underlying mechanisms of these racial variations merit further investigation.

Cost-effectiveness of employing a total parenteral nutrition surveillance nurse for the prevention of catheter-related bloodstream infections

The cost of catheter-related bloodstream infection (CRBSI) is substantial in terms of morbidity, mortality and financial resources. Total parenteral nutrition (TPN) is a recognised risk factor for CRBSI. In 1997, an intravenous nutrition nurse was promoted to TPN surveillance clinical nurse manager (CNM) and quarterly infection audit meetings were introduced to monitor trends in CRBSI. Data were prospectively collected over a 15-year period using specific TPN records in a 535-bed tertiary acute university hospital. A total of 20 439 CVC-days and 307 CRBSIs were recorded. Mean number of infections before, and after, the introduction of a dedicated TPN surveillance CNM were compared. Mean CRBSI per 1000 catheter-days+/-SD was 20.5+/-6.34 prior to 1997 and 14.64+/-7.81 after 1997, representing a mean reduction of 5.84 CRBSIs per 1000 catheter-days (95% CI: -4.92 to 16.60; P=0.05). Mean number of CRBSIs per year+/-SD was 28.3+/-4.93 prior to 1997 and 18.5+/-7.37 after 1997, representing a mean decrease of 9.8 infections per year (95% CI: 0.01 to 19.66; P<0.05). The savings made by preventing 9.8 infections per year were calculated from data on bed-days obtained from the hospital finance office. The cost in hospital days saved per annum was euro135,000. Introduction of a TPN surveillance CNM saved the hospital at least euro78,300 per annum and led to a significant decrease in CRBSIs in TPN patients.

Optimal Nutrition Should Improve the Outcome and Costs of Radical Cystectomy

INTRODUCTION

Nutritional support has been demonstrated to improve recovery from radical cystectomy, but is expensive and when used inappropriately may actually increase the costs and morbidity of surgery. We sought to establish national patterns of practice with regard to feeding following cystectomy in the UK.

AIMS AND METHODS

Following consultation with the specialist nutrition team, a questionnaire was designed to investigate the feeding strategy after cystectomy and dispatched by post to all UK urologists.

RESULTS

The majority (60%) of respondents employed a traditional strategy of resting the bowel and feeding orally after bowel recovery. A minority used either early total parenteral nutrition (TPN; 18.5%) or enteral nutrition (6.5%), but a larger proportion (29%) felt enteral nutrition was the 'optimal' feeding regime. Only 30% used guidelines and 52% felt trials would help to establish a nutrition strategy following cystectomy.

CONCLUSION

There is little evidence that TPN improves the outcome of cystectomy and it may actually increase morbidity and costs, whereas enteral nutrition may improve recovery. Despite this evidence TPN is widely used by urologists whereas enteral nutrition is used infrequently. Implementation of an evidence-based feeding regime after cystectomy is likely to reduce the morbidity and financial costs of cystectomy.

The Complex Gastrointestinal Patient and Jean Watsonʼs Theory of Caring in Nutrition Support

The care of the patient with gastrointestinal disease is complex and challenging. The reasons for the complexity are varied and different for each patient. Any of these variables can affect the nutritional health of the patient, an essential element of care that supports healing, recovery, and improved quality of life. A nutritional assessment, an evaluation of the patient's nutritional status, can be used to establish the patient's weight history, dietary habits, tolerances, and likes and dislikes. Intake and output values from this assessment provide information relating to the patient's ability to meet his or her nutritional requirements orally or whether alternate methods for nutrition support need be considered, such as a feeding tube or a central intravenous catheter. Parenteral nutrition is the intravenous nutrition supplementation required when the oral or enteral route for nutrition support is unavailable or impossible. In this article, a clinical case scenario for a 34-year-old man with a history of cancer and an extensive bowel resection will be presented to better explore the decision-making process for determining appropriate nutrition support. In addition, various issues the health practitioner needs to consider when managing the nutritional health of the complex gastrointestinal patient will be explored, relative to Jean Watson's Theory of Caring.

Ergonomic and economic aspects of total parenteral nutrition

PURPOSE OF REVIEW

Ergonomics in total parenteral nutrition include the work performed in the (hospital) pharmacy and on the medical ward. This article reviews the developments in total parenteral nutrition ergonomics and the related cost-savings.

RECENT FINDINGS

Research focuses on the ergonomic advantages of multi-compartment total parenteral nutrition bags compared with the multi-bottle system, of multi versus single-layered total parenteral nutrition bags and of the presence of a nutritional team and training in clinical nutrition to improve regimen prescription and delivery.

SUMMARY

Three-compartment bags are safe, economic and ergonomic. It is important, however, to keep the knowledge of pharmacies to compound total parenteral nutrition for children and (adult) patients with specific pathologies. Research is ongoing in the development of bags with more than three compartments, to include for instance vitamins. This necessitates improvements in bag materials and wrapping. Progress can be made regarding total parenteral nutrition prescription and delivery, as well as in the incidence of related infections by promoting training in clinical nutrition and the implementation of a multidisciplinary nutritional support team.

Parenteral nutrition

PURPOSE OF REVIEW

During the past 12 months there have been clinically important advances in intravenous nutrition and adjunctive therapies.

RECENT FINDINGS

Useful steps have been taken in the understanding of the altered physiology of the intravenously fed patient, the potential for specific gains from manipulation with gut hormones, and avoidance of complications from amended lipid emulsions. The role of the nutrition team and the place of IVN in malignancy have also been addressed.

SUMMARY

Glucagon-like peptide-2, and lipid emulsions based less on soy-bean oil appear safe and effective. Euglycaemia is recommended at all times, but not too much vitamin C. Long-term intravenous nutrition in cancer patients can be justified, and hospital nutrition teams are probably cost-effective.