K. Majewska

Innate immunity gene expression changes in critically ill patients with sepsis and disease-related malnutrition

The aim of this study was an attempt to determine whether the expression of genes involved in innate antibacterial response (TL R2, NOD 1, TRAF6, HMGB 1 and Hsp70) in peripheral blood leukocytes in critically ill patients, may undergo significant changes depending on the severity of the infection and the degree of malnutrition. The study was performed in a group of 128 patients with infections treated in the intensive care and surgical ward. In 103/80.5% of patients, infections had a severe course (sepsis, severe sepsis, septic shock, mechanical ventilation of the lungs). Clinical monitoring included diagnosis of severe infection (according to the criteria of the ACC P/SCC M), assessment of severity of the patient condition and risk of death (APACHE II and SAPS II), nutritional assessment (NRS 2002 and SGA scales) and the observation of the early results of treatment. Gene expression at the mRNA level was analyzed by real-time PCR. The results of the present study indicate that in critically ill patients treated in the IC U there are significant disturbances in the expression of genes associated with innate antimicrobial immunity, which may have a significant impact on the clinical outcome. The expression of these genes varies depending on the severity of the patient condition, severity of infection and nutritional status. Expression disorders of genes belonging to innate antimicrobial immunity should be diagnosed as early as possible, monitored during the treatment and taken into account during early therapeutic treatment (including early nutrition to support the functions of immune cells).

Damage of Central Catheters in Home Parenteral Nutrition Patients

UNLABELLED According to the ESPEN and ASPEN guidelines, in the case of a long-term (>3-month) parenteral nutrition should be administered via a subcutaneous central venous catheter (CVC). There are three types of mechanical complications of tunnelled central catheter: catheter rupture, occlusion by TPN depositing and thrombofibrotic occlusion. The aim of the study was to analyse the incidence of complications central catheter in a group of patients receiving HPN. MATERIAL AND METHODS Between January 2010 and June 2014, HPN was conducted in 584 patients (306 women and 278 men), ninety-nine patients were enrolled in the study: 67 women and 32 men in whom mechanical complications of central catheters were found. RESULTS Among 99 patients, 71 used the tunnelled Broviac catheter. Groshong catheters were placed only in patients receiving parenteral nutrition due to cancer. Analyses have shown differences between the older and younger in the number of mechanical complications. Younger patients were found to have a larger number of catheter complications (1.6 ± 1.1) in comparison with older patients (1.3 ± 0.7). The catheter that was most commonly damaged was the Broviac catheter 76.8%. The most frequent type of mechanical complications was catheter rupture 64.81%. CONCLUSIONS Mechanical complications of tunnelled central catheters in HPN patients can be repaired in an outpatient setting in half of the cases, which enables continuation of parenteral nutrition without the need to hospitalise the patient. The centres that conduct HPN should offer 24-hour care and help in case of problems with the central venous line to the patients.

A comparison of two methods of treatment for catheter-related bloodstream infections in patients on home parenteral nutrition

BACKGROUND & AIMS Home parenteral nutrition (HPN) enables patients who cannot eat normally to survive and function. Catheter-related bloodstream infections (CRBSIs) are the most dangerous complication, which may be fatal if left untreated or if treatment is delayed. For over 20 years CRBSIs were managed by catheter removal and implantation of a new one after completion of antibiotic treatment. However, frequent catheter replacements put the patient at risk of large vein thrombosis, which may render parenteral nutrition impossible. The management of CRBSIs evolved into antibiotic treatment without catheter removal. The effectiveness of this approach was, however, limited by the low penetration of the antibiotics into the biofilm. Filling catheters with concentrated ethanol destroys the biofilm and does not result in the emergence of drug resistance. The aim of our study was to assess the remote outcomes of CRBSI treatment using two approaches: antibiotic-ethanol lock therapy and catheter replacement. METHODS We retrospectively analysed the treatment outcomes of CRBSI diagnosed and managed in HPN patients. During the analysed period, a total of 428 patients between 13 and 96 years of age were on HPN and a total of 181 of them suffered a total of 352 CRBSI episodes managed with one of the two approaches. RESULTS We showed no significant differences between the two approaches in terms of survival likelihood or duration of catheter use after an episode of CRBSI caused by various bacterial species. CONCLUSION The use of antibiotic-ethanol lock therapy in the management of CRBSI is equally effective as catheter replacement.

Food, Mechanic and Septic Complications in Patients Enterally Nutritioned in Home Conditions

UNLABELLED Home enteral nutrition (HEN for short) allows practically normal living for patients who cannot be fed orally but at the same time do not have to stay in hospitals, which is often found to decrease their mental condition, increase of probability of complications and costs of medical treatment. The aim of the study was to analyze the frequency of nutritional, mechanical and septic complications in patients fed enterally in home conditions. MATERIAL AND METHODS The study performed using retrospective analysis of study results and reports from control visits for patients in the period between 2012-2013. 147 patients fed enterally using HEN method participated in the study, including 70 men and 77 women aged 19 to 99 years (average 65 years). The following type of gastrointestinal tract access was used for patients: PEG in 113 (76.5%), feeding jejunostomy - 21 (1.4%), PEG-PEJ - 5 (3.5%), in case of the remaining 8 patients the nasogastric gavage (5.5%) was used. RESULTS The most common complication were infections (of gastric tract, skin soft tissue in the region of nutritional fistula entry, in three cases the aspiration pneumonia was diagnosed) found in 55 (49.1%) of cases. Mechanical complications were found out in 29 (25.9% of all complications), nutritional complications were present 28 times, which constituted 25% of all complications. CONCLUSIONS In the studied group of patients with an implemented HEN procedure, septic complications were the most common problem. The longest average nutrition time with PEG-PEJ probably results from the effective protection of the patient against aspiration pneumonia.

Liver Disease in Patients Qualified for Home Parenteral Nutrition – A Consequence of a Failure to Adjust Rtu Bags in the Primary Centre?

UNLABELLED If planned improperly, parenteral nutrition may result in a number of severe metabolic complications caused by insufficient or excessive delivery of individual nutrients. One of the most common and the most dangerous complication is parenteral nutrition-associated liver disease (PNALD). Such a complication may also result from using RTU (ready-to-use) bags that are not adjusted adequately to individual patients. The aim of the study was the analysis of prevalence and determining the cause of liver disease in patients who had been receiving parenteral nutrition in primary centres prior to the implementation of home parenteral nutrition in the specialist centre. MATERIAL AND METHODS The study enrolled 146 patients who were referred to the Clinic in the period of 2006-2012 in order to be qualified for home parenteral nutrition. Interview and medical documentation revealed that 100 patients had been receiving parenteral nutrition by means of ready-to-use (RTU) bags in their primary centres. In the remaining 46 patients, such feeding had not been implemented. Upon admission, the following parameters were evaluated: bilirubin, aspartate aminotransferase (AspAT), alanine aminotransferase (AlAT), lactate dehydrogenase (LDH), gamma-glutamyltranspeptidase (GGTP), alkaline phosphatase (AP), triglycerides (TG), cholesterol, protein, albumins, amylase, urea, creatinine and C-reactive protein (CRP). The analysis of the results was conducted with the use of the Students T-test. RESULTS The patients who had been receiving parenteral nutrition manifested significantly increased (p < 0.05) levels of total bilirubin, TG, AlAT, LDH, GGTP, AP and CRP. 23% of patients were diagnosed with jaundice, in 70%, GGTP > 100 i.u. and a half manifested biochemical features of cholestasis. No correlation was observed between the CRP level and results of liver function tests. CONCLUSIONS It was found that there is a correlation between parenteral nutrition with RTU bags and liver disease. The probable cause of liver disease associated with parenteral nutrition received prior to the transfer to the Clinic is excessive administration of lipids. It can be accompanied by excessive administration of glucose. Modification of parenteral nutrition helped to compensate for liver disorders in all patients.

The Efficacy of Alcohol-Antibiotic Lock Therapy for Treatment of Catheter Related Bloodstream Infections in Patients Receiving Home Parenteral Nutrition

UNLABELLED In patients with chronic gastrointestinal tract failure, requiring access to the venous system, the subsequent catheter re-insertion are leading to large veins thrombosis impeding or preventing the insertion of another catheter and exposing patients to the risk of complications. Understanding the pathophysiology of catheter-related infections, enabled to use methods allowing to eradicate the source of infection without removal and replacement of central catheter with a new one. In our center, for many years we have been using an alternative method involving implementation of the alcohol-antibiotic lock in the treatment of infections. This method is based on the assumption that the destruction of biofilm with concentrated alcohol will enable antibiotic penetration and killing other microorganisms. Treatment with alcohol-antibiotic lock lasts from 8 to 10 days and involves filling the catheter with 96% alcohol followed by a solution of the antibiotic of high concentration. The aim of the study was to evaluate the efficacy of treatment of catheter-related bloodstream infections with two methods (catheter replacement with a new one and the alcohol-antibiotic lock therapy) in patients receiving home parenteral nutrition (HPN). MATERIAL AND METHODS 428 HPN in the period from 1 January 2005 to 31 December 2010. Among which 240 (56%) of women with an average age of 56.5 ± 16 years and 188 (44%) of men with an average age of 54 ± 17 years. The indications to HPN were as follows: short bowel syndrome in 298 (70%) patients, multilevel obstruction of the gastrointestinal tract in 52 (12%), postoperative gastrointestinal fistulas in 48 (11.2%), malabsorption syndrome in 17 (4%), motility disorders in 6, cachexia in 4 and radiation enteritis in 3 patients. RESULTS In 247 (57.5%) from 428 patients, no episode of catheter-related bloodstream infection was found, while 181 were diagnosed with 352 episodes of catheter-related bloodstream infections. In 40 (9.4%) from 428 patients, 168 (47.8%) episodes have been found - almost a half. The mean duration of treatment of patients receiving home parenteral nutrition, starting from the first episode of catheter-related bloodstream infection, in 48 patients treated with the lock was equal to 1053+748 days, and in 133 patients treated with catheter replacement was equal to 952+709 days (t-test p = 0.62). CONCLUSIONS The survival time of patients treated with alcohol-antibiotic lock is the same as in patients treated with the catheter removal and insertion of the new one. The use of alcohol-antibiotic lock to treat catheter-related bloodstream infections in order to eradicate selected microorganisms that colonize the lumen and cause an infection, is as effective as catheter replacement with a new one.

PP194-SUN MODIFIED FEMORAL VEIN ACCESS FOR LONG TERM HOME PARENTERAL NUTRITION (HPN)

Rationale: The use of the femoral vein for parenteral nutrition (PN) is relatively contraindicated, because of common believe it’s associated with a high risk of contamination at the exit site at the groin, leading to sepsis and a high risk of venous thrombosis. When veins of upper part of the body became occluded, the femoral access is the first choice for long term PN, but such situation is now recognised as indication for intestinal transplantation 1. The method of tunnelization of Broviac’s catheter introduced through saphenous vein has been described with tunnel exit opening directed up 2. However, this could predispose to exit site infection. The aim was to evaluate safety of modified femoral venous access for HPN. Methods: 20 from 962 HPN patients suffered from intestinal failure presented complete occlusion of upper vena cava on admission (n = 8) or during HPN (n =12 ), confirmed by phlebography and / or CT scan ( Fig 1-3) . 6,6 F Broviac catheter tunnelized to abdominal wall up for over 15-20 cm and then reversed, putting the cuff 5 cm down and exit site 2 cm lower, was inserted under fluoroscopy through femoral vein into right atrium (Fig 4-10) . Exit site infection and central catheter related blood stream infection (CRBSI) rate was retrospectively analysed and compared with observed in the same patients when tunnelised upper vein access was used before occlusion of upper veins or after theirs recanalization. Results: HPN was provided for total of 31 206 days through femoral and 20422 days through subclavian or jugular vein. Infectious complications are presented in table 1. Thrombosis of both femoral veins has occurred in 2 patients, upper veins recanalised after 3-12 years in 4 patients. Three catheters were or are used for 9, 9 and 14 years.

PP195-MON PEG-PEJ PREVENTS ASPIRATION PNEUMONIA AND INCREASES SURVIVAL IN HEN PATIENTS WITH DYSPHAGIA

Rationale: Percutaneous endoscopic gastrostomy (PEG) is the most popular access for long-term home enteral nutrition (HEN) in patients with neurological dysphagia and cancer stenosis of upper gastrointestinal tract. Although HEN is believed safe, it is associated with unexpected high mortality. Aspiration of saliva or food, resulting in aspiration pneumonia is one of the most serious complication of HEN. Coexisting gastro-esophageal reflux disease (GERD) and delayed gastric empting play a crucial role in the pathogenesis of vomiting and aspiration, causing sudden death. Aim was to evaluate survival and occurrence of aspiration pneumonia in HEN patients, in whom PEG has been replaced by jejunal extension (PEG-PEJ).