Donald F. Kirby

Use of ethanol lock therapy to reduce the incidence of catheter-related bloodstream infections in home parenteral nutrition patients.

BACKGROUND Catheter-related bloodstream infection (CRBSI) is a serious complication for home parenteral nutrition (HPN) patients. To reduce the incidence of infection in frequently infected HPN patients, prophylactic ethanol lock therapy (ELT) was initiated. METHODS Nine patients were selected as candidates for ELT because of their history of recurrent CRBSI. Diagnosis of CRBSI was determined by symptoms correlating with positive peripheral and access device blood cultures. Medical-grade ethyl alcohol 25%-70% was instilled into the central venous access device and allowed to dwell for 2-4 hours. The incidence of CRBSI and catheter changes was compared before and after initiation of ELT. RESULTS Nine patients experienced 81 CRBSIs (8.3 per 1,000 catheter-days) before starting ELT vs 9 infections (2.7 per 1,000 catheter-days: relative risk [RR], 0.325; confidence interval [CI] 95%, 0.17-0.64) after ELT. Catheter changes were also reduced from 69 (7.0 per 1000 days) before ELT to 1 (0.3 per 1,000 days: RR, 0.043; CI 95%, 0.01-0.25) after ELT. No significant adverse effects were noted, although some patients complained of transient dizziness and nausea. CONCLUSIONS ELT shows promise in reducing the incidence of CRBSI in the frequently infected HPN population. Further studies are warranted.

Percutaneous endoscopic gastrostomies: a prospective evaluation and review of the literature.

The results of the first 55 consecutive percutaneous endoscopic gastrostomies (PEGs) that were performed over an 18-month period in a tertiary care center are presented. We followed these cases prospectively to assess the morbidity, mortality, staff acceptance, short-and long-term complications, and cost effectiveness of the technique. Fifty-one (93%) were successful with no mortality. Long-term morbidity included 6/55 (11%) tube extrusions; 5/55 (9%) cellulitis around the catheter site; 5/55 (9%) aspiration pneumonias; and 2/55 (3.6%) clogged tubes requiring replacement. Morbidity was considered minor and easily dealt with in all but five instances (9%) where more prolonged treatment was required. A review of the literature including other techniques used for percutaneous gastrostomy is also presented. It is concluded that percutaneous gastrostomies are relatively safe, cost-effective, and should be given first consideration for long-term enteral therapy in appropriate patients.

Endoscopic nasogastric-jejunal feeding tube placement in critically ill patients

BACKGROUND Historically, placement of small bowel nasoenteric feeding tubes in the critically ill patient has been difficult because of lack of bedside fluoroscopy, inadequately designed endoscopic tubes, or failure of the tube to spontaneously pass into the duodenum following placement. METHODS We followed-up 54 consecutive critically ill patients who had a combined nasogastric-jejunal feeding tube placed at the bedside using a new endoscopic, nonfluoroscopic method of placement. Data were obtained on the placement procedure, outcomes, and complications that followed. RESULTS Tubes were successfully placed in 94% of the patients in an average time of 12 minutes. Negative outcomes included the following: inadvertent removal by patient or staff (21%), intolerance to tube feeding (14%), clogging (9%), kinking (6%), and cracking at the tube adapter (11%). The duration of the tube following placement ranged from 1 to 42 days, with an average of 9 days. CONCLUSION The combined tubes were easy to place endoscopically. The endoscopic, nonfluoroscopic method of placing feeding tubes can be performed at the bedside and allows for gastric decompression and enteral feeding to be rapidly and efficiently achieved, which is particularly useful for intubated patients in an intensive care setting. Negative outcomes should decrease by avoidance of inadvertent tube removal and by improved tube maintenance and materials.

Epidemiology of bloodstream infections in patients receiving long-term total parenteral nutrition

Goals To describe the epidemiology and microbiologic characteristics of bloodstream infections (BSIs) in patients receiving long-term total parenteral nutrition (TPN). Background Home TPN therapy has been reported as a risk factor for BSI. However, little knowledge exists regarding the epidemiology of BSIs in this patient group. Study A descriptive, observational epidemiologic study of patients receiving long-term TPN from January 1981 to July 2005 was performed. Variables analyzed include age, gender, time of follow-up, number of BSIs, microbiologic characteristics, underlying disease necessitating long-term TPN, catheter type, complications related to TPN, and clinical outcome. Results Forty-seven patients receiving long-term TPN were evaluated. The most frequent indication for long-term TPN was ischemic bowel disease (25.5%). The mean duration of follow-up was 4.5 years. Thirty-eight patients (80.9%) developed 248 BSIs while receiving TPN. More than 1 BSI episode occurred in 78.9% of these patients, and 23.8% of BSI episodes were polymicrobial. The most prevalent pathogen was coagulase negative staphylococci (33.5%). The most frequent complication among patients with BSI was central venous thrombosis (44.7%). Five patients were intravenous drug users. There were 11 deaths among the patients on long-term TPN, 4 of these were related to infection and 4 were related to intravenous drug use. Conclusions The incidence of BSI is high, and a significant proportion of BSIs in long-term TPN patients are polymicrobial and due to multidrug-resistant bacteria and fungi. Careful management of the infusion line is required and interventions are needed to reduce the risk of catheter-related infections in this population.

Percutaneous endoscopic gastrojejunostomy: a dual center safety and efficacy trial.

Although jejunal tube placement through a percutaneous endoscopic gastrostomy (PEG) has not been proven to be preferable to PEG feeding, it would be theoretically advantageous for those patients prone to gastrointestinal aspiration. However, reliable placement of a small bowel feeding tube through a PEG has been technically difficult. We have previously reported successful placement of a percutaneous endoscopic gastrojejunostomy (PEG/J) with minimal complications. These results are in contrast to other series that report technical difficulty, frequent tube dysfunction and gastric aspiration. We describe an over-the-wire PEG/J technique performed by multiple operators at two medical centers. Gastrostomy tube placement was successful in 94% of patients. Initial placement of the jejunal tube was successful in 88% of patients. Second attempts were 100% successful. The average procedure time was 36 minutes. The distal duodenal and jejunal placement of the jejunal tube resulted in no episodes of gastroduodenal reflux. Complications included jejunal tube migration (6%), clogging (18%), and unintentional removal (11%). The majority of patients were ultimately converted to either oral or intragastric feedings. We conclude that the PEG/J system is a reliable, reproducible method of small bowel feeding and is associated with no episodes of tube feeding reflux when the jejunal tube is positioned in the distal duodenum or beyond. Furthermore, it provides a temporary nutritional bridge for those patients who are later transitioned to either PEG or oral feeding.

Review: Short-Bowel Syndrome: A Review of the Role of Nutrition Support

Advances in long-term venous access devices and in parenteral nutrition solutions have made it possible for patients with severe short bowel syndrome to survive and to live in our society. The spectrum of this disease is such that some patients may be able to lessen their dependence or even become free from parenteral therapy. This review will discuss the role of nutrition support in the patient with short bowel syndrome.

Early Enteral Nutrition After Brain Injury by Percutaneous Endoscopic Gastrojejunostomy

Twenty-seven patients in a series of 52 patients with severe brain injury (Glasgow Coma Scale score less than or equal to 8) underwent insertion of intestinal feeding tubes at the bedside. The technique required endoscopy with externalization of gastric and intestinal ports through the abdominal wall. Feedings were begun through the intestinal tube with Vital HN within 4 hours of its insertion with simultaneous gastric decompression via the gastric tube. Tubes were placed 2.3 (range 0-5) days after injury. Full caloric intake (3020 kcal/24 h) was achieved by 6.8 (range 2-8) days after injury to 4.2 (range 2-8) days after placement of the feeding tube. Only 1 patient failed to tolerate feedings immediately after tube insertion. Technical inability to insert the tubes occurred in 3 patients and the intestinal tube migrated into the stomach in 2 patients; diarrhea occurred in only 1 patient. With this technique, it was possible to deliver an average daily intake of 1.2 g/kg of protein in 8-day balance periods beginning at the time of tube insertion. These data included 3- to 4-day periods in which feedings were steadily increased. In 16 patients in whom nitrogen balance was measured for 8-day balance periods, average nitrogen balance was -5.7 (range -11.3 to +3.5) g/24 h. The reduction in nitrogen loss by this technique appears equal to or superior to either gastric feeding or TPN. This technique provides the ability to enterally feed a high proportion of brain-injured patients (except those in barbiturate coma) very early after injury using a bedside procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

Ethanol Lock Therapy in Reducing Catheter-Related Bloodstream Infections in Adult Home Parenteral Nutrition Patients Results of a Retrospective Study

BACKGROUND Equivocal data demonstrate the efficacy of ethanol lock therapy (ELT) in preventing catheter-related bloodstream infections (CRBSIs) in home parenteral nutrition (HPN) patients, but it is not currently a standard of practice. The objective of this study is to investigate the efficacy of ELT in reducing the incidence of CRBSIs in HPN patients. METHODS Medical records from the Cleveland Clinic database of adult HPN patients with CRBSIs placed on prophylactic ELT were retrospectively studied from January 2006 to August 2009 (n = 31). Outcomes were compared pre- and post-ELT with the patients serving as their own controls. Medical-grade (70%) ethanol was instilled daily into each lumen of the central venous catheter (CVC) between PN infusion cycles. Comparative analysis was performed using McNemars test and Wilcoxon ranked tests. RESULTS Thirty-one patients had 273 CRBSI-related admissions prior to ELT in comparison to 47 CRBSI-related admissions post-ELT. Adjusted data for only tunneled CVC pre- and post-ELT showed a similar reduction of CRBSI-related admissions from 10.1 to 2.9 per 1000 catheter days (P < .001). There was also a statistically significant reduction in culture-positive CRBSIs and number of catheters changed pre- and post-ELT. There were no reported side effects or complications in any patient undergoing ELT. CONCLUSIONS This study supports the efficacy and safety of ELT in reducing CRBSI-related admissions in HPN patients and potentially helps reduce the burden of CRBSI-related healthcare costs. This novel technique shows great promise as a standard prophylaxis for CRBSI in HPN patients and must be incorporated in routine practice.

As the Gut Churns: Feeding Challenges in the Head-Injured Patient

Even though it was recognized by Drew et all in 1947 that rapid nutritional deterioration occurred after craniotomy, the approach toward nutrition support for the head-injured patient has been relatively slow compared with that for other critically ill populations. The reasons for this are unclear. Perhaps it is due in part to the fact that this population of patients is more likely to be adequately nourished prior to the acute neurologic event, which leads to the perception of a stable nutritional status. Attempts at enteral feeding have been hampered by the high degree of gastric feeding intolerance in the head-injured population. In addition, there were also beliefs that total parenteral nutrition (TPN), with its hyperosmolar solutions and high volumes, could be deleterious to brain-injured patients because of concerns over the possible progression of cerebral edema.2 Thus, there were few attempts at feeding, either enterally or parenterally, until the classic study by Rapp and colleagues3 demonstrated not only the safety of TPN in head-injured patients, but also improved survival compared with those patients who were fed enterally and were unable to tolerate intragastric feedings. In this issue of JPEN, Weekes and Elia relate some interesting observations about head-injured patients.4 Because of the small number of patients in this report, one must be very careful of making sweeping conclusions about this population. Although some trends are noteworthy , they require confirmation in additional trials with use of larger sample sizes. In the present study, two sets of measurements were performed. The first battery was performed on six patients between days 3 and 5 postinjury and included measurements of indirect calorimetry continuously at the bedside, body composition, urinary nitrogen excretion, gastric emptying studies by the phenol red technique, and collection of random samples of saliva during fasting and feeding to detect glucose concentration. A second set of measurements, including indirect calorim-etry and body composition, was performed on four patients between weeks 2 and 3 postinjury. Changes in energy expenditure (EE) are easily measured with the use of indirect calorimetry devices. These are now available as metabolic cart units or, more recently, as integrated hardware in ventilator systems that specifically detect moment-to-moment or day-today changes in EE. With use of an indirect calorimeter continuously for a mean of 20 hours, the data in this study suggest that in a stable, sedated, ventilated patient who complies with the ventilator , a short-term measurement will be …

Intestinal Failure Management at the Cleveland Clinic

The Cleveland Clinic institutional guidelines for the management of intestinal failure, including long-term or home parenteral nutrition and related complications, intestinal rehabilitation, and small bowel transplantation, were reviewed. PubMed was searched for relevant articles. The search was performed in November 2008; keywords used were home parenteral nutrition, short bowel syndrome, intestinal rehabilitation, and small-bowel transplantation. Randomized, prospective, observational, retrospective reviews and case report articles that contained relevant data for long-term parenteral nutrition, intestinal rehabilitation, and intestinal transplantation were selected. Researchers reviewed 67 selected articles that met our inclusion criteria. Our institution data registries for intestinal rehabilitation and home parenteral nutrition were also reviewed for relevant data. The survival of tens of thousands of children and adults with complicated gastrointestinal problems has been possible because of parenteral nutrition. In selected patients, a program of intestinal rehabilitation may avoid the need for long-term parenteral nutrition.