ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Venous access

Vascular rehabilitation in children with chronic intestinal failure reduces the risk of central-line associated bloodstream infections and catheter replacements

BACKGROUND & AIMS

Children with chronic intestinal failure (IF) require a long-term central venous catheter (CVC) for provision of parenteral nutrition. Vascular, mechanical and infectious complications such as central line-associated bloodstream infections (CLABSI) may lead to progressive loss of venous access sites. Handling and management of CVCs therefore play an important role. Our vascular rehabilitation concept (VRC) is a core component of our intestinal rehabilitation program (IRP) and consists of an education program, optimization of skin care, catheter fixation and lock solution, and the use of hybrid technique for catheter placement. Aim of this study is to analyse the effectiveness of our VRC on CLABSI rates and need for CVC replacements.

METHODS

Retrospective analysis of all children treated in our IRP that were followed up between 2018 and 2023.

RESULTS

A total of 117 children with chronic IF could be included for analysis of 248864 catheter days (CD). 91 patients were referred from other hospitals (127117 CD before and 89359 CD after entry into our IRP). Children receiving primary care at our IRP (32388 CD) showed a significantly lower CLABSI and line replacement rate than patients referred from external centers (p < 0.001). After entering our IRP, CLABSI rates and need for CVC replacements per 1000 CD decreased significantly in referred patients: 1.19 to 0.26 and 1.77 to 0.59, respectively (p < 0.001).

CONCLUSION

Management of paediatric chronic IF patients by an IRP with a vascular rehabilitation concept significantly lowers the rate of CLABSI episodes and the need for catheter replacements.

[Taurolidine lock in pediatric patients with intestinal failure. A practical guideline from the Spanish Society of Pediatric Gastroenterology, Hepatology and Nutrition (SEGHNP)]

Introduction

Objectives: the prevention of central line-associated bloodstream infections is a critical aspect of care for patients with intestinal failure who are treated with parenteral nutrition. The use of taurolidine in this context is becoming increasingly popular, however there is a lack of standardization in its pediatric application. The objective of this work is to develop a guide to support its prescription. Methodology: the guide is based on a review of the literature and expert opinions from the Intestinal Failure Group of the SEGHNP. It was developed through a survey distributed to all its members, addressing aspects of usual practice with this lock solution. Results: this manuscript presents general recommendations concerning taurolidine indications, commercial presentations, appropriate forms of administration, use in special situations, adverse reactions, and contraindications in the pediatric population Conclusions: taurolidine is emerging as the primary lock solution used to prevent central line-associated bloodstream infections, proving to be safe and effective. This guide aims to optimize and standardize its use in pediatrics.

Parenteral nutrition in the hospital setting/short-term parenteral nutrition

PURPOSE

This article is based on presentations and discussions held at the International Safety and Quality of Parenteral Nutrition (PN) Summit concerning the acute care setting. Some European practices presented in this article do not conform with USP general chapter <797> requirements. Nevertheless, the purpose is to cover the challenges experienced in delivering high-quality PN within hospitals in the United States and Europe, in order to share best practices and experiences more widely.

SUMMARY

Core issues regarding the PN process within an acute care setting are largely the same everywhere: There are ongoing pressures for greater efficiency, optimization, and also concurrent commitments to make PN safer for patients. Within Europe, in recent years, the use of market-authorized multi-chamber bags (MCBs) has increased greatly, mainly for safety, cost-effectiveness, and efficiency purposes. However, in the US, hospitals with low PN volumes may face particular challenges, as automated compounding equipment is often unaffordable in this setting and the variety of available MCBs is limited. This can result in the need to operate several PN systems in parallel, adding to the complexity of the PN use process. Ongoing PN quality and safety initiatives from US institutions with various PN volumes are presented. In the future, the availability of a greater selection of MCBs in the US may increase, leading to a reduction in dependence on compounded PN, as has been seen in many European countries.

CONCLUSION

The examples presented may encourage improvements in the safety and quality of PN within the acute care setting worldwide.

Evaluation of non-infectious complications in children receiving parenteral nutrition

BACKGROUND

Parenteral nutrition may lead to inevitable complications.

AIMS

To determine the indications, metabolic and mechanical complications of parenteral nutrition in children.

METHODS

One hundred fifty-eight children (91 males; 57.8%) who received 179 episodes of individualized parenteral nutrition for ≥ 5 days within 2 years were analyzed. Indications and duration of parenteral nutrition, effect on growth, and metabolic and central venous catheter-related non-infectious complications were evaluated.

RESULTS

Parenteral nutrition was administered in 179 different episodes (109 males; 60.9%), and the median age during these episodes was 64.0 (14.0-129.0) months. The most common indications were hematological malignancies, gastrointestinal surgery, and hematopoietic stem cell transplantation. Most of the electrolyte imbalances occurred in the first 3 days. Hypophosphatemia (44.7%), hypomagnesemia (43.0%), hypokalemia (43.0%), hyponatremia (40.8%), and hypertriglyceridemia (38.2%) were the most common metabolic complications. Liver transaminases elevated in 32/145 (22.1%) episodes and bilirubin in 30/149 (21.0%). Ursodeoxycholic acid treatment was added to 25 patients with hypertransaminasemia and/or hyperbilirubinemia. Transaminase levels improved in 16 (64%) and bilirubin levels in 15 (60%) patients receiving ursodeoxycholic acid. Catheter thrombosis was seen in 4.5% of the episodes. The targeted energy could be given more efficiently via central catheters rather than peripheral venous accesses. Patients' bodyweights increased in 39.1% of the episodes.

CONCLUSIONS

Close monitoring of electrolyte levels, especially in the first 3 days, is crucial to prevent complications of parenteral nutrition. When individualized PN preparations are used for metabolically unstable patients, it can be easier to maintain the blood glucose, lipids, and electrolyte levels within the normal range.

Risk factors for catheter-related bloodstream infections associated with home parental nutrition in children with intestinal failure: A prospective cohort study

BACKGROUND & AIMS

Catheter-related bloodstream infection (CRBSI) is the most common, potentially life-threatening complication of long-term parenteral nutrition (PN). We prospectively assessed the incidence and risk factors for CRBSI in children receiving long-term home PN (HPN) for intestinal failure (IF) in a single IF rehabilitation center.

METHODS

Data regarding episodes and potential risk factors for CRBSI in children on HPN were prospectively recorded.

RESULTS

Forty-one of 75 children were diagnosed with CRBSI. The overall CRBSI rate was 1.61 per 1000 catheter days. The indications for HPN were gastrointestinal motility disorders in 35%, short bowel syndrome (SBS) in 28% graft versus host disease (GvHD) post bone marrow transplant in 17%, congenital enteropathy in 15%, and severe neurodevelopmental impairment in 5%. Gastrointestinal motility disorders had significantly higher CRBSI rate compared to other groups (p < 0.0005; 2.74 in motility group vs 1.54 in GvHD group vs 0.52 in congenital enteropathies vs 0.36 in SBS group vs 0.67 in severe neurodevelopmental delay). Multivariate analysis revealed that enterocutaneous distal stoma (ileostomy or colostomy) (HR 3.35 [95% CI, 1.63-6.86]; p < 0.001), age <2 years (HR 0.28 [95% CI, 0.15-0.53]; p < 0.0001), male sex (HR 2.28 [95% CI, 1.51-3.43]; p < 0.0001), non-use of taurolidine citrate lock (HR 2.70 [95% CI, 1.72-4.11]; p < 0.0001) and gastrointestinal motility disorder (HR 3.02 [95% CI, 1.81-4.91]; p < 0.001) were independent risk factors for developing CRBSI.

CONCLUSIONS

Extra care in managing PN connections and disconnections should be taken in children with an underlying gastrointestinal motility disorder, distal enterocutaneous stoma, male sex and those aged <2 years since they are at a significantly higher risk of CRBSI. Early introduction of taurolidine lock should be considered.

A survival analysis of cuffed tunneled silicon central venous catheters in children affected by short bowel syndrome: A lesson from the past

BACKGROUND

Tunneled central venous catheters (CVC) are crucial in the management of children affected by short bowel syndrome (SBS). This work aims to investigate the outcomes of tunneled CVC and to identify factors influencing their survival.

METHODS

All the children diagnosed with SBS and undergone a procedure of insertion of a tunneled CVC from 2010 to 2019 were included. Demographic data and surgical information about the procedures were collected. Regression models and Kaplan-Meier analysis were performed to estimate the survival.

RESULTS

Eighteen patients, eight males (44%), with a median length of residual bowel measuring 72 cm (IQR 50-102 cm), were enrolled. Thirty-nine Broviac CVCs were inserted with a mean number of 2.2 CVCs per patient and 13365 line-days. The overall incidence of complications was 3.2/1000 line-days, and the incidence of central line associated bloodstream infections (CLABSI) was 1.1/1000 line-days. No episode of catheter thrombosis was reported. The median survival was 269 days (IQR 82-1814 days). The survival was negatively influenced by a younger age at insertion (R2 = 0.29; p < 0.001), 2.7 Fr diameter (median survival 76 days; p < 0.001) and the occurrence of complications (median survival 169 days; p = 0.002). The length of residual bowel was a mild risk factor for anticipated removal (OR 1.1; CI95 1.0-1.1; p = 0.05).

CONCLUSION

CVC-related complications negatively influenced the survival of the line. An elder age at insertion together with a larger CVC diameter increased the survival of the line, while a shorter residual bowel was associated with an anticipated removal due to complications.

Nutrition and Intestinal Rehabilitation of Children With Short Bowel Syndrome: A Position Paper of the ESPGHAN Committee on Nutrition. Part 1: From Intestinal Resection to Home Discharge

Short bowel syndrome (SBS) is the leading cause of intestinal failure (IF) in children. The mainstay of treatment for IF is parenteral nutrition (PN). The aim of this position paper is to review the available evidence on managing SBS and to provide practical guidance to clinicians dealing with this condition. All members of the Nutrition Committee of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) contributed to this position paper. Some renowned experts in the field joined the team to guide with their experience. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE, and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. Literature on SBS mainly consists of retrospective single-center experience, thus most of the current papers and recommendations are based on expert opinion. All recommendations were voted on by the expert panel and reached >90% agreement. The first part of this position paper focuses on the physiological mechanism of intestinal adaptation after surgical resection. It subsequently provides some clinical practice recommendations for the primary management of children with SBS from surgical resection until discharged home on PN.

Nutrition and Intestinal Rehabilitation of Children With Short Bowel Syndrome: A Position Paper of the ESPGHAN Committee on Nutrition. Part 2: Long-Term Follow-Up on Home Parenteral Nutrition

Short bowel syndrome (SBS) is the leading cause of intestinal failure (IF) in children. The preferred treatment for IF is parenteral nutrition which may be required until adulthood. The aim of this position paper is to review the available evidence on managing SBS and to provide practical guidance to clinicians dealing with this condition. All members of the Nutrition Committee of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) contributed to this position paper. Some renowned experts in the field joined the team to guide with their expertise. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE, and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. Literature on SBS mainly consists of retrospective single-center experience, thus most of the current papers and recommendations are based on expert opinion. All recommendations were voted on by the expert panel and reached >90% agreement. This second part of the position paper is dedicated to the long-term management of children with SBS-IF. The paper mainly focuses on how to achieve intestinal rehabilitation, treatment of complications, and on possible surgical and medical management to increase intestinal absorption.

The relationship between the PICC tip position and weight gain, length growth of premature infants under ultrasonography: a correlation analysis study

Objective

This study aimed to analyze the correlation between PICC tip position and weight/length changes in preterm infants in different positions using ultrasonography.

Methods

The study is a prospective before and after self-control clinical trial. The study analyzed the distance between the PICC tip and the entrance of the heart under ultrasonography for premature infants who underwent PICC insertion. The infants were positioned and tracked weekly, and their weight and length were recorded. The Spearman rank correlation test was used to analyze the relationship between the displacement distance of the PICC tip under ultrasonography in different positions and weight/length changes.

Results

A total of 202 premature infants were included in the study, and 100% of them experienced changes in the PICC tip position. During the first week, 134 (66.33%) cases in a flexed position and 153 (75.74%) cases in a straight position showed displacement of the catheter toward the heart. The displacement distance of the tip during catheter retention was significantly correlated with weight change (r_s = 0.681/0.661, P < 0.05) and length change (r_s = 0.629/0.617, P < 0.05). In the third and fifth weeks, weight increased by 451 ± 178 and 750 (715-975) g, length increased by 1.50 (1.00-2.12) and 3.00 (2.00-3.70) cm, the catheter moved 1.27 ± 0.89 and 2.23 ± 0.95 cm, respectively, in a flexed position.

Conclusion

The PICC tip position in preterm infants is influenced by weight and length changes. It is crucial to use ultrasonography to track and locate the catheter within the first week of placement and to increase the frequency of catheter localization starting from the third and fifth weeks. The flexed position is recommended during catheter localization.

Case report: Central venous catheter thrombosis complicated by chronic thromboembolic disease/pulmonary hypertension in two children requiring parenteral nutrition

Chronic thromboembolic pulmonary hypertension is a rare but life-threatening complication of long-term central venous catheters (CVC) in children. However, evidence in terms of potential treatment strategies and outcome data remains scarce. We describe two cases of CVC-related thrombosis (Hickman-catheter) complicated by recurrent pulmonary emboli. One patient experienced a complete thromboembolic obstruction of the right pulmonary artery with normal pulmonary pressures and the second patient suffered from a central thromboembolic obstruction of both pulmonary arteries associated with severe pulmonary hypertension. Both patients successfully underwent surgical thromboendarterectomy with deep hypothermic circulatory arrest.

ESPEN practical guideline: Home parenteral nutrition

This guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home parenteral nutrition (HPN) providers, as well as healthcare administrators and policy makers, about appropriate and safe HPN provision. This guideline will also inform patients requiring HPN. The guideline is based on previous published guidelines and provides an update of current evidence and expert opinion; it consists of 71 recommendations that address the indications for HPN, central venous access device (CVAD) and infusion pump, infusion catheter and CVAD site care, nutritional admixtures, program monitoring and management. Meta-analyses, systematic reviews and single clinical trials based on clinical questions were searched according to the PICO format. The evidence was evaluated and used to develop clinical recommendations implementing Scottish Intercollegiate Guidelines Network methodology. The guideline was commissioned and financially supported by ESPEN and members of the guideline group were selected by ESPEN.

Intracardiac Thrombi in Preterm Infants-A Case Study and Review of the Literature

Intracardiac thrombi in preterm infants are not common but may lead to fatal outcomes. Predisposing and risk factors include small vessel size, hemodynamic instability, immaturity of the fibrinolytic system, indwelling central catheters and sepsis. In this paper, we present our own experience with a case of a catheter-related right atrial thrombus in a preterm infant, which was successfully treated with an aspiration thrombectomy. Then, we review the literature on intracardiac thrombosis in preterm infants: epidemiology, pathophysiology, clinical signs, echocardiographic diagnostic features and treatment options are discussed.

Nutritional Management of Intestinal Failure due to Short Bowel Syndrome in Children

BACKGROUND

The most common cause of intestinal failure (IF) in childhood remains short bowel syndrome (SBS), where bowel mass is significantly reduced due to a congenital atresia or resection and parenteral nutrition (PN) needed. Home PN has improved outcome and quality of life, but the long-term therapeutic goal is to achieve enteral autonomy whilst avoiding long term complications. This paper is aimed at discussing nutritional strategies available to clinicians caring for these patients.

METHODS

A literature search was performed from 1992 to 2022 using Pubmed, MEDLINE and Cochrane Database of Systematic Reviews, and recent guidelines were reviewed. In the absence of evidence, recommendations reflect the authors' expert opinion.

RESULTS

Consensus on the best possible way of feeding children with IF-SBS is lacking and practice varies widely between centres. Feeding should commence as soon as possible following surgery. Oral feeding is the preferred route and breast milk (BM) the first milk of choice in infants. Donor BM, standard preterm or term formula are alternatives in the absence of maternal BM. Extensively hydrolysed or amino acid-based feeds are used when these are not tolerated. Solids should be introduced as soon as clinically appropriate. Children are encouraged to eat by mouth and experience different tastes and textures to avoid oral aversion. Aggressive weaning of PN and tube (over-) feeding are now discouraged.

CONCLUSIONS

To date, uniform agreement on the optimal type of feed, timing of food introduction and feeding regime used is lacking and great difference in practice remains. There is need for more research to establish common treatment protocols.

Calculation and management of ketogenic diet parenteral nutrition in super-refractory status epilepticus

Super-refractory status epilepticus (SRSE) is an important neurological emergency associated with high mortality and morbidity and poses a heavy economic burden on patients. Ketogenic diet parenteral nutrition (KD-PN) is ketogenic diet therapy provided through parenteral administration and may be an adjuvant treatment for these who cannot accept enteral diet. However, the calculation and management of KD-PN presents a challenge for clinicians. This review focuses on the practical aspects of KD-PN therapy for treatment of SRSE, including the dietary composition, potential drug-diet interactions, and monitoring during KD-PN treatment. As with all SRSE treatments, KD-PN has many adverse effects, like hyperlipemia, hepatotoxicity, metabolic acidosis, insufficient ketosis or hyper-ketosis, and propofol infusion syndrome. We summarize monitoring and treatment methods in our review. This review provides some practical aspects for treatment of SRSE.

Care of patients on home parenteral nutrition during the first year of the COVID-19 pandemic: Management of central line-associated bloodstream infections

BACKGROUND AND AIM

The aim of this study was to analyze central line-associated bloodstream infections (CLABSI) in home parenteral nutrition (HPN) patients assisted by an interdisciplinary team during the first year of the COVID-19 pandemic in Argentina.

METHODS

Longitudinal, retrospective and analytical study of patients on HPN for ≥90 days during 2020. Data collection included age (adults >18 years, pediatric ≤18 years), gender, diagnosis, type of catheter, number of lumens, venous access, days on HPN, infusion modality and number of CLABSI-associated events. In COVID-19 cases, number of patients, disease progression, mortality rate and microorganisms involved were analyzed.

RESULTS

A total of 380 patients were included, 120 (31.6%) pediatric and 260 (68.4%) adult patients. Median age was 44.50 years (10; 62.25). Twelve patients (3.15% of the total) had COVID-19; of these, two pediatric and seven adult patients had no complications, and three adults died of COVID-19 pneumonia. The diagnoses observed were benign chronic intestinal failure (CIF, n = 311), grouped into short bowel (n = 214, 56.3%), intestinal dysmotility (n = 56, 14.7%), intestinal fistula (n = 20, 5.3%), and extensive small bowel mucosal disease (n = 21, 5.5%); malignant tumors (n = 52, 13.7%); other (n = 17, 4.4%). Total catheter days were 103,702. Median days of PN duration per patient were 366 (176.2, 366). The types of catheters used were tunneled (317 patients, 83.4%); peripherally inserted central (PICC) line (55 patients, 14.5%) and ports (8 patients; 2.1%). A total of 111 CLABSI was registered, with a prevalence of 1.09/1000 catheter days (adult, 0.86/1000 days; pediatric, 1.51/1000 days). The microorganisms identified in infectious events were Gram + bacteria (38, 34.5%); Gram-bacteria (36, 32%); mycotic (10, 9%); polymicrobial (4, 3.6%); negative culture and signs/symptoms of CLABSI (23, 20.3%). The odds ratio between pediatric and adult patients was 2.29 (1.35, 3.90).

CONCLUSION

The rate of CLABSI during the COVID-19 pandemic was within the ranges reported by international scientific societies. The risk of CLABSI was higher in pediatric patients, and mortality rate in COVID-19 infected patients was higher than in the general population.

Improved Macro- and Micronutrient Supply for Favorable Growth and Metabolomic Profile with Standardized Parenteral Nutrition Solutions for Very Preterm Infants

Very preterm infants are at high risk for suboptimal nutrition in the first weeks of life leading to insufficient weight gain and complications arising from metabolic imbalances such as insufficient bone mineral accretion. We investigated the use of a novel set of standardized parenteral nutrition (PN; MUC PREPARE) solutions regarding improving nutritional intake, accelerating termination of parenteral feeding, and positively affecting growth in comparison to individually prescribed and compounded PN solutions. We studied the effect of MUC PREPARE on macro- and micronutrient intake, metabolism, and growth in 58 very preterm infants and compared results to a historic reference group of 58 very preterm infants matched for clinical characteristics. Infants receiving MUC PREPARE demonstrated improved macro- and micronutrient intake resulting in balanced electrolyte levels and stable metabolomic profiles. Subsequently, improved energy supply was associated with up to 1.5 weeks earlier termination of parenteral feeding, while simultaneously reaching up to 1.9 times higher weight gain at day 28 in extremely immature infants (<27 GA weeks) as well as overall improved growth at 2 years of age for all infants. The use of the new standardized PN solution MUC PREPARE improved nutritional supply and short- and long-term growth and reduced PN duration in very preterm infants and is considered a superior therapeutic strategy.

Umbilical venous catheter- and peripherally inserted central catheter-associated complications in preterm infants with birth weight < 1250 g : Results from a survey in Austria and Germany

BACKGROUND AND OBJECTIVE

Umbilical venous catheters (UVC) and peripherally inserted central catheters (PICC) are commonly used in preterm infants but have been associated with a number of serious complications. We performed a survey in Austria and Germany to assess the use of UVCs and PICCs in preterm infants with a birth weight < 1250 g and associated rates of catheter-related adverse events.

METHODS

Electronic survey of participating centers of the NeoVitaA trial. Main outcome parameter was the reported rates of UVC- and PICC-associated complications (infection, thrombosis, emboli, organ injury, arrhythmia, dislocation, miscellaneous).

RESULTS

In total, 20 neonatal intensive care units (NICU) providing maximal intensive care in Austria and Germany (level I) were contacted, with a senior neonatologist response rate of 12/20 (60%). The reported rates for UVC with a dwell time of 1-10 days were bacterial infection: 4.2 ± 3.4% (range 0-10%); thrombosis: 7.3 ± 7.1% (0-20%); emboli: 0.9 ± 2.0% (0-5%); organ injury: 1.1 ± 1.9% (0-5%); cardiac arrhythmia: 2.2 ± 2.5% (0-5%); and dislocation: 5.4 ± 8.7% (0-30%); and for PICCs with a dwell time of 1-14 days bacterial infection: 15.0 ± 3.4% (range 2.5-30%); thrombosis; 4.3 ± 3.5% (0-10%); emboli: 0.8 ± 1.6% (0-5%); organ injury: 1.5 ± 2.3% (0-5%); cardiac arrhythmia: 1.5 ± 2.3% (0-5%), and dislocation: 8.5 ± 4.6% (0-30%).

CONCLUSION

The catheter-related complication rates reported in this survey differed between UVCs and PICCs and were higher than those reported in the literature. To generate more reliable data on this clinically important issue, we plan to perform a large prospective multicenter randomized controlled trial investigating the non-inferiority of a prolonged UVC dwell time (up to 10 days) against the early change (up to 5 days) to a PICC.

Nutrition in Pediatric Intensive Care: A Narrative Review

Nutrition support in pediatric intensive care is an integral part of a complex approach to treating critically ill children. Smaller energy reserves with higher metabolic demands (a higher basal metabolism rate) compared to adults makes children more vulnerable to starvation. The nutrition supportive therapy should be initiated immediately after intensive care admission and initial vital sign stabilization. In absence of contraindications (unresolving/decompensated shock, gut ischemia, critical gut stenosis, etc.), the preferred type of enteral nutrition is oral or via a gastric tube. In the acute phase of critical illness, due to gluconeogenesis and muscle breakdown with proteolysis, the need for high protein delivery should be emphasized. After patient condition stabilization, the acute phase with predominant catabolism converts to the anabolic phase and intensive rehabilitation, where high energy demands are the keystone of a positive outcome.

Surgical Treatment of Short Bowel Syndrome—The Past, the Present and the Future, a Descriptive Review of the Literature

Short bowel syndrome (SBS) is a devastating disorder with both short- and long-term implications for patients. Unfortunately, the prevalence of SBS has doubled over the past 40 years. Broadly speaking, the etiology of SBS can be categorized as congenital or secondary, the latter typically due to extensive small bowel resection following diseases of the small intestine, e.g., necrotizing enterocolitis, Hirschsprung’s disease or intestinal atresia. As of yet, no cure exists, thus, conservative treatment, primarily parenteral nutrition (PN), is the first-line therapy. In some cases, weaning from PN is not possible and operative therapy is required. The invention of the longitudinal intestinal lengthening and tailoring (LILT or Bianchi) procedure in 1980 was a major step forward in patient care and spawned further techniques that continue to improve lives for patients with severe SBS (e.g., double barrel enteroplasty, serial transverse enteroplasty, etc.). With this review, we aim to provide an overview of the clinical implications of SBS, common conservative therapies and the development of operative techniques over the past six decades. We also provide a short outlook on the future of operative techniques, specifically with respect to regenerative medicine.

HPN Standard of Care and Long-Term Outcomes of CIF Pediatric Patients: Twenty-Eight Years' Experience in a Reference Center

Background and Aims

Chronic intestinal failure (CIF) therapy changed significantly in recent decades, and both survival and complication rates improved over time. International guidelines claim that early referral of long-term home parenteral nutrition (HPN) patients to an expert center with specific standards of care may positively affect long-term outcomes. Herein, we retrospectively analyse the long-term outcomes of a cohort of pediatric patients with CIF followed-up since our Pediatric Intestinal Failure Unit foundation, in 1989.

Methods

Data of the 120 children followed up at Pediatric Intestinal Failure Unit during the last 28 years were retrospectively collected. Patients' and HPN characteristics, as well as dependence, survival, and complication rates, were described.

Results

Incidence and prevalence of CIF increased during the study period particularly due to the increase of HPN for non-digestive disease (NDD) CIF (47.5% of the study sample). Catheter-related bloodstream infection (CRBSI) rate decreased over the study period: 0.33 episodes/1,000 catheters days before 2011 and 0.19 episodes/1,000 catheters days afterwards. Only 1 patient out of 12 died because of HPN complications. The survival rate of patients with PDD was 98.4% at 1 year from the beginning of HPN, 96.5% at 2 years, and 93.8% from the fifth year onwards. Concerning the dependence rate, 70.6% of patients were still on HPN 1 year after the start of HPN, 63.7% at 2 years, 52.4% at 5 years, and 40.8% from the 9th year onwards, with no significant difference according to the underlying intestinal pathology. The survival rate of NDD patients was 91.2% at 1 year from the beginning of HPN, 87.4% at 2 years, and 81.9% from the third year onwards. For what concerns the enteral autonomy, it was regained by 56.7% 1 year after the start of HPN, 74.5% at 2 years, and 95.0% in the 5th year.

Conclusions

Our data confirmed the importance of appropriate standards of care and suggest that applying a specific set of standards and protocols may further improve patients' outcomes and survival. Indeed, both primary and non-digestive diseases HPN showed good outcomes.

Management of Central Venous Catheters in Children and Adults on Home Parenteral Nutrition: A French Survey of Current Practice

Although central venous catheter (CVC)-related thrombosis (CRT) is a severe complication of home parenteral nutrition (HPN), the amount and quality of data in the diagnosis and management of CRT remain low. We aimed to describe current practices regarding CVC management in French adult and pediatric HPN centers, with a focus on CVC obstruction and CRT. Current practices regarding CVC management in patients on HPN were collected by an online-based cross-sectional survey sent to expert physicians of French HPN centers. We compared these practices to published guidelines and searched for differences between pediatric and adult HPN centers’ practices. Finally, we examined the heterogeneity of practices in both pediatric and adult HPN centers. The survey was completed by 34 centers, including 21 pediatric and 13 adult centers. We found a considerable heterogeneity, especially in the responses of pediatric centers. On some points, the centers’ responses differed from the current guidelines. We also found significant differences between practices in adult and pediatric centers. We conclude that the management of CVC and CRT in patients on HPN is a serious and complex situation for which there is significant heterogeneity between HPN centers. These findings highlight the need for more well-designed clinical trials in this field.

Difficult Vascular Access in Children with Short Bowel Syndrome: What to Do Next?

Short Bowel Syndrome and intestinal failure are chronic and severe conditions that may require life-long parenteral nutrition in children. Survival of these children rely on the correct functioning of central venous catheters; therefore, careful management, prevention, and treatment of complications is of paramount importance. Despite a growing awareness of preserving the vascular real estate, a certain number of patients still experience a progressive and life-threatening exhaustion of vascular access. We searched the literature to highlight the current management of children with vascular exhaustion, specifically focusing on vascular access salvage strategies and last-resource alternative routes to central veins. Given the paucity of data, results are reported in the form of a narrative review.

Spectrum of Interventional Procedures During Hybrid Central Line Placement in Pediatric Intestinal Rehabilitation Patients With End-Stage Vascular Access

Background

Loss of available central vein access sites for parenteral nutrition delivery represents one of the main indications for intestinal transplantation in children with intestinal failure. Placement of central venous catheters can be challenging in advanced loss of patent venous pathways. We recently described the hybrid technique (interventional plus surgical approach) of central line placement in children. The aim of this study was to describe and analyze the interventions used during the hybrid procedures regarding feasibility, safety and outcome.

Methods

We retrospectively analyzed the course of all children in our intestinal rehabilitation program undergoing hybrid central line placement. We evaluated patients' conditions, interventional techniques and surgical peculiarities as well as outcome.

Results

203 children were treated in our intestinal rehabilitation program between 2010 and 2021. Due to loss of venous access, hybrid technique was performed in 53 children during 76 interventions. In 40 cases the same vessel was reused via Seldinger technique. Among the 30 ultrasound-guided new vessel punctures, 12 were performed by puncture of collateral vessels. Extended interventions due to thoracic central venous obstruction and/or thrombosis requiring additional access via a femoral vein for rehabilitation of the vascular system was performed during 29 procedures including catheter extraction (1), angioplasties (18), stent placement (1), revascularization (5) and thrombectomy (4). Placement of a central line was not possible in 6 children which eventually underwent extended thoracic/vascular surgery: in three children the previously placed catheter could not be removed, in one child, placement of a thrombectomy-catheter was not possible because of inferior vena cava occlusion, and in two children, revascularization failed. Intestinal transplantation was considered in one patient because of impending loss of vascular access. Two self-limiting minor extravasations and one intervention-associated pericardial effusion occurred.

Conclusions

Hybrid interventions for central venous catheter placement and vascular rehabilitation enable a high success rate in children with intestinal failure and end-stage vascular access, circumventing the need for intestinal transplantation or advanced surgery. The relevant procedures are complex and require a foresighted and individualized approach with a wide range of interventional techniques. If performed with expertise, this combined interventional/surgical approach is feasible and safe.

Meta-analysis of the efficacy of taurolidine in reducing catheter-related bloodstream infections for patients receiving parenteral nutrition

BACKGROUND

Parenteral nutrition administered via central venous catheter is an established treatment option for people with intestinal failure. A serious complication of central venous catheters is the high risk of catheter-related blood stream infections (CRBSI). Catheter locking solutions are one strategy for CRBSI prevention, with the solution taurolidine showing beneficial effects. The aim of this meta-analysis was to identify and synthesize evidence to assess taurolidine efficacy against comparators for the prevention of CRBSI for people with intestinal failure on parenteral nutrition.

METHODS

Six health literature databases were searched for efficacy data of rate of CRBSI for taurolidine versus control among our study population, no study design limits were applied. Individual study data were presented for the number of CRBSI and catheter days, and rate ratio. Overall data were synthesized as a pooled risk ratio, with sub-group analysis by study design, control type, and taurolidine solution.

RESULTS

Thirty-four studies were included in the final analysis. At the individual level all studies showed superior efficacy of taurolidine versus control for prevention of CRBSI. When the data were synthesized, the pooled risk ratio was 0.49 (95% CI 0.46 to 0.53, p=<0.0001), indicating a 51% decreased risk of CRBSI through the use of taurolidine. Sub-group analysis showed no difference depending on study design (p=0.23), or control type (p=0.37), and a significant difference for taurolidine type (p=0.0005).

CONCLUSION

Taurolidine showed superior efficacy over controls regardless of study design or comparator group. The results show that taurolidine provides effective CRBSI reduction for people with intestinal failure on parenteral nutrition. This article is protected by copyright. All rights reserved.

Venous Thromboembolic Complications in Pediatric Gastrointestinal Diseases: Inflammatory Bowel Disease and Intestinal Failure

In children with gastrointestinal disorders such as inflammatory bowel disease (IBD) and intestinal failure (IF), the risk of venous thromboembolism (VTE) is increased. VTE may lead to pulmonary embolism, sepsis and central line infection, stroke and post-thrombotic syndrome. The purpose of this review is to summarize current knowledge and recent advances around VTE management in pediatric gastroenterology with a focus on IBD and IF. The VTE incidence in children with IBD is reported to be around 4-30 per 10,000 patient-years, with higher incidences for hospitalized children. While in general, IF is less common than IBD, the VTE incidence in children with IF is around 750 per 10,000 patient-years. The most common risk factors for development of VTE involve deviations leading to Virchow's triad (endothelial damage, stasis, and hypercoagulability) and include active inflammation, particularly with colonic involvement, presence of a central venous catheter, underlying thrombophilia, reduced mobility, surgery, and hospitalization. Classes of anticoagulants used for treatment of VTE are low molecular weight heparins and vitamin K antagonists. However, the use of direct oral anticoagulants for treatment or prevention of VTE has not been studied in this pediatric population yet. Pediatric gastroenterologists apply different VTE prevention and treatment strategies due to lack of literature and lack of consensus. We discuss the role of primary and secondary prophylactic use of anticoagulants, and provide tools and recommendations for screening, prevention and management for the specific pediatric populations.

Comparison of bedside ultrasonography and bedside chest radiography in neonatal peripherally inserted central catheters: A before and after self-control study

OBJECTIVE

This study aimed to compare the applications of bedside ultrasonography (US) and bedside chest radiography (CR) in positioning peripherally inserted central venous catheter (PICC) at Neonatal Intensive Care Units (NICUs).

METHODS

The study is a prospective before and after self-control clinical trial. A consecutive series of 181 neonate patients were finally enrolled for PICC placement. CR, followed by US, was used to evaluate and readjust the sites of catheter tips. The imaging capability for PICC key structures, fluctuation of the measured data, measurement of tip-to-atrium distance, operation time, infants' body temperature changes, and direct expenses of the two imaging modalities were obtained and compared.

RESULTS

(1) Comparison in viewing PICC key structures: the display rate of catheter tip, SVC-and-right-atrium junction, IVC-and-right-atrium junction and tip-to-atrium distance is 99.47%, 100%, 100% and 99.47% for US and 100%, 98.42%, 97.37% and 95.79% for CR, respectively. (2) Fluctuation of the measured data by US and CR: the tip-to-atrium distance measured by US is 0.631 (0.435-0.820) cm, and that measured by CR is 0.593 (0.210-0.825) cm. US showed a narrower range of datum variance. (3) Consistency between US and CR: for consistency analysis, the Kappa coefficient (κ) was 0.843 (P < 0.05), showing their favorable consistency. (4) Comparison of operation time and infants' body temperature drop: for a CR exam, the time period taken was significantly longer than that of US (59.7 ± 26.33 vs. 79.6 ± 28.06, P < 0.001); and CR operations caused a significant babies' body temperature drop compared to US (0.14 ± 0.11 vs. 0.34 ± 0.19, P < 0.001). (5) Comparison of the direct expenses: the total cost for CR positioning was significantly higher than that for US (¥153.99 vs. ¥143, P = 0.026).

CONCLUSION

US exhibited superior traits to CR in the positioning of PICC tip. It could be promising for routine use in NICU.

Infection Prevention and Management in Pediatric Short Bowel Syndrome

Short bowel syndrome (SBS) is a rare disease with potentially life-threatening consequences. In addition to intestinal failure-associated liver disease, infections and other complications related to central venous catheters (CVCs) cause a significant burden to patients with SBS and may even necessitate an intestinal transplant eventually. The need for long-term central venous access and the intestinal dysfunction associated with SBS drive the need for intestinal failure-specific approach to prevent and treat infections in patients with SBS. In bacterial infections, the line can often be salvaged with proficient antibiotic therapy. Repeated catheter replacements are predisposed to recurrent infections and thrombotic complications, which may limit the long-term survival of patients with SBS. Protocol-based CVC access procedures and daily care including taurolidine and ethanol catheter locks have been shown to reduce infection rates substantially. Compromised intestinal function in SBS predisposes to small bowel bacterial overgrowth, mucosal injury, and increased permeability. These pathophysiological changes are concentrated in a subset of patients with excessive bowel dilatation and frequent bowel-derived infections. In such patients, reconstructive intestinal surgery may be indicated. Probiotics have not been effective in infection prevention in SBS and carry a significant risk of complications. While more studies focusing on the prevention of infections and their complications are needed, protocol-based approach and multidisciplinary teams in the care of patients with SBS have been shown to reduce complications and improve outcomes.

Nutritional Factors Associated with Late-Onset Sepsis in Very Low Birth Weight Newborns

BACKGROUND

Delayed onset of minimal enteral nutrition compromises the immune response of preterm infants, increasing the risk of colonization and clinical complications (e.g., late-onset sepsis). This study aimed to analyze associations between late-onset sepsis in very low birth weight infants (<1500 g) and days of parenteral nutrition, days to reach full enteral nutrition, and maternal and nutritional factors.

METHODS

A cross-sectional study was carried out with very low birth weight infants admitted to a neonatal intensive care unit (NICU) of a reference maternity hospital of high-risk deliveries. Data regarding days of parenteral nutrition, days to reach full enteral nutrition, fasting days, extrauterine growth restriction, and NICU length of stay were extracted from online medical records. Late-onset sepsis was diagnosed (clinical or laboratory) after 48 h of life. Chi-squared, Mann-Whitney tests, and binary logistic regression were applied.

RESULTS

A total of 97 preterm infants were included. Of those, 75 presented late-onset sepsis with clinical (n = 40) or laboratory (n = 35) diagnosis. Maternal urinary tract infection, prolonged parenteral nutrition (>14 days), and extrauterine growth restriction presented 4.24-fold, 4.86-fold, and 4.90-fold higher chance of late-onset sepsis, respectively.

CONCLUSION

Very low birth weight infants with late-onset sepsis had prolonged parenteral nutrition and took longer to reach full enteral nutrition. They also presented a higher prevalence of extrauterine growth restriction than infants without late-onset sepsis.

Prophylactic anticoagulation in children receiving home parenteral nutrition

BACKGROUND

Children with intestinal failure (IF) are at risk of loss of vascular access because of catheter-related venous thrombosis. Whether primary prophylactic anticoagulation is effective and safe in preventing catheter-related thrombosis is largely unknown. Our aim was to assess the incidences of catheter-related venous thrombosis and bleeding complications in children with IF receiving home parenteral nutrition (HPN) treated with primary prophylactic anticoagulation.

METHODS

All children, aged 0-18 years, treated with HPN at the Emma Children's Hospital/Amsterdam UMC were followed from January 2007 to July 2019. All patients were offered primary prophylactic anticoagulation from the start of HPN. The primary outcomes were catheter-related venous thrombosis and bleeding on prophylactic anticoagulation.

RESULTS

In total, 55 (76%) of 74 patients received primary prophylactic anticoagulation. The median age at the start of prophylaxis was 8.4 (interquartile range [IQR], 5.0-55.7) months. Patients were followed for a median of 31.2 (IQR, 10.7-53.5) months, with a total of 65,463 catheter days. The incidence of catheter-related thrombosis on prophylactic anticoagulation was 0.2 per 1000 catheter days. In total, the incidence of clinically relevant bleeding was 0.1 per 1000 catheter days. The median time to first event was 1268 (IQR, 149-2014) days for thrombosis and 389 (IQR, 227-2912) days for clinically relevant bleeding. Cumulative event-free survival after 5 years was 78% for thrombosis.

CONCLUSIONS

Our study shows a low rate of catheter-related venous thrombosis and a slightly elevated rate of clinically relevant bleeding in children receiving HPN and primary prophylactic anticoagulation.

Non-conventional vascular accesses for the management of superior vena cava syndrome in patients with Intestinal Failure. Case series and systematic review

BACKGROUND

Type III Intestinal Failure (IF) is a devastating clinical condition.characterized by the inability of the gut to absorb necessary macronutrients, and/or water and electrolytes, requiring Parenteral Nutrition (PN) as chronic therapy. Long-term PN may lead to life-threatening complications; the loss of central venous access (LCVA) is the most frequent and challenging. To date, few studies in the literature have reported the relevance of Non-conventional Vascular Accesses (NCVA) in the management IF as part of the comprehensive multidisciplinary care.

METHODS

A retrospective analysis of a database collected from January 2006 to December 2019 was performed using SPSS v25.0 for statistical analysis, followed by a systematic review, using the PRISMA.methodology RESULTS: From January 2006 to December 2019, 184 NCVA were placed in 71 patients with LCVA as IF-related complication; 173 were placed in 61 patients by interventional radiology (IR) and 11 NCVA were placed in 10 patients by the surgical team during the intestinal transplant (ITx) operation. From the 173 IR procedures 166 (95.9%) were successful with 3 ± 2.7 procedures/patient; average catheter permanence rate was 738.68 ± 997 days; complications related to the procedures occurred in 18/173 (10.4%), including two deaths. On the other hand, among the 11 NCVA implanted by the surgical team, 7 (64%) were successful and were safely withdrawn 30 days after ITx when were no longer needed; 2 (18%) catheters malfunctioned during the first week and could not be further used, and 1 was accidently removed; average catheter permanence rate was 26 ± 4 days. There was one complication (9%) requiring laparotomy; there was no mortality associated the procedure in this group. A systematic review was conducted to evaluate the success and safety of NCVA as part of the treatment of HPN-related complications; from 337,542 papers, 14 studies were included. A total of 28 HPN-patients with LCVA received NCVA; 34 procedures were successfully performed, while procedure-related complications were reported in 11.7%, as well as one death.

CONCLUSIONS

The data analyzed show that NCVAs may be successfully placed by expert teams, allowing to sustain long-term PN, as well as increasing the Intestinal Transplantation applicability for candidates in the extreme need of vascular access.

Pediatric Home Parenteral Nutrition in France: A six years national survey

BACKGROUND AND AIMS

Home Parenteral Nutrition (HPN) is the cornerstone management for children suffering from chronic intestinal failure (CIF). In France, HPN is organized from a network of 7 certified centers located in University Hospitals spread across the national territory. This study aims to review the data involving children on HPN over a 6-years period in France to outline the global and continuous improvement in care.

PATIENTS AND METHODS

This cross-sectional study included all children enrolled in any of the 7 French HPN certified centers from January 1st, 2014 to December 31st, 2019. Data was recorded from annual databases provided by each center regarding: age at inclusion, indication and duration of HPN, type of intravenous lipid emulsion (ILE), outcome [PN weaning off, transfer to adult center, death, intestinal transplantation (ITx)], rate of catheter-related bloodstream infections (CRSBIs) for 1000 days of HPN, Taurolidine lock procedure (TLP) use and prevalence of cholestasis defined as conjugated bilirubin ≥20 μmol/l.

RESULTS

The number of patients increased by 43.6% from 268 in 2014 to 385 in 2019. According to the year of follow up, the indications for HPN were short bowel syndrome (SBS) (42.3-46.6%), congenital enteropathies (CE) (18.5-22.8%), chronic intestinal pseudo-obstruction syndrome (CIPOS) (13.0-16.3%), long segment Hirschsprung's disease (LSHD) (9.7-13.3%), Crohn's disease (CD) (1.6-2.6%) and other non-primary digestive diseases (NPDD) such as immune deficiency, cancer or metabolic disease (4.0-9.2%). The median age at discharge on HPN decreased from 11.7 months in 2014 to 8.3 months in 2019 (p < .001). By December 31st, 2019, 44.8% of children had left the HPN program after a median duration ranging between 39.9 and 66.4 months. Among these patients, 192 (74.2%) were weaned off PN (94.7% SBS), 41 (15.8%) were transferred to adult centers for CIPOS (42%), SBS (31%) or CE (27%), 21 died (8.1%) - mostly in relation to cancer or immune deficiency - and 5 were transplanted (1.9%): 4 underwent combined liver-intestine transplantation for LSHD (n = 2), SBS, CE and one multivisceral Tx for CIPOS. The use of a composite fish-oil based ILE increased from 67.4% in 2014 to 88.3% in 2019 (p < 0.001). CRBSIs dropped from 1.04 CRSBIs per 1000 days HPN in 2014 to 0.61 in 2019 (p < 0.001) while meantime, the percentage of children receiving TLP increased from 29.4% to 63.0% (p < 0.001). The prevalence of cholestasis (conjugated bilirubin ≥ 20 μmol/l) was low and stable between 4.1 and 5.9% of children during the study period.

CONCLUSION

In France, the number of children enrolled in a HPN program continuously increased over a 6 years period. SBS is the leading cause of CIF requiring HPN. The rate of CRBSIs dropped dramatically as the use of TLP increased. Mortality rate was low and mainly in relation to the underlying disease (cancer, immune deficiency). Cholestasis and intestinal Tx remained very rare.

Parenteral nutrition extravasation into the abdominal wall mimicking an abscess

Objectives

Peripherally inserted central catheters (PICC) are used in the neonatal intensive care unit (NICU) setting for medication and nutrition administration. PICCs are easy to place and may remain inserted up to several weeks. Serious complications are rare. Cases of infection, dysfunction, thrombosis, malposition into other vessels, catheter migration, vessel erosion, perforation into pleura, pericardium, abdomen and even into the epidural space with extravasation have been reported [1, 2].

Case presentation

We present the case of a preterm infant with a right leg inserted PICC with the tip supposedly being placed in the external iliac vein with further catheter migration into the abdominal wall during the course of treatment.

Conclusions

Our patient developed extravasation of lipid infusion, which was initially misinterpreted as an abscess due to signs of local inflammation.

Positioning of Vascular Access in Pediatric Patients: An Observational Study Focusing on Adherence to Current Guidelines

Venous access devices (VADs) play an important role in different clinical contexts. In pediatric subjects, VAD placement is more complicated than in adults due to children’s poor cooperativity and reduced vascular access. Adherence to guidelines for the placement of VADs could prevent the occurrence of complications, but data in the literature are general and not exhaustive, especially with regard to the pediatric population. The objective of this study was to assess adherence to guidelines for the placement of VADs in a pediatric setting. A retrospective observational study was conducted in the general ward of a pediatric hospital in the northern region of Italy. Data related to consecutive admissions in the period from 1 January to 31 December 2019 were collected according to the availability of clinical documentation. A cohort of 251 subjects was considered, yielding a total of 367 VADs. Device permanence in situ and the effective administration of intravenous therapy were associated with an increased risk of complications, while adherence to guidelines was an important protective factor. Adherence to guidelines for the placement of VADs is an independent and positive predictive factor for the prevention of complications due to the presence of a vascular device.

Parenterale Ernährung in deutschen Perinatalzentren

Hintergrund

Die Leitlinien der „European Society for Paediatric Gastroenterology, Hepatology and Nutrition“ (ESPGHAN) liefern evidenzbasierte Empfehlungen zu parenteraler Ernährung (PE) von Frühgeborenen und kranken Neugeborenen. Im Jahr 2013 wurde gezeigt, dass sie in Westeuropa nur teilweise angewendet werden und ihre klinische Implementierung verbessert werden sollte.

Ziel der Arbeit

Ziel dieser Arbeit ist, die derzeitige Anwendung der ESPGHAN-Leitlinien in Deutschland sowie Barrieren, die die Umsetzung verhindern, abzubilden.

Material und Methoden

Zusammen mit einer Expertengruppe und Institutionen aus dem deutschsprachigen Raum hat die „European Foundation for the Care of Newborn Infants“ (EFCNI) eine Befragung durchgeführt. Mit einem Online-Fragebogen wurden Pädiaterinnen/Pädiater (PÄD) und Krankenhausapothekerinnen/Krankenhausapotheker (KHA) aus deutschen Perinatalzentren und Krankenhausapotheken bezüglich der Umsetzung der Leitlinien befragt. Die Ergebnisse wurden qualitativ und quantitativ ausgewertet.

Ergebnisse und Diskussion

Von 558 angeschriebenen Kontakten wurden 196 gültige Umfragen ausgewertet. Nach Eigenangaben wenden 77 % der PÄD und 48 % der KHA die ESPGHAN-Leitlinien an. Barrieren wurden innerhalb der klinischen Anwendung identifiziert und waren teilweise struktureller und/oder organisatorischer Natur. Verbesserungsbedarf wurde in der Bereitstellung von parenteralen Standardlösungen, insbesondere am Wochenende, und elektronischen Verordnungssystemen, der Verabreichung von Lipiden bereits am 1. Lebenstag und der regelmäßigen Beurteilung aller Laborparameter beobachtet.

Simplify long-term venous access via external jugular vein in children

Background

Bone marrow transfer has begun to be widely used in complicated conditions, such as chemotherapy or hemodialysis, following the description of indwelling central venous catheters and demonstrating their suitability in pediatric patients. The widespread use of it has increased the incidence of complications as well. The use of external jugular vein catheterization, which is a safer route compared to the blind route of administration, has topographical difficulties. The findings obtained in this study showed that these difficulties could be overcome. Our study revealed that the catheterization was possible and described a facilitating technique. Of the pediatric patients involved in the bone marrow transfer programs, patients who were deemed eligible candidates for the use of external jugular vein, based on the preoperative assessment, were included in the present study.

Results

No early complication was observed in this study. The central catheter was placed on all patients in the same session. Catheters were inserted using the external jugular vein in 98 patients and percutaneous internal jugular vein in 2 patients. A central catheter was inserted through 105 interventions and 103 incisions in 100 patients. External jugular vein use, which was planned before the procedure, was achieved in 98 patients. The internal jugular vein was selected as the second option in 2 patients. The success rate of external jugular vein use was 95.1%.

Conclusions

The findings obtained in this study suggest that placement of a central catheter using an external jugular vein is an appropriate option. Application difficulties can be overcome. Mechanical and early complications are negligible compared to percutaneous blind techniques. The use of the external jugular vein route is easy, requires less equipment, has few complications, and the success of the procedure is a preoperatively predictable technique. External jugular vein catheterization is a better alternative compared to the Seldinger technique, in the absence of ultrasonography, which enhances the success of the percutaneous technique, and in cases where blind techniques, such as bleeding diathesis, may be unfavorable.

What are the new guidelines and position papers in pediatric nutrition: A 2015-2020 overview

BACKGROUND

Nutrition related publications in pediatric population cover wide range of topics and therefore it is usually difficult for clinicians to get an overview of recent nutrition related guidelines or recommendations.

METHODS

The Special Interest Group (SIG) of Pediatrics of European Society for Clinical Nutrition and Metabolism (ESPEN) performed a literature search to capture publications in the last five years aiming to provide the latest information concerning nutritional issues in children in general and in specific diseases and to discuss progression in the field of pediatric nutrition evidence-based practice.

RESULTS

Eight major topics were identified as the most frequently reported including allergy, critical illness, neonatal nutrition, parenteral and enteral nutrition, micronutrients, probiotics and malnutrition. Furthermore, it was noted that many reports were disease focused or included micronutrients and were, therefore, represented as tables.

CONCLUSION

Overall, it has been shown that most reports on nutrition topics in pediatrics were systematic reviews or guidelines/position papers of relevant societies, but many of them basing the conclusion on a limited number of high-quality randomized controlled trials or large observational cohort studies.

[Operation and management guidelines for peripherally inserted central catheter in neonates (2021)]

Peripherally inserted central catheter (PICC) has been widely used in the neonatal intensive care unit (NICU) in recent years, but there are potential risks for complications related to PICC. Based on the current evidence in China and overseas, the operation and management guidelines for PICC in neonates were developed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) in order to help the NICU staff to regulate the operation and management of PICC.

Lipid Emulsion Use in Pediatric Patients Requiring Long-Term Parenteral Nutrition

The ability to deliver nutrients via parenteral nutrition (PN) has markedly improved the prognosis of infants and children with intestinal failure. Technical refinements and advances in knowledge have led to the development of highly sophisticated PN solutions that are tailored to meet the needs of pediatric patients. However, children who require long-term PN have an increased risk of complications such as catheter-related sepsis, liver disease, and bone disease. Although the pathogenesis of intestinal failure associated liver disease (IFALD) is multifactorial, studies have identified a possible link between the dose of lipid emulsions based on soybean oil and cholestasis, shown to occur with a significantly higher frequency in patients receiving >1 g lipids/kg/d. Potential contributing factors include oxidative stress, high ω-6 polyunsaturated fatty acid (PUFA) and phytosterol content, and relatively low α-tocopherol levels. Lipid emulsions containing fish oil offer potential advantages compared with traditional emulsions with a high soybean oil content, such as decreased ω-6 and increased ω-3 PUFA concentrations, high concentrations of α-tocopherol, and reduced phytosterol content. Studies in PN-dependent children at risk for IFALD have shown that lipid emulsions containing fish oil reduce the risk of cholestasis and improve biochemical measures of hepatobiliary function compared with pure soybean oil emulsions. This review summarizes evidence regarding the role of lipid emulsions in the management of pediatric patients with intestinal failure requiring long-term PN, with a particular focus on the prevention and treatment of IFALD.

Unexpected tunnelled central venous access demise: a single institutional study from the UK

PURPOSE

To explore the factors involved in the demise of tunnelled central vascular access devices (CVADs) in children and describe patterns of failure.

METHODS

A retrospective study including children under 16 years of age undergoing CVAD insertion in a tertiary centre between October 2014 and December 2019. The Kaplan-Meier estimator was used to study CVAD survival and piecewise exponential curves to approximate hazard rates. Related factors were analysed using multivariable regression.

RESULTS

Totally, 684 CVADs were inserted in 499 children. Devices were in situ for 213,821 days (median 244.5). Of those, 261 CVADs (38.2%) failed prematurely; 176 (67%) required replacement. Tunnelled external lines (TELs) failed more frequently than totally implantable devices (p < 0.005).TEL displacement occurred in two high-risk phases, falling to baseline after 90 days. Low age at device insertion and open placement were strongly associated with an increased failure rate. Previous CVAD failure did not increase subsequent failure rate. Premature failure increased procedural cost by £153,949 per year.

CONCLUSIONS

TIDs should be placed in preference to TELs where appropriate. TELs are at highest risk of displacement for 90 days and must be well secured for this duration. Meticulous line care offers significant potential cost savings by reducing line replacements.

LEVEL OF EVIDENCE

Level III.

Short bowel syndrome in infancy: recent advances and practical management

Short bowel syndrome (SBS) is a rare condition characterised by extensive loss of intestinal mass secondary to congenital or acquired disease. The outcomes are determined by dependency on parenteral nutrition (PN), its possible complications and factors that influence intestinal adaptation. In order to achieve the best results, patients should be managed by a specialised multidisciplinary team with the aims of promoting growth and development, stimulating intestinal adaptation and preventing possible complications. This involves timely surgical management aimed at rescuing maximum bowel length and eventually re-establishing intestinal continuity where appropriate. A combination of enteral and parenteral nutrition needs to be targeted towards maintaining a balance between fulfilling the nutritional and metabolic needs of the child while preventing or at least minimising potential complications. Enteral nutrition and establishment of oral feeding play a fundamental role in stimulating bowel adaptation and promoting enteral autonomy. Other measures to promote enteral autonomy include the chyme recycling in patients where bowel is not in continuity, autologous gastrointestinal reconstruction and pharmacological treatments, including promising new therapies like teduglutide. Strategies such as lipid reduction, changing the type of lipid emulsion and cycling PN are associated with a reduction in the rates of intestinal failure-associated liver disease. Even though vast improvements have been made in the surgical and medical management of SBS, there is still lack of consensus in many aspects and collaboration is essential.

The efficacy and safety of peripheral intravenous parenteral nutrition vs 10% glucose in preterm infants born 30 to 33 weeks' gestation: a randomised controlled trial

BACKGROUND

Preterm infants born 30 to 33 weeks' gestation often require early support with intravenous fluids because of respiratory distress, hypoglycemia or feed intolerance. When full feeds are anticipated to be reached within the first week, risks associated with intravenous delivery mode and type must be carefully considered. Recommendations are for parenteral nutrition to be infused via central venous lines (because of the high osmolarity), however, given the risks associated with central lines, clinicians may opt for 10% glucose via peripheral venous catheter when the need is short-term. We therefore compare a low osmolarity peripheral intravenous parenteral nutrition (P-PN) solution with peripheral intravenous 10% glucose on growth rate in preterm infants born 30 to 33 weeks' gestation.

METHODS

In this parallel group, single centre, superiority, non-blinded, randomised controlled trial, 92 (P-PN 42, control 50) infants born 30+ 0 to 33+ 6 weeks' gestation, were randomised within 24 h of age, to receive either P-PN (8% glucose, 30 g/L amino acids, 500 IU/L heparin and SMOFlipid®) or a control of peripheral intravenous 10% glucose. Both groups received enteral feeds according to hospital protocol. The primary outcome was rate of weight gain from birth to 21 days of age.

RESULTS

The rate of weight gain was significantly increased in P-PN infants compared with control (P-PN, n = 42, 18.7, SD 6.6 g/d vs control, n = 50, 14.8, SD 6.0 g/d; adjusted mean difference 3.9 g/d, 95% CI 1.3 to 6.6; P = 0.004), with the effect maintained to discharge home. Days to regain birthweight were significantly reduced and length gain significantly increased in P-PN infants. One infant in the P-PN group had a stage 3 extravasation which rapidly resolved. Blood urea nitrogen and triglyceride levels were significantly higher in the P-PN group in the first week of life, but there were no instances of abnormally high levels. There were no significant differences in any other clinical or biochemical outcomes.

CONCLUSION

P-PN improves the rate of weight gain to discharge home in preterm infants born 30 to 33 weeks gestation compared with peripheral intravenous 10% glucose.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12616000925448 . Registered 12 July 2016.

Y-Site Physical Compatibility of Numeta G13E with Drugs Frequently Used at Neonatal Intensive Care

Preterm neonates require parenteral nutrition (PN) in addition to intravenous drug therapy. Due to limited venous access, drugs are often co-administered with PN via the same lumen. If incompatible, precipitation and emulsion destabilization may occur with the consequent risk of embolism and hyper-immune reactions. Information on intravenous compatibility is scarce. Our aim was to analyse the compatibility of Numeta G13E with paracetamol, vancomycin and fentanyl because of the frequency of their use. A panel of methods was chosen to assess precipitation (sub-visual particle counting, turbidity measurement, Tyndall beam effect and pH measurement) and emulsion destabilization (mean droplet diameter measurement and sub-visual counting of oil droplets, followed by estimation of PFAT5 (percentage of fat residing in globules larger than 5 µm) and pH measurement). Samples in clinically relevant mixing ratios were tested immediately and after 4 h. All samples of drugs mixed with Numeta G13E were compared to unmixed controls. None of the tested drugs precipitated in contact with Numeta G13E, and we did not see any sign of emulsion destabilization when clinically relevant mixing ratios were applied. These results are reassuring. However, when contact time exceeds the established norm, caution in the form of filter utilisation and close inspection is advised.

Chinese expert consensus and practice guideline of totally implantable access port for digestive tract carcinomas

Totally implantable access port is a fully implantable drug delivery system that is implanted subcutaneously and can be retained for a long time. Advantages of ports include a simple nursing process, low risk of infection and embolism, and high patient comfort. In order to promote the standardized application of ports in the treatment of digestive tract tumors and reduce port-related complications, the Chinese Research Hospital Association Digestive Tumor Committee, the Chinese Association of Upper Gastrointestinal Surgeons, the Chinese Gastric Cancer Association, and the Gastrointestinal Surgical Group of Chinese Surgical Society Affiliated to Chinese Medical Association have organized multidisciplinary expert discussions at the General Hospital of the People’s Liberation Army and nation-wide expert letter reviews and on-site seminars, and formulated an expert consensus of the operation guidelines.

Ultrasound-guided double central venous access for azygos vein via the ninth and tenth intercostal veins

Some patients with intestinal failure, who are dependent on total parenteral nutrition for long periods, suffer from a lack of suitable conventional venous access points, including axillary, external jugular, internal jugular, subclavian, saphenous, and the brachio-cephalic and femoral veins, due to their occlusion. Furthermore, extensive central venous stenosis and/or thrombosis of the superior and inferior vena cava may preclude further catheterization, so uncommon routes must be used, which can be challenging. In such patients, the azygos vein via the intercostal vein is a viable candidate. Thoracotomy-assisted, thoracoscopy-assisted, and cut-down procedures are currently suggested such access. We found that ultrasound-guided percutaneous puncture method was a safe and minimally invasive approach and successfully placed two central venous lines in preparation for small bowel transplantation via two different intercostal veins (ninth and tenth). Although the lung was actually located just below the target veins, an ultrasound provided augmented and clear vision, which contributed to the safe performance of the procedure without the need for invasive surgical intervention, such as thoracotomy, thoracoscopy, or rib resection using the cut-down technique. Furthermore, constant positive-pressure ventilation during vein puncture under general anesthesia also helps avoid venous collapse. Despite carrying a slight risk of light injury to the lung, artery, and nerve along with the vein compared to other procedures, we believe that ultrasound-guided puncture under general anesthesia is feasible as a minimally invasive method.

An Exploratory Study of the Everyday Life of Swedish Children on Home Parenteral Nutrition and Their Families

BACKGROUND

Improved survival rates of preterm infants and critically ill children has resulted in an increasing number of children growing up on HPN. However, how the child and the child's family experience HPN is sparsely studied.

PURPOSE

Thus, this study aims to elucidate the everyday life experiences of children with intestinal failure on HPN from the perspective of the child and the child's family.

DESIGN AND METHODS

We used a qualitative inductive study that included semi-structured interviews from 13 family members in six families, and we analyzed them using content analysis.

RESULTS

The family members' experiences had an overall theme, having to take on a full-time (nursing) responsibility, and fell into three categories: family restrictions, family adjustments, and family uncertainty.

CONCLUSION

Families on HPN had to shoulder an in-home round-the-clock (nursing) responsibility that came with a daily logistical challenge. The complexity of HPN complicates the possibility of external support, so the families choose to keep the burden within the family; consequently single-parent households have limited possibilities for relief and recovery.

PRACTICE IMPLICATIONS

To minimize the intrusion of the treatment in family's everyday life and, thereby, support the families, health care professionals might find it beneficial to obtain an inventory of the everyday life needs of each specific family when first introducing HPN. Further, by encouraging close kin to participate in the HPN education these families may be unburdened some more. In addition, it is essential that professionals follow the families protocol for management and not the other way around.

Long-term vascular access in differently resourced settings: a review of indications, devices, techniques, and complications

Central venous access is frequently essential for the management of many acute and chronic conditions in children. Millions of central venous access devices (CVADs) are placed each year. In this review article, we discuss the indications for long-term vascular access, the types of devices available, the state of the art of central venous cannulation and device placement, and the complications of long-term central venous access. We pay a special attention to the challenges of, and options for long-term central venous access, also those in developing countries, with limited financial, human, and material resources.

ESPEN guideline on home parenteral nutrition

This guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home parenteral nutrition (HPN) providers, as well as healthcare administrators and policy makers, about appropriate and safe HPN provision. This guideline will also inform patients requiring HPN. The guideline is based on previous published guidelines and provides an update of current evidence and expert opinion; it consists of 71 recommendations that address the indications for HPN, central venous access device (CVAD) and infusion pump, infusion line and CVAD site care, nutritional admixtures, program monitoring and management. Meta-analyses, systematic reviews and single clinical trials based on clinical questions were searched according to the PICO format. The evidence was evaluated and used to develop clinical recommendations implementing Scottish Intercollegiate Guidelines Network methodology. The guideline was commissioned and financially supported by ESPEN and members of the guideline group were selected by ESPEN.