Chronic intestinal failure and short bowel syndrome in Crohn’s disease

Chronic intestinal failure (CIF) is a rare but feared complication of Crohn’s disease. Depending on the remaining length of the small intestine, the affected intestinal segment, and the residual bowel function, CIF can result in a wide spectrum of symptoms, from single micronutrient malabsorption to complete intestinal failure. Management of CIF has improved significantly in recent years. Advances in home-based parenteral nutrition, in particular, have translated into increased survival and improved quality of life. Nevertheless, 60% of patients are permanently reliant on parenteral nutrition. Encouraging results with new drugs such as teduglutide have added a new dimension to CIF therapy. The outcomes of patients with CIF could be greatly improved by more effective prevention, understanding, and treatment. In complex cases, the care of patients with CIF requires a multidisciplinary approach involving not only physicians but also dietitians and nurses to provide optimal intestinal rehabilitation, nutritional support, and an improved quality of life. Here, we summarize current literature on CIF and short bowel syndrome, encompassing epidemiology, pathophysiology, and advances in surgical and medical management, and elucidate advances in the understanding and therapy of CIF-related complications such as catheter-related bloodstream infections and intestinal failure-associated liver disease.

The Influence of a Novel Needleless Valve on Central Venous Catheter Occlusions in Pediatric Patients

Background: Although it is common for central line catheters to develop a thrombotic occlusion, pediatric patients are at especially high risk of occlusion due to smaller vessels, smaller-gauge catheters, and slower rates of infusion. Mitigating catheter occlusions is costly, requiring tissue plasminogen activator, supplies, and nursing time. Our facility tested a novel neutral displacement needle-free valve designed to reduce occlusion.

Methodology: The organization determined a baseline occlusion rate for Hickman/Broviac catheters, in our 38-bed inpatient hematology/oncology department and our outpatient hematology/oncology clinic from August 2010 through October 2010. In 2011, a premarket test of the Neutron device (ICU Medical, San Clemente, CA) was conducted on the units. Based on the positive trial results, it was decided to implement the device housewide in December 2012.

Results: A comparison of baseline central line complete occlusion rates from August to October 2010 with Neutron trial data from July to October 2011. This pilot project demonstrated a 74.3% reduction (from a rate of 3.82 to a rate of 0.98) in all hematology/oncology department Hickman and Broviac complete catheter occlusions. Subsequently, comparing 5 months of housewide occlusion data from June through October 2012 to 2013, complete occlusions fell by 32.1% (from a rate of 1.56 to a rate of 1.06).

Conclusions: The use of the Neutron needle-free catheter patency device was associated with a reduction in complete occlusions. The corresponding reduction in treatment delays, nursing time spent managing occluded catheters, and fewer needlesticks to patients likely translates to financial benefit for the organization and improved patient and family satisfaction.

Treatment of catheter occlusion in pediatric patients

A proper initial assessment of catheter occlusion is the key to successful management. The assessment screens are for both thrombotic and nonthrombotic causes (including mechanical occlusion). If mechanical occlusion is excluded, thrombotic occlusion is treated with alteplase. Nonthrombotic occlusions are treated according to their primary etiologies: lipid occlusion is treated with 70% ethanol, mineral precipitates are treated with 0.1-N hydrochloric acid (HCl), drug precipitates are treated according to their pH-acidic drugs can be cleared with 0.1-N HCl, basic medications can be cleared with sodium bicarbonate or 0.1-N sodium hydroxide (NaOH). Prevention of occlusion of central venous access devices is also critical. To date, no data conclusively show heparin flushes to be superior to saline flushes. No prophylactic regimen, including low-dose warfarin, low-molecular-weight heparin, or 1 unit heparin/mL of parenteral nutrition has been endorsed by any major medical, nursing, or pharmacy group due to lack of scientific evidence. The most encouraging information on decreasing occlusion rate comes from experience with positive-pressure devices that attach to the hub of most catheter lumens and prevent retrograde blood flow and, consequently, decrease the risk of thrombus formation in the catheter lumen.

The use of alteplase for restoring patency to occluded central venous access devices in infants and children

A 21-month retrospective review was completed at the Lucile Packard Children's Hospital to assess the experience of 22 infants and children who received alteplase for the clearance of occluded central venous access devices. After the first dose, 86% (n = 19) of the catheters cleared. Two additional catheters cleared with a second dose. With alteplase treatment, 95% (n = 21) of the catheters cleared. No adverse events were noted within 24 hours after the alteplase was received. Infusion of alteplase appeared to be safe and effective in restoring patency to occluded central venous access devices in infants and children.

Development of evidence-based protocols for evaluation and management of dysfunctional vascular access devices in interventional radiology

Assessment and treatment of dysfunctional vascular access devices (VADs) is a mutual responsibility of nurses who use these devices and the interventional radiology (IR) team. Understanding causes of dysfunction, implementing assessment and treatment protocols, and communication between referral areas and the IR team are beneficial to both areas and to the patient. This study describes development of evidence-based protocols, combining research utilization and a quality improvement educational process.