Robert DeChicco

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.

Tip Position of Long-Term Central Venous Access Devices Used for Parenteral Nutrition

BACKGROUND Venous thrombosis is a potential postplacement complication of a central venous access device (VAD). Improper catheter tip position is a predisposing factor, especially when the device is used to administer parenteral nutrition (PN). American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) guidelines recommend that a central VAD used for PN be placed with its tip in the superior vena cava (SVC) adjacent to the right atrium (RA). The purpose of this study is to determine the prevalence of improper central VAD tip position and factors associated with malpositioning. METHODS All adult patients with a longterm VAD (ie, tunneled central venous catheter, peripherally inserted central catheter [PICC], or implanted port) placed before the current admission who were scheduled to receive PN also received chest x-rays to evaluate position of the catheter tip. Position was determined by a staff radiologist. A catheter with its tip ranging from the middle third of the SVC to the RA was considered acceptable; a catheter with its tip in any other position was considered malpositioned. Subjects with multiple VADs or multiple evaluations for the same catheter had the first placement and last evaluation considered. A logistic regression analysis was used to study the univariable and multivariable associations of these factors with tip malposition. RESULTS Data were collected for catheters in 124 patients, including 74 tunneled catheters (71 Hickman, 2 Broviac, 1 Groshong), 38 PICCs, and implanted ports. Most of the catheters were placed for (81.9%) or chemotherapy (14.5%). Median catheter duration was 1.6 months at time of evaluation. Of 138 catheters studied, 15.9% (95% confidence interval, 10.2-23.1) were malpositioned at time of evaluation. According to univariable analysis, factors associated with malpositioned catheters included shorter catheter duration (p = .001), greater number of lumens (p = .029), venous entry site on the arm (p <.001) and catheters placed at institutions other than Cleveland Clinic (p = .007). Additionally, PICCs were likely to be malpositioned at time of evaluation compared with other long-term VADs combined (34.2% vs 9.0%; p < .001). CONCLUSIONS A high percentage of long-term VADs improperly positioned for PN in the present study. were more likely to be malpositioned at time of evaluation compared with tunneled catheters and implanted These findings suggest the tip position of long-term should be confirmed before infusing PN.

Fish oil-based lipid emulsion: current updates on a promising novel therapy for the management of parenteral nutrition-associated liver disease.

Intestinal failure is characterized by loss of enteral function to absorb necessary nutrients and water to sustain life. Parenteral nutrition (PN) is a lifesaving therapeutic modality for patients with intestinal failure. Lifelong PN is also needed for patients who have short bowel syndrome due to extensive resection or a dysmotility disorder with malabsorption. However, prolonged PN is associated with short-term and long-term complications. Parenteral nutrition-associated liver disease (PNALD) is one of the long-term complications associated with the use of an intravenous lipid emulsion to prevent essential fatty acid deficiency in these patients. PNALD affects 30–60% of the adult population on long-term PN. Further, PNALD is one of the indications for isolated liver or combined liver and intestinal transplantation. There is no consensus on how to manage PNALD, but fish oil-based lipid emulsion (FOBLE) has been suggested to play an important role both in its prevention and reversal. There is significant improvement in liver function in those who received FOBLE as lipid supplement compared with those who received soy-based lipid emulsion. Studies have also demonstrated that FOBLE reverses hepatic steatosis and reduces markers of inflammation in patients on long-term PN. Future prospective studies with larger sample sizes are needed to further strengthen the positive role of FOBLE in PNALD.

Type and prevalence of adverse events during the parenteral nutrition cycling process in patients being prepared for discharge.

BACKGROUND The mechanism for cycling parenteral nutrition (PN) varies from institution to institution. However, the types and frequency of adverse events (AEs) involved with this process are not well understood. PURPOSE To determine the type and prevalence of AE in patients during PN cycling and identify factors associated with the occurrence of AEs. METHODS Patients without severe organ dysfunction or uncontrolled diabetes mellitus scheduled to be discharged on cyclic PN with a goal of 12 hours were eligible. Patients were cycled from 24 to 12 hours over 2 or 3 days based on previously established criteria. Demographic, nutrition, and monitoring data were collected. AEs were documented and graded as mild or serious. RESULTS Mild AEs occurred in 35 of 38 patients (92.1%) consisting primarily of mild hyperglycemia (86.8%) and tachycardia (29.0%). Serious AEs occurred in 8 of 38 patients (21.1%), including 7 patients (18.4%) with capillary blood glucoses between 255 and 324 mg/dL and 1 (2.6%) with tachypnea/tachycardia requiring immediate medical attention. No significant associations were made between demographic, medical, nutrition, or laboratory factors and serious AEs. No significant differences in demographic information, nutrition information, comorbidities, diet, medications, or composition of PN were found except for lower body weight in unsuccessful cyclers compared with successful cyclers (P = .042). CONCLUSIONS Most patients incur AEs during PN cycling, primarily mild hyperglycemia and tachycardia. These findings suggest patients need to be monitored closely and treated aggressively for complications during PN cycling.

Developing an Education Program for Nutrition Support Teams

Focused training and continuing medical education are necessary for nutrition support clinicians to acquire new skills, maintain competence, and keep abreast of advancements in the field. Unfortunately, there is a lack of physician-nutrition specialists to act as teachers and role models. One solution is to have members of a multidisciplinary nutrition support team, regardless of discipline, share their expertise with others. This is best accomplished within the framework of a formal education program that can accommodate the knowledge and skill level of each instructor and educational goals of each student. Developing an education program should include the following steps: formulate general goals of the program, specify learning objectives, assess each students current level of knowledge and educational goals, determine educational strategies and learning activities that will best meet the goals of each student and the program, and devise a method to evaluate the performance of each student and the program as a whole.

Contribution of Calories from Propofol to Total Energy Intake

Abstract Propofol is a lipid-soluble, short-acting IV hypnotic/sedative administered continuously to provide sedation in mechanically ventilated ICU patients. Propofol is available in an emulsion similar in composition to a 10% parenteral lipid emulsion which provides 1.1kcals/mL as fat. Therefore, administration of propofol also provides calories from lipid. These calories are often ignored as a part of total energy intake which may result in overfeeding in patients concurrently receiving nutrition support (NS). Mechanically ventilated ICU patients receiving continuous infusions of propofol and NS in the form of total parenteral nutrition (TPN) or tube feedings (TF) for a minimum of 48 hours were surveyed to determine calorie intake from propofol. Total energy expenditure (TEE) was estimated by multiplying basal energy expenditure as determined by the Harris-Benedict equation by a factor of 1.5. Patients were followed for seven days or until NS or propofol was discontinued or the patient expired. Nineteen patients, 13 male and 6 female, were surveyed. Mean TEE was estimated at 2273kcals/day (range 1550–3375). Propofol provided an average 215kcals/day (range 79–535) which comprised 9.5% (range 3.4–24.9) of TEE. On average, the contribution of calories from propofol is probably not clinically significant. However, the amount of propofol administered to individual patients can be substantial. In one patient, propofol contributed an average of 535kcals/day (25% of TEE) . Theoretically, this amount of surplus calories can result in overfeeding in patients where NS is already providing 100% of TEE. Therefore, calories from the administration of propofol should be considered as part of total energy intake in mechanically ventilated ICU patients receiving NS.

Expediting Transition to Home Parenteral Nutrition With Fast-Track Cycling

Background. Delivery of home parenteral nutrition (PN) is typically cycled over 12 hours. Discharge to home on PN is often delayed due to potential adverse events (AEs) associated with cycling PN. The purpose was to determine whether patients requiring long-term PN can be cycled from 24 hours to 12 hours in 1 day instead of 2 days without increasing the risk of PN-related AEs. Methods. Hospitalized patients receiving PN at goal calories infused over 24 hours without severe electrolyte or blood glucose abnormalities were eligible. Patients were randomly assigned to a 1-step “fast-track” protocol or 2-step “standard” protocol. AEs were defined as hypoglycemia or hyperglycemia, new-onset or worsening dyspnea, tachycardia, tachypnea, lower extremity or sacral edema, pulmonary edema, or abdominal ascites and were graded as minor or major. Results. In the 63 patients studied, the most prevalent PN-related AE was hyperglycemia, occurring in 24.2% and 30.0% of patients in the fast-track and standard groups, respectively. Overall, there was no significant difference in the prevalence of PN-related minor AEs between fast-track and standard groups (33.3% and 53.3%, P = .5). No major PN-related AEs occurred in the fast-track group, while 1 major PN-related AE (pulmonary edema) occurred in the standard group. Conclusions. Fast-track cycling is as safe as standard cycling in patients without diabetes mellitus or major organ dysfunction requiring long-term PN. Fast-track cycling could potentially expedite hospital discharge, resulting in decreased healthcare costs and improved patient satisfaction.

Selection of Nutrition Support Regimens

The selection of a nutrition support regimen should be the product of a logical, stepwise process. After an appropriate candidate is selected, the integrity and function of the gastrointestinal tract must be assessed to determine if nutrients can be administered enterally or must be given by vein. The anticipated length of therapy will help determine the type of feeding access. Long-term nutrition support requires permanent access, such as a percutaneously or surgically placed feeding tube for enteral nutrition or a tunnelled catheter or implanted port for parenteral nutrition. Formula selection for enteral nutrition, providing adequate liver and renal function, depends largely on the patients ability to assimilate intact nutrients. The primary decision in parenteral formula selection is whether to provide the macronutrients as a mixed fuel system. The ultimate goal of nutrition support is to make a smooth transition to oral feedings while maintaining adequate nutritional intake.

Thirty-Day Readmission Rate Is High for Hospitalized Patients Discharged With Home Parenteral Nutrition or Intravenous Fluids

Background: Reducing hospital readmissions decreases healthcare costs and improves quality of care. There are no published studies examining the rate of, and risk factors for, 30-day readmissions for patients discharged with home parenteral support (HPS). Objective: Determine the rate of 30-day readmissions for patients discharged with HPS and whether malnutrition and other demographic or clinical factors increase the risk. Materials and Methods: Retrospective review of patients discharged with HPS from the Cleveland Clinic between July 1, 2013, and June 30, 2014, and followed by the Cleveland Clinic Home Nutrition Support Service. Results: Of the 224 patients studied, 31.6% (n = 71) had unplanned readmissions within 30 days of hospital discharge. Of these, 21.1% (n = 15) were HPS related, with catheter-related bloodstream infection (n = 5) and dehydration (n = 5) the most common. The majority of patients (84.4%) were diagnosed with malnutrition, but the presence or degree did not influence the readmission rate (P = .41). According to univariable analysis, patients with an ostomy (P = .037), a small bowel resection (P = .002), a higher HPS volume at discharge (P < .001), and a shorter period between HPS consult and hospital discharge (P < .026) had a lower risk of 30-day readmission than their counterparts. On multivariable analysis, patients had a higher risk of 30-day readmission if they had a history of heart disease (P = .048) and for every 1-unit increase in white blood cells (P = .026). Conclusions: Patients discharged with HPS have a high 30-day readmission rate, although most readmissions were not related to the HPS itself. The presence and degree of malnutrition were not associated with 30-day readmissions.

Comparison Between Handgrip Dynamometry and Manual Muscle Testing Performed by Registered Dietitians in Measuring Muscle Strength and Function of Hospitalized Patients

BACKGROUND The Academy of Nutrition and Dietetics and American Society the Parenteral and Enteral Nutrition (ASPEN) Consensus Statement recommends a standardized set of diagnostic characteristics to identify adult malnutrition. Due to lack of a consensus definition and challenges with measurements, physical function or performance has traditionally been difficult to assess. The purpose of this study was to determine whether manual muscle testing (MMT) performed by registered dietitians (RDs) can be used as a surrogate measurement of muscle strength and function in hospitalized patients. METHOD Patients admitted to the heart failure service on the cardiac stepdown units at the Cleveland Clinic Main Campus in Cleveland, Ohio, were eligible for the study, and those who met the inclusion criteria underwent handgrip strength (HGS) testing and evaluation of nutrition status using the Academy/ASPEN Characteristics Recommended for the Identification of Adult Malnutrition. MMT was then performed within 24 hours by a different study investigator blinded to the HGS and malnutrition assessment results. RESULTS It was found that HGS and MMT overall were in agreement for 84% of patients and that MMT had a high sensitivity (98%) but low specificity (13%). CONCLUSION This study shows feasibility for RDs to perform MMT on patients to determine muscle strength and functioning. Future practice application may be to incorporate MMT into screening criteria for patients being evaluated for malnutrition and reserve HGS testing only for patients with an abnormal MMT.