Ezra Steiger

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.

Mortality of Intra-Abdominal Desmoid Tumors in Patients With Familial Adenomatous Polyposis A Single Center Review of 154 Patients

Introduction:Intra-abdominal desmoid tumors are one of the leading causes of death in patients with familial adenomatous polyposis. Their behavior is unpredictable and their biology is poorly understood, accounting for the lack of a standardized medical and surgical approach. The aim of this study was to evaluate the mortality rate of patients with intra-abdominal desmoid tumors and to identify prognostic factors for the evolution of the disease. Materials and Methods:A total of 154 patients with intra-abdominal desmoid tumors were included in the study. Each tumor was staged and each patient was categorized according to the stage of their most advanced tumor. Mortality was analyzed and the univariate risk factors associated with survival were included in a multivariable Cox regression model. A scoring system was derived from the multivariate analysis to refine outcomes within stages. Results:Five-year survival of patients with stage I, II, III, and IV intra-abdominal desmoid tumor were 95%, 100%, 89%, and 76% respectively (P < 0.001). Severe pain/narcotic dependency, tumor size larger than 10 cm, and need for total parenteral nutrition were shown to further define survival within stages. Five-year survival rate of stage IV patient with all of the above-mentioned risk factors was only 53%. Conclusions:Our study confirmed the validity of the staging system to predict mortality in patients with intra-abdominal desmoid tumors and identified additional risk factors able to better define the risk of death within each stage. Risk stratification is crucial in directing patients with advanced disease and poor prognosis to the most appropriate medical and surgical options.

Postoperative Oral and Intravenous Nutrition

Oral and intravenous high calorie-amino acid nutritional therapy postoperatively resulted in significant weight gain, improved colonic wound healing and maintenance of normal intravascular albumin levels. Provision of caloric needs without amino acids minimized weight loss postoperatively. However, infusion of hypertonic dextrose solutions resulted in severe generalized hepatic fatty infiltration and marked hypoalbuminemia. Protein and calorie deprivation by administration of 5% dextrose and water resulted in the greatest postoperative weight loss, reduced intravascular albumin levels and decreased colonic anastomotic strength. Comparison of oral and intravenous diet administration demonstrated that hypertonic dextrose infusion was markedly deleterious to hepatic morphology and serum protein metabolism in normal rats. Further clinical investigation appears indicated in previously well-nourished patients undergoing extensive surgery who will not be able to ingest adequate nutrients in the postoperative period.

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.

Obtaining and Maintaining Vascular Access in the Home Parenteral Nutrition Patient

Obtaining and maintaining vascular access is a critical part of successful home parenteral nutrition (HPN) management. Most of the HPN related rehospitalization of patients is caused by problems associated with long-term vascular access. The causes of death in HPN patients are mostly related to their primary underlying disease. However, approximately 12% of deaths in HPN patients are related to catheter-associated problems. The appropriate placement of long-term vascular access devices and their care and management should be familiar to all clinicians helping to manage these patients and will be discussed.

Development of Sustain™ A.S.P.E.N.’s National Patient Registry for Nutrition Care

The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) developed a Web-based registry for nutrition care launched in early 2011, initially focusing on the home parenteral nutrition (HPN) patient population. The purpose of Sustain is to collect information regarding the patients and populations who require HPN in the United States, measure outcomes associated with HPN, allow institutional benchmarking against the aggregate data, and publish the findings to improve the quality of care for patients receiving HPN. The registry is open to all sites (hospital and home based) who care for new or existing HPN patients. Preliminary data should be available in early 2012.

Inhibition of collagen synthesis by the proline analogue cis-4-hydroxyproline

Abstract These data demonstrate clearly that subcutaneous administration of cis -4-hydroxyproline in the postoperative period can significantly decrease the bursting strength of colonic anastomoses in rats directly, and that the effect is not explained by malnutrition or adverse systemic toxic effects.

Serum Lipids in Total Parenteral Nutrition

Intravenous hyperalimentation or total parenteral nutrition (TPN) is a technique of intravenous feeding designed to meet the nutritional requirements of patients when their gastrointestinal system does not adequately function to provide for these needs. There are a number of disease states in which the gastrointestinal tract is not functional in absorbing sufficient nutrients to provide for adequate nutrition. Some of these conditions include obstructing intestinal cancers, pyloric stenosis secondary to severe peptic ulcer disease, enterocutaneous fistulae, and severe inflammatory diseases of the intestine. Malnutrition often accompanies these processes and compounds the risk of necessary surgery. To provide for the patient’s caloric intake and vitamin, mineral, and nitrogen requirements, a concentrated dextrose solution with crystalline amino acids, and added vitamins and minerals are infused through a large-bore central vein (Dudrick et al., 1970). For the usual patient, the daily infusion of approximately 3000 calories and 20 grams of nitrogen (in the form of crystalline amino acids) is delivered through a percutaneously placed subclavian catheter whose tip lies in the superior vena cava. This method allows for the achievement of positive nitrogen balance and weight gain. The techniques used in placing and caring for the catheter, assessing the patient’s ability to tolerate the hypertonic sugar solution, and monitoring of the patient have been well documented.