Administration Of Parenteral Nutrition Research Articles

Ultrasound vs. standard radiography to determine peripherally-inserted central catheter tip location

Background The use of a peripherally-inserted central catheter (PICC) has increased in preterm neonates to facilitate the administration of total parenteral nutrition. Standard radiography (thoracoabdominal X-ray) is the gold standard for determining the position of the PICC tip. However, radiography is not always accurate, influenced by the position of the extremities and anatomic variations, time-consuming procedural process, involves radiation, and is costly. Ultrasonography (USG) may serve as an easier, safer, less costly, and more real-time alternative in the neonatal intensive care unit (NICU) patients. Objective To assess the accuracy of USG use in determining PICC tip position compared to that of standard radiography. Methods This diagnostic study was conducted in the NICU at Dr. Cipto Mangunkusumo Hospital, Jakarta. The PICCs were placed using standard NICU procedure, then the tip position was evaluated using the USG immediately before standard radiography was performed. A 2x2 table was constructed to compare the diagnostic accuracy of the two modalities. Results A total of 29 neonates were included in our study. Subjects’ mean gestational age and weight were 31.7 weeks and 1,618.9 g respectively. Concordance of PICC tip positioning between standard radiography and USG occurred in 27 neonates (93.1%). USG had 88.89% sensitivity, 95% specificity, and 93.1% diagnostic accuracy. Conclusion USG has excellent diagnostic accuracy for confirmation of the PICC tip position.

Parenteral Nutrition in the Critically Ill Adult: A Narrative Review.

Malnutrition in adult intensive care unit patients is associated with poor clinical outcomes. Providing adequate nutritional support to the critically ill adult should be an important goal for the intensivist. This narrative review aims to delineate the role of parenteral nutrition (PN) in meeting nutritional goals. We examined the data regarding the safety and efficacy of PN compared to enteral nutrition. In addition, we describe practical considerations for the use of PN in the ICU including patient nutritional risk stratification, nutrient composition selection for PN, route of PN administration, and biochemical monitoring.

Parenteral nutrition at home/long-term parenteral nutrition.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Some diseases require that patients receive parenteral nutrition (PN) over a prolonged time period. Long-term administration of PN can further complicate an already complex therapy, posing additional risk of potential complications. This article is based on presentations and discussions held at the International Safety and Quality of PN Summit, providing insights into aspects of home PN (HPN) and examples of good HPN practice. One critical step in the HPN process is when patients transition from a hospital to a home setting, and vice versa. Generally, electronic PN ordering is not feasible in an HPN setting, leading to potential difficulties in communication and coordination. HPN requires that patients (or their home caregivers) administer PN, and thus their education and competency are crucial. Likewise, the choice of PN formulation is of great importance. For example, using more modern intravenous lipid emulsions containing medium-chain triglycerides, olive oil, and/or fish oil can provide benefits in terms of liver function during long-term HPN. Internationally, there are wide variations in delivery of HPN, with compounded PN dominating in some countries while others make greater use of market-authorized multichamber bags (MCBs). Patient-related factors, institutional considerations, and the availability of different MCB formulations, are also contributing factors guiding formulation and delivery system preferences. Education and communication remain key components of a successful HPN process. The information shared here may help to motivate efforts to improve HPN processes and to consider the often-differing perspectives of patients and their healthcare professionals.

Y-Site Compatibility Studies of Parenteral Nutrition and Other Intravenous Medications in Neonatal and Pediatric Patients: A Review of the Literature Evidence.

Polytherapy in neonatal and pediatric patients requiring parenteral nutrition (PN) administration is a challenging task. Due to limited intravenous access, the Y-site administration of medication with PN admixtures is sometimes inevitable. This review aims to summarize the evidence on the compatibility of the Y-site of intravenous medications and PN admixtures in neonatal and pediatric settings. A literature review of the PubMed database was conducted. Articles published between January 1995 and November 2023 concerning the compatibility of intravenous medications in pediatric-dose PN admixtures or with intravenous lipid emulsions only were included. Studies concerning the compatibility/stability of the ingredients of PN admixtures and those concerning unapproved medications were excluded. Based on the methodology used, the quality of the research was assessed. A total of fifteen studies were explored. Among fifty-five different drug substances assessed in the research reviewed, 56% (31/55) were found to be compatible, 13% (7/55) were assigned as incompatible, and for 31% (17/55), the data were ambiguous. None of the studies demonstrated an "A" grade (very high quality), and the grades "B", "C", and "D" were assigned to four, six, and five studies, respectively. The compatibility data are presented in two tables, the first concerning the simultaneous administration of medications with 2-in-1 PN formulations (without lipids) and the second, with 3-in-1 formulations (with lipids) and lipid emulsions. This review presents data on compatibilities between intravenously administered medications and PN mixtures intended for neonates and pediatric patients found in the PubMed database. It should be highlighted, however, that this work has some limitations. The clinical decisions on the simultaneous administration of intravenous medication with PN admixtures should be based not only on this review (including assessment of the quality of evidence) but also on manufacturer data, available electronic databases, and incompatibility data for PN admixtures dedicated to adult patients.

The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69).

An objective and validated index of nausea and vomiting such as the Pregnancy-Unique Quantification of Emesis (PUQE) and HyperEmesis Level Prediction (HELP) tools can be used to classify the severity of NVP and HG. [Grade C] Ketonuria is not an indicator of dehydration and should not be used to assess severity. [Grade A] There are safety and efficacy data for first line antiemetics such as anti (H1) histamines, phenothiazines and doxylamine/pyridoxine (Xonvea®) and they should be prescribed initially when required for NVP and HG (AppendixIII). [Grade A] There is evidence that ondansetron is safe and effective. Its use as a second line antiemetic should not be discouraged if first line antiemetics are ineffective. Women can be reassured regarding a very small increase in the absolute risk of orofacial clefting with ondansetron use in the first trimester, which should be balanced with the risks of poorly managed HG. [Grade B] Metoclopramide is safe and effective and can be used alone or in combination with other antiemetics. [Grade B] Because of the risk of extrapyramidal effects metoclopramide should be used as second-line therapy. Intravenous doses should be administered by slow bolus injection over at least 3 minutes to help minimise these. [Grade C] Women should be asked about previous adverse reactions to antiemetic therapies. If adverse reactions occur, there should be prompt cessation of the medications. [GPP] Normal saline (0.9% NaCl) with additional potassium chloride in each bag, with administration guided by daily monitoring of electrolytes, is the most appropriate intravenous hydration. [Grade C] Combinations of different drugs should be used in women who do not respond to a single antiemetic. Suggested antiemetics for UK use are given in AppendixIII. [GPP] Thiamine supplementation (either oral 100 mg tds or intravenous as part of vitamin B complex (Pabrinex®)) should be given to all women admitted with vomiting, or severely reduced dietary intake, especially before administration of dextrose or parenteral nutrition. [Grade D] All therapeutic measures should have been tried before considering termination of pregnancy. [Grade C].

Practical Aspects of Providing Intradialytic Parenteral Nutrition for Hemodialysis Patients in Indonesia

This paper conducts a comprehensive literature review on the administration of intradialytic parenteral nutrition (IDPN) for patients undergoing hemodialysis (HD) in Indonesia. The objective is to assess the current status and challenges associated with IDPN in the country and propose potential strategies for enhancement. The review, encompassing articles published between 2013 and 2023 from databases such as PubMed, Scopus, and Google Scholar, exposes significant risks and the prevalence of malnutrition, particularly protein-energy wasting (PEW), among patients undergoing HD. This patient cohort often necessitates nutritional therapy, and IDPN emerges as a viable option for both prevention and definitive treatment. However, detailed data on malnutrition among HD patients in Indonesia are limited. Challenges include a shortage of nutrition experts in kidney care, low patient adherence to dietary advice, and the inability of Indonesian hospitals to provide IDPN to malnourished hemodialysis patients. The non-uniform cost coverage by the National Health Insurance further complicates matters, despite consumable costs for HD being uniform across all hospitals. The payment system by BPJS does not accommodate the provision of parenteral IDPN with varying prices, as listed in the e-catalog by the national public procurement agency. To offer IDPN to patients, hospitals must achieve cost-efficiency within their HD units, or they risk financial losses. Currently, IDPN is exclusively administered to HD patients with acute conditions in an inpatient setting. A recommendation for policymakers is to explore the adoption of distinct tariffs for HD patients undergoing outpatient care, particularly those managing complex conditions such as PEW. This approach can contribute to improved nutritional support for hemodialysis patients in Indonesia.

Parenteral Nutrition-Associated Sepsis and Extravasation in Iraqi Neonates: Case-Series Prospective Study

Background: Extravasation and sepsis are two of the many side effects linked to the use of intravascular devices during parenteral nutrition (PN). Objective: To assess the incidence of sepsis and extravasation in Iraqi neonates receiving PN in the critical care unit. Methods: From January 27, 2022, to January 15, 2023, a case-series prospective study was carried out in two tertiary neonatal intensive care units (NICUs) in Children Welfare Hospital and Baghdad Teaching Hospital, Baghdad, Iraq. The study reports the rate of sepsis and extravasations and correlates their occurrence to other neonatal features. Results: Of the 94 newborns examined, 24 patients (25.5%) experienced 35 instances of stage IV extravasation, and 34.04% of them experienced 40 episodes of sepsis in total. They have a strong and significant correlation with the newborns' body weight, treatment duration, gestational age, and postnatal age. Conclusions: The administration of PN to neonates in Iraq has been linked to severe side effects such as sepsis and extravasation.

Intestinal failure-associated liver disease: Current challenges in screening, diagnosis, and parenteral nutrition considerations.

Intestinal failure-associated liver disease (IFALD) is a serious life-limiting complication that can occur throughout the clinical course of intestinal failure and its management by parenteral nutrition (PN). Despite this, there is a lack of a standardized definition for IFALD, which makes this insidious condition increasingly difficult to screen and diagnose in clinical practice. Attenuating the progression of liver disease before the onset of liver failure is key to improving morbidity and mortality in these patients. This requires timely detection and promptly addressing reversible factors. Although there are various noninvasive tools available to the clinician to detect early fibrosis or cirrhosis in various chronic liver disease states, these have not been validated in the patient population with IFALD. Such tools include biochemical composite scoring systems for fibrosis, transient elastography, and dynamic liver function tests. This review article aims to highlight the existing real need for an accurate, reproducible method to detect IFALD in its early stages. In addition, we also explore the role PN plays in the pathogenesis of this complex multifactorial condition. Various aspects of PN administration have been implicated in the etiology of IFALD, including the composition of the lipid component, nutrient excess and deficiency, and infusion timing. We aim to highlight the clinical relevance of these PN-associated factors in the development of IFALD and how these can be managed to mitigate the progression of IFALD.

Effect of Zinc-Deficient Diet on Two Strains of Mice.

Zinc (Zn) deficiency is one of the most common nutritional deficiencies worldwide. It is associated with reduced nutritional status and has been reported in cases of growth retardation, alopecia, and decreased serum alkaline phosphatase (ALP). It has also been reported to occur during total parenteral nutrition (TPN) administration and is associated with various diseases, such as liver diseases, diabetes, and kidney disease. We used Zn-deficient mice of ICR and C57BL/6J strains to investigate the various effects of Zn deficiency on the body, assuming that a healthy person may also become deficient in Zn either due to an unbalanced diet or malabsorption. The results showed that a Zn-deficient diet suppressed body weight gain and increased the tissue weight of the kidneys and cecum in both strains of mice. Biochemical data showed no decrease in serum ALP activity in either strain. Furthermore, in C57BL/6J mice, a Zn-deficient diet caused alopecia, loss of villi in the small intestine, and eventually affected the intestinal mucosa, which could be a risk factor for poor nutritional status. Although previous reports have shown that serum ALP activity is decreased during Zn deficiency, this is the first study that used 4-wk-old mice of ICR and C57BL/6J strains to show that serum ALP activity, which is a Zn deficiency marker, did not decrease in the two strains of Zn-deficient mice; furthermore, a Zn-deficient diet causes various symptoms.

1680. Characterization of Ethanol Lock Use and Line Infections in Pediatric Patients with Intestinal Failure Requiring Central Venous Access

Abstract Background Pediatric patients with intestinal failure often require central venous line access for administration of parenteral nutrition and/or fluids, which leads to increased risk for central line associated-bloodstream infections (CLABSI). Ethanol lock therapy (ELT) has been used to reduce the risk of CLABSI in this patient population, but recent significant increases in the price of ethanol have prompted healthcare systems to explore cost-saving measures such as decreasing ELT frequency from daily to thrice weekly (TIW) or using antibiotic lock therapy as an alternative to ELT. The objective of this study was to compare the incidence and microbiology of CLABSI in pediatric patients with intestinal failure who received different lock therapies. Methods This was a single-center, retrospective, descriptive study that included pediatric patients who were followed by the Michigan Medicine Children’s Intestinal Rehabilitation Program between July 1, 2020 and June 30, 2022. Data were collected via the electronic health record. Incidence of CLABSI and microbiology were compared based on the type of lock therapy patients received (daily ELT, TIW ELT, or no ELT). Results A total of 46 patients were analyzed in this study, including 13 on daily ELT, 23 on TIW ELT, and 10 on no ELT. During the study period, 69% (9/13) of patients on daily ELT, 35% (8/23) of patients on TIW ELT, and 60% (6/10) of patients on no ELT had at least one CLABSI (for comparison between daily and TIW ELT, p = 0.0819). Of 75 episodes of CLABSI identified during the study period, the most commonly isolated pathogens were Staphylococcus epidermidis (n = 33), S. aureus (n = 19), S. hominis (n = 17), and Escherichia coli (n = 8). Almost half (44%, 33/75) of CLABSI reported were polymicrobial (see Table 1 for comparison of microbiology by type of lock therapy).Table 1:Number of monomicrobial vs. polymicrobial CLABSI by Gram stain results and type of lock therapy. Conclusion There was no statistically significant difference in the incidence of CLABSI between pediatric patients with intestinal failure who received TIW ELT and those who received either daily ELT or no ELT. TIW ELT appears to be an effective and cost-efficient option compared to daily ELT in this patient population. Disclosures All Authors: No reported disclosures

Evaluating the efficacy of a programme to educate nurses on CLABSI linked to total parenteral nutrition administration.

There is a major need to improve the knowledge and practice of critical care nurses in India regarding central line-associated bloodstream infection (CLABSI), which is a serious potential complication of total parenteral nutrition (TPN). To develop and validate a skills competency programme; assess knowledge and practice of critical care nurses regarding prevention of CLABSI due to TPN administration; evaluate the effectiveness of the programme; find correlation between knowledge and practice scores. Quasi-experimental: non-equivalent pre-test post-test design. Two hospitals in Meerut, India. 80 nurses (40 in the control group in one hospital, 40 in the experimental group in another hospital). Inclusion criteria: staff nurses from critical care units only, who were present at the time of data collection and willing to participate. Exclusion criteria: staff nurses with <6 months' work experience. Knowledge was assessed using a structured knowledge questionnaire and interpretation scoring. To assess practice, the OSCE (objective structured clinical examination) method was used with four stations and interpretation scoring. The skills-competency programme was delivered to the experimental group only. The post test was conducted with both groups. The post-test knowledge and practice scores in the control group were: mean=12.55; SD=2.57 and mean=21.82; SD= 5.13 respectively. In the experimental group, the post-test knowledge and practice scores were: mean=23.75; SD=1.75 and mean=38.9; SD=2.02 respectively. The unpaired t-test in post-test knowledge between the control and experimental groups was t=22.78, with P=0.0001 at df 39, 0.05 level of significance, 95% CI; for post-test practice the results were, t=19.59, with P=0.0001 at df 39, 0.05 level of significance, 95% CI. Correlation between post-test knowledge and the practice score was r=0.7 (P<0.05), 95% CI. There was a significant difference in post-test knowledge and practice scores, therefore, the skills competency programme was effective. It also highlighted areas that institutions should focus on for effective training and professional development programmes.

The Use of Parenteral Nutrition and Disparities in Its Allocation Following Traumatic Injury

IntroductionSevere traumatic injury requires rapid and extensive deployment of resources to save the lives of the critically injured. The sequelae of traumatic injuries frequently require extensive intervention obligating patients to a complicated recovery process devoid of meaningful nutrition. In this setting, parenteral nutrition (PN) is key in enabling appropriate wound healing, recovery, and rehabilitation. We sought to examine the use of PN in adult trauma management and to highlight any disparities in the utilization of PN in adult trauma patients. MethodsWe queried the 2017-2019 Trauma Quality Improvement Program (TQIP) for adult patients (aged > 18 y) who sustained blunt or penetrating traumatic injuries and received PN as part of their hospitalization. We compared time to PN administration based on demographics. We then used a multivariable logistic regression model to identify factors associated with the use of PN. We hypothesized that PN would be less commonly employed in the uninsured and minority groups. ResultsWe identified 2,449,498 patients with sufficient data for analysis. Of these, 1831 patients were treated with PN. On univariate analysis, PN patients were more commonly male (74.7% PN versus 60.2% non-PN; P < 0.001). PN use was more frequent in the Black population (24.3% PN versus 15.5% non-PN; P < 0.001) and less frequent in the White population (72.7% PN versus 81.2% non-PN; P < 0.001). PN use was also much more common among patients covered by Medicaid. Penetrating trauma was over twice as common among PN recipients relative to non-PN patients (% PN versus % non-PN). PN patients had higher injury severity scores (ISSs), more intensive care unit days, longer hospitalizations, and increased mortality compared to non-PN patients. PN patients were half as likely to discharge home and twice as likely to discharge to a long-term care facility. Multivariable analysis including age, race, trauma mechanism, primary payer, and ISS, demonstrated an association of PN use with increasing age (OR 1.01, P < 0.001), cases of penetrating trauma (odds ratio [OR], 2.47; P < 0.001), and patients with high ISS (OR, 0.1.06; P < 0.001). There was decreased use in Uninsured patient (OR, 0.54; P < 0.001). ConclusionsPN use following traumatic injury is rarely required. Patients treated with PN typically have a resource-intense hospital course. More severe injuries, penetrating trauma, and increased age are more likely to result in PN use. Variations in PN use are apparent based on insurance payer, further examination into allocation of hospital and intensive care resources, as it pertains to patient socioeconomic status, is warranted in light of these findings.

The Development of Magnolol-Loaded Intravenous Emulsion with Low Hepatotoxic Potential.

Intestinal failure-associated liver disease (IFALD) is a severe liver injury occurring due to factors related to intestinal failure and parenteral nutrition administration. Different approaches are studied to reduce the risk or ameliorate the course of IFALD, including providing omega-3 fatty acids instead of soybean oil-based lipid emulsion or administering active compounds that exert a hepatoprotective effect. This study aimed to develop, optimize, and characterize magnolol-loaded intravenous lipid emulsion for parenteral nutrition. The preformulation studies allowed for chosen oils mixture of the highest capacity of magnolol solubilization. Then, magnolol-loaded SMOFlipid was developed using the passive incorporation method. The Box-Behnken design and response surface methodology were used to optimize the entrapment efficiency. The optimal formulation was subjected to short-term stress tests, and its effect on normal human liver cells and erythrocytes was determined using the MTT and hemolysis tests, respectively. The optimized magnolol-loaded SMOFlipid was characterized by the mean droplet diameter of 327.6 ± 2.9 nm with a polydispersity index of 0.12 ± 0.02 and zeta potential of -32.8 ± 1.2 mV. The entrapment efficiency of magnolol was above 98%, and pH and osmolality were sufficient for intravenous administration. The magnolol-loaded SMOFlipid samples showed a significantly lower toxic effect than bare SMOFlipid in the same concentration on THLE-2 cells, and revealed an acceptable hemolytic effect of 8.3%. The developed formulation was characterized by satisfactory stability. The in vitro studies showed the reduced cytotoxic effect of MAG-SMOF applied in high concentrations compared to bare SMOFlipid and the non-hemolytic effect on human blood cells. The magnolol-loaded SMOFlipid is promising for further development of hepatoprotective lipid emulsion for parenteral nutrition.

A possible manifestation of pancreas divisum–pancreatic pseudocyst in an infant with no apparent history of pancreatitis: a case report

BackgroundPancreas divisum (PD), the most common pancreatic anomaly, is caused by the failure of pancreatic bud fusion in the embryo. Although most cases are asymptomatic, it can cause pancreatitis or epigastric pain. We report an unusual case of PD in an infant.Case presentationThe patient was a 9-month-old girl with no pertinent medical history. She had suffered vomiting and diarrhea for 1 week before transfer to our hospital. Her general condition was poor, and abdominal distention was noted. Blood tests revealed microcytic anemia with normal chemical markers. The parents reported no episode of pancreatitis. Ultrasonography revealed massive ascites, which was later found to be bloody. Enhanced computed tomography and magnetic resonance imaging depicted a cystic lesion, approximately 2 cm in size, anterior to the second portion of the duodenum. During exploratory laparotomy, a pinhole was identified on the cyst wall, which was mistakenly identified as a duodenal perforation, and direct closure was performed. Postoperative levels of serum amylase and inflammation markers were elevated, and the amount of ascites increased, impairing oral feeding. The level of pancreatic enzymes in the ascites was high. Imaging studies were repeated, but the cause of pancreatic fistula was not identified. Conservative therapy, including administration of total parenteral nutrition, antibiotics, and octreotide, was initiated, but the situation did not improve. Three months after admission, endoscopic retrograde cholangiopancreatography showed a thick dorsal pancreatic duct communicating with a hypoplastic ventral duct, which was indicative of PD. Contrast medium leaking from the dorsal duct near the minor ampulla revealed the presence of a pseudocyst. Stenting via the minor papilla was impossible because the minor papilla was obstructed. Instead, a stent was inserted into the ventral pancreatic duct. Endoscopic transgastric drainage of the cyst was effective, and the patient was discharged, 7 months after admission. The patient is healthy, but the gastric stent needs to be replaced regularly.ConclusionIn children, PD can manifest with pancreatic pseudocyst that causes pancreatic ascites, even in the absence of pancreatitis. This may be a previously unrecognized manifestation of PD in children, and clinicians need to be aware of it.

False positive Aspergillus galactomannan assay results caused by specific parenteral nutrition.

In September 2022, the proportion of clinically false positive results with high index values for the galactomannan (GM) assay increased dramatically in our hospital and remained high until November 2022. We aimed to identify the possible causative agent that led to the dramatic increase in false positivity in GM assay. A case-control-control study was conducted, and patients admitted to two intensive care units between September and November 2022 were included. We defined each time point at which the GM assay was conducted in a patient as an episode and classified episodes into strong-positive (≥10.0 index; case), positive (control), and negative (<0.5 index; control) groups. We compared the medications administered in three groups and measured GM levels in relevant medications, including parenteral nutrition (PN). In total, 118 episodes in 33 patients were classified into three groups. There were 46 negative, 23 positive, and 49 strong-positive episodes, and there was a significant difference in the use of Winuf® PNs (P<.001) between the three groups. Forty episodes (82%) in the strong-positive group received Winuf®, compared with three (6.5%) in the negative group and one (4.3%) in the positive group (P<.001). All samples of Winuf® PNs used in the five patients whose GM results were repeatedly strong-positive were strongly positive for GM. False positivity in GM assay can be caused by the administration of specific PNs. A thorough investigation of prescribed medications should be considered when there is an abrupt increase in the proportion of strong-positive or positive GM results.

Evaluation of infections associated with central venous catheters in ICU

Objective: Central venous catheter-related infections lead to an increase in widespread antibiotic use, prolonged hospital stays, increased costs, as well as morbidity and mortality. In this study, we aimed to evaluate the infections associated with central venous catheters used in our intensive care unit (ICU) and identify the possible contributing factors. Methods: The hospital records of patients aged 18 and above who were admitted to ICU and had central venous catheters (femoral, jugular, and subclavian catheters) were retrospectively evaluated. Patients’ demographic data and also reason for admission, APACHE II score, duration of ICU stay, and 28-day mortality were recorded. Additionally, data on the time of catheter insertion, catheter site, catheter type, administration of blood and total parenteral nutrition (TPN) through the catheter, presence of catheter-related infection, identified pathogens, time of infection development after catheter insertion, and concurrent blood culture results were recorded. Results: A total of 169 patients were included in the study, of whom 99 (58.6%) were male and 70 (41.4%) were female. The catheters were located in the femoral region in 56 (33.1%) cases, jugular region in 99 (58.6%) cases, and subclavian region in 14 (8.3%) cases. There was no significant difference in the development of catheter infection based on the site of application (p=0.929). The rates of infection were significantly higher in catheters used for TPN and blood transfusion (p=0.002 and p=0.005, respectively). The average duration of intensive care stay was significantly higher in patients who developed catheter infections. Conclusion: Catheter-related bacteremia is an important risk factor for morbidity and mortality, especially in critically ill patients. In our study, no significant differences were found in the rates of catheter-related infection based on the application sites. We observed that the use of TPN, blood transfusion, and longer catheter duration posed risks for infection.

FTP4.3 Improving awareness of total parenteral nutrition administration in general surgical patients: a tertiary care hospital experience

Abstract Introduction Dieticians on the general surgical ward are valuable in providing recommendations to optimise patient nutrition, including the administration of total parenteral nutrition (TPN). Prescribing TPN is time-intensive as patients' clinical status and biochemical profile are assessed to avoid re-feeding syndrome. This needs adjustment of the dieticians’ recommendations, highlighting the importance of clinician awareness of patients recommended for TPN. Methods We carried out a quality improvement project (QIP) on the general surgical ward of a tertiary centre teaching hospital which involved two plan-do-study-act (PDSA) cycles. We used primary and secondary qualitative surveys to collect data. In the first cycle, we implemented a daily whiteboard handover system in the doctors’ office which displayed the patients recommended for TPN. In the second cycle, we added a TPN recommendation section to the daily patient handover / ward patient list. Results Pre-intervention respondents reported lack in awareness of patients recommended for TPN, and felt prescription was often delayed. Use of a whiteboard was well accepted by junior doctors as well as dieticians and improved awareness of patients on TPN. However, this duplicated the workload and information sources for dieticians and doctors. Use of the patient handover list resulted further improved awareness and subsequently quicker timeliness of TPN prescribing. Conclusions Both whiteboard displays &amp; highlighting the potential TPN patients in the handover lists were well-accepted and effective ways to improve awareness of patients on TPN. Sustainable interventions should not result in duplication of workload or information. Future work could include quantitative analysis of the above interventions.

Improving the Safety of Clinical Management of COVID-19 Patients Receiving Aminoglycosides and Parenteral Nutrition: Y-site Compatibility Studies

PurposeAminoglycosides (AMGs) are broad-spectrum bactericidal antibiotics that can resolve bacterial infections co-existing with COVID-19 or exploit their potential antiviral activities. Patients presenting the most severe forms of COVID-19 due to escalating catabolism and significant lean body mass loss often require the concomitant administration of parenteral nutrition (PN) and antibiotics. The Y-site administration is one of the approaches allowing the co-administration of two intravenous medications in patients with limited vascular access. Our study aimed to investigate the compatibility of AMGs and selected commercial PN admixtures enriched in omega-3 fatty acids. MethodsGentamycin (GM), amikacin (AM), and tobramycin (TM) solutions for infusion were combined with Nutriflex Omega Special (NOS) and Smofkabiven (SFK). Three different volume ratios were investigated: 1:2, 1:1, and 2:1, simulating Y-site administration. Samples underwent visual examination and determination of the lipid emulsion particle size, zeta potential, and pH immediately after preparation and after four hours of storage at room temperature (22 ± 2 °C) with sunlight exposure. ResultsGM and AM combined with NOS in all studied ratios met the set-up acceptance criteria. The addition of TM to NOS in a 2:1 volume ratio and all tested AMGs to SFK in all studied combinations significantly influenced the stability of the oil-water system leading to the appearance of globules larger than 5 µm exceeding the pharmacopeial limit of 0.05% immediately after preparation or after four hours of storage. ConclusionIn conclusion, our study showed that NOS was less prone to destabilization of oil-in-water systems by AMGs than SFK. In justified clinical cases, due to the lack of appearance of precipitate or enlarged lipid droplets, the combined administration of GM and AM with the NOS could be considered, provided tested volume ratios of the drug and MCB in the infusion line are maintained. However, it should be noted that such an infusion may be associated with the risk of changes in the pharmacokinetics of the drug.

Central venous catheters: Which, when and how.

Short-term or long-term CVCs are now considered the standard of practice for the administration of chemotherapy, fluid therapy, antibiotic therapy, and parenteral nutrition. Central venous access catheters are broadly divided into tunneled or non-tunneled catheters. Tunneled catheters can be further subdivided into totally implanted and totally not implanted devices. Device selection generally depends on various factors such as availability of peripheral veins, expected duration of therapy, and desired flow rate. Ultrasound-guided access is the safest technique for central venous access compared to the landmark technique and departments should strive to for a 100% ultrasound guided access. This review gives a basic overview of the differences of CVC catheters including PICCs, Hickman-catheters and port-catheters along with the criteria for CVC selection. It will also describe technical tips on placement of CVCs. Finally, it aims to highlight complications which are associated with CVC placement and options to treat or prevent them.

Central Line-Associated Bloodstream Infection in Patients With Hematologic Malignancy Receiving Parenteral Nutrition.

Parenteral nutrition (PN) has been shown to be a safe method of feeding in the intensive care unit with modern infection prevention practices, but similar analysis in the hematology-oncology setting is lacking. A retrospective analysis of 1,617 patients with hematologic malignancies admitted and discharged from the Hospital of the University of Pennsylvania during 3,629 encounters from 2017 to 2019 was undertaken to evaluate the association of PN administration with risk of central line-associated bloodstream infection (CLABSI). Proportions of mucosal barrier injury (MBI)-CLABSI and non-MBI-CLABSI were also compared between groups. Risk of CLABSI was associated with cancer type and duration of neutropenia but not with PN administration (odds ratio, 1.015; 95% CI, 0.986 to 1.045; P = .305) in a multivariable analysis. MBI-CLABSI comprised 73% of CLABSI in patients exposed to and 70% in patients not exposed to PN, and there was no significant difference between groups (χ2 = 0.06, P = .800). PN was not associated with increased risk of CLABSI in a sample of patients with hematologic malignancy with central venous catheters when adjusting for cancer type, duration of neutropenia, and catheter days. The high proportion of MBI-CLABSI highlights the effect of gut permeability within this population.