Ethanol Lock Efficacy and Associated Complications in Children With Intestinal Failure

Central venous catheter safety in pediatric patients with intestinal failure

Children with intestinal failure (IF) require long-term central venous access to provide life-sustaining parenteral nutrition. Mechanical, thrombotic, and infectious complications are potentially life-threatening and may necessitate central venous catheter (CVC) replacement. Repeated central line replacements may lead to a loss of vascular access sites and increases risk for intestinal transplantation. Children with IF face unique challenges for CVC safety given their young age, altered anatomy, and increased risk of thrombosis and infection. The following review addresses preventative, diagnostic, and treatment strategies for central line safety concerns specific to children with IF as well as recommendations for promoting catheter safety during activities, travel, and emergencies.

Ethanol Lock for Prevention of CVC-Related Bloodstream Infection in Pediatric Patients: A Systematic Review and Meta-Analysis

Ethanol lock therapy (ELT) can be used in patients with an indwelling central line to assist in the prevention of central venous catheter (CVC)-associated infections. However, its efficacy has not been consistently demonstrated in the pediatric population. The primary objective of this review and meta-analysis was to determine the efficacy and safety of ELT in prevention of central line-associated bloodstream infection (CLABSI) in the pediatric population. A search was conducted with the PubMed, CINAHL, PSCYInfo, Cochrane Library, and Academic Search Premier databases from inception through January 21, 2022. Studies were included if they reported incidence of CVC-related infections with ELT in pediatric patients. Meta-analyses used random-effects models according to the heterogeneity of all included studies. Of 736 studies, 25 met inclusion criteria for review and 10 for inclusion in the meta-analysis. Meta-analysis with pre- and post-ELT treatment showed that use of ELT significantly decreased mean CVC-related infections when compared with pre-treatment with no ELT with a mean difference of -5.79 (95% CI, -9.08 to -2.51; p < 0.001). The number of CVC infections also significantly decreased (OR, 0.42; 95% CI, 0.23-0.75; p = 0.004). Increased risk of thrombosis and increased frequency of catheter breakage, repair, and replacement were noted in several studies. Ethanol lock therapy is effective in preventing infection related to central venous catheter use in pediatric patients. Further study is warranted to determine the optimal protocol for, and incidence of, adverse events related to use of ELT.

Systematic Review of Antimicrobial Lock Solutions for Prevention of Bacteremia in Pediatric Patients With Intestinal Failure

OBJECTIVES

The goal of this systematic review was to determine whether antimicrobial lock (AML) solutions prevent catheter-related bloodstream infections (CRBSI) in children with intestinal failure (IF).

METHODS

Electronic databases were searched: Ovid MEDLINE (1946-), Ovid Embase (1974-), Wiley Cochrane Library (inception-), and Web of Science Core Collection via Clarivate Analytics (1900-). Randomized and nonrandomized trials, case or cohort studies that studied any AML solution, and used comparator groups were included if they studied children with IF. A meta-analysis compared the rates of CRBSI with AML solutions versus controls, and a Boucher analysis was used to indirectly compare AML solutions.

RESULTS

Twenty-eight studies met eligibility criteria (1 open label and 27 observational studies). Quality was good (N = 13), fair (N = 9), and poor (N = 6). All but 4 studied ethanol and taurolidine. Of 15 ethanol studies, 11 reported a decrease and 3 reported a trend toward a decreased incidence of CRBSI compared to controls; 1 reported no difference. Of 9 taurolidine studies, 7 reported a decrease and 2 a trend toward decreased CRBSI rates. There was a decrease in CRBSI with ethanol versus control ( P = 0.008) and with taurolidine-citrate versus control ( P < 0.0005). Using Bucher indirect comparison of the pooled estimates from ethanol versus control to taurolidine versus control, the estimated difference was -0.99 (-4.125, 2.27; P = 0.55).

CONCLUSIONS

There were no randomized trials and over half of the 28 included studies were fair or poor quality. All but 1 reported at least a trend toward reduction in CRBSI. AML solutions appear to prevent CRBSI.

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.

SHEA Neonatal Intensive Care Unit (NICU) White Paper Series: Practical approaches for the prevention of central-line-associated bloodstream infections

This document is part of the "SHEA Neonatal Intensive Care Unit (NICU) White Paper Series." It is intended to provide practical, expert opinion, and/or evidence-based answers to frequently asked questions about CLABSI detection and prevention in the NICU. This document serves as a companion to the CDC Healthcare Infection Control Practices Advisory Committee (HICPAC) Guideline for Prevention of Infections in Neonatal Intensive Care Unit Patients. Central line-associated bloodstream infections (CLABSIs) are among the most frequent invasive infections among infants in the NICU and contribute to substantial morbidity and mortality. Infants who survive CLABSIs have prolonged hospitalization resulting in increased healthcare costs and suffer greater comorbidities including worse neurodevelopmental and growth outcomes. A bundled approach to central line care practices in the NICU has reduced CLABSI rates, but challenges remain. This document was authored by pediatric infectious diseases specialists, neonatologists, advanced practice nurse practitioners, infection preventionists, members of the HICPAC guideline-writing panel, and members of the SHEA Pediatric Leadership Council. For the selected topic areas, the authors provide practical approaches in question-and-answer format, with answers based on consensus expert opinion within the context of the literature search conducted for the companion HICPAC document and supplemented by other published information retrieved by the authors. Two documents in the series precede this one: "Practical approaches to Clostridioides difficile prevention" published in August 2018 and "Practical approaches to Staphylococcus aureus prevention," published in September 2020.

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.

ASPEN definitions in pediatric intestinal failure

Pediatric intestinal failure (PIF) is a relatively rare disease entity which requires focused interdisciplinary care and specialized nutrition management. There has long been a lack of consensus in the definition of key terms related to PIF due to its rarity and plethora of small studies rather than large trials. As such, the American Society for Parenteral and Enteral Nutrition (ASPEN) Pediatric Intestinal Failure Section, composed of clinicians from a variety of disciplines caring for children with intestinal failure, is uniquely poised to provide insight into this definition void. This document is the product of an effort by the Section to create evidence-based consensus definitions, with the goal of allowing for appropriate comparisons between clinical studies and measurement of longterm patient outcomes. This manuscript was approved by the ASPEN Board of Directors. This article is protected by copyright. All rights reserved.

Elimination of hospital-acquired central line-associated bloodstream infection on a mixed-service pediatric unit

INTRODUCTION

Hospital-acquired central line-associated bloodstream infections (CLABSI) are "never events" in U.S. healthcare. National efforts to improve CLABSI rates are ongoing. Efforts are important for all patients with a central venous catheter (CVC) and critical to children with intestinal failure (IF) who depend on long-term, daily use of a CVC and undergo extended hospitalizations. We describe outcomes of a multidisciplinary CLABSI elimination effort on a 24-bed medical-surgical unit caring for children with IF.

METHODS

Unit CLABSI events from 1/9/2012 to 4/16/2020 were evaluated with multiple improvement interventions. We leveraged prospectively maintained clinical registries and National Healthcare Safety Network (NHSN) reporting data to extract patient and unit demographics, ethanol lock utilization, and unit CVC days. Interventions were developed utilizing expert consensus and CDC guidelines with active frontline staff engagement. Descriptive statistics and tests of non-parametric data were employed for analysis.

RESULTS

Ninety-five patients with IF and 862 non-IF patients experienced a total of 1,629 admissions with 20,372 CVC days. Twelve hospital-acquired CLABSI events occurred during the study period, including 7 following NHSN definition change on 1/1/2015 (0.56 per 1,000 CVC days). After the last unit CLABSI on 12/5/2016, there were 7,117 CVC days through study conclusion.

CONCLUSIONS

Described interventions with an enhanced culture of collaborative care profoundly improved hospital-acquired CLABSI occurrence. Success in a specific population translated to all other unit patients with a CVC. Findings suggest elimination is not the result of a single new product or practice, but also includes support and empowerment of those caring for the patient and their CVC.

Cost-effectiveness of ethanol lock prophylaxis to prevent central line-associated bloodstream infections in children with intestinal failure in the United States

INTRODUCTION

Central line-associated bloodstream infections (CLABSIs) lead to significant morbidity and mortality in children with intestinal failure (IF). Ethanol lock prophylaxis (ELP) greatly reduces CLABSI frequency with minimal side effects. However, in the United States, a recently approved orphan drug designation for dehydrated alcohol has greatly increased 70% ethanol cost from about $10/day to $1000/day. We examined the cost-effectiveness of ELP in relation to these changes.

METHODS

We simulated a previously developed IF Markov model over 1 year. Costs were measured in 2020 US dollars and effectiveness in quality-adjusted life-years (QALYs). CLABSI rate with and without ELP was estimated from the largest available comparative observational study. The primary outcome was incremental cost-effectiveness ratio (ICER) between treatments. Secondary outcomes included CLABSI frequency. Sensitivity analyses on all model parameters were performed.

RESULTS

In the base model, children with IF not using ELP accumulated $131,815 in costs and 0.32 QALYs per patient compared with $437,884 and 0.33 QALYs per patient in those using ELP. The ICER was nearly $17 million/QALY gained. ELP resulted in a 40% reduction in CLABSI frequency. ELP became cost-effective at $68/day and cost-saving at $63/day. Sensitivity analysis identified no other plausible parameter variation to reach the benchmark of $100,000/QALY gained.

CONCLUSIONS

At the current price, ELP is not cost-effective for CLABSI prevention in children with IF in the United States. This study highlights the critical need for the approval of an affordable lock therapy option to prevent CLABSIs in these children.

Management of Central Venous Access in Children With Intestinal Failure: A Position Paper From the NASPGHAN Intestinal Rehabilitation Special Interest Group

ABSTRACT

Intestinal failure requires the placement and maintenance of a long-term central venous catheter for the provision of fluids and/or nutrients. Complications associated with this access contribute to significant morbidity and mortality, while the loss of access is an increasingly common reason for intestinal transplant referral. As more emphasis has been placed on the prevention of central line-associated bloodstream infections and new technologies have developed, care for central lines has improved; however, because care has evolved independently in local centers, care of central venous access varies significantly in this vulnerable population. The present position paper from the Intestinal Failure Special Interest Group of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) reviews current evidence and provides recommendations for central line management in children with intestinal failure.

Etiology and Management of Pediatric Intestinal Failure: Focus on the Non-Digestive Causes

Background: Intestinal failure (IF) is defined as reduction in functioning gut mass below the minimal amount necessary for adequate digestion and absorption. In most cases, IF results from intrinsic diseases of the gastrointestinal tract (digestive IF) (DIF); few cases arise from digestive vascular components, gut annexed (liver and pancreas) and extra-digestive organs or from systemic diseases (non-digestive IF) (NDIF). The present review revised etiology and treatments of DIF and NDIF, with special focus on the pathophysiological mechanisms, whereby NDIF develops. Methods: We performed a comprehensive search of published literature from January 2010 to the present by selecting the following search strings: “intestinal failure” OR “home parenteral nutrition” OR “short bowel syndrome” OR “chronic pseudo-obstruction” OR “chronic intestinal pseudo-obstruction” OR “autoimmune enteropathy” OR “long-term parenteral nutrition”. Results: We collected overall 1656 patients with well-documented etiology of IF: 1419 with DIF (86%) and 237 with NDIF (14%), 55% males and 45% females. Among DIF cases, 66% had SBS and among NDIF cases 90% had malabsorption/maldigestion. Conclusions: The improved availability of diagnostic and therapeutic tools has increased prevalence and life expectancy of rare and severe diseases responsible for IF. The present review greatly expands the spectrum of knowledge on the pathophysiological mechanisms through which the diseases not strictly affecting the intestine can cause IF. In view of the rarity of the majority of pediatric IF diseases, the development of IF Registries is strongly required; in fact, through information flow within the network, the Registries could improve IF knowledge and management.

Prolonged Use of Ethanol Lock Prophylaxis With Polyurethane Catheters in Children With Intestinal Failure: A Single-Center Experience

BACKGROUND

Children with intestinal failure (IF) receiving home parenteral nutrition (HPN) require long-term central venous catheters (CVCs). Ethanol lock prophylaxis (ELP) can reduce central line-associated bloodstream infections, but there are some concerns of increased breakage rates when used with polyurethane catheters. We reviewed our experience using ethanol locks in both polyurethane and silicone CVCs.

METHODS

A 10-year retrospective study of children with IF receiving HPN that used ELP was conducted. Complications per 1000 catheter days were extracted and a multivariable, mixed-effects Poisson model was used to compare catheter breakage rates and other complications between polyurethane and silicone CVCs.

RESULTS

A total of 10 patients were included, comprising 85 CVCs and 13,227 catheter days. The most common cause of IF was necrotizing enterocolitis. Breakages were the most common complication: polyurethane 1.46/1000 vs silicone 3.76/1000 catheter days. Silicone catheters had a significantly higher breakage rate (adjusted rate ratio [RR], 2.86; 95% confidence interval [CI], 2.84-2.88; P < .001) whereas polyurethane catheters had higher rates of occlusion (adjusted RR, 0.14; 95% CI, 0.07-0.28; P < .001) and displacements. However, there were no differences in the overall catheter replacement rates and any other catheter-related outcomes.

CONCLUSIONS

In children with IF receiving long-term HPN, the use of ELP in polyurethane catheters was associated with a lower risk of breakages when compared with silicone CVCs. These results should be regarded as preliminary data, and further studies with a higher number of participants are necessary to provide a better level of evidence.

Short Bowel Syndrome in an Infant

Short bowel syndrome (SBS) is a malabsorptive state that may occur either after surgical bowel resection or as the result of congenital bowel anomalies. SBS can incur significant morbidity and mortality including intestinal failure, cholestasis, sepsis, and death. For patients with SBS, management involves a multidisciplinary approach that begins with neonatology, pediatric surgery, nutritionists, pharmacists, and nurses in the NICU and also includes the transition to an intestinal rehabilitation program. The aim of this review is to provide the neonatologist with an overview of the common causes of neonatal SBS, anticipated nutritional deficiencies, complications associated with SBS, and the surgical and medical management of SBS to assist in counseling affected families.

Necrotizing enterocolitis totalis: High mortality in the absence of an aggressive surgical approach

BACKGROUND

Necrotizing enterocolitis is the leading case of gastrointestinal-related morbidity in premature infants. Necrotizing enterocolitis totalis is an aggressive form of necrotizing enterocolitis, which has traditionally been managed with comfort care. Recent advances in management of short bowel syndrome have resulted in some reported long-term survival.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, studies that reported outcomes in children with necrotizing enterocolitis totalis were identified. The definition of necrotizing enterocolitis totalis was captured along with length of follow-up, patient demographics, and outcomes.

RESULTS

A total of 766 articles were screened, of which 166 were selected for full article review. Of these, 32 articles included data on 414 patients with necrotizing enterocolitis totalis. In the majority of studies (52%), necrotizing enterocolitis totalis was not defined. Aggressive surgical therapy (defined as bowel resection or fecal diversion) was undertaken in 32 patients (7.7%), with a mortality rate of 68.8%. In contrast, nonaggressive surgical therapy was undertaken in 382 patients (92.3%), and the mortality in these patients was 95%. Long-term outcomes for necrotizing enterocolitis totalis survivors, such as length of time on parenteral nutrition, progression to liver and/or small bowel transplant, and quality of life, were not reported.

CONCLUSION

We found that there is no accepted definition of necrotizing enterocolitis totalis. Aggressive surgical therapy is rarely pursued, which likely drives the overall high mortality rate. This study underscores the importance of standardizing the definition of necrotizing enterocolitis totalis and capturing short and long-term outcomes prospectively. With more aggressive surgical therapy, more infants are likely to survive this abdominal catastrophe, which was once thought to be uniformly fatal.

Evidence-Based Strategies and Recommendations for Preservation of Central Venous Access in Children

Children with chronic illness often require prolonged or repeated venous access. They remain at high risk for venous catheter-related complications (high-risk patients), which largely derive from elective decisions during catheter insertion and continuing care. These complications result in progressive loss of the venous capital (patent and compliant venous pathways) necessary for delivery of life-preserving therapies. A nonstandardized, episodic, isolated approach to venous care in these high-need, high-cost patients is too often the norm, imposing a disproportionate burden on affected persons and escalating costs. This state-of-the-art review identifies known failure points in the current systems of venous care, details the elements of an individualized plan of care, and emphasizes a patient-centered, multidisciplinary, collaborative, and evidence-based approach to care in these vulnerable populations. These guidelines are intended to enable every practitioner in every practice to deliver better care and better outcomes to these patients through awareness of critical issues, anticipatory attention to meaningful components of care, and appropriate consultation or referral when necessary.

Enhanced central venous catheter bundle for pediatric parenteral-dependent intestinal failure

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) cause substantial morbidity and increase antimicrobial use and length of stay among hospitalized children in the United States. CLABSI occurs more frequently among high-risk pediatric patients, such as those with intestinal failure (IF) who are parenteral nutrition (PN) dependent. Following an increase in CLABSI rates, a quality improvement (QI) initiative was implemented.

METHODS

Using QI methodology, an enhanced central venous catheter (CVC) maintenance bundle was developed and implemented on 2 units for pediatric PN-dependent patients with IF. CLABSI rates were prospectively monitored pre- and postimplementation, and bundle element adherence was monitored. Enhanced bundle elements included chlorhexidine-impregnated patch, daily bathing, ethanol locks, 2 nurses for CVC care in a distraction-free zone, peripheral laboratory draws, bundling routine laboratory tests, and PN administration set changes every 24 hours.

RESULTS

Adherence to enhanced bundle elements increased to >90% over 3 months. CLABSI rates averaged 1.41 per 1,000 central line days preimplementation compared with 0.40 per 1,000 device days postimplementation (P = .003), an 85% absolute reduction in CLABSI rates over 12 months.

CONCLUSIONS

Patients with IF are at an increased risk for CLABSI. Enhanced CVC maintenance bundles that specifically target prevention practices in this population may be beneficial.

Insights into medical management of pediatric intestinal failure

Medical management of children with Intestinal failure continues to evolve. The development of specialized teams focused on the management of these children has made the most significant impact in improving outcomes. Medical management strategies are centered on the provision of adequate fluid electrolytes and calories to allow for appropriate growth and neurological development. Enteral therapy and drugs are required to enhance bowel adaptation while parenteral nutrition is the main source of nutrients, electrolytes and fluid. Modification in parenteral nutrition with the availability of lipid alternatives are contributing to decreasing incidence of Intestinal failure associated liver disease. Utilization of patient centered central line care bundles has also significantly contributed to the decrease in morbidity and mortality. This review provides insight into the current medical therapy available for managing intestinal failure in children.

Pediatric Intestinal Failure Review

The term, ‘intestinal failure’, signifies the inability of the body to meet the digestive, absorptive and nutritive needs of the body. As such, these individuals require parenteral nutrition (PN) for survival. The subsequent nutritional, medical and surgical facets to the care are complex. Improved care has resulted in decreased need for intestinal transplantation. This review will examine the unique etiologies and management strategies in pediatric patients with intestinal failure.

Tunneled central venous catheters in pediatric intestinal failure: a single-center experience

BACKGROUND

Parenteral nutrition for intestinal failure (IF) often requires a tunneled central venous catheter (CVC). The purpose of this study was to characterize complications after CVC placement and contributors to line loss in pediatric IF patients.

METHODS

An institutional review board-approved retrospective review of pediatric (<18 y) IF patients who had a silicone tunneled CVC newly inserted or exchanged from 2012 to 2016 in an IF center was conducted. Patient demographics, procedure service (surgery versus interventional radiology), procedure type (new versus exchange), vessel, and complications related to CVCs were evaluated. Complications included dislodgement, infection, break, occlusion/malfunction, and others. An ethanol-lock protocol for silicone CVCs in IF patients was instituted in January 2012.

RESULTS

Twenty-nine IF patients with tunneled CVCs were identified with 182 lines and 18,534 line d. Median age at line insertion was 17.1 mo (interquartile range [IQR] 7.6-31.5) with a median of five catheters (IQR 2-8) per patient. There were 19.2 complications per 1000 line d. Occlusions/malfunctions were the most common complication (6.0/1000 line d) followed by breaks (5.6/1000 line d). Median life of catheters was 51.5 d (IQR 21-129). On regression, adjusting for age, insertion service, and procedure type, shorter line life was associated with younger age (P = 0.04) and placement by interventional radiology (P < 0.01). Dislodgement was associated with newly placed lines relative risk 6.5 (95% CI 2.2-28.8).

CONCLUSIONS

CVCs in pediatric IF patients have frequent complications and short line lifetimes. Dislodgement of CVC was an unexpectedly common complication with loss of access in newly placed lines. There may be modifiable processes to mitigate CVC complications.

Systematic Review and Meta-Analysis of the Utilization of Ethanol Locks in Pediatric Patients With Intestinal Failure

BACKGROUND

Intestinal failure is a chronic condition related to loss of bowel length and/or function, resulting in dependence on central venous catheters for fluids and nutrition. Catheter use can be associated with significant complications, including catheter-related bloodstream infections (CRBSIs), which can lead to loss of vascular access, advancing intestinal failure associated-liver disease and death. Our objective was to evaluate the effectiveness and safety of ethanol locks as compared with standard heparin locks in pediatric intestinal failure.

METHODS

Databases, including MEDLINE and EMBASE, were searched until March 2017. Titles and abstracts were reviewed independently and relevant articles reassessed by full-text review. The main outcome was the rate of CRBSIs, while secondary outcomes were catheter replacement and repair.

RESULTS

Nine observational studies were included. The mean difference in rate of CRBSIs was 6.27 per 1000 catheter days (95% CI, 4.89-7.66) favoring ethanol locks, with a 63% overall reduction in infection rate. The mean difference in catheter replacement rate (per 1000 catheter days) was 4.56 (95% Cl, 2.68-6.43) favoring ethanol locks. The overall effect on catheter repair rate (per 1000 catheter days) was -1.67 (95% CI, -2.30 to -1.05), indicating lower repair rate with heparin locks.

CONCLUSION

Sufficient evidence was noted showing that ethanol locks reduced CRBSIs and catheter replacements. Our findings raise questions about the effect of the ethanol lock on catheter integrity based on the noted increase in repair rate. This requires further prospective evaluation and may support selective application of ethanol locks to patients with documented CRBSIs.

Long-term outcomes of pediatric intestinal failure

Management of pediatric intestinal failure has evolved in recent decades, with improved survival since the advent of specialized multidisciplinary intestinal failure centers. Though sepsis and intestinal failure associated liver disease still contribute to mortality, we now have growing data on the long-term outcomes for this population. While intestinal adaptation and parenteral nutrition weaning is most rapid during the first year on parenteral support, achievement of enteral autonomy is possible even after many years as energy and protein requirements decline dramatically with age. Intestinal transplant is an option for patients experiencing complications of long-term parenteral nutrition who are expected to have permanent intestinal failure, but outcomes are hindered by immunosuppression-related complications. Much of the available data comes from single center retrospective reports, with variable inclusion criteria, intestinal failure definitions, and follow-up durations; this limits the ability to analyze outcomes and identify best practices. As most children now survive long-term, the focus of management has shifted to the avoidance and management of comorbidities, support of normal growth and development, and optimization of quality of life for these medically and surgically complex patients.

Redefining short bowel syndrome in the 21st century

In 1968, Wilmore and Dudrick reported an infant sustained by parenteral nutrition (PN) providing a potential for survival for children with significant intestinal resections. Increasing usage of TPN over time led to some patients developing Intestinal Failure Associated Liver Disease (IFALD), a leading cause of death and indication for liver/intestinal transplant. Over time, multidisciplinary teams called Intestinal Rehabilitation Programs (IRPs) began providing meticulous and innovative management. Usage of alternative lipid emulsions and lipid minimization strategies have resulted in the decline of IFALD and an increase in long-term and transplant-free survival, even in the setting of ultrashort bowel (< 20 cm). Autologous bowel reconstructive surgeries, such as the serial tapering enteroplasty procedure, have increased the likelihood of achieving enteral autonomy. Since 2007, the number of pediatric intestinal transplants performed has sharply declined and likely attributed to the newer innovations healthcare. Recent data support the need for changes in the listing criteria for intestinal transplantation given the overall improvement in outcomes. Over the last 50 y, the diagnosis of short bowel syndrome has changed from a death sentence to one of hope with a vast improvement of quality of life and survival.