Elizabeth A. Krzywda

Treatment of Hickman Catheter Sepsis Using Antibiotic Lock Technique

Antibiotic lock therapy, an alternative treatment for Hickman catheter sepsis, was evaluated in six recipients of prolonged outpatient intravenous therapy. Twenty-two episodes of catheter sepsis were identified, involving coagulase-negative staphylococci (11), gram-negative bacilli (3), gram-positive bacilli (1), yeast (4), and mixed bacteria or fungi (3). In a select group of patients, treatment was successful 92% of the time.

Reoperative parathyroidectomy: An algorithm for imaging and monitoring of intraoperative parathyroid hormone levels that results in a successful focused approach

BACKGROUND Advances in preoperative imaging and use of intraoperative parathyroid hormone (IOPTH) levels are changing the approach to reoperative parathyroidectomy (ReopPTX). We sought to develop a protocol for imaging and IOPTH monitoring that allows for a focused, successful operative approach. METHODS We reviewed our prospective database of consecutive patients with primary hyperparathyroidism who underwent ReopPTX with IOPTH monitoring between December 1999 and June 2007. RESULTS Thirty-nine patients underwent 43 ReopPTXs for persistent (79%)/recurrent (21%) disease. All underwent ultrasonography and sestamibi imaging; 24 cases (56%) underwent additional imaging studies. Sensitivity of ultrasonography was 56%, sestamibi 53%, both studies 67%, computed tomography (CT) 48%, magnetic resonance imaging (MRI) 67%, and selective venous sampling (SVS) 50%. IOPTH monitoring predicted accurately cure in 100% and failure in 78%. A focused/unilateral approach was performed in 60%; median operative time was 45 minutes (range, 12-127). At last follow-up, 36 (92%) patients were normocalcemic. CONCLUSIONS We propose that ultrasonography and sestamibi studies should be done before all ReopPTXs; failure to localize should prompt sequential CT, MRI, and SVS until localization is achieved. IOPTH monitoring defines cure and is recommended for all ReopPTXs. This algorithm allows for a focused operative approach in >50% of ReopPTXs with operative times comparable with first-time, minimally invasive parathyroidectomy.

Pinch-Off Syndrome: A Rare Etiology for Central Venous Catheter Occlusion

BACKGROUND Catheter pinch-off syndrome is a rare and often misdiagnosed complication of tunneled Silastic central venous catheters. Pinch-off syndrome occurs when the catheter is compressed between the first rib and the clavicle, causing an intermittent mechanical occlusion for both infusion and withdrawal. We report its incidence in a large series of catheter insertions and describe the clinical presentation, radiographic findings, and recommended treatment. METHODS A total of 1457 tunneled Silastic central venous catheters that were inserted using the percutaneous subclavian approach were prospectively studied. Indications for catheter placement included bone marrow transplant, continuous or intermittent chemotherapy, long-term antibiotics, and parenteral nutrition. Catheters were evaluated for clinical presentation of an occlusion relieved by postural changes and radiographic findings of luminal narrowing. RESULTS Pinch-off syndrome was identified in 16 (1.1%) catheters. Radiographic findings were present in all catheters; clinical findings were present in 15 catheters. Clinical symptoms presented within a median of 2 days after placement (range, 0 to 167 days). Partial or complete catheter transection, a serious sequela of catheter pinch-off syndrome, occurred in 19% of the identified catheters. CONCLUSIONS (1) Catheter pinch-off syndrome presents clinically as a catheter occlusion related to postural changes; (2) clinical symptomatology should be confirmed radiographically; and (3) catheter removal with a more lateral replacement in the subclavian vein or in the internal jugular vein will avoid a recurrent complication.

Elimination of Intraluminal Colonization by Antibiotic Lock in Silicone Vascular Catheters

An in vitro model was designed to evaluate the efficacy of instilled antimicrobials to reduce or eliminate intraluminal microbial colonization. Minimal inhibitory concentration and minimal bactericidal concentration activity of appropriate test anti-infectives were determined using standard methodology against clinically derived and reference test strains commonly associated with catheter-related infection. Drug activity was validated by bioassay for the test anti-infectives. Reference and clinical test strains were inoculated to the intraluminal surface of silicone catheter segments and incubated for 30 min, after which the inoculum was replaced with total parenteral nutrition (TPN) solution and reincubated for 12 h. For 7 d, instillation of antibiotic and TPN solution was alternated every 12 h to simulate clinical conditions. On days 1, 4, and 7, catheter segments were rinsed, bisected, and sonicated for quantitative plate count to determine mean microbial counts per centimeter of catheter surface. Catheter segments were also prepared for scanning electron microscopy. A significant decrease in staphylococcal intraluminal colonization after instillation of nafcillin, ceftriaxone, gentamicin, and vancomycin was demonstrated (P < 0.001). Aztreonam, ceftriaxone, and gentamicin completely eliminated gram-negative catheter colonization (P < 0.001). Yeast was eradicated from the internal catheter surface after treatment with amphoteracin B, and fluconazole significantly decreased intraluminal colonization (P < 0.001). Results show a significant decrease in staphylococcal, gram-negative, and fungal intraluminal colonization after instillation of appropriate antimicrobial. In vitro results support early clinical success using this technique. Future studies are warranted to identify optimal drug concentrations and dosing intervals.

Operative failures after parathyroidectomy for hyperparathyroidism: the influence of surgical volume.

Objective:To determine whether surgical volume influences the cause of operative failures after parathyroidectomy for hyperparathyroidism. Summary and Background Data:The surgical success rate for hyperparathyroidism from high-volume centers exceeds 95%, but some patients have unsuccessful parathyroidectomies. Although operative failure can be due to hyperfunctioning parathyroid glands in ectopic locations, less experienced surgeons may be more likely to miss an abnormal parathyroid in normal anatomic locations, which we describe as “preventable operative failure.” Methods:We used 2 prospective databases containing over 2000 consecutive patients who underwent parathyroidectomy. We identified 159 patients with persistent/recurrent hyperparathyroidism subsequently cured with additional surgery. The initially failed operations were classified as being performed at high- (>50 cases/yr) or low-volume (<50 cases/yr) hospitals. Hospital volume was obtained from a Wisconsin state database of 89 hospitals, which reported 6336 parathyroid operations during the same decade. Results:Patients who initially failed their operation performed at the high- or low-volume centers were similar with regard to age, laboratory values, gender, and parathyroid weights. Despite a higher incidence of multigland disease (which increases the likelihood of operative failure) in the high-volume group, patients in the low-volume group were more likely to have a missed parathyroid gland in a normal anatomic location (89% vs. 13%, P < 0.0001), and thus a higher proportion of preventable operative failures. Conclusions:Surgical volume influences the failure pattern after parathyroidectomy for hyperparathyroidism. Preventable operative failures are more common in low-volume centers.

Glucose response to abrupt initiation and discontinuation of total parenteral nutrition.

Plasma glucose was studied during the initiation of total parenteral nutrition (TPN) and the discontinuation of TPN without a tapering schedule. Blood was sampled every 5 minutes for 2 hours after the start of TPN and 1 week later as TPN was discontinued. A total of 14 initiations and 14 discontinuations were studied in 18 patients. Severity of illness in patients ranged from stable condition postoperatively to multiple-system failure; six patients had diabetes mellitus. The TPN solution was a 3:1 admixture that provided a caloric intake equal to 1.2 times the resting energy expenditure, with 40% fat and 60% carbohydrate calories. An average of 1963 kcal was provided per day (340 g of glucose, 79 g of fat). During the initiation phase, the mean increase in plasma glucose was 60 mg/dL. The increase for diabetic patients was 79 +/- 14 mg/dL compared with 52 +/- 23 mg/dL for the nondiabetics. During the discontinuation phase, the mean plasma glucose decreased 40 +/- 20 mg/dL; two patients with high concentrations of regular insulin (50 and 100 units) showed an increase in plasma glucose when the TPN was stopped. Plasma glucose returned to the preinfusion baseline after discontinuation. During both initiation and discontinuation, plasma glucose showed little change after the first 60 minutes. No clinical symptoms of hypoglycemia were observed. In conclusion, TPN as a 3:1 admixture can be safely started as full nutrition support and stopped abruptly without a tapering schedule. Plasma glucose response is rapid, predictable, and mostly complete within 60 minutes.

The Malfunctioning Silastic Catheter—Radiologic Assessment and Treatment

Occlusion of silastic catheters is attributed to several documented causes. One factor not yet adequately documented is fibrin sleeve formation. In this instance, the catheter functions for infusion purposes, but blood withdrawal is no longer feasible. This is a troublesome occurrence when encountered in the clinical setting. This report reviews the assessment of fibrin sleeve formation, the use of catheter phlebography and treatment with low-dose streptokinase. Seventeen instances of the inability to aspirate blood from silastic catheters are evaluated with restoration of full catheter function in all cases after streptokinase administration.

Catheter Infections: Diagnosis, Etiology, Treatment, and Prevention

Infection remains the leading complication that is associated with intravascular access devices. Despite continuous research efforts and advances in technology, the rate of central venous catheter infections has remained relatively constant over the past decade. This article focuses on four pertinent aspects of central venous access infection: microbial etiology and pathogenesis, diagnosis, prevention, and treatment. An update of the scientific literature in this area will aid clinicians in their patient care practices and serve to identify unanswered questions.

Nutrition and Pancreaticoduodenectomy

Pancreaticoduodenectomy (Whipple) is the surgical procedure of choice for curative resection of pancreatic head, periampullary, and distal bile duct cancers. This procedure involves removal of the pancreatic head, duodenum, distal common bile duct, and sometimes the pylorus and gastric antrum. The 2 most common complications are pancreatic fistula and delayed gastric emptying. Preoperative nutrition status has been shown to influence surgical outcomes. This technically demanding operation involves an extensive surgical resection and alters digestive processes, which can influence nutrition long term. This review article identifies the surgical and nutrition consequences associated with pancreaticoduodenectomy.

Primary hyperparathyroidism with a history of head and neck irradiation: The consequences of associated thyroid tumors

BACKGROUND Information on thyroid tumors is scant in patients with primary hyperparathyroidism (HPT) and history of head and neck irradiation. The study objective was to investigate thyroid pathology in primary HPT patients with irradiation history presenting for parathyroidectomy. METHODS A prospective database of 1,020 parathyroidectomy patients was analyzed. 916 consecutive HPT patients were identified. History of radiation, neck ultrasound results, thyroid operations, and pathology was assessed. Patients with radiation history were compared to those with no radiation. RESULTS Of the 916 HPT patients, 49 (5%) had a history of radiation and were more likely to have nodular thyroid disease (95% vs 52%), undergone a prior thyroidectomy (29% vs 4%), or had concurrent thyroidectomy (49% vs 26%). Nine of 49 (24%) had thyroid cancer. Of the 867 patients with no history of radiation, 259 underwent thyroid resection (32 prior and 227 concurrent) and 32 (12%) had thyroid cancer. CONCLUSION Primary HPT patients with head and neck irradiation presenting for parathyroidectomy had marked increase in nodular thyroid disease: nearly 1 in 2 had concurrent thyroidectomy, and nearly 1 in 4 had thyroid carcinoma. High resolution ultrasound prior to parathyroidectomy detects associated thyroid pathology and allows the surgeon to plan the extent of thyroid resection.