Denise S. Richardson

Efficacy of ethanol locks in reducing central venous catheter infections in pediatric patients with intestinal failure

PURPOSE We sought to determine whether a regimen of 70% ethanol locks could reduce the rate of central venous catheter (CVC) infections in parenteral nutrition-dependent children with intestinal failure. METHODS We performed a retrospective review of 23 parenteral nutrition-dependent children in our multidisciplinary intestinal rehabilitation clinic who started ethanol lock therapy between September 2007 and June 2009. The treatment regimen consisted of a 70% ethanol lock instilled 3 times per week in each catheter lumen. The rate of CVC infections before and after initiation of ethanol lock therapy was compared using the Wilcoxon signed ranks test with significance set at P < .05. RESULTS The most common diagnoses leading to intestinal failure were necrotizing enterocolitis (26.1%), gastroschisis (21.7%), and intestinal atresia (14.3%). Ethanol locks were well tolerated with no reported adverse side effects. The infection rate decreased from 9.9 per 1000 catheter days prior to initiation of ethanol locks to 2.1 per 1000 catheter days during therapy (P = .03). CONCLUSIONS A regimen of ethanol lock therapy administered three days per week appears to be a safe and effective means of reducing the rate of CVC infections in parenteral nutrition-dependent children with intestinal failure.

Effectiveness of a clinical practice guideline for parenteral nutrition: a 5-year follow-up study in a pediatric teaching hospital

OBJECTIVE To determine the effectiveness of a clinical practice guideline (CPG) on the use of parenteral nutrition (PN) at a tertiary care pediatric hospital. METHODS Review of prospectively collected data on hospital-wide PN use 2 years before and 5 years after the establishment of the CPG. Effectiveness of the CPG was measured as the percentage of PN courses lasting fewer than 5 days and the number of PN starts per 1000 patient days. RESULTS During the study period, 5745 PN courses were administered. The mean (SD) number of PN starts per 1000 inpatient days was 8.86 (0.78) before the CPG and 9.54 (2.49) afterwards (p = .28). The percentage courses of PN lasting for fewer than 5 days declined from 26.3% before the CPG to 18.4% afterwards (p < .0001). A multivariate model confirmed that the rate of short-term PN starts declined after the CPG was issued. The mean (SD) number of PN courses shorter than 5 days in the 2 years before the CPG was 2.33 (0.42) per 1000 patient days versus 1.75 (0.45) in the 5 years after the CPG was instituted (p = .005), which is a 25% decline. The services with the highest volume of PN use showed the most significant decreases in short-term PN use. A cost savings to the hospital of more than

Success rates and cost-effectiveness of antibiotic combinations for initial treatment of central-venous-line infections during total parenteral nutrition.

50,000 may have been realized. CONCLUSIONS In a large pediatric tertiary care hospital, a CPG was successfully deployed. CPGs can favorably affect the use rates and costs of parenteral nutrition.

Immune deficiencies in chronic intestinal pseudo-obstruction

BACKGROUND Central-venous-line infections can be successfully treated with appropriate antibiotics, thus avoiding the need for catheter removal. Based on our experience, vancomycin, gentamicin, piperacillin, ceftazidime, and amphotericin, alone or in combination, are usually administered, pending sensitivity results. This empirical list, however, has never been verified against actual sensitivity results nor has it been tested for cost or efficacy. METHODS Medical records of inpatients on hyperalimentation over 1 year were reviewed. Success rate, therapy duration, and drug acquisition cost and charge were assessed for central-venous-line infections. Antibiotics then were paired and evaluated in terms of charge and efficacy against all microorganisms as determined by sensitivity results. RESULTS In 500 inpatients receiving hyperalimentation for 9,698 patient-days, 8.4 central-venous-line infections/1,000 patient-days occurred. Staphylococcus non-aureus, Candida species, Enterococcus faecium, and Staphylococcus aureus predominantly were isolated. Of the infections, 51 (67%) were sensitive to one or more of the initial antibiotics. A 2-week course of antibiotics successfully treated 50 (66%) catheter infections without line removal. Appropriate initial therapy on average reduced treatment duration by 8 to 10 days and drug charges by

Standardized Competencies for Parenteral Nutrition Administration: The ASPEN Model

400 to

Nutritional and other postoperative management of neonates with short bowel syndrome correlates with clinical outcomes

700. CONCLUSIONS Amikacin-vancomycin appears to be the most cost-effective selection for presumed central-venous-line infections, pending sensitivity results, followed by valid alternatives. Lower failure rates are well worth the extra cost in pharmaceutical charges.

Malnutrition in hospitalized pediatric patients. Current prevalence.

Aim: Chronic intestinal pseudo‐obstruction has been associated with urinary disorders, myopathy, and ophthalmoplegia in adults and cholelithiasis in children. We observed a high percentage of total‐parenteral‐nutrition‐dependent patients with pseudo‐obstruction and recurrent infections requiring gammaglobulin infusions. Methods: AH records for 23 children with chronic intestinal pseudo‐obstruction (10 females and 13 males, mean age 9.8 y ± 4.9 y, range 4–24 y) referred for a nutritional evaluation from 1992 to 1995 were reviewed. Chronic intestinal pseudo‐obstruction was diagnosed by clinical, radiographic findings and antroduodenal manometry. Intestinal full‐thickness biopsies were performed in seven children. Results: Hypogammaglobulinemia was diagnosed in 18 patients (78%): 16 patients had various immunoglobulin deficiencies and 2 had selective antibody deficiency. Intravenous gammaglobulin was administered in 14 patients. Other medical conditions affecting the children are summarized as follows: autonomic dysfunction in 10 patients (43%), recurrent hypoglycemia in 9 (39%), asthma in 9 (39%), cholecystitis in 7 (30%), low serum carnitine level in 6 (26%), urinary dysfunction in 6 (26%), pancreatitis in 5 (22%), behavioral problems in 5 (22%), myopathy in 2 (9%), idiopathic thrombocytopenia in 2 (8%), velopharyngeal insufficiency in 1 (4%), oculocutaneous albinism in 1 (4%), Pierre‐Robin syndrome in 1 (4%), and protein C deficiency in 1 (4%). Munchausen syndrome was suspected in two patients. Conclusions: Chronic intestinal pseudo‐obstruction appears to be associated with immune deficiencies. It is unclear if the immune deficiencies, intestinal pseudo‐obstruction, and the other medical conditions have a common underlying etiology. Repeated infections may be due to impaired immune function in children with chronic intestinal pseudo‐obstruction. We recommend screening for immune deficiencies in children with chronic intestinal pseudo‐obstruction.

The role of enteral nutrition in the reversal of parenteral nutrition–associated liver dysfunction in infants

Parenteral nutrition (PN) is a highly complex medication and its provision can be prone to a variety of errors. Safe administration of this therapy requires that the competency of clinicians, particularly nurses, be demonstrated using a standardized process. In this document, a standardized model for PN administration competency is proposed based on a competency framework, the ASPEN-published interdisciplinary core competencies, discipline-specific standards of practice, safe practice recommendations, and clinical guidelines. ASPEN recognizes that all healthcare institutions may not currently meet the aspirational goals of this document. This framework will guide institutions and agencies in developing tools and procedures and maintaining competency of staff members around safe PN administration. The ASPEN Board of Directors has approved this document.