Total parenteral nutrition via multilumen catheters does not increase the risk of catheter-related sepsis: a randomized, prospective study

Parenteral Nutrition

Parenteral nutrition (PN) is a therapy to nourish patients who cannot tolerate feeding via the gut. Though a life-saving intervention, it does have risks associated. In this article, we aim to dispel myths associated with PN. Practitioners who manage critically ill patients or patients with intestinal failure should be equipped with evidence-based knowledge of PN including the indications, contraindications, feasibility, complications, and long-term management of PN.

Central venous catheter-related infections in hematology and oncology: 2020 updated guidelines on diagnosis, management, and prevention by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO)

Cancer patients frequently require central venous catheters for therapy and parenteral nutrition and are at high risk of central venous catheter-related infections (CRIs). Moreover, CRIs prolong hospitalization, cause an excess in resource utilization and treatment cost, often delay anti-cancer treatment, and are associated with a significant increase in mortality in cancer patients. We therefore summoned a panel of experts by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) and updated our previous guideline on CRIs in cancer patients. After conducting systematic literature searches on PubMed, Medline, and Cochrane databases, video- and meeting-based consensus discussions were held. In the presented guideline, we summarize recommendations on definition, diagnosis, management, and prevention of CRIs in cancer patients including the grading of strength of recommendations and the respective levels of evidence. This guideline supports clinicians and researchers alike in the evidence-based decision-making in the management of CRIs in cancer patients.

Central Venous Access Devices (CVAD) in Pediatric Oncology Patients-A Single-Center Retrospective Study Over More Than 9 Years

Background: Central venous access devices (CVAD) provide important benefits in the management of oncological pediatric patients. However, these catheters are responsible for severe complications. Methods: In this context, we aimed to analyze all patients receiving a CVAD in the Department of Pediatric Hematology and Oncology of the University hospital of Mainz over a period of 9 years, focused on CVAD related complications. Data on demographics, as well as intraoperative and postoperative complications were extracted. Results: A total of 296 patients with a mean age 93.2 ± 62.4 months were analyzed. The majority suffered from leukemia (n = 91, 30.7%), lymphomas (n = 50, 16.9%), and brain tumors (n = 48, 16.2%). In 63 (21.3) patients, complications were observed. No death caused by complications of CVADs was found in our series. Catheter-related blood stream infections (BSI) (7.4%) were most prevalent, followed by dislodgements (5.4%), occlusions (2.7%), thrombosis (2.4%), and catheter leakage (2.4%). Insertion site infections were observed in three patients (1.0%). Fifty-nine percent of all patients with catheter-related BSI suffered from Leukemia. In patients with Catheter-related BSIs we detected the condition leukemia as the underlying disease as a risk factor compared to solid tumors as the underlying disease. Overall, totally implanted devices (ports) have a lower complication rate than tunneled catheter. Conclusion: Implantation of CVADs seems to be safe and reliable in this large pediatric patient cohort. Even if complications occur in the long-term management of CVADs, they can be treated successfully and long-term catheter survival rates are excellent.

Does a Dedicated Lumen for Parenteral Nutrition Administration Reduce the Risk of Catheter-Related Bloodstream Infections? A Systematic Literature Review

Guidelines recommend using single-lumen central vascular access devices (CVADs) for the administration of parenteral nutrition (PN) or lipid-based solutions, or a dedicated lumen on a multilumen CVAD. Publications reviewed by the authors reported comparative rates of catheter-related bloodstream infection (CR-BSI) in patients with CVADs who received PN through a dedicated lumen compared with those who had PN administered through multilumen CVADs. Two studies included 650 patients with 1349 CVADs. CR-BSIs were equally distributed between the 2 groups. Both studies were poorly reported and had significant risk of bias. These results should be interpreted with caution.

Challenges and opportunities in the management of Clostridium difficile infection

Clostridium difficile infection (CDI) is increasing in all regions of the world where sought. There is no gold standard for diagnosis of CDI, with available tests having limitations. Prevention of CDI will be seen with antibiotic stewardship, improved disinfection of hospitals and nursing homes, chemo- and immuno-prophylaxis and next generation probiotics. The important therapeutic agents are oral vancomycin and fidaxomicin with metronidazole being used only in mild cases or when oral therapy cannot be given. Current therapy of CDI for 10 days is associated with high rate of recurrence that may be prevented by prolonging initial therapy. Future treatment strategies will focus on drugs that inhibit C. difficile, reduce toxin activity and inflammation in the gut, and improve colonic flora diversity.

Catheter-related and infusion-related sepsis

This article focuses on the pathogenesis, diagnosis, prevention, and management of infectious complications of intravascular cannulation and fluid infusion. Although continuous vascular access is one of the most essential modalities in modern-day medicine, there is a substantial and underappreciated potential for producing iatrogenic complications, the most important of which is blood-borne infection. Clinicians often fail to consider the diagnosis of infusion-related sepsis because clinical signs and symptoms are indistinguishable from bloodstream infections arising from other sites. Understanding and consideration of the risk factors predisposing patients to infusion-related infections may guide the development and implementation of control measures for prevention.

Central venous catheter-related infections in hematology and oncology: 2012 updated guidelines on diagnosis, management and prevention by the Infectious Diseases Working Party of the German Society of Hematology and Medical Oncology

BACKGROUND

Cancer patients are at increased risk for central venous catheter-related infections (CRIs). Thus, a comprehensive, practical and evidence-based guideline on CRI in patients with malignancies is warranted.

PATIENTS AND METHODS

A panel of experts by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) has developed a guideline on CRI in cancer patients. Literature searches of the PubMed, Medline and Cochrane databases were carried out and consensus discussions were held.

RESULTS

Recommendations on diagnosis, management and prevention of CRI in cancer patients are made, and the strength of the recommendation and the level of evidence are presented.

CONCLUSION

This guideline is an evidence-based approach to the diagnosis, management and prevention of CRI in cancer patients.

The role of total parenteral nutrition in inflammatory bowel disease: current aspects

Total parenteral nutrition (TPN) represents a therapeutic modality that could save the life of a patient with inflammatory bowel disease (IBD) facing severe nutritional problems, by restoring the patient's impaired nutritional status. TPN does not compete with enteral nutrition (EN), the latter being the first choice for all patients having anatomically intact and functionally normal digestive tract. TPN allows bowel rest while supplying adequate calorific intake and essential nutrients, and removes antigenic mucosal stimuli. The value of TPN in malnourished patients with intestinal failure due to CD is beyond doubt. However, it is difficult to suggest TPN as a sole treatment for active CD. An increased rate of remission could not be expected by applying TPN. The utility of TPN is restricted to certain cases involving efforts to close enterocutaneous or other complicated fistulas in patients with fistulizing CD, the treatment of short bowel syndrome following extensive resections for CD, or when EN is impractical for other reasons. There are no advantages of TPN therapy over EN therapy regarding fistula healing. TPN has no influence on the surgical intervention rate and little benefit by bypassing the intestinal passage could be expected. Also TPN shows no advantage if the disease is chronically active. However, an optimal supply of nutrients improves bowel motility, intestinal permeability and nutritional status, and reduces inflammatory reactions. TPN might be associated with an increased risk of adverse events, although TPN undertaken by experienced teams does not cause more complications than does EN.

Risk factors for the development of catheter-related bloodstream infections in patients receiving home parenteral nutrition

BACKGROUND

Risk factors for development of catheter-related bloodstream infections (CRBSI) were studied in 125 adults and 18 children who received home parenteral nutrition (HPN).

METHODS

Medical records from a national home care pharmacy were reviewed for all patients that had HPN infused at least twice weekly for a minimum of two years from January 1, 2006-December 31, 2011. Infection and risk factor data were collected during this time period on all patients although those patients who received HPN for a longer period had data collected since initiation of HPN.

RESULTS

In adults, 331 central venous catheters (CVCs) were placed. Total catheter years were 1157. Median CVC dwell time was 730 days. In children, there were 53 CVCs placed. Total catheter years were 113.1. Median CVC dwell time was 515 days. There were 147 CRBSIs (0.13/catheter year;0.35/1000 catheter days). In children there were 33 CRBSIs (0.29/catheter year;0.80/1000 days; P < .001 versus adults). In adults, univariate analysis showed use of subcutaneous infusion ports instead of tunneled catheters (P = .001), multiple lumen catheters (P = .001), increased frequency of lipid emulsion infusion (P = .001), obtaining blood from the CVC (P < 0.001), and infusion of non-PN medications via the CVC (P < .001) were significant risk factors for CRBSI. Increased PN frequency was associated with increased risk of CRBSI (P = .001) in children, but not in adults. Catheter disinfection with povidone-iodine was more effective than isopropyl alcohol alone. There were insufficient patients to evaluate chlorhexidine-containing regimens.

CONCLUSION

Numerous risk factors for CRBSI were identified for which simple and current countermeasures already exist.

Access technique and its problems in parenteral nutrition - Guidelines on Parenteral Nutrition, Chapter 9

Catheter type, access technique, and the catheter position should be selected considering to the anticipated duration of PN aiming at the lowest complication risks (infectious and non-infectious). Long-term (>7-10 days) parenteral nutrition (PN) requires central venous access whereas for PN <3 weeks percutaneously inserted catheters and for PN >3 weeks subcutaneous tunnelled catheters or port systems are appropriate. CVC (central venous catheter) should be flushed with isotonic NaCl solution before and after PN application and during CVC occlusions. Strict indications are required for central venous access placement and the catheter should be removed as soon as possible if not required any more. Blood samples should not to be taken from the CVC. If catheter infection is suspected, peripheral blood-culture samples and culture samples from each catheter lumen should be taken simultaneously. Removal of the CVC should be carried out immediately if there are pronounced signs of local infection at the insertion site and/or clinical suspicion of catheter-induced sepsis. In case PN is indicated for a short period (max. 7-10 days), a peripheral venous access can be used if no hyperosmolar solutions (>800 mosm/L) or solutions with a high titration acidity or alkalinity are used. A peripheral venous catheter (PVC) can remain in situ for as long as it is clinically required unless there are signs of inflammation at the insertion site.

Canadian home total parenteral nutrition registry: preliminary data on the patient population

BACKGROUND

Long-term administration of home total parenteral nutrition (HTPN) has permitted patients with chronic intestinal failure to survive for prolonged periods of time. However, HTPN is associated with numerous complications, all of which increase morbidity and mortality. In Canada, a comprehensive review of the HTPN population has never been performed.

OBJECTIVES

To report on the demographics, current HTPN practice and related complications in the Canadian HTPN population.

METHODS

This was a cross-sectional study. Five HTPN programs in Canada participated. Patients' data were entered by the programs' TPN team into a Web site-based registry. A unique confidential record was created for each patient. Data were then downloaded into a Microsoft Excel (Microsoft Corp, USA) spreadsheet and imported into SPSS (SPSS Inc, USA) for statistical analysis.

RESULTS

One hundred fifty patients were entered into the registry (37.9% men and 62.1% women). The mean (+/- SD) age was 53.0+/-14 years and the duration requiring HTPN was 70.1+/-78.1 months. The mean body mass index before the onset of HTPN was 19.8+/-5.0 kg/m(2). The primary indication for HTPN was short bowel syndrome (60%) secondary to Crohn's disease (51.1%), followed by mesenteric ischemia (23.9%).

COMPLICATIONS

over one year, 62.7% of patients were hospitalized at least once, with 44% of hospitalizations related to TPN. In addition, 28.6% of patients had at least one catheter sepsis (double-lumen more than single-lumen; P=0.025) and 50% had at least one catheter change. Abnormal liver enzymes were documented in 27.4% of patients and metabolic bone disease in 60% of patients, and the mean Karnofsky score was 63.

CONCLUSIONS

In the present population sample, the data suggest that HTPN is associated with significant complications and health care utilization. These results support the use of a Canadian HTPN registry to better define the HTPN population, and to monitor complications for quality assurance and future research.

Central venous catheterization

OBJECTIVE

To provide current information related to central venous catheterization.

DESIGN

Review of literature relevant to central venous catheterization and its indications, insertion techniques, and prevention of complications.

RESULTS

Central venous catheterization can be lifesaving but is associated with complication rates of approximately 15%. Operator experience, familiarity with the advantages and disadvantages of the various catheterization sites, and strict attention to detail during insertion help in reducing mechanical complications associated with catheterization. Strict aseptic technique and proper catheter maintenance decrease the frequency of catheter-related infections.

CONCLUSIONS

Appropriate catheter and site selection, sufficient operator experience, careful technique, and proper catheter maintenance with removal as soon as possible are associated with optimal outcome.

Peripherally Inserted Central Venous Catheters Are Not Superior to Central Venous Catheters in the Acute Care of Surgical Patients on the Ward

BACKGROUND

Peripherally inserted central venous catheters (PICC) have supplanted central venous catheters (CVC) for the administration of intravenous antibiotics and total parenteral nutrition to patients in our hospital. From the literature, it appears that this change has occurred in a number of other surgical units. Accounting for the change are the expected advantages of low complication rates at insertion, prolonged use without complications and interruption, and cost- and time-savings.

METHODS

We have proceeded with a review of the literature to understand and justify this change in practice. Our hypothesis was that the routine adoption of PICC instead of CVC for the acute care of surgical patients has occurred in the absence of strong scientific evidence. Our aim was to compare the associated infectious, thrombotic, phlebitic, and other common complications, as well as PICC and CVC durability. Articles concerning various aspects of PICC- and CVC-related complications in the acute care of adult patients were selected from the literature. Studies were excluded when they primarily addressed the use of long-term catheters, outpatient care, and pediatric patients. Data were extracted from 48 papers published between 1979 and 2004.

RESULTS

Our results show that infectious complications do not significantly differ between PICC and CVC. Thrombotic complications appear to be more significant with PICC and to occur early after catheterization. Phlebitic complications accounted for premature catheter removal in approximately 6% of PICC. Finally, prospective data suggest that approximately 40% of PICC will have to be removed before completion of therapy, possibly more often and earlier than CVC.

CONCLUSIONS

We believe that there is no clear evidence that PICC is superior to CVC in acute care settings. Each approach offers its own advantages and a different profile of complications. Therefore, the choice of central venous access should be individualized for surgical patients on the ward. More comparative prospective studies are needed to document the advantages of PICC over CVC.

Examination of Factors That Lead to Complications for New Home Parenteral Nutrition Patients

Home parenteral nutrition carries a risk of infectious, metabolic, and mechanical complications that cause significant morbidity and mortality. This study investigated the incidence and the causative factors of these complications that occur within the first 90 days after discharge from the hospital to home. Data were prospectively collected and analyzed for 97 adult patients. A complication developed in one third of the patients, and the majority required rehospitalization. Infectious complications were the most prevalent, followed by mechanical and then metabolic complications. The authors describe their methods of collecting data in a quantifiable manner with the ultimate goal of improving patient outcomes.

Infection control issues in central venous catheter care

Central venous catheters (CVCs) are now a routine part of patient management in the intensive care unit (ICU). Over time, a vast amount of literature associated with the use and care of CVCs has accumulated. The purpose of this article is to discuss the literature associated with the care of these devices in a narrative format. Although particular attention is paid to infection control issues, other fundamental areas such as catheter design, dressings, line changing and post insertion management are also discussed. The article goes on to look at the future of CVC design and concludes with an analysis of future developments related to CVCs.

Uso de cateteres venosos totalmente implantados para nutrição parenteral: cuidados, tempo de permanência e ocorrência de complicações infecciosas

Cateteres venosos totalmente implantados são utilizados em pacientes com síndrome do intestino curto, para realizar o suporte nutricional parenteral, o qual mantém estes pacientes vivos, pois fornece-lhes nutrientes que são absorvidos pela via digestiva. No entanto, estes cateteres não são isentos de complicações. As infecções relacionadas aos cateteres venosos são as complicações mais temidas e sua incidência varia de 3% a 20%, aumentando em pacientes mais graves. O objetivo do presente estudo é descrever as complicações infecciosas em pacientes recebendo nutrição parenteral por meio de cateteres venosos totalmente implantados. Tais cateteres são utilizados pela Divisão de Nutrição Clínica do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, para realizar o suporte nutricional parenteral em pacientes submetidos a ressecções extensas de intestino delgado. Foram avaliadas as complicações infecciosas ocorridas com 21 cateteres, implantados em 16 pacientes. O tempo de permanência dos cateteres foi de 768±664,3 dias (mediana 529 dias) e a taxa de infecção foi de 0,029 infecções/paciente/ano, resultados que se comparam às taxas de infecção observadas em países desenvolvidos. Concluiu-se que os cuidados observados no manuseio destes cateteres foram de fundamental importância para diminuir a incidência de infecção nestes pacientes.

Colonization and bloodstream infection with single- versus multi-lumen central venous catheters: a quantitative systematic review

There is a controversy as to whether the number of lumens in the central venous catheters may impact the incidence of catheter-related bloodstream infection. We performed a systematic search (MEDLINE, PREMEDLINE, Cochrane Library, EMBASE, BIOSIS Previews, CINAHL, HealthSTAR/Ovid healthstar, bibliographies, any language, to April, 2003) for full reports on randomized comparisons of single-lumen and multi-lumen catheters. Trials had to report on dichotomous data of catheter colonization or bloodstream infection. Meta-analyses were performed using a fixed effect model. Data were expressed as odds ratio (OR) and number-needed-to-treat (NNT) with 95% confidence interval (CI). Five randomized trials (1987-1995) with data on 255 single-lumen and 275 multi-lumen catheters were analyzed. Average insertion times were 8 to 21 days with multi-lumen catheters and 9 to 24 days with single-lumen catheters. In 4 trials, 23 of 176 (13.1%) multi-lumen and 26 of 177 (14.7%) single-lumen catheters were colonized (OR, 0.92; 95% CI, 0.49-1.72). In 5 trials, bloodstream infection occurred with 23 of 275 (8.4%) multi-lumen and with 8 of 255 (3.1%) single-lumen catheters (OR, 2.58; 95% CI, 1.24-5.37; NNT, 19; 95% CI, 11-75). For every 20 single-lumen catheters inserted, one bloodstream infection will be avoided that would have occurred had multi-lumen catheters been used. The risk of catheter colonization is not decreased. Although these conclusions are based on limited data, single-lumen catheters should be used whenever feasible.

Do Simultaneous Bilateral Tunneled Infusion Catheters in Patients Undergoing Bone Marrow Transplantation Increase Catheter-related Complications?

PURPOSE

Secure venous access with multiple lumens is necessary for the care of allogeneic hematopoietic stem cell transplant (HSCT) recipients. The outcomes associated with simultaneous bilateral tunneled internal jugular infusion catheter placement in the HSCT recipient population were investigated in an attempt to determine whether simultaneous introduction of these catheters compounds or magnifies the risks (infection, venous thrombosis) associated with tunneled catheters.

MATERIALS AND METHODS

Patients undergoing HSCT and receiving bilateral tunneled infusion catheters in a single procedure were identified using a quality assurance data base. Medical records for the duration of catheterization were reviewed; 43 patients were included in the study (mean age, 42 years; range, 22-56). Diagnoses included acute lymphocytic leukemia (n = 4), acute myelogenous leukemia (n = 8), aplastic anemia (n = 2), chronic myelogenous leukemia (n = 17), chronic lymphocytic leukemia (n = 1), Hodgkin lymphoma (n = 1), myelodysplasia (n = 4), myelofibrosis (n = 2), and non-Hodgkin lymphoma (n = 4). Cox proportional hazards regression analysis was performed to determine differences in infection rates between dual- and triple-lumen catheters.

RESULTS

Forty-three pairs of catheters were placed. All met venous access needs for HSCT recipient care. Complete follow-up was achieved for 77 of 87 (89%) catheters. The overall infection rate was 0.25 per 100 catheter-days. The rate was 0.19 and 0.33 for dual- and triple-lumen catheters, respectively (P =.15). Mechanical failure did not differ between catheter types (dual: 0.14 episodes per 100 days, triple: 0.05 per 100 days, P =.2).

CONCLUSIONS

Bilateral multilumen tunneled infusion catheter placement in a single procedure using imaging guidance is safe with acceptable outcomes and meets venous access needs for HSCT. There is a trend toward higher infection rates, with more lumens and more mechanical failure with dual-lumen catheters.

Rates of infection for single-lumen versus multilumen central venous catheters: a meta-analysis

OBJECTIVE

Since the introduction of multilumen central venous catheters two decades ago, there has been controversy whether the additional lumens place patients with these catheters at higher risk for infection. Our objective was to determine the risk of catheter-related bloodstream infection (CRBSI) and catheter colonization in multilumen catheters compared with single-lumen catheters.

DATA SOURCE

Studies were identified by a computerized search of MEDLINE, EMBASE, CINAHL, Current Contents, and PREMEDLINE databases and by review of bibliographies and expert consultation. Studies comparing the prevalence of CRBSI or catheter colonization among single-, double-, and triple-lumen central venous catheters were included. We excluded studies if they included central venous catheters that were long-term, cuffed, tunneled, or coated with antibiotic or antiseptic agents.

DATA ABSTRACTION

Two independent reviewers abstracted data on: 1) risk factors for CRBSI and colonization, 2) outcome definitions used, 3) the absolute prevalence of CRBSI and catheter colonization, and 4) study design and quality.

DATA SYNTHESIS

A total of 15 studies met inclusion criteria. Summary odds ratios were calculated using a random-effects model. Although CRBSI was more common in multilumen catheters (summary odds ratios, 2.15; 95% confidence interval, 1.00-4.66), catheter colonization was not (summary odds ratios, 1.78; 95% confidence interval, 0.92-3.47). Tests for heterogeneity, however, suggested substantial variation by study. When only studies of higher quality were included, multilumen catheters were found not to be associated with a significant increase in CRBSI prevalence (summary odds ratios, 1.30; 95% confidence interval, 0.50-3.41).

CONCLUSIONS

Multilumen central venous catheters may be associated with a slightly higher risk of infection when compared with single-lumen catheters; however, this relationship diminishes when only high-quality studies that control for patient differences are considered. The slight increase in infectious risk when using multilumen catheters is likely offset by their improved convenience, thereby justifying the continued use of multilumen vascular catheters.

Catheter-tip colonization as a surrogate end point in clinical studies on catheter-related bloodstream infection: how strong is the evidence?

In clinical trials, the incidence of catheter-tip colonization (CTC) is frequently used as a surrogate end point for the incidence of catheter-related bloodstream infection (BSI). It is not clear whether the correlation between CTC and catheter-related BSI is good. We searched the MEDLINE database and conducted a literature search for the years 1990-2002 and retrieved 29 studies (with a total of 60 study groups) with incidence data on predefined CTC and catheter-related BSI definitions. A good linear correlation between CTC and catheter-related BSI was found (r=0.69; r2=0.48; P<.001). The data from the medical literature about catheter-related infection seem to support the use of CTC as a surrogate end point for catheter-related BSI. In evaluations of clinical interventions or new techniques for the prevention of catheter-related BSI, investigation of the prevention of CTC seems to be a logical first step.

Clinical management of catheter-related infections

Central venous catheters represent a major source of nosocomial bloodstream infections, which cause considerable excess morbidity. It is currently unknown to what extent these infections contribute to mortality. Most catheter-related infections (CRIs) are caused by Gram-positive organisms (mainly coagulase-negative staphylococci). Definite diagnosis of CRI necessitates removal of the catheter in most cases. However, the recently described technique of differential time to positivity may allow diagnosis of CRI with the catheter left in place. Removal of the catheter has been standard clinical practice for the management of CRI in the past and is still recommended in many cases. In specific situations, such as infections of implanted catheters with coagulase-negative staphylococci, a trial of catheter salvage may be justified. In catheter-related bloodstream infection Staphylococcus aureus and Candida spp., the catheter should be removed immediately, due to the high risk of metastatic infection and increased mortality. A clinical work-up for the detection of additional foci (including transesophageal echocardiography in S. aureus infections) is advisable in these cases. All CRIs should be treated with antibiotics to which the causative agent has been shown to be susceptible. In addition to systemic antimicrobial therapy, antibiotic lock therapy may be applied, especially in patients with implanted long-term catheters if catheter salvage is attempted.

Evidence-based prevention of catheter infection during parenteral nutrition

Parenteral nutrition is a risk factor for catheter-related bloodstream infection. Here we reviewed strategies for the prevention of catheter-related infections, which always must begin with the cornerstone of prevention: the strict adherence to aseptic techniques. Most research has been interested in coated catheters. From these results, it may be concluded that antibiotics or antiseptic-impregnated catheters, like those with minocycline-rifampicin or chlorhexidine/silver sulfadiazine, significantly reduce catheter-related blood stream infections. Antibiotics or antiseptic-impregnated central venous catheters may even result in cost saving in intensive care units. Antiseptic or antibiotic-lock techniques would also be of interest to prevent catheter-related sepsis in high-risk patients who are receiving parenteral nutrition.

Nutrition

The use of nutrition for the medical patient, in the inpatient setting and at home, will likely continue to increase in the future. Each patient should be evaluated in an individualized but systematic fashion. Each patient in whom malnourishment is suspected should undergo a thorough assessment for the presence and degree of malnutrition with an accurate calculation of nutritional requirements. It is important to choose the correct method of delivery of nutrition, to monitor and recognize any complications or problems that may arise, and to tailor the nutritional therapy to the unique diseases that are encountered in medicine. Although increasingly new advances and changes are occurring in the field of nutrition, nutritional support and therapy are best delivered and supplied to the patient with a network of health care workers, including the physician, the nurse, the dietitian, the social worker, and pharmacist.

Central venous catheters: preventing infection and occlusion

As central venous catheters (CVCs) become more widely used in today's healthcare environment, nurses require expert knowledge in relation to CVC maintenance to prevent complications and maximize efforts to optimize the individual's health status. This is especially so since CVCs have begun to be used outside intensive care units, e.g. in general wards, and can be associated with high incidences of infection, occlusion and subsequent compromise in patient health. Nurses are responsible for the maintenance and use of central access devices, such as CVCs, resulting in a need for literature specific to the nursing aspects of CVC management. This article addresses many nursing issues pertaining to care of the central line, focusing on evidence- and research-based literature, and also reviews the literature to make recommendations for practice.