A prospective audit of total parenteral nutrition at a major teaching hospital

Parenteral nutrition with standard solutions: not the best solution for everyone? A retrospective audit of 300 patients

An observational retrospective study audited the incidence of adverse events in 300 consecutive inpatients receiving a single, premade total nutrient admixture. No patient experienced critically high triglycerides; 16% of patients had a metabolic adverse event, including raised bilirubin, urea, creatinine, or liver enzymes. Line sepsis occurred on 30 occasions representing 0.67 infections per 1000 catheter days. Mortality was significantly higher in dialysis, nonsurgical, and intensive care unit patients. The use of a standard formulation for all parenterally nourished patients does not lead to an unacceptable incidence or severity of metabolic complications; however, it did not meet the protein requirements of surgical or critically ill patients.

Analysis of the potential risk of central intravenous lines and/or total parenteral nutrition with ventriculoatrial shunts

OBJECT

The distal catheter of a ventriculoatrial (VA) cerebrospinal fluid shunt is potentially exposed to bacterial seeding from a subclavian central line. The risk of blood stream infections (BSIs) from central lines increases with administration of total parenteral nutrition (TPN). The potential risks of shunt malfunction or infection in patients with a VA shunt and a concurrent subclavian central line and/or TPN administration have not been studied.

METHODS

A retrospective review of 49 pediatric patients with placement of a VA shunt was performed. Three outcome measures were studied: shunt malfunction, shunt infection, and bacteremia/fungemia requiring shunt removal. All outcomes were measured by 1 year after shunt insertion. We analyzed the following potential risk factors: age at shunt insertion, prior ventriculoperitoneal (VP) shunt, prior shunt infection, abdominal infection/necrotizing enterocolitis (NEC), concurrent subclavian central line, and administration of TPN. The association between each risk factor and outcome was evaluated using Fisher's exact test to generate the relative risk. Additionally, a logistic regression analysis was performed to evaluate the odds ratio of the outcomes to risk factors considering age as a covariate.

RESULTS

The average age at shunt insertion was 6.3 ± 7.6 years. The most common diagnosis was posthemorrhagic hydrocephalus of prematurity (53.1 %). Fifteen patients (30.1 %) had a shunt malfunction within 1 year, 6 (12.2 %) had a shunt infection, and 3 (6.1 %) required removal of the shunt due to bacteremia/fungemia. The age at shunt insertion was not a statistically significant independent risk factor for any of the three outcomes. Prior shunt infection predicted an increased risk for both future shunt malfunction and infection in both the associative relative risk analysis and the age-dependent logistic regression analysis, although the correlation did not reach statistical significance. The presence of a subclavian central line or TPN administration did not statistically increase the risk over baseline for any of the outcomes in either analysis.

CONCLUSIONS

The relatively small number of patients limits the power of the study. Considering this limitation, the data suggests that the presence of a concurrent subclavian central line or administration of TPN does not increase the risk of shunt malfunction or infection over the baseline of this high-risk cohort.

Culture Positivity of CVCs Used for TPN: Investigation of an Association with Catheter-Related Infection and Comparison of Causative Organisms between ICU and Non-ICU CVCs

A relationship between central venous catheter (CVC) tip colonisation and catheter-related blood-stream infection (CRBSI) has been suggested. We examined culture positivity of CVC tips (colonised and infected CVCs) in a total parenteral nutrition (TPN) population. Our aims were to define the relationship between culture positivity and CRBSI, and to compare causative organisms between culture positive and CRBSI CVCS, and between ward and ICU CVCs. All patients receiving TPN via non-tunnelled CVCs during the study (1997–2009) were included. All CVC tips were analysed. Data were collated contemporaneously. A TPN audit committee determined whether CVC tip culture positivity reflected colonisation/CRBSI using CDC criteria. 1,392 patients received TPN via 2,565 CVCs over 15,397 CVC days. 25.4% of CVCs tips were culture positive, of these 32% developed CRBSI. There was a nonsignificant trend of higher Gram negative Bacilli isolation in ICU CVCs (P = 0.1), ward CVCs were associated with higher rates of staphylococcal isolation (P = 0.01). A similar pattern of organisms were cultured from CRBSI and culture positive CVCs. The consistent relationship between CRBSI and culture positive CVCs, and similar pattern of causative organisms further supports an aetiological relationship between culture positive CVC tips and CRBSI, supporting the contention that CVC culture-positivity may be a useful surrogate marker for CRBSI rates.

Current practices in the delivery of parenteral nutrition in Australia

OBJECTIVE

To determine current practice in the delivery of parenteral nutrition (PN) in Australian hospitals.

DESIGN

A cross-sectional mail survey.

SETTING

Acute-care adult hospitals with greater than 200 beds in Australia.

SUBJECTS

A total of 67 hospitals (65.7% response rate).

INTERVENTION

Surveys were posted to hospitals. A reminder letter with a second copy of the survey was posted 3 weeks later to non-respondents.

RESULTS

Twenty-seven (40.3%) of the hospitals have a PN team and 50 (74.6%) have a hospital protocol for PN delivery. An inaccessible or non-functional gastrointestinal tract is the most common indicator for commencing PN. Fat infusion is calculated by 24 (38.7%) respondents with a mean (s.d.) maximum amount of fat provided of 2.0 (0.7) g/kg/day. Over half (n=35) reported calculating carbohydrate infusion at a maximum amount of 5.4 (1.0) mg/kg/min. Two-thirds (n=41) reported commencing PN at a rate of 50% or less of goal rate. Blood glucose levels (BGL) were monitored at least once per day by the majority of respondents (n=56, 83.6%). Insulin infusion was commenced at varying BGL. Most respondents (n=40, 59.7%) reported ceasing PN when at least half of the patient's requirements are being met either orally or enterally. A number of practice guidelines were identified and the results of the survey were compared with these guidelines.

CONCLUSIONS

Where there are clear practice guidelines, current practice appears to be in line with these recommendations, however, where evidence is lacking, practice is varied.

Measuring line-related bacteraemia in intensive care patients

All patients with an intravascular device in the intensive care units at Prince of Wales and Prince Henry Hospitals between July and September 1995 were followed for the development of line-related bacteraemia per 1000 line days. Cases of sepsis related to an intravascular device were identified using a case definition which incorporated clinical and laboratory parameters. Data were collected prospectively for the dates of insertion and removal of devices for 188 lines inserted in 69 patients. The majority (90%) of lines had both date of insertion and removal documented allowing the calculation of the rate of primary bacteraemia over 832 at-risk line days. Multiple concurrent lines were more common (88.4%) than single lines, with one central and one or two peripheral lines being the most common (42.3%) combination. Five cases of bacteraemia were diagnosed clinically and confirmed microbiologically. The incidence density of primary bacteraemia was 6.0 per 1000 line days (CI 95% 5.7-6.3).

Evolution of the nutritional support pattern in pediatric intensive care

OBJECTIVES

To evaluate patterns of usage and monitoring of nutritional support in a Pediatric ICU of a teaching hospital and the role of an education program in nutritional support given throughout the resident physician training.

DESIGN

In a historical cohort study, records from children who received nutritional support during the year 1992 were analyzed. Thereafter a continuing education program in Nutritional Support was conveyed to the residents. In a second phase of the study, the same parameters were reevaluated in children who received nutritional support throughout the year 1995.

SETTING

Pediatric Intensive Care Unit of Department of Pediatrics, Escola Paulista de Medicina.

PATIENTS

All the children who were given nutritional support during a period of five days or more. Based on this criteria 37 children were selected for the first phase of this study, and 35 for the second one.

INTERVENTION

The education program included theoretical lectures about basic themes of nutritional support and journal article reading sessions. It was given to successive groups of residents on a weekly schedule.

MEASUREMENTS

Daily records of fluid, protein, caloric and micronutrient supply, nutritional assessment and metabolic monitoring.

RESULTS

In the first phase of the study, an exclusively parenteral route was utilized for 80.5%, and a digestive route 19.5% of the time period. Nutritional assessment was performed on 3 children; no patient had the nutritional goals set. The nitrogen to nonprotein calories ratio and the vitamin supply were inadequate, whilst the supply of trace elements was adequate except for zinc. Nutritional monitoring was performed on almost all patients but without uniformity. In the second phase, the exclusive parenteral route was used for 69.7% and the digestive route for 30.3% of the time period; no significant increase in the use of the digestive route was detected. The nonprotein calories to nitrogen ratio and micronutrient supply were adequate. The frequency of nutritional assessment increased, but deficiency in nutritional monitoring and infrequent enteral feeding were still detected.

CONCLUSION

There were deficiencies in the implementation of nutritional support, which were partially corrected in the second phase of the study by the training of the residents. Reinforcement of the education program, which should be applied to the whole medical staff, and the organization of a multidisciplinary team in charge of coordinating the provision of nutritional support are suggested.

Assessment of physicians' ability to prescribe parenteral nutrition support in a community teaching hospital

OBJECTIVE

To assess the knowledge and skill base of the physicians in our hospital in prescribing parenteral nutrition support.

DESIGN

Physicians completed parenteral nutrition orders for three mock patients. A range of clinically appropriate responses was established before the survey by the hospital Nutrition Support Team. Each case was scored according to set criteria, and the three case scores were averaged to yield a total score of 0 to 100.

SUBJECTS/SETTING

Forty-eight attending, resident, and student physicians in the departments of family practice, internal medicine, and general surgery in a community teaching hospital.

STATISTICAL ANALYSIS

Student's t test was used to compare interval data between two groups, and analysis of variance was used to compare interval data among three or more groups. If Bartlett's test for homogeneity of variance showed differences between the groups, the Kruskal-Wallis one-way analysis of variance was used. If analysis of variance revealed a significant difference, the data were reanalyzed using three different multiple-comparison procedures (Tukey, Scheffe, and Bonferroni) to decrease the possibility of a type I error.

RESULTS

The mean total score was 48.6 +/- 20.8. Total score differed according to the number of nutrition lectures attended during residency. Total score tended to differ by specialty and number of patients treated with parenteral nutrition; however, these differences did not reach statistical significance.

APPLICATIONS/CONCLUSIONS

This tool can be adapted and used by other hospitals, medical schools, and residency programs to assess physicians' knowledge base, design educational programs, and improve the parenteral nutrition ordering process.