Hospital Infection Control

Nutrition services and total parenteral nutrition

Nutrition services and total parenteral nutrition

How do nutrition services and total parenteral nutrition impact infection control?

Below are some of the definitions and abbreviations used in this chapter:

  • CRBSI = Catheter related blood stream infection – a systemic infection involving the catheter

  • CVAD = Central venous access device– a catheter whose tip optimally lies in the lower third of the superior vena cava adjacent to the right atrium

  • EN = Enteral nutrition – refers to any method of feeding that utilizes the gastrointestinal tract including oral intake, use of supplements and more commonly used as a term that may imply the use of a feeding tube to deliver food, blenderized or commercially obtained products to feed an individual

  • NS = Nutrition support - refers to the delivery of nutrients by enteral feeding tube or via a catheter for parenteral nutrition

  • PEG = Percutaneous endoscopic gastrostomy – a tube placed via endoscopy (an alternative to a surgically placed feeding tube) into the stomach to establish long-term access for tube feeds

  • PICC = Peripherally inserted central catheter – a catheter inserted peripherally (usually in the basilic, brachial, or cephalic veins) and advanced centrally into the superior vena cava

  • PN = Parenteral nutrition – (or central vein nutrition) refers to nutrition support that is delivered via a catheter tip that optimally lies in the lower third of the superior vena cava adjacent to the right atrium - this allows highly osmolar solutions optimal mixing due to turbulent blood flow - this decreases the risk of venous thrombosis related to PN therapy

  • PPN = Peripheral parenteral nutrition – utilizes a small peripheral vein and is usually used short term - the incidence of chemical phlebitis or catheter infection rises with the number of days the intravenous (IV) catheter is in the same place.

  • TPN = Total parenteral nutrition – an older term that relates to providing all of the elements of nutrition by vein that would supply the proper nutrients for growth, development, and tissue health for weight maintenance, loss or gain, as appropriate.

How do the contributions of nutrition support and enteral and/or parenteral nutrition impact infection control currently?

Enteral nutrition (EN)

Nutrition support and enteral nutrition can impact infection control in multiple ways. Access to the GI tract can be obtained by several techniques that increase the risk and possibility of morbidity associated with it. Below lists the common ways to access the GI tract.

  • Nasoenteric (nasogastric, nasoduodenal, and nasojejunal)

  • Oroenteric (orogastric, oroduodenal, and orojejunal)

  • Pharyngostomy (cervical or esophagostomy) – rarely preformed

  • Gastrostomy (endoscopically, radiologically, or surgically placed)

  • Jejunostomy (endoscopically, radiologically, or surgically placed)

One of the most commonly performed procedures in medicine is placement of a tube nasally that enters into the GI tract for a number of purposes, but often for a route of feeding. A common source of infection can come from the presence of a tube adjacent to delicate nasal structures. This can lead to sinusitis and in those patients who are asymptomatic nasal carriers of Methicillin Resistant Staphylococcus aureus (MRSA); it could potentially lead to more significant infections.

A frequent cause of infection related to EN is the occurrence of aspiration pneumonia. While it is known that almost everyone aspirates small amounts of material, normal host defenses prevent most individuals from developing pneumonia. However, when normal defenses are overwhelmed, aspiration pneumonia becomes a significant cause of morbidity and mortality, especially in critically ill individuals in the intensive care setting.

When more invasive forms of enteral access are required, placement techniques will depend on local expertise in most instances. Thus, placement of gastrostomy and jejunostomy tubes can be accomplished endoscopically, radiologically or by surgical methods. The use of adequate skin preparation and prophylactic antibiotics has been shown to decrease the risk of insertion site infections.

Parenteral nutrition (PN)

While patients who require PN may have underlying the medical/surgical conditions that may predispose them to an increased risk of infections, the major contributions related to infections from nutrition support are related to infections due to the venous access. Inadequate technique and adherence to infection prevention protocols can lead to both catheter related blood stream infections (CRBSIs) as well as more serious infectious complications such as endocarditis, suppurative thrombophlebitis or osteomyelitis. This increases the morbidity and mortality as well as the cost of care, both for inpatients and outpatients.

Venous access options

  • Peripheral vein access – Peripheral vein catheters, midline, and others

  • Central vein access

    • Short term: Peripherally Inserted Central Catheter (PICC), common in hospital catheters – subclavian, jugular, or femorally placed catheters

    • Long term: Tunneled catheters e.g., Hickman®, Groshong®, Broviac®, Hohn (tunneled and non-disintegrating cuff variety). Implanted ports e.g., Port-a-Cath®, Mediport®.

What elements of nutrition services and total parenteral nutrition are necessary for infection prevention and control?

Enteral nutrition

Keys to reducing problems from enteral nutrition related to nasoenteric feeding would be to use the smallest tube possible that performs the tasks needed and to provide oronasal care to minimize problems while the tubes are in place. Simple concepts such as elevation of the head of the bed and checking for feeding intolerance (elevated gastric residuals) can lessen the potential risks of EN. Also verifying the position of the feeding tube tip can help predict the risk for aspiration that may be related to tube feeding itself.

Prevention of EN associated infectious complications

  • Provision of oronasal care to limit development of sinusitis, bleeding, or pressure necrosis causing further morbidity

  • Selection of the smallest size tube to complete the tasks

  • Verify feeding tube tip location

  • Elevation of the head of the bed to decrease aspiration even in patients who are intubated

Prevention of EN associated infectious complications (long term tube placement)

  • Adequate skin preparation and prophylactic antibiotics prior to gastrostomy or jejunostomy placement

  • Postplacement care to site to decrease the risk of infectious complications

Parenteral nutrition

Regardless of whether the venous access is for short term or long term use and whether it is placed at the bedside or in an operating room, sterile procedure protocol must be followed to minimize the short term, placement related complications. Maximum barrier, sterile technique has been linked to lower complication rates.

Prevention of PN associated infectious complications

  • Selection of catheter type with the fewest number of lumens necessary

  • Prompt removal of the central venous access device (CVAD) upon discontinuation of IV therapy

  • Use of maximal barrier protection and aseptic technique prior to and during insertion of the CVAD

  • Hand hygiene before and after accessing, dressing change, before repair, or any maintenance to the CVAD

  • Education to healthcare workers and patients on care of the CVAD focused on proper technique to prevent infection

  • Limiting manipulation of line for blood draws (coordination of the timing of laboratory studies between multiple clinicians to avoid multiple blood draws during a short time period)

Anecdotal experience of the author (DFK)

  • Patients that are trained to care for the CVAD exclusively and do not allow other health care professionals to manipulate the CVAD is another potential way to prevent infection.

  • Patients are responsible in caring for the exit site, dressing changes, blood draws, and administration of any fluids, PN, and medications via the CVAD. This may be a way to ensure consistent care is provided to the CVAD by only having one caregiver. Patients must receive exceptional education and training to assume this role and demonstrate independence and ability to perform procedures properly as well as motivation.

  • There is no prospective or control data to support this for routine care and even with excellent care, the CVAD could be seeded from another source leading to infection.

Short term complications of PN

Tunnel infection

  • Signs & symptoms: Erythema, tenderness, swelling of the skin overlaying the track of the tunnel

  • Treatment: Catheter removal and replacement at an alternate site

  • The cuff acts as a barrier for infections and tunnel infections are rare after the cuff has adhered to the subcutaneous tissue. If the cuff is visible, a chest X-ray should be obtained to verify tip placement. The catheter should be replaced if the tip of the catheter has migrated above the middle third of the Superior Vena Cava or if at risk of the catheter being pulled out further by the patient (i.e., active lifestyle or stitches previously removed).

Exit site infection

  • Signs & symptoms: Erythema, tenderness, with drainage within 2 cm from the catheter exit site

  • Treatment:

    • Oral antibiotics: Common protocols

      • Cephalexin 500mg 4 times/day PO for 7-10 days

      • Erythromycin 500mg 4 times/day PO for 7-10 days if allergy to penicillin or Cephalexin

      • Consider IV antibiotics if the patient does not have adequate bowel to absorb oral antibiotics (i.e., s/p enterectomy, high output enterostomies, or if oral antibiotics fail to show improvement, etc.)

    • Increase frequency of dressing changes

    • Remove stitch if present. The stitch on cuffed and tunneled catheters such as Hickman®/Broviac® catheters can be removed after the cuff adheres which is usually approximately 6 weeks post placement. Stitches should not be removed on Groshong® catheters since there is no cuff.

Port pocket infection

  • Signs & symptoms: Erythema over reservoir of port, purulent liquid in subcutaneous pocket

  • Treatment: Surgical removal of implanted port and antibiotics

Insertion related infections

  • Bacteremia after initial placement of a CVAD may be placement related

Deep vein thrombosis (DVT) with insertion (at catheter site)

  • Signs & symptoms: Unilateral edema on extremity where CVAD placed, pain, redness, warmth

  • Treatment: Consult Vascular Medicine after DVT confirmed. Removal of CVAD after anticoagulation at direction of Vascular Medicine consultation

Long term complications of PN

Catheter related blood stream infection (CRBSI)

  • CRBSI is the most common and serious infectious complication of PN. Patients with frequent episodes of CRBSI should be referred to a transplant center for evaluation of small bowel transplantation (one of the Medicare criteria for consideration of a small bowel transplant).

  • Signs & symptoms:Fever and rigors with PN infusion, positive blood culture results from both the CVAD and peripheral blood, elevated WBC, possible elevation of liver enzymes (nonspecific for CRBSI, but general elevation seen in infection/sepsis)

  • Treatment:

    • Consultation to Infectious Disease (ID)

    • If tunneled, long term CVAD (Hickman®, Broviac®, Groshong®), ID to assess ability to salvage the long term catheter* versus removal

    • Hold infusion of PN via the CVAD

    • In addition to holding PN, withhold delivery of any parenteral lipids (as fungemias are lipophilic)

    • Delivery of intravenous fluids via peripheral catheter to preserve the use of the CVAD for IV antibiotic administration seems prudent

    • Omission of any form of parenteral iron in the presence of infection is prudent

    • A 5% dextrose in water solution can be provided with customized electrolytes added similar to the electrolyte content of PN and infused via a peripheral IV if the osmolarity does not exceed 900 mOsm/L with 10 milliliters of IV multivitamin and trace element solution added daily

    • In the case of fungemia or prolonged episodes of CRBSI after one week without PN infusion, consideration of the addition of protein to the 5% Dextrose in Water with customized electrolyte solution for patients with malabsorption or increased protein requirements to assist in avoiding further protein deficit. Protein concentrations should not exceed 2% while keeping total osmolarity at 900mOsm for peripheral infusion.

    • Resuming PN after clearance by Infectious Disease Consultation after negative blood cultures document the treatment and clearance of the CRBSI

    • When PN is resumed via a salvaged CVAD, clinicians and patients should monitor for return of fevers or symptoms related to CRBSI

Short term, non-tunneled catheters such as peripheral IV’s, peripherally inserted central catheters (PICC), or temporary non-cuffed / non-tunneled CVAD’s are not appropriate for catheter salvage regardless of the infectious organism.

*In the presence of fungemia or Staphylococcusaureus, CVADs should be removed (not appropriate for attempts to salvage, Infectious Disease Society of America [IDSA] 2009 guideline 32). Rare circumstances may exist in which a long-term catheter is infected with S. aureus and venous access is limited due to multiple vascular insults (no other venous access is attainable), salvage can be attempted with close input from Infectious Disease Consultation in the absence of sepsis (2009 IDSA Guideline 83). Mediports are generally unable to be salvaged in presence of any CRBSI.

CRBSI with S. aureus

  • Patients with a CRBSI involving S. aureus are at particular risk for sepsis, septic thrombophlebitis, endocarditis, and venous thrombosis. Endocarditis should routinely be ruled out if the infectious organism is S. aureus (2009 IDSA Guideline)

  • Crowley et al. (2008). Studied 48 patients with CRBSI due to S. aureus

  • CVAD was either temporary or long-term

  • All patients were examined for physical signs of thrombosis

  • An ultrasound of the internal jugular, subclavian, and brachial veins was completed within 48 hours of a positive blood culture for S. aureus

  • Physical exams did not identify of thrombosis, but ultrasound found 71% of patients (34 out of 48 patients) had a definite or possible thrombosis

  • Authors suggest routine imaging to rule out thrombosis for CRBSIs involving S. aureus

What clinical trials or meta-analyses related to nutrition services and total parenteral nutrition guide infection control practices and policies?

Enteral nutrition

There are no meta-analyses at the present time that exist for infection control related to EN as a whole. However, the subcategory of pancreatitis has a well defined reduction in infection with use of EN. In the past, PN was the therapy of choice for pancreatitis; however, with ability to obtain enteral access easily and quickly, the provision of EN has shown excellent outcomes in this patient population.

Al-Omaran et al. (2010)

In patients with pancreatitis, EN decreased mortality, organ failure, systemic infections, and need for operative intervention compared to the patients with pancreatitis who received PN. There was also a trend towards decrease in LOS when EN was utilized.

McClave et al. (2006)

Patients with acute pancreatitis and use of EN were associated with reduction in infectious morbidity, hospital length of stay, a trend toward reduced organ failure, but no effect on mortality compared to patients supported by PN.

Parenteral nutrition

CRBSI is the most important, life threatening, and still a too common complication of PN. Although the causes of CRBSI are likely multifactorial (co-morbid conditions, type of catheter, catheter site, type of and duration/frequency infusion, and quality of catheter care), Maki et al., (2006) examined the risk of CRBSI with different types of CVADs.

Maki et al. (2006)

  • Review of 200 published prospective studies

  • All types of access devices have inherent but differing risks of blood steam infection.

  • All types of catheters were included such as hemodialysis catheters, arterial lines, pulmonary artery catheters, midlines, left ventricular assist devices, intra-aortic balloon pumps, etc (i.e., devices not limited to only use for PN therapy).

  • Of CVADs that would be appropriate for infusion of PN (or PPN), implanted ports had the least risk of infection, followed by tunneled and cuffed CVADs. The length of therapy is important to consider as well as the solution infused. Although ports were associated with the lowest risk of blood stream infection, they must be removed in presence of infection further adding to the patients’ incurred expense. Implanted ports are more appropriate for intermittent therapy, and tunneled, cuffed CVADs more appropriate for daily therapy that will continue uninterrupted.

  • Again, continuation of therapy may play a role in interpretation of this data.

See Table I for details about the rates of bloodstream infections by catheter type.

Table I

The catheter with the fewest number of lumens should always be selected due to a potential for infection although studies have not shown a direct link to increased infection. Additional lumens may be convenient, but should be streamlined if the therapy is to continue beyond hospital discharge.

Dezfulian et al. (2003)

  • Meta-analysis of 15 studies using temporary central lines for hospitalized patients

  • Excluded from the analysis were long term, cuffed, tunneled catheters, antibiotic coated catheters, hemodialysis catheters, PICCs, and pulmonary artery catheters.

  • PN was utilized in each of the 15 studies

  • Compared single versus multilumen temporary catheters

    • Multilumen catheters may be associated with a higher risk of infection compared to single lumen catheters. Studies used in the meta-analysis were rated for quality and when lesser quality studies were removed, the relationship between multilumen catheters and infection decreased.

  • It is unclear if these results can be extrapolated to other types of CVADs excluded from the study.

  • Each lumen of a multilumen catheter should be considered as a potential source of infection for diagnosis of CRBSI

    • Dobbins et al., (2003) reported that sampling of only one lumen of a triple lumen catheters has only a 60% chance of detecting colonization of an organism. When only one lumen is sampled, CRBSI cannot be ruled out

Two important meta-analyses reported on the timing of PN based on nutritional status are listed below. Determination of nutritional status aids in determining the timing of PN in critically ill patients to prevent potential infectious complications.

  • The Society for Critical Care Medicine (SCCM) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) joint 2009 guidelines suggests the following:

    • If EN is not available the first 7 days following ICU admission, no nutrition support (i.e., standard therapy) should be provided in the patient who was previously healthy prior to critical illness and hasno evidence of protein-calorie malnutrition.

Heyland (1998)

Use of PN with no evidence of malnutrition showed increase in mortality with the use of PN and a trend toward greater rates of complications when compared to standard therapy (i.e., no nutrition support).

Braunschweig (2001)

Standard therapy (i.e., no nutrition support) was associated with reduced infectious morbidity, and a trend toward overall reduced complications compared to the use of PN when there was no evidence of protein-calorie malnutrition.

If thereis evidence of protein-calorie malnutrition on admission and EN is not feasible, it is appropriate to initiate PN as soon as possible following admission and adequate resuscitation.

Heyland (1998)

Use of PN in malnourished patients was associated with fewer overall complications than standard therapy (i.e., no nutrition support)

Braunschweig (2001)

Standard therapy (i.e., no nutrition support) was associated with higher mortality and a trend toward higher rate of infection compared to if PN was used. In the presence of malnutrition, PN should promptly be initiated if EN is not possible.

What are the consequences of ignoring nutrition services and total parenteral nutrition?

Enteral nutrition

EN morbidity and mortality can be reduced by careful attention to the methods and the use of technology used to deliver the therapy.

Aspiration

  • The cause of aspiration needs to be identified since aspiration can be related to oropharyngeal secretions or enteral feedings.

  • The location of the tip of the enteral feeding tube will not make a difference in reducing the patients’ risk for aspiration if it is due to oral/pharyngeal secretions.

  • Blue dye should not be added to enteral feeds.

  • There are poor correlations between gastric residuals and aspiration

  • To minimize risk of aspiration:

    • Elevate the head of the bed 30-45 degrees

    • Provide enteral feeds continuously via pump

    • Oral care

    • Use of prokinetic agents, as appropriate

    • Minimize or eliminate narcotic delivery as possible

    • Remember that a cuffed endotracheal tube is not a guarantee against pulmonary aspiration

Sinusitis

  • Signs & symptoms: irritation of the nasal mucosa can be seen when enteral feeding tubes are left in place for a prolonged period of time.

  • Treatment: tube removal, local care, and antibiotics (if appropriate)

  • Prevention: use small bore feeding tubes since sinusitis is more often seen with large bore feeding tubes, site rotation, if enteral access required long-term consider permanent enteral access (i.e., gastrostomy or jejunostomy tubes)

Confirmation of feeding tube tip placement

After placement of an enteral feeding tube, a KUB should be obtained to verify tube placement before initiation of enteral feeds to ensure not to feed into the airway (which could lead to pneumonia or acute respiratory distress syndrome)

Bridle versus stitching of a feeding tube

  • Stitching of tubes has been performed for many years

    • Little or no data exists on this seemingly barbaric practice which is practiced mostly by ENT physicians

  • May lead to the development of pressure necrosis from the tube or infection due to the stitches or sinusitis

  • Bridling techniques have been available for years – this has recently been simplified and is commercially available and may help decrease the number of nasoenteric tube dislodgements

    • Commercialized bridles now feature magnets to avoid reaching into the oropharynx to pull the ends of the umbilical tape from around the septum.

Red rubber tubes

  • While generally not considered a typical nasoenteric tube, red rubber tubes have been used by ENT and thoracic surgeons as a tube in patients with oropharyngeal dysphagia or esophageal diseases for many decades.

  • There are no known comparisons examining differences between typically available nasoenteric tubes to the red rubber tubes

  • These tubes have often been sutured in by physicians, but the ramifications of that have not been systematically examined

  • Red rubber tubes are typically latex based, and in comparison to silicon or polyurethane tubes, degrade more quickly

Gastrostomy complications: Placement may be endoscopic, radiologic, or surgical

  • Gastrostomy site infection

    • Signs & symptoms: Pain at site, redness, drainage of pus

    • Treatment: Local wound care, antibiotics (if appropriate)

    • Prevention: daily inspection and local cleansing of the tube external site with soap and water

Jejunostomy complications: Placement may be endoscopic, radiologic or surgical

  • Jejunostomy site infection

    • Same as above

Enteral tube infections

  • Suturing of external bumpers: Suturing of percutaneous endoscopic gastrostomy (PEG) external bumpers is generally not necessary and does not guarantee that a PEG tube cannot be pulled out. It is more appropriate for tubes placed either radiologically or surgically to have the tube secured to the skin. However, this can be associated with wound infections and cellulitis.

    • Signs & symptoms: Pain at site, redness, ulceration +/or drainage of pus around suture sites

    • Treatment: Removal of sutures, possible use of antibiotics, and local wound care

    • Prevention: daily inspection and local cleansing of the site with soap and water

Pressure necrosis from internal and external bumpers

  • Signs & symptoms: If the external bumper of a gastrostomy or jejunostomy (if present) is pulled too tightly, it can cause a pressure ulceration on the external skin which can become infected

  • Treatment:Local wound care, antibiotics (if appropriate)

  • Prevention: Daily inspection, appropriate tension between the internal and external bumpers & rotate the tube daily to show that the tube is snug, but not too tight

Buried bumper syndrome

Unique to percutaneous endoscopic gastrostomies (PEGs). This can occur when the external bumper is pulled too tightly and a more rigid styled internal gastric bumper begins to cut into the gastric wall causing an ulceration from necrosis of the gastric mucosa and the internal bumper with the presence of pain, leakage from around the tube, pain with infusion of enteral feeds, site infection, gastrointestinal bleeding or necrotizing fasciitis. The tube can become further imbedded and actually work its way out of the stomach completely leaving no tube in the stomach. Then the tube becomes lodged in the subcutaneous tissues and may cause infection at the site or even peritonitis.

  • Signs & symptoms: Pain at site, redness, drainage of all infused material through the tube coming back along the side of the tube, drainage of pus or rarely may cause peritonitis

  • Treatment:Usually requires endoscopic management to verify extent of internal gastric wall damage and current location of the internal bumper. May require endoscopic removal and replacement or on rare occasion may require surgical intervention. If an infection of the gastric tract is present, will usually require antibiotics.

  • Prevention: Daily inspection, appropriate tension between the internal and external bumpers & rotate the tube daily to show that the tube is snug, but not too tight

Complications from radiologically placed gastrostomies/jejunostomies

  • Signs & symptoms: Main complications here are related to suturing of the tubes to the skin, localized infections and dislodgement of the tubes. The latter could result in peritonitis

  • Treatment: Local wound care, antibiotics, if necessary

Complications from surgically placed gastrostomies/jejunostomies

  • Signs & symptoms: Usual postoperative issues including wound infection, peritonitis, tube dislodgement

  • Treatment:Local wound care, possible removal of the tube, surgical exploration, and antibiotics, if appropriate

  • Prevention: Good surgical technique, daily inspection

Parenteral nutrition

PN therapy either while hospitalized or at home, requires adherence to key guidelines and recommendations to minimize potential for complications, both infectious and noninfectious alike.

Infectious complications of ignoring key concepts for PN therapy

CRBSI: Ignored signs and symptoms of ongoing infection can delay diagnosis and make the patient more vulnerable to potentially more serious infectious ramifications of blood stream infections such as endocarditis or osteomyelitis.

  • Patients should contact the medical team prescribing the PN in the presence of rigors or fevers.

Thrombosis

  • The etiology of thrombosis can be multifactorial

    • The presence of a CVAD, a foreign body, may play a role in predisposing the patient to thrombotic events

    • Patients with underlying hypercoagulable states

    • Infection

  • Predisposing factors for thrombus related to the CVAD: traumatic catheter insertion, dehydration, malposition, catheter size and composition (less with catheters made from silicon or polyurethane), Virchow’s triad (stasis, altered coagulation, and local trauma)

  • Catheter related thrombosis of upper extremities

  • Signs & symptoms: Swelling of the arm or neck, tenderness of the axilla when pressing on axillary vein, discoloration of the arm

SVC thrombosis

  • Signs & symptoms: Swelling (shoulder, neck, or face) on same side as the catheter, prominent/enlarged veins on the chest wall, sore throat, excessive tearing, or rhinorrhea

  • Ignoring these symptoms can be life threatening as well as in addition to the potential loss of venous access

  • Loss of available sites for venous access

    • The most common infectious complication of PN is CRBSI. In patients that have had multiple CRBSIs, episodes of thrombosis or vascular insults can lead to loss of the common vascular access points.

    • Safe and reliable venous access may need to be achieved with creative surgical techniques with use of the translumbar approach to access the inferior vena cava.

    • Loss of multiple sites for vascular access is one of the criteria for consideration of candidacy for small bowel transplantation

Exit site infection

  • Untreated exit site infections can lead to more serious infections as mentioned above (CRBSI, tunnel infections)

Consequences of ignoring key concepts for PN therapy

Catheter type

  • PPN versus PN

    • PPN can be infused via a peripheral line or a CVAD, but PN should never be infused via peripheral lines (authors’ editorial note: often happens in July with new staff or nursing oversight). PN should only be infused through a CVAD with the tip optimally in the lower third of the Superior Vena Cava adjacent to the right atrium, right atrium, or the middle to lower third of the superior vena cava.

  • No PN via midline

    • Midline catheters are long peripheral catheters that can be placed at the bedside and the tip terminates in the axillary vein. Midlines should not be used for central PN due to the potential for phlebitis and the tip of the catheter is too short to reach optimal position for central PN.

  • Tunneled CVADs

    • Moureau and colleagues (2002) found the incidence of thrombotic events and non-thrombotic dysfunction is greater in patients with PICC lines compared to tunneled catheters in an analysis of 50,000 patients and 2.8 million catheter days.

    • Fewer infectious complications were seen with tunneled catheters

  • Catheter placement

    • The CDC recommends subclavian placement for non-tunneled temporary CVCDs over jugular or femoral vein placement to decrease the risk of infection

    • Ruesch et al., (2002) found that catheters placed via the internal jugular vein were less likely to be malpositioned in comparison to those placed via the subclavian vein

    • Patients should play an active role in selecting the site of the catheter where it is easily viewed and comfortable for self care

Catheter tip placement

  • Infusing central PN via CVADs with tips not in optimal position places the patient at risk of venous thrombosis

  • Verification of tip placement before infusion of PN is prudent after the CVAD is placed or if any concerns that the catheter tip may have migrated (i.e., CVAD has accidentally been pulled on by the patient or healthcare worker, cuff of tunneled catheter is exposed, or if problems with infusion or swelling of the neck and face)

    • Some Nutrition Support Teams will obtain a new chest x-ray when patients are admitted to the hospital to verify the CVAD has not migrated and remains in optimal position

  • Any patient on long term home PN therapy should not have a CVAD tip pointing toward the side of the wall of the superior vena cava on a chest x-ray; the tip of the catheter could erode the wall of the vein

    • This is most common with CVADs placed on the left via the internal jugular or subclavian veins

  • Exposed cuff

    • The tunneled catheter cuff acts as a barrier for infections and tunnel infections are rare after the cuff has adhered to the subcutaneous tissue. If the cuff is visible, a chest X-ray should be obtained to verify tip placement. The catheter should be replaced if the tip of the catheter has migrated above the middle third of the superior vena cava or if at risk of the catheter being pulled out further by the patient (i.e., active lifestyle or stitches previously removed).

    • If the cuff becomes exposed, but catheter remains in place, it is unclear if increased risk of infection/tunnel infection. The CVAD has potential to migrate if the stitches have been removed and the cuff is no longer adhered to the skin.

Air embolism

  • Signs & symptoms: Coughing, shortness of breath when the catheter is not clamped and end cap is disconnected.

  • Medical emergency: Patients need to position themselves on the left side if experiencing these symptoms until medical help arrives

  • Prevention: Patients should receive education on this as a possible complication of having a CVAD. Always keep catheter clamped when changing end cap or when the catheter is not in use. If part of the catheter breaks off, blunt tipped clamps should be placed between the exit site and the break to prevent air from entering circulation. The catheter should promptly be repaired/replaced.

Occlusion

  • Occlusions may be due to:

    • Fibrin sleeve

    • Blood clotting

    • Drug or lipid precipitate

  • Before administration of thrombolytic agents:

    • Check to see if re-positioning the patient allows for infusion/withdrawal

    • Have the patient cough or raise over the head (hand on the same side where the catheter is located)

    • Inquire about presence of fevers/infection

  • Treatment

    • Fibrin sleeve: Thrombolytic agent such as tissue plasminogen activator (t-PA)

    • Blood clotting: Thrombolytic agent such as t-PA

    • Drug or lipid precipitate

      • 0.1 N HCl – drug precipitate

      • sodium bicarbonate – drug precipitate

      • ethyl alcohol – lipid precipitate

    • If the above agents are not successful in restoring patency to the CVAD, exchange of the catheter over a guidewire may be required

  • Untreated occlusions place patients at increased risk of infection

A summary of current controversies regarding infection control and nutrition services and total parenteral nutrition.

Enteral nutrition

Do EN formulas make a difference in infection?

Immune modulating enteral nutrition formulas are commercially available and have been studied in specific disease states.

  • Patients with acute respiratory distress syndrome (ARDS) or acute lung injury (ALI) are appropriate for an enteral formula supplemented with an anti-inflammatory lipid profile with W-3 fish oils, borage oil, and antioxidants

  • Three large studies, to support use showed a reduced length of ICU stay, decreased time of mechanical ventilation, decreased organ failure and mortality compared to use of standard formulas

    • Gadek (1999) - ARDS

    • Singer (2006) - ARDS & ALI

    • Pontes-Arruda (2006) - Sepsis

  • Immune-modulating enteral formulations (supplemented with agents such as arginine, glutamine, nucleic acid, W-3 fatty acids, and antioxidants) should be used for the following patients population (major elective surgery, trauma, burns, head and neck cancer, and critically ill patients on mechanical ventilation), with caution in patients with severe sepsis.

  • Outcomes:

    • Decreased time on mechanical ventilation, decreased infectious morbidity, decreased hospital length of stay compared to standard EN formulations and there was no effect on mortality

    • Caveat: Multiple formulations commercially available have varying amounts of the individual components. It is unclear if data from these studies can be extrapolated to formulations not formally evaluated in the literature.

  • Sepsis

    • For medical ICU patients, the use of arginine has been a topic of discussion for the potential of increased risk. There is a theoretical pathway that arginine could be converted to nitric oxide and further contribute to instability; however, controversy still exists between the available research. SCCM/A.S.P.E.N. Guidelines (2009) recommend the following: use of arginine containing immune formulas in mild to moderate sepsis, but caution with severe sepsis

Nasal bridles

  • Feeding tubes can be maintained in place by tape, but tape may become loosened and damp with secretions leading to loss of enteral access

  • The nasal bridle is an old technique that has become more practical with improvements in design over time and now new commercially available products

    • Older bridles were made of tubing and required reaching into the oropharynx pulling out the ends of the tube that wrapped around the nasal septum. In the past, bridles may have caused some discomfort due to the bulky material and damage to the septum.

  • The following studies not only address the low morbidity associated with the nasal bridle, but also the ability to better meet nutritional requirements

    • Seder et al. (2010)

      • Study looked to identify if nasal bridling was a low morbidity practice and if decreased feeding tube dislodgement among ICU patients

      • Bridled tubes were less likely to be dislodged compared to enteral tubes secured with tape (18% versus 63%)

      • When tubes are less likely to be dislodged, the patient can avoid possible morbidity associated with additional procedures to obtain enteral access

      • When bridled tubes were dislodged, no damage to the nasal septum occurred

      • Bridled patients received an increased amount of calories via enteral nutrition

      • Five cases of mild epistaxis upon insertion of the bridle and four cases of superficial nasal ulceration in the bridle group

      • No sinusitis was diagnosed in the bridle group, but did occur in the non-bridled group

      • Both safety and efficacy was established for utilizing a nasal bridle

      • Authors suggest routine nasal bridling for all patients in the ICU requiring enteral feeds

    • Seder et al. (2008)

      • Study compared use of the bridle versus securing the enteral tube with tape to evaluate dislodgement and also to identify if there was a cost saving

      • Bridled group had lower incidence of dislodgement

      • Incidence of ulceration with the bridle was evaluated: Five cases of nasal ulceration per 1000 tube feeding days, all cases of ulceration were when red rubber tubes were used for the bridle, no ulceration was found in the tape group

      • Cost savings was identified with use of the bridle and low risk of morbidity

    • Popovich et al. (1996)

      • Study looked to demonstrate the efficacy and safety of a nasal bridle using improved materials (umbilical tape in place of a red rubber or polyurethane tube)

      • No cases of bleeding, infection, sinusitis, or nasal septum trauma were caused by the bridle that was placed in the 26 surgical ICU patients

      • Two cases of feeding tube removal (the clamp failed in one of these cases)

      • Successful continuation of enteral feeds for 170 consecutive days for one patient & the same bridle and tube was maintained. Five of the 26 patients had the bridle in place for greater than 30 days

      • No consensus exists on which patients should have enteral tubes bridled

Some experts suggest use of a bridle with uncooperative patients, prior tube removal, or when the risk of accidental removal is high, while other experts suggest routine bridling of all patients.

Parenteral nutrition

Prophylactic anticoagulation with CVAD insertion and thereafter

  • For patients with hypercoagulable states or have increased risk of a catheter related thrombus, some experts suggest administration of low dose warfarin therapy (1-2 mg of warfarin/day) to reduce thrombotic risk prior to insertion of a long term catheter and postplacement while the CVAD is in place.

  • Boraks et al., (1998) demonstrated decreased incidence of CVAD related thrombosis in oncology patients with tunneled catheters given 1mg/day of warfarin upon insertion until the line was removed.

  • Bern et al., (1990) showed reduced thrombus related to indwelling central catheters in oncology patients given 1 mg/day of warfarin 3 days prior to CVAD placement and continued therapy for 90 days post line placement.

    • Ports were utilized and correct placement for the study was defined as within the tip of the superior vena cava or proximal innominate vein.

    • For purposes of infusing PN, these lines would be considered malpositioned and at greater risk of thrombus due to tip location. It is unclear if these results could transfer to the PN patient population.

  • Couban et al (2005) reviewed 250 oncology patients with tunneled or implanted CVADs given 1mg/day warfarin 72 hours post CVAD placement until CVAD removed, death or thrombus versus no prophylaxis. No reduction on the incidence of CVAD associated thrombus was found, but the authors suggest that the overall low rate of symptomatic CVAD associated thrombus requires larger trials to address this.

  • Meta-analysis of studies using multiple forms of anticoagulation medications (fixed low dose heparin, low molecular weight heparin, and warfarin) shows no increased risk of major bleeding associated with prophylaxis.

    • However, one trial not included in the meta-analysis due to outcome data only being reported for 90% of the patients was Young et al (2003). Researchers compared 1 mg/day warfarin versus an adjusted dose of warfarin to maintain an INR between 1-2 in oncology patients with multiple types of CVADs with tips of the catheter terminating the junction of the superior vena cava and the right atrium. The results suggest adjusted dose therapy is superior to prevent catheter-associated thrombosis, but increased bleeding was also noted.

  • Patients receiving PN therapy through a CVAD may also benefit from low dose warfarin therapy; however, past studies within the PN population have been completed with heparin and not warfarin.

  • CDC Guidelines (2002) do not comment on routine use of warfarin, but state it is not known to reduce CRBSI.

  • The decision to use this potentially beneficial therapy in PN patients is based on clinical judgment of the managing physician until future studies are completed. Treatment with anticoagulation prophylaxis in Oncology patients receiving PN has yet to be studied. Given the increased risk of venous thrombosis in patients with cancer, therapy should be considered, discussed with the patient, and monitored closely, if selected.

Length of use for PICC/additional PICC complications

As originally conceived, the use of a PICC was to be a less invasive method of attaining central access that was intended to be “short term”. However, over time the concept of “short term” has become blurred and instead of an in-hospital option for central access, it is often used to send patients home or to facilities to receive treatments such as long-term antibiotic therapy or PN. There are many patients that receive PN for “shorter periods” of time where a PICC may be preferred to a tunnel catheter. To decrease potential complications, if the proposed length of time for use of a PICC is greater than 6 weeks, then serious consideration should be given to placing a tunneled catheter. Also because the catheter which is usually placed in an upper extremity is subject to more motion due to movement of the extremity, the catheter may become dislodged from the optimal distal Superior Vena Cava position and be prone to more complications, especially thrombus.

PICC issues

  • More difficult for patient themselves to care for than a tunneled catheter

    • Homecare RN required or another trained caregiver since patient does not have use of both hands to complete procedures required and dressing changes

  • Compared to tunneled catheters, PICCs have:

    • Increased risk of infection

    • Increased risk of thrombosis

    • Increased risk of tip displacement

Femoral lines

Placement of a CVAD in the femoral vein is relatively contraindicated for long term use with PN infusion given the location. Patients are at high risk of CRBSI with possible contamination from urinary, stool/ostomy, and fistula sources that could easily come in contact with the CVAD. Femoral vein catheters have an increased rate of infection compared to jugular or subclavian venous sites as well as DVT.

Use

  • In cases when the patient has had multiple vascular insults (thrombi/occlusions) with few remaining sites for access, femoral lines may be necessary although not ideal.

  • When other vascular access sites are available for CVAD placement, they should always be utilized over the femoral site to minimize infection risk.

  • Potentially can decrease risk with femoral placement by tunneling the catheter

    • To the anterior thigh or up the RLQ or LLQ

    • Still allows patient to have easily observable exit site and easy site for self care

  • Femoral catheters should not be placed or tunneled near fistulas or ostomies

Points of controversy to decrease infections in CVADs

Antibiotic lock

  • Developed to assist in salvage of a CVAD due to the main cause of CRBSI in cuffed long-term CVADs, intraluminal hub contamination

  • 100-1000 fold higher concentrations of antibiotics are used and allowed to dwell in the lumen of the catheter

  • Antibiotic locks are for use with systemic antibiotics for treatment of a CRBSI when the goal is to salvage the CVAD

  • Not beneficial when the infection is extraluminal, only for intraluminal infections

  • IDSA Guidelines (2009):

    • Antibiotic lock should not be used alone for treatment of CRBSI, but in conjunction with systemic antibiotics for 7-14 days

    • Used when salvage is the goal of treatment

    • Antibiotic lock and CVAD salvage is not recommended in presence of S. aureus or Candida species (unless no alternative catheter insertion site)

  • CDC Guidelines (2002) recommends NOT using antibiotic lock for prevention of CRBSI in general, but can be used prophylactically only in situations with long-term CVADs in patients with a history of multiple cases of CRBSI

  • Variable length of use among studies, but generally antibiotic locks used as treatment for 2 weeks after CRBSI

    • Some clinicians have utilized antibiotic lock for long-term therapy which may lead to the selection of potentially worse infectious organisms

  • Drawbacks of antibiotic lock:

    • Potential for development of resistance and “super bugs”

    • Used as treatment for CRBSI, not prevention

    • Stability concerns with heparin

    • Optimal duration of antibiotic lock remains an unresolved issue by the Infectious Disease Society of America (2009)

  • Antibiotic locks are not practical in the hospital setting due to multiple manipulations of the CVAD (fluids, PN, systemic antibiotics, IV meds, etc.) that have the potential to drastically limit dwell time

Ethanol (ETOH) lock

  • Currently there is insufficient data for the Infectious Disease Society of America to comment on treatment of CRBSI’s with ETOH lock; however, several experts are utilizing ETOH lock for prevention of CRBSI, especially in patients who have had a history of multiple CRBSIs.

  • Benefits of ETOH over antibiotic lock include:

    • Low cost

    • No concerns regarding resistance (ethanol acts to denature proteins)

    • Both bactericidal and fungicidal properties

  • Small studies have demonstrated a statistically significant decrease in CRBSI and catheter changes.

  • More studies are warranted in this area to define many unanswered questions regarding the optimal ethanol concentration, optimal dwell time in the catheter, as well as studies for cost savings analysis and if quality of life is impacted in home PN patients.

  • 3mL of 70% ETOH is administered after cycled PN infusions are complete allowing the solution to dwell in the lumen of the CVAD for the longest number of hours patient is disconnected from PN (usually 12 hours) until patients resume PN infusion. The ETOH solution is flushed through with normal saline before resuming PN.

  • Other concentrations have been utilized and can be effective if the patient does not tolerate the standard concentration.

  • Heparin is not mixed with ethanol for lock due to precipitate formation

  • ETOH lock solutions should only be used in CVADs made from silicon or polyurethane. Studies investigating the effects of ethanol on catheter materials have only been completed on select brands of catheters.

  • Currently, 70% ETOH locks must be compounded in the pharmacy into pre-filled syringe. Stability of the compounded ethanol within the syringe has been studied and documented.

  • Optimal use of the ethanol lock should include using it immediately after a new catheter has been placed since Biofilm begins to form on the internal surface of the catheter soon after placement. The ETOH lock is less likely to be as effective in older catheters where significant Biofilm has had an opportunity to form.

  • Potential side effects that the patient experience are as follows: a warm flush after flushing the ETOH lock with saline; a metallic taste (if it occurs, a piece of hard candy can ameliorate it), a feeling of dizziness (may be ameliorated by lowering the percent of ethanol).

  • Some patients may have a religious reason not to use this therapy, but if they have experienced multiple CRBSIs, an explanation that this is a therapy similar to any antibiotic may be helpful in some situations, but unlikely all.

  • There can be a drug/drug interaction with metronidazole which includes nausea and rarely vomiting similar to the Antabuse® (disulfiram) reaction between drinking alcohol and receiving metronidazole.

Taurolidine lock

  • Currently this product is not available for use in the United States, but has shown promise in prevention of CRBSI in Europe

  • Antiseptic agent, derived from aminosulphonic acid taurinamide

  • Bactericidal and fungicidal properties

  • Mechanism of action: prevents bacterial adhesion to biological surfaces by methylol taurinamide reacting with bacterial cell walls

  • Resistance has yet to be reported

  • Used in chemotherapy, hemodialysis, and Home PN patients

    • Bisseling (2010) studied 30 Home PN patients with a prior CRBSI on taurolidine lock in a crossover design. Only one episode of CRBSI (a fungemia) was noted in the Taurolidine group compared to 10 CRBSIs in the control group.

  • A multicenter study with taurolidine lock is warranted as many unanswered questions remain that are similar for use of ETOH lock (i.e., long-term stability of catheter material in presence of Taurolidine, optimal dwell time and concentration, potential for development of “super bugs,” and possible impact on quality of life in the HPN population).

Biopatch® at exit site

  • A Biopatch® is a commercially available chlorhexidine impregnated sponge that is applied over the exit site of a CVAD and changed weekly (continuous release of chlorhexidine)

  • Multi-center studies showed reduced catheter colonization and CRBSI when Biopatch® is used with short-term CVADs.

  • Well studied in short-term catheters, but NO evidence exists for use in long-term, tunneled CVADs or with long-term home PN patients.

  • Individuals caring for the CVAD must be sure to apply the Biopatch® correctly (chlorhexidine side down and in contact with the exit site) for any potential benefit to be observed

  • The exit site of the catheter cannot be visually monitored when the Biopatch® is utilized which is a strong drawback of the Biopatch®. The CDC recommends monitoring the catheter sites on a regular basis (visually or palpation through the dressing). If tenderness develops, fevers, drainage, etc., the dressing should be removed for examination of the site. However, exit sites can be easily viewed daily when not obstructed by the Biopatch®.

  • Currently the CDC 2002 Guidelines list the use of a chlorhexidine sponge as an unresolved issue and makes no recommendations for its use to reduce infection

  • In tunneled or implanted CVADs, the hub of the catheter is noted to be the most common route of infection and the Biopatch® doesn’t accomplish decreasing infection via that route. No evidence exists to show this product is beneficial when used long-term or in reducing infection in long-term tunneled catheters.

  • Chlorhexidine impregnated transparent dressings are also coming to market and similar to the Biopatch®, does not address the main site of potential for contamination at the catheter hub.

  • Once exit sites are well healed, the CDC does not make any recommendations for the necessity of any dressings on long term cuffed and tunneled CVADs or the Biopatch®.

Tissue plasminogen activator (t-PA)

  • Thrombolytic agents should not be used in the presence of fever based on the idea that septic emboli could spread throughout the body. The Infectious Disease Society of America (2009) does not recommend thrombolytic agents in the presence of CRBSI

  • Cases of catheter occlusion should be treated promptly (in absence of any signs of infection) within the first week of difficulty with infusion or withdrawal as thrombus material is converted to fibrous connective tissue that is not susceptible to being dissolved by t-PA.

Customized fluid and electrolyte solutions during CRBSI

The authors' institutional practice is to withhold full calorie PN and lipids during the first several days of treatment of a CRBSI and substitute delivery of a customized intravenous fluid and electrolyte solution. Since there are no prospective studies to validate this practice, the authors add this as an anecdotal experience.

  • With confirmed CRBSI, PN infusion is held via the CVAD

  • In addition to holding PN, withhold delivery of any parenteral lipids

  • Delivery of intravenous fluids via peripheral catheter to preserve the use of the CVAD for IV antibiotic administration seems prudent

    • A 5% dextrose in water solution can be provided with customized electrolytes added similar to the electrolyte content of PN and infused via a peripheral IV if the osmolarity does not exceed 900 mOsm/L with 10 milliliters of IV multivitamin and trace element solution added daily

    • In the case of fungemia or prolonged episodes of CRBSI after one week without PN infusion, protein can be added to the 5% Dextrose in Water with customized electrolyte solution for patients with malabsorption or increased protein requirements to assist in avoiding further protein deficit. Protein concentrations should not exceed 2% while keeping total osmolarity at 900mOsm for peripheral infusion.

  • Resuming PN after initial clearance by Infectious Disease Consultation after negative blood cultures document the treatment and clearance of the CRBSI. This is usually after 2 days of negative blood cultures.

    • When PN is resumed via a salvaged CVAD, clinicians and patients should monitor for return of fevers or symptoms related to CRBSI.

Since patients on PN typically require increased amounts of electrolytes (sodium, potassium, magnesium, and phosphorus) due to ongoing GI losses, we find this practice avoids routine repletion of electrolytes and a quick return to full calorie PN without risk of electrolyte abnormalities after the treatment of the infection has begun. This is an institutional practice of the authors. No current data is available to support this practice, but this is utilized due to such severely ill patients.

Tunneled versus implanted ports

One innovation to try and decrease CRBSIs was the use of an implanted port rather than a tunneled catheter. Several issues emerged from this. It is more expensive to place an implanted port and if it becomes infected or the patient becomes septic, then another operation is required to remove the port. The port is accessed by a Huber needle. Ports are very useful for Oncology patients who may have limited venous access and require INTERMITTENT therapy where a needle is placed on a weekly basis or as needed. For most PN patients, PN is daily and the practice is to leave the Huber needle in place from infusion to infusion. This increases the risk for infection and thus decreases the potential infection reduction desired by selection of a port.

Howard et al., (1989) explored implanted versus tunneled catheters in the home PN population. Of the fifty-eight patients that were included in the 5-year study, a subset of this group had experience with both types of catheters. Although infectious complications were similar for both types of catheters, patients with implanted ports not only had fewer mechanical complications with clotting, but also had the unique complication of skin erosion of the overlying skin resulting in skin ulceration and reservoir erosion. The authors recommend selecting a site for the implanted port where there is a small amount of subcutaneous fat so erosion through taut skin would be less likely as well as rotating the needle site to avoid skin ulceration caused by placing the Huber needle in the same site with each cannulation. Patient involvement with CVAD selection is important because a frank discussion of the options must include possible complications, ability for independence in access care, and body image.

Controversies in detail

Lock therapies

Antibiotic versus ethanol lock

Catheter related blood stream infection (CRBSI) is one of the most important and potentially life threatening risk to patients receiving Parenteral Nutrition (PN). Various methods have been suggested to prevent and treat CRBSI, but controversy remains over the use of antibiotic and ethanol lock therapies. More research is warranted, specifically on the effectiveness of ethanol lock, to clarify the advantages it may offer over antibiotic lock.

  • Antibiotic and ethanol lock therapies have been utilized in the home PN population for both treatment and prevention of CRBSI. Ethanol has been used over the years to treat central venous access device (CVAD) occlusions from lipid emulsions. More recently, ethanol lock therapy was developed as a means to avoid the drawbacks of antibiotic lock and focus on prevention of CRBSI. Although studies with ethanol lock have shown positive results, more research is needed, especially randomized trials.

  • Ethanol lock is utilized as a proactive preventative therapy and not for the treatment of CRBSI. Antibiotic lock is used in conjunction with systemic antibiotics for treatment of CRBSI.

  • Currently many societies and insurance providers do not support the use of ethanol lock due to the lack of data on optimal dwell time, concentration, and proven effectiveness from randomized controlled trials.

  • The inherent flaw of utilizing antibiotic lock is the potential for development of resistance or development of more virulent organisms such as yeast. This is of particular concern for patients requiring PN therapy either long-term or for life. Experts caring for patients requiring long-term home PN are proponents of ethanol lock therapy and focusing research efforts to validate their findings from clinical use.

    • Opilla et al. (2007): A small study showing promise for ethanol lock therapy that was specific to the home PN population. Nine HPN patients with history of CRBSI were given 25-70% ethanol lock in Groshong PICCs for a 2-4 hour dwell time. A significant reduction in CRBSI was observed.

      • Pre-ethanol lock therapy: 81 infections in nine patients (8.3 per 1,000 catheter-days)

      • Post-ethanol lock therapy: Nine infections (2.7 per 1000 catheter-days)

  • The Centers for Disease Control and Prevention (CDC) 2002 Guidelines: Routine use of antibiotic lock is not recommended (only in special circumstances: recurrent CRBSIs in long-term cuffed CVADs where aseptic technique is not the culprit). Resistance is of concern with routine prophylactic use.

  • No recommendations for the use of ethanol lock has been given by the CDC or the Infectious Disease Society of America (IDSA)

Taurolidine lock

Beyond the controversy of antibiotic and ethanol locks, taurolidine lock is coming to the forefront in European research as another potential therapy to benefit patients receiving PN by preventing CRBSI. Although not currently available in the United States, Taurolidine raises similar questions as antibiotic and ethanol locks (i.e., optimal dwell time, concentration, any potential for resistance or development of “super bugs,” catheter stability with long-term use, toxicity, effect on quality of life in home PN patients etc.).

  • Taurolidine has been used in chemotherapy, hemodialysis, and home PN patients with CVADs for prevention of CRBSI without reports of resistance

  • It is an antiseptic agent, derived from aminosulphonic acid and taurinamide having both fungicidal and bactericidal properties

  • Taurolidine prevents bacterial adhesion to biological surfaces by methylol taurinamide reacting with bacterial cell walls

  • Taurolidine therapy appears promising, but little is known about the long-term use in patients receiving PN and multicenter trials are needed before routine clinical use can be strongly recommended

  • Possible variation of dwell time of Taurolidine between studies may influence interpreting the benefits of this therapy

  • Proponents of this therapy focus on the decrease in CRBSI without adverse effects

    • Bisseling et al. (2010). Thirty home PN patients with history of CRBSI were assigned to receive either Taurolidine or Heparin lock.

      • Taurolidine group (intervention): One infection

      • Heparin group (control): Ten infections

      • Cross over from heparin to taurolidine: One infection

    • Jurewitsch et al. (2005). Seven home PN patients with recurrent episodes of CRBSI were given Taurolidine as a daily lock for 12 hours. Patient’s had either a newly placed CVAD or had a history of using antibiotic lock therapy with a salvaged CVAD.

      • Pre-taurolidine therapy: 10.8 infections per 1,000 catheter days

      • Post-taurolidine therapy: 0.8 infections per 1000 catheter days

    • Solomon et al. (2010): Renal population. Dialysis catheters were locked with either Taurolidine or heparin from placement of the catheter. Although the sample size was small.

      • Taurolidine group: Eleven episodes of bacteremia (1.4 episodes/1000 patient days, fewer infections from gram negative organisms, increased need for thrombolytic agents was noted.

      • Heparin group: Twenty-three episodes of bacteremia (2.4 episodes/1000 patient days)

Bacteremia was not limited to only CRBSI in this study which may skew the ability to interpret results as taurolidine would only be helpful for prevention of CRBSI and not other sources of bacteremia.

See Table II for the benefits and drawbacks of antibiotic and ethanol locks.

Table II

Intravenous fat emulsions in the ICU setting

Lipids are among one of the topics that have leaders in the nutrition support field divided in opinion. In the United States only long chain, W-6 or pro-inflammatory soy based lipid emulsions are available. The timing of when to introduce parenteral lipid emulsions during trauma or in critical care settings remains unsettled. Intravenous fat emulsions have the advantage of providing a large amount of calories in a small volume, however; this is not without risk. Lipids may be hepatotoxic and large doses of intravenous lipid emulsions given long-term (i.e., with those receiving PN long-term or indefinitely) may have consequences.

  • If the availability of lipid emulsions in the United States mirrored those in Europe, the long-term delivery of fat may not be as troublesome to the liver

  • At present, W-3 based fish oils are only available in the United States for compassionate use (mainly in the pediatric population)

    • Experts practicing in nutrition support have differing opinions regarding:

      • When to initiate intravenous fat emulsions

      • How fat much to provide and how frequently

      • The rate of infusion of intravenous fat emulsions

  • The general recommendation is not to exceed of 1 gram/kg of lipid, discontinue lipids promptly when adequate fat is tolerated via the enteral route, and monitor liver function.

  • Yeast is lipophilic and fat emulsions should therefore be withheld during episodes of fungemia

  • Timing of intravenous lipid emulsions related to infections earns a closer look and more research to fully understand this relationship

    • Battistella et al. (1997)

      • Trauma patients in the ICU were randomized to receive fat emulsions (both DiprivanÒ and parenteral fat emulsions were included) or to have fat withheld for the first 10 days

      • Patients did not receive full energy requirements during the study period

      • Results (related to infection): Lipid emulsion within the first 10 days (72 infections in 30 patients), no lipid emulsion for the first 10 days (39 infections in 27 patients)

      • Patients exposed to lipid emulsions early experienced increased length of stay (both hospital & ICU), increased ventilator days, increased infections

      • It is unclear if underfeeding influenced the results of this study

    • Society for Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition (SCCM / A.S.P.E.N.) ICU Nutrition Guidelines

      • Recommends withholding intravenous fat emulsions for the first 7 days of PN therapy (Grade D recommendation). Not strong evidence (Grade A thru E rating)

    • Canadian guidelines

      • Recommends to consider holding lipid emulsions when tolerance to some enteral nutrition is established or if short term PN to be provided (less than 10 days)

      • Insufficient data to make a recommendation regarding withholding lipid emulsions in critically ill patients who are malnourished or patients requiring PN long term (greater than 10 days

    • German guidelines

      • Recommends administering lipid emulsions within ≤ 7 days after starting PN to avoid essential fatty acid deficiency

    • European Society for Parenteral and Enteral Nutrition (ESPEN) Guidelines and United Kingdom Guidelines

      • Timing of introduction of lipid emulsions with PN not addressed at time of publication

Biopatch®

Multiple methods have been suggested to decrease CRBSI. The Biopatch® is a chlorhexidine-impregnated sponge that is applied to the exit site of CVADs (specifically short term, temporary CVADs) for prevention of CRBSI. The Biopatch® provides a continuous release of chlorhexidine until the dressing is changed.

  • In short term CVADs, the insertion site is the most common route of infection.

    • The Biopatch® is designed to decrease bacterial colonization of the skin where the catheter is inserted and has shown good results.

    • Timsit et al. (2009)

      • Major catheter related-infections were decreased by 60% in the ICU with use of a chlorhexidine-impregnated sponge when applied onto the exit site of short term catheters (non antibiotic or antiseptic impregnated arterial and/or temporary central-vein catheters)

      • Contact dermatitis was noted in eight patients, leading to chlorhexidine-impregnated sponge removal permanently

  • In long-term, tunneled CVADs (Hickman, Broviac, Groshong) the hub of the catheter is noted to be the most common route of infection (not the insertion site), however; the Biopatch® isn’t designed to prevent infection via the hub.

    • Biopatch® is well studied in short-term catheters, but no evidence exists for use in long-term tunneled catheters and no research has been done on the potential benefits this product can offer in long-term tunneled CVADs

    • Multiple questions regarding use of the Biopatch® remain for patients with long-term CVADs, including home PN patients

      • Does the Biopatch® prevent infections long-term?

      • Are there benefits of the Biopatch® once the cuff on long-term tunneled CVADs adheres to the skin?

      • Are there any benefits of the Biopatch® before the exit site is healed?

      • Are there benefits of the Biopatch® once the exit site is healed?

  • The Biopatch® was designed and targeted to decrease infections from bacterial colonization of the skin, which is most problematic for short-term catheters becoming infected. It is unclear if using the Biopatch® with use on long-term catheters, where skin contamination is not the primary route of infection, is beneficial. Further research is needed to understand its role beyond the use in short term catheters.

What national and international guidelines exist related to infection control and nutrition services and total parenteral nutrition?

  • Both national and international evidence based guidelines are available for nutrition support. Specific nutrition guidelines also exist for specialized states such as kidney disease, hematopoietic cell transplantation, and adult critical illness from the A.S.P.E.N. General guidelines exist for use of enteral and parenteral nutrition.

  • As medicine moves to incorporate evidence based approach into daily nutrition care, these guidelines are valuable to assist clinicians, however; are not intended to take the place of clinical judgment.

  • Each society has developed separate nomenclature for grading systems and rating the level of evidence. Comparing recommendations between societies can often be a challenge until the nomenclature between societies has been reviewed.

    • Noting the date of publication of the guidelines will also be helpful in understanding why societies possibly rate the same topic differently. Guidelines are fluid and are commonly updated by the society as new research is brought forward.

  • All practitioners working with patients receiving PN via a CVAD should be familiar with guidelines on prevention, diagnosis, and management of CRBSI from IDSA and the CDC.

National guidelines: nutrition support

  • Society for Critical Care Medicine and A.S.P.E.N.ICU Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill patient – 2009

  • A.S.P.E.N. Enteral Nutrition Practice Recommendations – 2009

  • A.S.P.E.N. - Safe Practices for Parenteral Nutrition – 2004

  • A.S.P.E.N. Clinical Guideline: Nutrition Support in Adult Acute and Chronic Renal Failure – 2010

  • A.S.P.E.N. Clinical Guideline: Nutrition Support Therapy During Adult Anticancer Treatment and in Hematopoietic Cell Transplantation – 2009

International guidelines: nutrition support

  • Canadian Clinical Practice Guidelines for Nutrition Support in Mechanically Ventilated, Critically Ill patients – 2003 / Revision – 2009

  • ESPEN Guidelines on Parenteral Nutrition: Central Venous Catheters (access, care, diagnosis, and therapy of complications) – 2009

  • ESPEN Guidelines on Parenteral Nutrition: Intensive Care – 2009

  • ESPEN Guidelines on Enteral Nutrition: Intensive Care – 2006

  • United Kingdom Guidelines on Adult Nutrition Support – 2010

  • Guidelines on Parenteral Nutrition from the German Society for Nutritional Medicine – 2007

Infectious disease guidelines: nutrition related

  • Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update by the Infectious Diseases Society of America

  • CDC: Guidelines for the Prevention of Intravascular Catheter-Related Infections – 2002

See Table III and Table IV below for more information regarding the national and international guidelines.

Table III

Table IV

References

Al-Omran, M, Albalawi, ZH, Tashkandi, MF, Al-Ansary, LA. "Enteral vs. parenteral nutrition for acute pancreatitis". Cochrane Database Syst Rev. vol. 20. 2010. pp. 1-56.

(A nice overview of the routes of nutrition support specific to the pancreatitis population.)

Bankhead, RR, Fang, JC, Gottschlich, MM, DeLegge, MH, Mattox, T, Mueller, C, Worthington, P. "The A.S.P.E.N. Nutrition Support Core Curriculum: a case based approach – the adult patient. 2007". American Society for Parenteral and Enteral Nutrition. Silver Spring. 2007. pp. 233-245.

(Excellent nutrition support reference from A.S.P.E.N. suitable for any nutrition support or general practitioner.)

Bern, MM, Lokich, JJ, Wallach, SR, Bothe, A, Benotti, PN, Arkin, CF. "Very low doses of warfarin can prevent thrombosis in central venous catheters". Ann Intern Med. vol. 112. 1990. pp. 423-428.

(This study discusses the benefits of prophylactic anticoagulation in patients with a CVAD.)

Bisseling, TM, Willems, MC, Versleijen, MW, Hendriks, JC, Vissers, RK, Wanten, GJ. "Taurolidine lock is effective in preventing catheter-related bloodstream infections in patients on home parenteral nutrition: a heparin-controlled prospective trial". Clinical Nutrition. 2010.

(Taurolidine is a promising therapy for prevention of catheter related blood stream infections currently used in Europe, but not yet available for use in the United States.)

Boraks, P, Seale, J, Price, J, Bass, G, Ethell, M, Keeling, D. "Prevention of central venous catheter associated thrombus using minidose warfarin in patients with haematological malignancies". Br J Haematol. vol. 101. 1998. pp. 483-486.

(This study discusses the benefits of prophylactic anticoagulation in patients with a CVAD.)

Braunschweig, CL, Levy, P, Sheean, PM, Wang, X. "Enteral compared with parenteral nutrition: a meta-analysis". Am J Clin Nutr. vol. 74. 2001. pp. 534-542.

(Noteworthy meta-analysis for determining when to use parenteral nutrition based on nutritional status.)

Cadman, A, Lawrance, JAL, Fitzsimmons, L, Spencer-Shaw, A, Swindell, R. "To clot or not to clot? That is the question in central venous catheters". Clin Radiol. vol. 59. 2004. pp. 349-355.

(This paper makes the point that the safest catheter tip location is at the junction of lower third of the Superior Vena Cava and the right atrium to prevent thrombus.)

"Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular catheter related infections". MMWR. vol. 51. 2002. pp. 1-29.

(All health care professionals caring for patients with a CVAD should be familiar with these recommendations by the CDC.)

Crinch, CJ, Halfmann, JA, Crone, WC, Maki, DG. "The effects of prolonged ethanol exposure on the mechanical properties of polyurethane and silicon catheters used for intravascular access". Infect Control Hosp Epidemiol. vol. 26. 2005. pp. 708-714.

(A well-done investigation to showing ethanol lock for 10 weeks will not affect the physical properties of catheters.)

Crnich, CJ, Maki, DG. "The promise of novel technology for the prevention of intravascular device-related blood stream infection. I. Pathogenesis and short term devices". Clin Infect Dis. vol. 34. 2002. pp. 1232-1342.

(CRBSI is the greatest risk with presence of a CVAD. Part I and II of this article series discusses the pathogenesis of infection in both long and short term devices along with advances to prevent infections.)

Crnich, CJ, Maki, DG. "The promise of novel technology for the prevention of intravascular device-related bloodstream infection. II. Long term devices". Clin Infect Dis. vol. 34. 2002. pp. 1362-1368.

(CRBSI is the greatest risk with presence of a CVAD. Part I and II of this article series discusses the pathogenesis of infection in both long and short term devices along with advances to prevent infections.)

Cober, MP, Johnson, CE. "Stability of 70% alcohol solutions in polypropylene syringes for use in ethanol-lock therapy". Am J Health Syst Pharm. vol. 64. 2007. pp. 2480-2482.

(A good reference for stability of 70% ethanol in syringes for preparation of ethanol lock.)

Couban, S, Goodyear, M, Burnell, M, Dolan, S, Wasi, P, Barnes, D. "Randomized placebo controlled study of low dose warfarin for the prevention of central venous catheter-associated thrombus in patients with cancer". J Clin Oncol. vol. 23. 2005. pp. 4063-4069.

(This study discusses the benefits of prophylactic anticoagulation in patients with a CVAD.)

Dannenberg, C, Bierback, U, Rothe, A, Beer, J, Korholz, D. "Ethanol lock technique in the treatment of bloodstream infections in pediatric oncology patients with broviac catheter". J Pediatr Hematol Oncol. vol. 25. 2003. pp. 616-625.

(A reporting the pediatric literature for use of ethanol lock for treatment of a CRBSI in contrast to the established use of ethanol lock for prevention of CRBSI.)

DeChicco, R, Seidner, DL, Brun, C, Steiger, E, Stafford, J, Lopez, R. "Tip position of long-term central venous access devices used for parenteral nutrition". JPEN J Parenter Enteral Nutr. vol. 31. 2007. pp. 382-387.

(This paper makes the point that the safest catheter tip location is at the junction of lower third of the superior vena cava and the right atrium.)

Dezfulian, C, Lavelle, J, Nallamothu, BK, Kaufman, SR, Saint, S. "Rates of infection for single-lumen versus multilumen central venous catheters". Crit Care Med. vol. 31. 2003. pp. 2385-2390.

(This reference discusses the age old question: Do multilumen catheters place patients at higher risk of a CRBSI. Temporary CVADs were studied and not long term tunneled catheters commonly utilized in the home PN population.)

Dobbins, BM, Catton, JA, Kite, P, McMahon, MJ, Wilcox, MH. "Each lumen is a potential source of central venous catheter-related bloodstream infection". Crit Care Med. vol. 31. 2003. pp. 1688-1690.

(Excellent reference to support obtaining cultures from each lumen of a multilumen catheters for proper diagnosis of CRBSI.)

Gadek, JE, DeMichele, SJ, Karlstad, MD. "Effect of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid and antioxidants in patients with acute respiratory distress syndrome". Crit Care Med. vol. 27. 1999. pp. 1409-1420.

(Evidence to support a specialized blend of fat and antioxidants in an enteral tube feeding product for treatment of ARDS.)

Heyland, DK, MacDonald, S, Keefe, L, Drover, JW. "Total parenteral nutrition in the critically ill patient: a meta-analysis". JAMA. vol. 280. 1998. pp. 2013-2019.

(A noteworthy meta-analysis for determining when to use parenteral nutrition based on nutritional status.)

Howard, L, Claunch, C, McDowell, R, Timchalk, M. "Five years experience in patients receiving home nutrition support with the implanted reservoir: a comparison with the external catheter". JPEN J Parenter Enteral Nutr. vol. 13. 1989. pp. 478-483.

(CVAD access devices are compared (implanted port versus tunneled catheters) for use in long-term PN.)

Kirby, DF, DeLegge, MH, Fleming, CR. "American Gastroenterological Association technical review on tube feeding for enteral nutrition". Gastroenterology. vol. 108. 1995. pp. 1282-1301.

(An excellent review by expert clinicians of enteral nutrition and enteral access devices.)

Kirby, DF, Opilla, M, Merritt, R, DeLegge, MH, Holcombe, B, Mueller, C, Ochoa, J, Ringwald Smith, K, Schwenk II, WF. "Enteral access and infusion equipment". The A.S.P.E.N. Nutrition Support Practice Manual. vol. 2nd edition. 2005. pp. 54-62.

(Excellent nutrition support reference from A.S.P.E.N. suitable for any nutrition support or general practitioner.)

Kirkpatrick, A, Rathbun, S, Whitsett, T, Raskob, G. "Prevention of central venous catheter associated thrombus: a meta-analysis". Am J Med. vol. 120. 2007. pp. 901-910.

(This meta analysis reviews the literature on prophylactic anticoagulation in patients with a CVAD.)

Krzywda, EA, Andris, DA, Edminston, CE, Wallace, JR, Gottschlich, MM, DeLegge, MH, Mattox, T, Mueller, C, Worthington, P. "Parenteral access devices". The A.S.P.E.N. Nutrition Support Core Curriculum: a case based approach – the adult patient. 2007. 2007. pp. 300-322.

(Excellent nutrition support reference from A.S.P.E.N. suitable for nutrition support professionals.)

Lysen, LK, Matarese, LE, Gottschlich, MM. "Enteral Equipment". Contemporary nutrition support practice, a clinical guide. 2003. pp. 201-214.

(A reference that is a nice accompaniment to the A.S.P.E.N. references covering a variety of nutrition support topics.)

Maiefski, M, Rupp, ME, Hermsen, ED. "Ethanol lock technique: review of the literature". Infect Control Hosp Epidemiol. vol. 30. 2009. pp. 1096-1108.

(A current review of the literature pertaining to ethanol lock.)

Maki, DG, Kluger, DM, Crnich, CJ. "The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies". Mayo Clin Proc. vol. 81. 2006. pp. 1159-1171.

(An excellent analysis of CRBSI based on the type of CVAD and therapy utilized via the CVAD.)

Maki, DG, Crnich, CJ, Safdar, N. "Successful use of a 25% alcohol lock solution for prevention of recurrent CVC-related bloodstream infection in a patient on home TNA". Abstract presented at: 42nd interscience conference on antimicrobial agents and chemotherapy. 2002.

Marra, AR, Opilla, M, Edmond, MB, Kirby, DF. "Epidemiology of blood stream infections in patients receiving long-term parenteral nutrition". J Clin Gastroenterol. vol. 41. 2007. pp. 19-28.

(A nice study describing the types of organisms leading to CRBSI in home PN patients.)

McClave, SA, Martindale, RG, Vanek, WV, McCarthy, M, Roberts, P, Taylor, B. "Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patients". JPEN J Parenter Enteral Nutr. vol. 33. 2009. pp. 277-316.

(Excellent resource - the premier adult ICU nutrition guidelines from the Society for Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition.)

McClave, SA, Chang, WK, Dhaliwal, R, Heyland, DK. "Nutrition support in acute pancreatitis: a systematic review of the literature". JPEN J Parenter Enteral Nutr. vol. 30. 2006. pp. 143-156.

(A great review of acute pancreatitis and evidence based nutrition interventions, specifically utilizing the enteral route.)

Mermel, LA, Allon, M, Bouza, E, Craven, DE, Flynn, P. "Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America". Clin Infect Dis. vol. 49. 2009. pp. 1-45.

(A thorough and useful resource that should be well known for any clinician working with patients that have a CVAD and therefore a potential risk of CRBSI.)

Merrer, J, DeJonghe, B, Golliot, F, Lefrant, J, Raffy, B, Barre, E. "Complications of femoral and subclavian venous catheterization in critically ill patients". JAMA. vol. 286. 2001. pp. 700-707.

(A study comparing location of CVADs with infection and complications.)

Metcalf, SC, Chambers, ST, Pithie, AD. "Use of ethanol locks to prevent recurrent central line sepsis". J Infect. vol. 49. 2004. pp. 20-22.

(Another study supporting the use of ethanol lock for prevention of CRBSI.)

Metheny, NA, Meert, KL, Clouse, RE. "Complications related to feeding tube placement". Curr Opin Gastroenterol. vol. 23. 2007. pp. 178-182.

(Enteral tube placement complications such as malpositioned feeding tubes, aspiration, perforation, and sinusitis are discussed.)

Moureau, N, Poole, S, Murdock, MA, Gray, SM, Semba, CP. "Central venous catheters in home infusion care: outcomes analysis in 50,470 patients". J Vasc Interv Radiol. vol. 13. 2002. pp. 1009-1016.

(This article discusses complications of CVADs in the home settings (from thrombus, mechanical complications, and infectious complications).)

Mouw, E, Chessman, K, Lesher, A, Tagge, E. "Use of an ethanol lock to prevent catheter-related infections in children with short bowel syndrome". J Pediatric Surgery. vol. 43. 2008. pp. 1025-1029.

(Adults as well as the pediatric PN population can benefit from ethanol lock for the prevention of CRBSI.)

Opilla, MT, Kirby, DF, Edmond, MB. "Use of ethanol lock therapy to reduce the incidence of catheter related blood stream infections in home parenteral nutrition patients". JPEN J Parent Enteral Nutr. vol. 31. 2007. pp. 302-305.

Pomplun, M, Johnson, JJ, Johnston, S, Kolesar, JM. "Stability of a heparin-free 50% ethanol lock solution for central venous catheters". J Oncol Pharm Practice. vol. 13. 2007. pp. 33-37.

(Stability data for compounding ethanol lock is available from this reference.)

Pontes-Arruda, A, Aragao, AMA, Albuquerque, JD. "Effects of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in mechanically ventilated patients with severe sepsis and septic shock". Crit Care Med. vol. 34. 2006. pp. 2325-2333.

(Evidence to support a specialized blend of fat and antioxidants in an enteral tube feeding product for treatment of patients with sepsis.)

Popovich, MJ, Lockrem, JD, Zivot, JB. "Nasal bridle revisited: an improvement in the technique to prevent unintentional removal of small bore nasoenteric feeding tubes". Crit Care Med. vol. 24. 1996. pp. 429-431.

(Description of a new method to bridle a feeding tube to prevent accidental removal.)

Popovich, MJ. "The bridle: path to improved enteral nutrition efficiency". Crit Care Med. vol. 38. 2010. pp. 984-985.

(Although not the inventor of the bridle, this author shows efficacy and safety of the bridling technique by improving the device with new materials.)

Raad, II, Hohn, DC, Gilbrath, BJ, Suleiman, N, Hill, LA, Bruso, PA. "Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion". Infect Control Hosp Epidemiol. vol. 15. 1994. pp. 231-238.

(Prevention of CRBSI begins with insertion as clearly depicted in this study and will also positively affect costs to the health care system.)

Ruesch, S, Walder, B, Trammer, M. "Complications of central venous catheters: internal jugular versus subclavian access - a systematic review". Crit Care Med. vol. 30. 2002. pp. 454-460.

(A systematic review on placement of CVADs.)

Sands, MJ. "Vascular access in the adult home infusion patient". JPEN J Parent Enteral Nutr. vol. 30. 2006. pp. S57-S64.

Different types of vascular access commonly used for PN are described and pictured. (The many CXR, MRI, and ultrasound images are very helpful in demonstrating CVAD placement and complications.)

Seder, CW, Janczyk, R. "The routine bridling of nasojejunal tubes is a safe and effective method of reducing dislodgement in the intensive care unit". Nutr Clin Pract. vol. 23. 2008. pp. 651-654.

(Another reference, along with Popovich et al. to support the use of a nasal bridle for securing feeding tubes, but the authors also discuss cost savings and complications.)

Seder, CW, Stockdale, W, Hale, L, Jancyk, R. "Nasal bridling decreases feeding tube dislodgement and may increase caloric intake for the surgical intensive care unit: a randomized controlled trial". Crit Care Med. vol. 38. 2010. pp. 797-801.

(This author has previously studied the use of the nasal bridle for not only securing the tube and decreasing costs associated with replacing tubes. This article also includes how nutrient delivery is impacted with use of a bridle.)

Segarra-Newnham, M, Martin-Cooper, EM. "Antibiotic lock technique: a review of the literature". Ann Pharmacother. vol. 39. 2005. pp. 311-318.

(A nice review of antibiotic lock for treatment and prevention of CRBSI.)

Singer, P, Theilla, M, Fisher, H, Gibstein, L, Grozovski, E, Cohen, J. "Benefit of an enteral diet enriched with eicosapentaenoic acid and gamma-linolenic acid in ventilated patients with acute lung injury". Crit Care Med. vol. 34. 2006. pp. 1033-1038.

(Evidence to support a specialized blend of fat and antioxidants in an enteral tube feeding product for treatment of ALI.)

Steiger, E. "Vascular access for parenteral nutrition". Nutrition and Gastrointestinal Disease, DeLegge MH. Humana Press. 2008. pp. 289-298.

(An excellent overview by an expert on vascular access.)

Steiger, E. "Dysfunction and thrombotic complications of vascular access devices". JPEN J Parent Enteral Nutr. vol. 30. 2006. pp. S70-S72.

(Every clinician caring for a patient with a CVAD on home PN should be familiar with the signs and symptoms of the complications discussed within this article.)

Steiger, E. "Consensus statements regarding optimal management of home parenteral nutrition access". JPEN J Parent Enteral Nutr. vol. 30. 2005. pp. S94-95.

(Key recommendations about CVADs for patients on home PN authored the physician who developed the home PN program at the Cleveland Clinic.)

Timsit, JF, Schwebel, C, Bouadma, L, Geffroy, A, Garrouste-Orgeas, M, Pearse, S. "Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial". JAMA. vol. 301. 2009. pp. 1231-1241.

(This study looks at the use of a chlorhexidine-impregnated sponge over the insertion site of a CVAD and how it relates to CRBSI.)

Young, AM, Billingham, LJ, Begurn, G, Kerr, KJ, Hughes, AI, Rea, DW. "Warfarin thromboprophylaxis in cancer patients with central venous catheters (WARP): and open-label randomized trial". Lancet. vol. 373. 2003. pp. 567-574.

(This study discusses the benefits of prophylactic anticoagulation in patients with a CVAD.)

August, DA, Huhmann, MB. "A.S.P.E.N. clinical guidelines: nutrition support therapy during adult anticancer treatment and in hematopoietic cell transplantation". JPEN J Parenter Enteral Nutr. vol. 33. 2010. pp. 472-500.

(A recommended nutrition reference for professionals caring for these patients.)

Bankhead, R, Boullata, J, Brantley, S, Corkins, M, Guenter, P, Krenitsky, J. "Enteral practice recommendations". JPEN J Parenter Enteral Nutr. vol. 33. 2009. pp. 122-167.

(Specific recommendations for only enteral nutrition for daily practice and nursing care.)

Battistella, FD, Widergren, JT, Anderson, JT, Siepler, JK, Weber, JC, MacColl, K. "A prospective, randomized trial of intravenous fat emulsion administration in trauma victims requiring total parenteral nutrition". J Trauma. vol. 43. 1997. pp. 52-58.

(An interesting study evaluating infectious outcomes in ICU patients receiving parenteral lipid emulsions or DiprivanÒ.)

Bisseling, TM, Willems, MC, Versleijen, MW, Hendriks, JC, Vissers, RK, Wanten, GJ. "Taurolidine lock is effective in preventing catheter-related bloodstream infections in patients on home parenteral nutrition: a heparin-controlled prospective trial". Clinical Nutrition. 2010.

(Excellent study showing Taurolidine as a promising therapy for prevention of CRBSI in patients on home PN.)

Brown, RO, Compher, C. "A.S.P.E.N. clinical guidelines: nutrition support in adult acute and chronic renal failure". JPEN J Parenter Enteral Nutr. vol. 34. 2010. pp. 366-377.

Specific recommendations for renal patients requiring nutrition support.

Heyland, DK, Dhaliwal, R, Drover, JW, Gramlich, L, Dodek, P. "Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients". vol. 27. 2003. pp. 355-373.

(The Canadian Guidelines and other important research findings of this group.)

Jurewitsch, B, Jeejeebhoy, KN. "Taurolidine lock: the key to prevention of recurrent catheter-related blood stream infections". Clin Nutr. vol. 24. 2005. pp. 492-465.

(An early study with home PN patients with recurrent CRBSIs showing a positive effect with use of Taurolidine.)

Koletzko, B, Jauch, KW, Verwied-Jorky, S, Krohn, K, Mittal, R. "Guidelines on parenteral nutrition from the German society for nutritional medicine (DEGM) - overview". Ger Med Sci. vol. 7. 2009.

(Guidelines on nutrition support, specifically PN, from the German society.)

Kreymann, KG, Berger, MM, Deutz, NEP, Hiesmayr, M, Jolliet, P, Kazandjiev, G. "ESPEN guidelines on enteral nutrition: intensive care". Clin Nutr. vol. 25. 2006. pp. 210-223.

(One of the three key guidelines for nutrition support in the ICU setting from ESPEN.)

McClave, SA, Martindale, RG, Vanek, WV, McCarthy, M, Roberts, P, Taylor, B, Ochoa, JB, Napolitano, L, Cresci, G. "Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patients". JPEN J Parenter Enteral Nutr. vol. 33. 2009. pp. 277-316.

(Excellent resource - the premier adult ICU nutrition guidelines from the American Society for Parenteral and Enteral Nutrition.)

Mirtallo, J, Canada, T, Johnson, D, Kumpf, V, Peterson, C, Sacks, G, Seres, D, Guenther, P. "Safe practices for parenteral nutrition". JPEN J Parenter Enteral Nutr. vol. 28. 2004. pp. S39-70.

(Key recommendations for labeling, pharmacy procedures for PN, and ensuring safe delivery of PN.)

"Nutrition support in adults". NICE Clinical Guideline No. 32. 2006.

(Nutrition support guidelines from the United Kingdom.)

Opilla, MT, Kirby, DF, Edmond, MB. "Use of ethanol lock therapy to reduce the incidence of catheter related blood stream infections in home parenteral nutrition patients". JPEN J Parent Enteral Nutr. vol. 31. 2007. pp. 302-305.

(A nice study describing the use and experience of ethanol lock in the home PN population.)

Pittiruti, M, Hamilton, H, Biffi, R, MacFie, J, Pertkiewicz, M. "ESPEN guidelines on parenteral nutrition: central venous catheters (access, care, diagnosis and therapy of complications)". Clin Nutr. vol. 24. 2009. pp. 365-377.

(One of the three key guidelines for nutrition support in the ICU setting from ESPEN.)

Singer, P, Berger, MM, Van den Berghe, G, Biolo, G, Calder, P, Forbes, A, Griffiths, R, Kreyman, G, Leverve, X, Pichard, C. ESPEN Guidelines on parenteral nutrition: intensive care. vol. 28. 2009. pp. 387-400.

(One of the three key guidelines for nutrition support in the ICU setting from ESPEN.)

Solomon, LR, Cheesbrough, JS, Ebah, L. "A randomized double-blind controlled trial of taurolidine-citrate catheter locks for the prevention of bacteremia in patients treated with hemodialysis". Am J Kidney Diseases. vol. 55. 2010. pp. 1060-1068.

(Like other lock therapies, Taurolidine has shown effects not only in the PN population, but also the hemodialysis population.)

Timsit, JF, Schwebel, C, Bouadma, L, Geffroy, A, Garrouste-Orgeas, M, Pease, S. "Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter related infections in critically ill adults". JAMA. vol. 301. 2009. pp. 1231-1241.

(Large study showing positive effects of the Biopatch® to reduce infections in ICU patients with short-term catheters.)
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