Peripherally inserted central catheters for parenteral nutrition: a comparison with centrally inserted catheters

BACKGROUND: Central venous access is crucial for the provision of adequate parenteral nutrition (PN). The type of central venous access device (CVAD) has evolved over the past 10 years. The most recent trend has been to use peripherally inserted central catheters (PICCs). This development has occurred without controlled clinical trials. METHODS: Over a 10-year period, the nutrition support service at a single institution has prospectively collected data on CVADs used for providing PN. The types of CVAD used for providing PN were analyzed, and the major complications associated with CVADs, thrombosis and line sepsis, were compared over three different time periods: 1988-1989; 1992-1993; 1996-1997. In addition, complications associated with PICCs were compared with other CVADs. RESULTS: The following were the dominant CVADs over each of the three time periods: 1988-1989: tunneled catheters, 80%; 1992-1993: nontunneled catheters, 46%; and 1996-1997: PICCs, 48%. There was a decreased incidence of sepsis and pneumothorax in 1996-1997 and an increase in severed or leaking catheters and phlebitis. In a comparison of PICC and non-PICC catheters over the past 3 years, there was a trend toward decreasing sepsis with PICC catheters but an increase in malposition, inadvertent removal, and severed or leaking catheters. CONCLUSIONS: PICCs have replaced tunneled and nontunneled central catheters as the most commonly used CVAD for providing PN. PICCs do not result in increased line sepsis or thrombosis but have an increased incidence of local complications such as leaking catheters, phlebitis, and malposition.     

Anti-infective-treated central venous catheters for total parenteral nutrition or chemotherapy: a systematic review

This systematic review assesses the effect of anti-infective-treated central venous catheters (CVCs) on catheter-related bloodstream infection (CRBSI) in patients who received a CVC for total parenteral nutrition (TPN) or chemotherapy. Randomised controlled trials were retrieved from Medline and the Cochrane Library up to 14 October 2007. Two reviewers independently assessed trial quality and extracted data. Data for CRBSI were combined where appropriate, using a random effects model, and subgroup meta-analysis was carried out where applicable. The impact of the risk for CRBSI in the control group on the effect of anti-infective CVCs was studied by using meta-regression based on the bivariate meta-analysis model. Nine trials were included in the review. One trial showed that antibiotic-treated CVCs reduced the risk for CRBSI in outpatients with chemotherapy and a CVC in-situ during a period of about nine weeks. Eight trials did not find an overall significant benefit in favour of antiseptic-treated CVCs in patients who had a CVC during a mean of about two weeks. No relationship could be established between the effect of anti-infective-treated CVCs and the underlying risk for CRBSI, although nearly all trials had serious methodological shortcomings. Thus, available scientific evidence to prevent CRBSI by the use of anti-infective-treated CVCs in patients receiving chemotherapy or TPN is not sufficient as a basis to recommend their use. The recommendation of the Centers for Disease Control and Prevention to use antibiotic- or antiseptic-impregnated CVCs, when the risk for CRBSI remains high despite good hygienic practice, should therefore be limited to patients in the intensive care/perioperative setting.     

The routine microbiological screening of central venous catheters in home parenteral nutrition patients

BACKGROUND & AIMS: Catheter-related bloodstream infection (CRBSI) is a major complication for patients receiving home parenteral nutrition (HTPN). Endoluminal sampling techniques allow the diagnosis of CRBSI without catheter removal and may allow the screening of asymptomatic patients. METHODS: Over a 5-year period, patients receiving HTPN were offered screening on a 3 monthly basis. All patients had tunnelled cuffed Hickman lines. All were asymptomatic at the time of screening, which took the form of either endoluminal brushing or quantitative cultures on through-line blood. RESULTS: Thirty-two patients were suitable for inclusion within the study period (10 male, median age 51 (iqr 46-61)) years with 30 of these having a least one screening performed. Four had positive screening results and underwent appropriate treatment. Of the remainder, 12 presented with at least one clinical episode of CRBSI and 14 had neither clinical CRBSI nor a positive screening result. The combined clinical and screening CRBSI rate was 0.39 episodes per catheter year. CONCLUSION: Although routine microbiological catheter screening can detect subclinical infections in HTPN patients the positive rate is low with the majority of patients still presenting clinical. Identification of higher risk patients and appropriate alterations to screening frequency may improve its value further.     

Complications associated with central venous catheters inserted in critically ill neonates

OBJECTIVE: To assess the incidence and spectrum of complications associated with central venous catheter (CVC) placement in the critically ill infant. DESIGN: A prospective study of all babies hospitalized in a neonatal intensive care unit (NICU) from January 1989 to December 1989. Potential risk factors associated with infection were evaluated by a case-control comparison. SETTING: Conducted at a university-affiliated, tertiary care community hospital. PATIENTS: Neonates requiring intensive care and a central venous catheter. Controls consisted of noninfected babies. RESULTS: Of 263 critically ill neonates, only 13 (4.9%) required a CVC insertion. Seventeen CVCs were placed in these 13 neonates for a total duration of 600 days (median, 32 days/cannula). Fifteen (88%) of these cannulas had one or more complications during its catheter life including dislodgement or leakage (53%), occlusion or thrombosis (47%), infections (29%), or minor bleeding (12%). Five babies (29%) developed 6 episodes of bloodstream infection including 3 sporadic cases due to Staphylococcus epidermidis and a cluster of fungemia due to Malassezia furfur associated with lipid emulsion therapy. Infants with a CVC-associated infection were a younger gestational age (24 weeks versus 32 weeks, p = .04) and weighed less at birth (580 g versus 1285 g, p = .02). The overall rate of bloodstream infection was one episode per 100 days of catheter use. CONCLUSIONS: CVCs may be lifesaving to a critically ill neonate, but complications occur frequently. Use must be restricted to infants in whom alternate delivery routes of intravenous therapy or support are otherwise unavailable.     

肠外、肠内营养支持的并发症及其管理与平衡监测

一、肠外、肠内营养支持的主要并发症1．机械性并发症：肠内、肠外营养置管失败、异位、阻塞、机械性损伤等。2．感染性并发症：营养制剂及配制、输入系统的污染，肠外营养导管感染、内源性感染，肠内营养误吸性肺炎等。     

Factors associated to hypermanganesemia in patients receiving home parenteral nutrition

BACKGROUND: Home parenteral nutrition (HPN) patients often present hypermanganesamia. AIM: To examine which factors may be associated to hypermanganesemia in HPN patients. METHODS: Plasma manganese (Mn), liver function tests, C-reactive protein concentrations, erythrocyte sedimentation rate (ESR), tumor necrosis factor-alpha (TNF- alpha), interleukin-6, soluble receptors of interleukin-2, and blood neopterin concentrations were determined in 21 HPN patients and 10 healthy controls. Brain magnetic resonance imaging (MRI) and careful neurologic clinical examination were performed in 11 patients. RESULTS: Mn concentration was higher in HPN patients than controls (1.96+/-1.1 vs 0.81+/- 0.4 microg/L;P<0.001) and positively correlated to the amount of parenteral nutrition (PN) supply, transaminases and alkaline phosphatase (r=0.53, P<0.0001) concentrations, as well as to ESR (r=0.61, P<0.0001), TNF- alpha and blood neopterin. The amount of calories provided by PN was positively correlated to inflammatory markers and liver parameters. All patients investigated by MRI showed hyperintense basal ganglia on T1-weighted images suggesting brain Mn deposition. Only one had slight clinical extrapyramidal symptoms. CONCLUSION: In HPN patients, sustained inflammation may facilitate hypermanganesemia through 1. cholestatic liver disease and thereby decreased Mn biliary excretion, 2. high nutritional requirements (responsible for increased Mn supply), and/or 3. modified Mn metabolism or body distribution. Neurologic complications appeared marginal whereas Mn brain deposition seems frequent.     

Local antibiotic lock for the treatment of infections related to central catheters in parenteral nutrition in children

BACKGROUND: Central venous catheter-related (CVC) infections represent the most common complication of parenteral nutrition. These infections are usually treated by means of long-term systemic antibiotic treatment. The objective of this study was to determine the efficacy of combining a local antibiotic lock with a short systemic double antibiotic to treat CVC-related staphylococci infections. METHODS: Any child with coagulase-negative staphylococci or Staphylococcus aureus septicemia, confirmed by a positive blood culture, was included in the study. A double antibiotic systemic treatment composed of amikacin and teicoplanin was started and continued for 5 days. The antibiotic treatment was combined from the first day (D0) with a local teicoplanin lock, which was left for 12 hours a day in the catheter for 15 days. Parenteral nutrition was continued on a nocturnal cyclic mode during antibiotic treatment. The efficacy of the treatment was evaluated by clinical (body temperature), biologic [C-reactive protein levels (CRP)], and bacteriologic (blood culture) measures. RESULTS: Twenty CVC-related infection episodes in 13 patients were analyzed for the study. In the initial biologic test, CRP varied from 2 to 130 mg/L (mean 43 mg/L). After 3 days of treatment, CRP varied from 2 to 61 mg/L (mean 12 mg/L). The median time until normalization of temperature and CRP levels after the beginning of antibiotic treatment was 3.2 days (range 1 to 14 days) and 6.2 days (range 2 to 19 days), respectively. All blood cultures were negative for infection 48 hours after stopping the treatment. Only 1 therapeutic failure was observed during the treatment. The patient had persistent signs of clinical septicemia that required removal of the CVC. Two catheter-related infection recurrences were observed in the month after termination of the local antibiotic lock, which also required removal of the CVC. The central venous catheter was maintained in the other cases. CONCLUSIONS: Teicoplanin antibiotic locks, combined with a short conventional systemic antibiotic treatment and continuation of cyclic parenteral nutrition, seem effective and well-tolerated treatments for CVC infections.     

老年肠外营养相关中心静脉导管微生物定植及危险因素分析

目的:研究老年病人肠外营养(PN)相关中心静脉导管(CVC)微生物定植(MC)的发生率和危险因素。方法:回顾性分析我院老年(≥60岁)住院病人。病人均禁食,通过CVC接受PN,拔管后进行导管尖端培养。采集病史资料、导管相关资料(放置部位、留置时间和培养结果)和PN相关指标(使用时间、输注液量、每天提供热量和PN液能量密度)。结果:204例老年病人入选本研究。总置管时间为2 983 d。MC发生率为20.6%(42/204),千导管日发生率为14次/千导管日(42/2 983 d)。Logistic回归分析显示,血清肌酐和前清蛋白水平、PN液能量密度、其他部位存在感染等是PN相关MC的危险因素。最常见的CVC定植微生物为革兰阳性球菌(50.0%),其次为革兰阴性杆菌(33.3%)和真菌(6株,14.3%)。机会致病菌占总微生物数的23.8%(共10株)。结论:血清肌酐水平降低以及输注能量密度较高的PN液,易导致老年病人发生MC。     

Catheter related sepsis during long-term parenteral nutrition in paediatric gastroenterology patients: a study of 185 consecutive central venous catheters

We report the results of a prospective study of catheter-related sepsis (CRS) in 154 gastroenterology paediatric patients treated for medical (n = 102) or surgical (n = 52) disorders. Over 2 years, 185 central venous catheters (CVC) were placed, including 155 Broviac and 30 Jonathan Shaw CVC. CVC remained in place 13,331 days (6,539 days of cyclic parenteral nutrition), with a mean catheter life of 72 days. Forty-eight episodes of CRS occurred, most of them due to coagulase-negative staphylococci (n = 29) and Staphylococcus aureus (n = 17). CRS rate was 0.26, with an overall incidence of 1 infection per 278 days of parenteral nutrition (PN). Factors significantly associated with CRS were: age 1-5 years (p < 0.01), a medical indication for treatment (p < 0.001) and summer months of PN (p < 0.01). Interestingly, CRS occurred predominantly (65%) within the first 2 months following CVC placement and the risk of infection correlated with local haemorrhage at the time of insertion (p < 0.01). Appropriate systemic therapy, without removing the catheter, permitted resolution of 90.9% (40 44 ) of all CRS and 100% (28 28 ) of CRS due to coagulase-negative staphylococci.     

M-mode and two-dimensional echocardiography in the routine follow-up of central venous catheters in children receiving total parenteral nutrition

A retrospective study in 38 children (1 day to 7 years) on total parenteral nutrition (TPN) (1 month-24 months) with a central venous catheter (CVC) evaluated the contribution of two-dimensional echocardiography (2D) and M-mode in the follow-up of CVC location and early diagnosis of related complications. Fifty examinations were performed routinely in 21 patients (group I) and 40 in 17 patients for sepsis of the CVC or clinical suspicion of thrombosis (group II). The tip of the CVC was located in the upper right atrium in 17 cases (45%), superior vena cava in 14 cases (37%), jugular or subclavian vein in 5 cases (13%), and was not visualized in 2 cases (15%). In group I, 2D was normal in 19 cases, and catheter thrombosis suspected in 2 was not confirmed by digital angiography (DA). In group II, 2D was normal in 11 cases. In 6 patients, subxiphoid and suprasternal planes identified superior vena cava thrombus in the right atrium (DA confirmed the diagnosis in 2). In 2 pulmonary embolism occurred (1 case died); the remaining patients were successfully treated by medical therapy and removal of the catheter. Echocardiography is a useful noninvasive technique to control CVC tip location and follow-up. In this study, the sensitivity of cardiac thrombus detection by echocardiography was 100% and the specificity 93%; this method appeared, therefore, appropriate for early detection of cardiac thrombosis in pediatric patients on TPN.     

早期全肠外营养及肠内、外混合营养对神经外科危重患者免疫功能的影响

目的探讨早期给予全肠外营养（TPN）及肠内营养（EN）、肠外营养（PN）混合支持对神经外科危重患者免疫功能的影响。方法采用前瞻性对照研究将神经外科危重患者按入院顺序随机分为TPN组及EN＋PN组,并对比营养支持前后两组CD3、CD4、CD8、CD4／CD8、CD3／CD25、IgA、IgG、IgM、血清白蛋白的变化。结果给予神经外科危重患者两种营养支持均可提高其CD3、CD4、CD8及CD3＋／CD25＋比值（P〈0．05,P〈0．01）;两种营养支持方式均可显著升高IgA、IgG、IgM、（P〈0．05）及血清白蛋白浓度（P〈0．01）。与TPN组比较,EN＋PN组CD3、CD4、CD8、CD4／CD8比值、IgA、IgG、IgM浓度及血清白蛋白水平均显著升高（P〈0．05,P〈0．01）。结论早期TPN及EN＋PN支持均可促进神经外科危重患者免疫功能的恢复及提高,EN＋PN的作用优于TPN,对于神经外科危重患者应早期给予营养支持治疗。     

全胃肠外营养患者中心静脉导管相关性感染的危险因素

目的 研究全胃肠外营养患者(TPN)中心静脉导管相关性感染(CVC-RI)的危险因素,为安全有效的临床治疗提供科学依据.方法 选取医院2010年1-12月45例经TPN治疗住院患者,选取经TPN治疗患者中发生中心静脉导管相关性感染者为感染组;无感染者为对照组;对其进行logistic回归性分析.结果 选取的45例经TPN治疗患者中发生中心静脉导管相关性感染7例,总发生率为15.56％;单因素分析显示,感染组和对照组在年龄、TPN治疗时间、置管时间、置管类型、免疫抑制剂使用和是否入住ICU治疗的比较差异有统计学意义(P＜0.05);根据多因素logistic回归分析,经TPN治疗患者出现CVC-RI的危险因素主要为年龄、TPN治疗时间、置管时间、置管类型、是否入住ICU治疗;其中年龄≥60岁占85.71％,TPN治疗时间≥5d占71.43％,置管时间≥4周占71.43％,使用三通管占71.43％,ICU治疗占71.43％.结论 通过了解经TPN治疗患者中心静脉导管相关性感染因素,有利于医护人员对患者做出更加针对性的治疗,以减少患者感染的风险.     

Liver dysfunction associated with long-term total parenteral nutrition in patients with massive bowel resection

Sixteen patients with massive bowel resection receiving long-term home total parenteral nutrition (HTPN) for 31 to 145 months were reviewed for evidence of liver disease. Patients were divided into three groups: group 1 with duodenocolostomy (n = 3), group 2 with an estimated 15-43 cm residual small bowel (n = 7), and group 3 with an estimated 55-120 cm residual small bowel (n = 6). Two patients in group 1 developed liver cirrhosis; one was diabetic and died of sepsis and liver failure at the 88th month on HTPN; the other died of lung cancer at the 46th month on HTPN. The third patient, followed for 33 months, had transient severe liver function abnormalities associated with a blood transfusion. In groups 2 and 3, only one patient (with a history of probable liver disease before HTPN) developed biopsy-proven cirrhosis at the 60th month of HTPN. All four patients with clinically apparent liver disease developed persistent elevation of serum aspartate aminotransferase (AST) early in HTPN. Four other patients (all in group 3) with abnormal AST values in the early phase of HTPN normalized them later; they did not develop clinical liver disease over a mean follow-up time of 110 months (range, 39-152). None of the remaining eight patients (seven in group 2 and one in group 3) had significant liver function test abnormalities and none developed clinical liver disease over a mean follow-up period of 72 months (range, 39-120).(ABSTRACT TRUNCATED AT 250 WORDS)     

肠外营养并发症的发生及防治

PN广泛应用于临床取得了较好的疗效,挽救了部分危重病人,并发症也较早期明显减少。但近几年来,随着各种技术和产品的成熟,认识到肠外营养有其不足之处,如用肠外营养要求医护人员增强防护意识、加强预防就能避免发生这些并发症。     

Relationship between iron deficiency and cholestasis associated with parenteral nutrition

In a study of 22 patients receiving total parenteral nutrition (TPN), we found that iron-deficient patients were less likely to develop cholestasis than patients with normal iron stores. The mean and S.D. of serum iron, total iron binding capacity and percent saturation in the 12 patients developing cholestasis were 12.7 +/- 5.2 micromol/L, 37.1 +/- 8.5 micromol/L and 37 +/- 24% whereas in the 10 patients who did not develop cholestasis, the values were 7.3 +/- 3.6 micromol/L, 54.8 +/- 17.9 micromol/L and 14 +/- 7% respectively. All differences were statistically significant. The relationship between iron stores and TPN-associated cholestasis deserves further study.     

Sinus bradycardia associated with peripheral lipids and total parenteral nutrition

This case report describes a 23-yr-old woman with Crohn's disease who developed sinus bradycardia 4 hr after initiation of total parenteral nutrition with lipids through a peripheral vein. The bradycardia persisted for 1 wk, with only slight improvement when the lipids were held for two 4-hr periods. The heart rate began to improve when lipids were changed from 10 to 20%, and continued to rise after Synthroid was started. The possible relationships between nutritional and thyroid status, as well as lipids and heart rate are discussed.