Parenteral Nutrition: Risks, Complications, and Management

Mechanical Complications in Central Lines Using Taurolidine Versus Ethanol Lock Therapy in Children With Intestinal Failure

OBJECTIVES

Ethanol lock therapy (ELT) is effective in reducing rates of catheter-related-bloodstream infections (CRBSI) in the pediatric intestinal failure (IF) population; however, ELT may increase the risk of line occlusion and breakage, significantly impacting preservation of vascular access. During a period of ethanol shortage, Health Canada temporarily approved the use of taurolidine lock therapy (TLT) in pediatric iF patients previously utilizing ELT. This provided a unique opportunity to directly compare rates of central venous catheter (CVC) complications, including CRBSi, breaks, occlusions, repairs and replacements in patients who utilized both ELT and TLT.

METHODS

A retrospective study of pediatric IF patients managed by three Western Canadian intestinal rehabilitation programs was performed. Event rates in patients who used both ELT and TLT during the study period were compared using Poisson regression analysis.

RESULTS

In 13 patients with 10,187 catheter days (CDs), TLT (vs ELT) had lower rates of CVC breaks (1.11 vs 5.19/1000 CDs, P < 0.001), occlusions (0.83 vs 4.06/1000 CDs, P  = 0.01) and repairs (1.94 vs 5.64/1000 CDs, P  = 0.01). There was no difference in CRBSI rates (0.83 vs 2.03/1000 CDs, P  = 0.25) or rates of CVC replacements due to mechanical events (0.28 vs 1.81/1000 CDs, P  = 0.08).

CONCLUSIONS

Although there was no difference in CRBSI rates, TLT was associated with lower rates of mechanical complications compared to ELT in this study. Taurolidine may be a suitable alternative to ethanol in preventing CRBSI and may be associated with improved preservation of central lines in children with IF.

Safety and impact of peripheral parenteral nutrition on nutrient delivery in patients with nutrition risk: A prospective observational study

BACKGROUND

Malnutrition is common in hospitalized patients and strategies to improve energy and protein intake have a positive impact on outcome. Despite early evidence suggesting the usefulness of peripheral parenteral nutrition (PPN), its adoption has been hampered by concerns regarding safety and efficacy. This study addresses this issue.

METHODS

This prospective observational study was performed in medical and surgical inpatients in who were screened for nutrition risk and assessed using Subjective Global Assessment (SGA). Data captured included nutrition status, energy and protein requirements, intravenous access, indications for PPN, use of supplemental micronutrients, and disposition of patients on PPN.

RESULTS

Ninety-eight patients were recruited from two centers over 8 months. The average age was 61.5 years, the mean Charlson Comorbidity Index was 4.21 (±3.09), 52% were male, and 48% were admitted to medicine, whereas 52% were admitted to surgery. Thirty-three percent of patients were SGA C, 44% were SGA B, and 19% were SGA A. Twenty-seven percent of patients had cancer. The average length of hospital stay was 22 days. The main indications for PPN were gastrointestinal tract dysfunction (72%) and postsurgical status (16%). PPN provided an average of 1296 kcal (±191) and 46 g of protein (±7). Intravenous access complications in patients receiving PPN did not occur in excess of expected. Almost 40% of patients required transition to central PN.

CONCLUSIONS

PPN is a safe, effective way to deliver supplemental protein, energy, and micronutrients to malnourished patients and supports transition to other modes of nutrition care.

Parenteral nutrition in emergency surgery: A multicentre cross-sectional study

BACKGROUND

Emergency general surgical patients are inherently at high risk of malnutrition. Early decision-making with implementation is fundamental to patient recovery. For many patients, parenteral nutrition (PN) is the only feeding option available. The present study assessed the timing and outcomes of this decision-making process.

METHODS

A sample of at least 10 consecutive adult patients admitted as a general surgical emergency to eight UK hospitals over 1 year who had received PN was identified. Patient demographics, basic descriptors and nutritional data were captured. Process measures regarding dates decisions were made or activities completed were extracted from records, as were outcome measures including PN complications. Six time frames examining the process of PN delivery were analysed. Associations between categorical and binary variables were investigated with a chi-squared test with significance determined as p < 0.05.

RESULTS

In total, 125 patients were included. Intestinal obstruction was the most common diagnosis with 59% of all patients deemed high risk on nutritional assessment at admission. Median time to decision for PN was 5 days following admission (n = 122, interquartile range = 7). Patients received PN for a mean of 11 days. Eighty-five percent of patients developed a complication, with a phosphate abnormality being the most commonly reported (54%). Only altered blood glucose levels appeared to correlate with a delay in starting PN (p < 0.01).

CONCLUSIONS

The present study shows there are delays in the decision to use PN in the acutely ill surgical patient. Once initiated, the pathway is relatively short. There are high rates of electrolyte abnormalities in this population.

Refeeding syndrome in hematological cancer patients - current approach

Introduction: According to estimates based on the GLOBOCAN database of the International Agency for Research on Cancer, in 2018 alone, 18 100 000 cancers were globally diagnosed. Importantly, the majority of cancer patients experience unintended weight loss that leads to many adverse clinical consequences, including malnutrition and cancer cachexia. At the same time, each nutritional intervention must be carried out individually, as it can lead to critical complications, resulting in a threat to the health and life of the cachectic patient. An example of this type of risk is refeeding syndrome.Areas covered: Three factors seem to be crucial in this case: early identification of patients at risk of malnutrition, the introduction of an individualized diet regimen and constant monitoring of nutritional intervention. It seems equally important to spread awareness about the possibility of refeeding syndrome and knowledge about its patomechanisms and consequences among medical staff. This should lead to minimizing the risk of refeeding syndrome.Expert opinion: It should be noted that current guidelines on the pathogenesis, risk factors and methods of prevention and treatment of refeeding syndrome require further modifications, that would harmonize the management regimen in both prevention and therapy of refeeding syndrome.

Renal Function in Children on Long Term Home Parenteral Nutrition

Objectives: To assess renal function in pediatric intestinal failure (IF) patients on long term home parenteral nutrition (HPN). Methods: Children who received HPN for a minimum of 3 years between 2007 and 2017 were identified from the IF clinic of a large tertiary referral center. Estimated glomerular filtration rate (eGFR) was calculated using the Schwartz formula at discharge on HPN, after 6 months, 1, 2, and 3 years. Results: Twenty five patients (40% male) fulfilled the inclusion criteria. The indications for HPN were due to an underlying motility disorder in 56% (14/25), enteropathy in 24% (6/25), and short bowel syndrome in 20% (5/25). At the start of HPN 80% (20/25) had a normal eGFR. Four children (17%) had an abnormal eGFR. In the group of patients with normal eGFR at the start of HPN 30% (6/20) had at least one episode of decreased eGFR in the following 3 years, however there was no significant decline in eGFR at the end of the 3 year study period. Overall there was no statistically significant deterioration of eGFR in the study population (p = 0.7898). Conclusion: In our cohort of children on long term HPN no significant decline of eGFR could be demonstrated within 3 years of starting PN.

Nutrition Options in Critical Care Unit Patients

Critically ill patients have increased metabolic requirements and must rely on the administration of nutritional therapy to meet those demands. Yet, according to research almost half of all hospitalized patients are not fed, are underfed, or are malnourished while in the hospital. This article demonstrates the importance of early feedings in critical care unit, and the available options open to nurses supporting initiation and management of early feedings. Enteral nutrition has proven to be an important therapeutic strategy for improving the outcomes of critically ill patients and the critical care nurse plays an integral role in their success.

A Mnemonic for Pharmacists to Ensure Optimal Monitoring and Safety of Total Parenteral Nutrition: I AM FULL

Objective: To present a guideline-derived mnemonic that provides a systematic monitoring process to increase pharmacists’ confidence in total parenteral nutrition (TPN) monitoring and improve safety and efficacy of TPN use. Data Sources: The American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines were reviewed. Additional resources included a literature search of PubMed (1980 to May 2016) using the search terms: total parenteral nutrition, mnemonic, indications, allergy, macronutrients, micronutrients, fluid, comorbidities, labs, peripheral line, and central line. Articles (English-language only) were evaluated for content, and additional references were identified from a review of literature citations. Study Selection and Data Extraction: All English-language observational studies, review articles, meta-analyses, guidelines, and randomized trials assessing monitoring parameters of TPN were evaluated. Data Synthesis: The ASPEN guidelines were referenced to develop key components of the mnemonic. Review articles, observational trials, meta-analyses, and randomized trials were reviewed in cases where guidelines did not adequately address these components. Conclusions: A guideline-derived mnemonic was developed to systematically and safely manage TPN therapy. The mnemonic combines 7 essential components of TPN use and monitoring: Indications, Allergies, Macro/Micro nutrients, Fluid, Underlying comorbidities, Labs, and Line type.

Outcomes of primary gastric transposition for long-gap esophageal atresia in neonates

BACKGROUND

Gastric transposition is a relatively novel method of esophageal replacement. The purpose of this retrospective study was to assess the outcomes of long-gap esophageal atresia (LGEA) treated with esophageal replacement using primary gastric transposition in neonates.

METHODS

Between March 2008 and May 2015, 14 newborns with LGEA were treated in our hospital. They were all found to have gaps of over 3 cm at the time of the surgery and were diagnosed with LGEA. Primary gastric transposition was performed. They also underwent a gastric drainage procedure by pyloromyotomy. The nasogastric tube was removed if no anastomotic fistula was present and oral feeding was initiated. After initial recovery and discharge, the patients were evaluated with outpatient follow-ups or telephone follow-ups from 1 month after the surgery.

RESULTS

The mean age of the neonates at the time of the surgery was 32 hours (range, 4-96 h). The mean birth weight was 2550 g (range, 2100-3500 g). There were 2 deaths in this series of patients due to respiratory failure or withdrawal of treatment by the parents, with a mortality rate of 14.3%. Seven of the neonates developed unilateral or bilateral severe pneumonia. Early anastomotic leak occurred in 3 cases and anastomotic strictures occurred in 4 cases. These 4 neonates were able to eat a fairly normal diet after esophageal balloon dilation. Gastroesophageal reflux occurred in 7 of 12 cases. Feeding multiple small meals and postural support for positioning and feeding were instructed for these 7 cases. Subsequently, the symptoms alleviated and they had no additional surgical therapy. None of the neonates had delayed gastric emptying or gastric retention.

CONCLUSION

Primary gastric transposition may be a rewarding reconstructive option in the treatment of LGEA.

Efficacy of ethanol locks to reduce the incidence of catheter-related bloodstream infections for home parenteral nutrition pediatric patients: comparison of therapeutic treatment with prophylactic treatment

PURPOSE

Children with intestinal failure (IF) requiring central venous catheters (CVCs) often experience frequent catheter-related bloodstream infections (CRBSIs), which is a serious and life-threatening complication. To reduce the incidence of CRBSI, prophylactic ethanol lock therapy (ELT) was initiated.

METHODS

Patients with IF received home parenteral nutrition via a silicone tunneled CVC. All of them had received therapeutic ELT from January 2009 (first period) and prophylactic ELT from December 2012 (second period). Prophylactic ELT refers to ethanol lock for 2 h during the monthly hospital visit. We compared the CRBSI rate and number of CVC replacements between both periods.

RESULTS

Four patients received 19 CVCs for a total of 5623 catheter days. In the first period, there were 12 CRBSIs in 1823 catheter days (rate 6.77 per 1000 catheter days). In the second period, there were 9 CRBSIs in 3800 catheter days (rate 3.13 per 1000 catheter days). Overall, the rate of CVC replacement decreased from 4.92 to 1.72 per 1000 catheter days (p = 0.04). No adverse reactions were experienced during ethanol instillation.

CONCLUSION

Monthly prophylactic ELT for IF patients is considered to be a safe and effective modality for reducing the replacement of CVCs due to CRBSIs.

Impact of Providing a Combination Lipid Emulsion Compared With a Standard Soybean Oil Lipid Emulsion in Children Receiving Parenteral Nutrition: A Systematic Review and Meta-Analysis

BACKGROUND

Soybean oil lipid emulsion may compromise immune function and promote hepatic damage due to its composition of long-chain fatty acids, phytosterols, high proportion of ω-6 fatty acids, and low α-tocopherol levels. Combination lipid emulsions have been developed using medium-chain triglyceride oil, fish oil, and/or olive oil, which provide adequate essential fatty acids, a smaller concentration of ω-6 fatty acids, and lower levels of phytosterols. The purpose of this systematic review is to determine if combination lipid emulsions have a more favorable impact on bilirubin levels, triglyceride levels, and incidence of infection compared with soybean oil lipid emulsions in children receiving parenteral nutrition.

METHODS

This study comprises a systematic review of published studies. Data were sufficient and homogeneous to conduct a meta-analysis for total bilirubin and infection.

RESULTS

Nine studies met the inclusion criteria. Meta-analysis showed that combination lipid emulsion decreased total bilirubin by a mean difference of 2.09 mg/dL (95% confidence interval, -4.42 to 0.24) compared with soybean oil lipid emulsion, although the result was not statistically significant (P = .08). Meta-analysis revealed no statistically significant difference in incidence of infection between the combination lipid emulsion and the soybean oil lipid emulsion groups (P = .846). None of the 4 studies that included triglyceride as an outcome detected a significant difference in triglyceride levels between the combination lipid emulsion and soybean oil lipid emulsion groups.

CONCLUSION

There is inadequate evidence that combination lipid emulsions offer any benefit regarding bilirubin levels, triglyceride levels, or incidence of infection compared with soybean oil lipid emulsions.

Effects of 70% ethanol locks on rates of central line infection, thrombosis, breakage, and replacement in pediatric intestinal failure

OBJECTIVES

Parenteral nutrition is essential for the growth and nutrition of patients with intestinal failure (IF). Catheter-related bloodstream infections (CRBSI) are a major complication of parenteral nutrition use. Few retrospective studies have shown that 70% ethanol lock (ETL) therapy for central lines can reduce the infection rate. Studies assessing line breakage, thrombosis, and replacement with the use of ETL are lacking in the pediatric literature.

METHODS

The present study is a retrospective chart review, with a primary outcome of CRBSI rate per 1000 catheter days, and secondary outcomes of line thrombosis, line breakage requiring repair, and line replacement rates with use of ETL compared with heparin locks. Rates were compared using the Wilcoxon signed-rank test for paired nonparametric data.

RESULTS

Seven patients satisfied the inclusion criteria that included having a single-lumen silicone central line exposed to both heparin and ETL therapy during the study period. There was a statistically significant decrease in overall and Gram-negative CRBSI rates per 1000 catheter days with a use of ETL therapy (10.3-1.4 per 1000 catheter days for overall CRBSIs, P = 0.02; 6.7-0 per 1000 catheter days for Gram-negative CRBSI, P = 0.03). There was an increasing trend in line thrombosis and repair rates with ETL therapy. Logistic regression analysis evaluating the impact of line luminal size on line repair rate showed a reduced risk of line repair when using larger-diameter central lines.

CONCLUSIONS

ETL therapy is an effective method for decreasing CRBSI in patients with IF; however, it may have a negative impact on line integrity. Patients should be carefully selected when deciding on ETL therapy use for central line care. Studies are needed on the effect of different ethanol concentrations on infection rate and line integrity to optimize the outcome in this high-risk population.

Non-operative management of high-grade pancreatic trauma: is it worth the wait?

BACKGROUND

Whether children with pancreatic trauma should be managed non-operatively or operatively is controversial. We reviewed outcomes of high-grade pancreatic injuries at two high-volume pediatric surgical centres comparing non-operative and operative management strategies.

METHODS

All pancreatic traumas presenting from January 1993 to July 2010 were reviewed. Patients with high-grade pancreatic injuries were stratified based on early operative or non-operative therapy. Baseline characteristics and outcomes were compared. Regression analyses were performed to assess complication rates, length of stay, and TPN duration while controlling for injury severity score and associated injuries.

RESULTS

Of 77 patients with pancreatic injuries, 39 were grade 3 or higher. The mean ISS was 19.2 ± 10.8. Nineteen patients (50%) had associated injuries. Fifteen patients (38%) were managed operatively. Baseline characteristics were similar between groups other than ISS (p=0.03). Duration of hospitalization (p=0.01), days of TPN (p=0.003), and overall complications (p=0.007) were higher in non-operative patients. Controlling for both ISS and any associated injury, non-operative management was associated with more complications (OR 8.11; 95% CI 1.60-41.23) and was a significant predictor of prolonged TPN (13 days longer; p=0.024).

CONCLUSION

Primary non-operative management of high-grade pancreatic injuries is associated with a significant increase in complications and TPN dependency. Early operative intervention should be pursued whenever feasible.