Central line management: Difficulties in a patient with short bowel syndrome

Abstract

Short bowel syndrome (SBS) is responsible of chronic intestinal malabsortion of nutrients, due to a loss of at least 50% of the small bowel absorption surface. The main causes are necrotizing enterocolitis (NEC), intestinal atresia, volvulus and gastroschisis. The incidence of SBS is about 24.5/100,000 newborns. These patients need a central venous access to allow a long-term parenteral nutrition. Complications such as infections, mechanical problems due to catheter insertion (as pleural effusion or cardiac tamponade), thromboembolism and vascular fibrin-lipid or calcium phosphate occlusion may occur. Central venous catheter (CVC) sepsis is one of the main causes of morbidity and mortality in patients with SBS and central venous access. Rates of infection in pediatric patients with SBS range from 1 to 6:1000 days of parenteral nutrition (PN). Intestinal decontamination may prove useful to counteract the over-bacterial growth: antimicrobials are typically administered cyclically, alternating different drugs in order to reduce bacterial resistance. However, decontamination treatment remains largely empirical due to lack of available scientific data. We describe the case of one of our patient affected by SBS who presented several episodes of CVC-mediated-sepsis. A 34weeks female (born after twin pregnancy) underwent ileocolonic resection (including the ileo-cecal valve) at 4th day of life forNEC,with 65 cmof small bowel residual anddistal colon. PNwas started immediately after surgery, following central line insertion. Shewas fully PNdependent until 6months of age and subsequently enteral feeding through gastrostomy was progressively increased. Currently (18months of age) her nutritional requirements are covered by 50% PN and 50% hydrolyzed formula. The clinical course has been characterized by 4 CVC related sepsis, initially treated with lock therapy (urokinase) and systemic antibiotics. In 4 of those episodes (1 case of Candida sepsis and 3 cases of medical treatment’s failure) line replacement has been required, despite antimicrobial prophylaxis. Three further central line replacements were needed because of accidental dislocation of the catheter. Overall she had 7 different lines inserted: 5 catheters surgically placed (3 Broviac and 2 Groshong lines) and 2 more central vascular accesses percutaneously placed. The average length of each catheter was found to be 45 days. It was not possible to identify any immunological underlyingdisease or predisposing familiar risk factors, possibly responsible for those episodes. Recently, a more intensive antibiotic intermittent prophylaxis regimen (including Metronidazole or Ciprofloxacin associated with Miconazole) has been started. No further infectious episodes have been recorded in the last 3 months. The patient is currently in good clinical condition with adequate neurocognitive development and satisfactory growth (currently auxological parameters lie between the 3rd and the 10th centile). PO4