Administration Of Total Parenteral Nutrition Research Articles

Enteral Agonism of the Farnesoid X Receptor-Fibroblast Growth Factor 19 Axis Prevents Cholestasis in TPN-Fed Piglets

Total parenteral nutrition (TPN) administration provides necessary nutrients to infants who cannot tolerate enteral feedings. However, the use of TPN can result in cholestasis which can cause parenteral nutrition-associated liver diseases. Previous mitigation strategies for cholestasis have included administering bile acids enterally to encourage normal bile acid metabolism. The objective of this study was to determine if treatment of either ursodeoxycholic acid (UDCA), Tropifexor (TPX), or fibroblast growth factor 19 (FGF19) will prevent cholestasis in a piglet TPN model through the activation of the farnesoid X receptor (FXR)-FGF19 axis. We hypothesize that UDCA will have minimum effects on FXR while TPX, a potent FXR agonist, will significantly affect the FXR pathway, and FGF19 will reduce bile acid synthesis to alleviate cholestasis. Piglets received TPN for 3 weeks and were treated enterally with either UDCA (25 mg/kg*day) or TPX (7.5 μg/kg*day) with minimal milk-based formula (12 mL/kg*day), or daily intravenous FGF19 (0.25 mg/d) injection. Body weight gain was not different after 3 weeks. Plasma markers of cholestasis such as of total bile acids, bilirubin, and gamma-glutamyl transferase were lower in pigs that received TPX compared to the control treatment at the end of the study. Circulating levels of FGF19 and tissue concentrations of total bile acids were not different across treatments. In the ileum, TPX increased mRNA expression of FGF19, ileal lipid binding protein, and organic solute transporter α compared to the control pigs. All treatments reduced the mRNA expression of apical sodium-dependent bile acid transporter compared to the control treatment. TPX also increased mRNA expression of small heterodimer protein and bile salt export pump in the liver. Overall, we conclude that UDCA and FGF19 had minimal effects on cholestasis, whereas TPX prevented cholestasis in part via activation of the FXR-FGF19 axis in TPN fed piglets. NIDDK R01-DK094616 K01 DK129408 T32 NIH grant DK07664. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

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.

Evaluation of the effect of parenteral nutrition on mortality and morbidity in hospitalized patients with non-variceal upper gastrointestinal bleeding

Objective: Nutritional support products should preferably be administered orally whenever possible, with rare exceptions, one of which is gastrointestinal bleeding. In our study, we examined the effects of parenteral nutrition support, which we have recently introduced in the treatment of patients with gastrointestinal bleeding, on the hospitalization duration and mortality-morbidity of these patients.
 Methods: We analyzed the patients admitted to the Internal Medicine Service with non-variceal upper gastrointestinal bleeding in our study. Patients were retrospectively analyzed in two groups, based on the years in which total parenteral nutrition (TPN) was initiated (2016-2017) and not initiated (2012-2013). Hospitalization durations and discharge methods were compared between the two groups.
 Results: Our study included a total of 369 cases after screening and application of our exclusion criteria. 35.5% of these cases received TPN, while 64.5% did not. When evaluated based on the TPN administration status after stabilizing the Rockall score of the patients, as well as considering the need for erythrocyte suspension (ES), fresh frozen plasma (FFP) replacement, and length of hospital stay, the length of hospital stay was significantly longer in those receiving TPN compared to those who did not.
 Conclusion: Although TPN may be the preferred choice in patients with upper gastrointestinal bleeding for whom oral nutrition is not suitable, our study suggests that this preference not only does not lead to a reduction in the number of blood and blood product replacements but also prolongs the hospital stay. While it is believed that complications of nutritional support with TPN may contribute to this result, our retrospective study did not provide data on this. Comprehensive prospective studies are needed on this issue.

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.

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.

Analysis of risk factors for neonatal short bowel syndrome in two tertiary centers in Brazil

IntroductionShort bowel syndrome (SBS) is defined as a severe reduction in intestinal mucosal absorption secondary to reduced intestinal functional area. The main causative factor for SBS is the length of intestinal resection in the neonatal period. The prognosticating factors are age, length of remnant intestine, preserved ileocecal valve, and venous maintenance. ObjectiveTo evaluate the clinical and surgical aspects affecting survival outcomes in neonates with SBS at two tertiary care centers. Patients & methodsRetrospective cohort study involving two university tertiary care neonatal centers with diagnosed SBS. Neonates were allocated into two groups, SBS (<60 cm) and USBS (ultra-short bowel syndrome) (<25 cm) and demographically compared. ResultsIn total, 53 neonates met the inclusion criteria, with 31 and 22 in the SBS and USBS, respectively; 20 survived and 33 died (37 % survival rate). The remnant bowel length was greater in those with SBS (p < 0.001), with greater ability to acquire full adaptation (p = 0.047). Increased survival rate was associated with use of total parenteral nutrition (TPN) (p = 0.002) and enteral nutrition (p = 0.036), and the ability to acquire full intestinal adaptation (p = 0.047). Risk factors associated with mortality were the inability to tolerate enteral nutrition (p = 0.036) and acquire full intestinal adaptation (p < 0.001); Use of TPN proved to be protective against death (p = 0.002). ConclusionSBS has high mortality rates in neonatal period (57 %). We recommend caution with time taken to full intestinal adaptation, with continued TPN administration during this time, which can improve overall survival outcomes.

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.

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.

Metabolic Complications Associated With Total Parenteral Nutrition

Total parenteral nutrition (TPN) is a very important means of providing nutrients to patients who have no access to receiving nutrients by enteral route. It consists of all the essential components like lipids, protein, dextrose, electrolytes, vitamins, minerals and trace elements. The concentration of all these components can be adjusted according to the requirement of the patients. They are also available as fixed solutions. Administration of TPN requires careful monitoring as small change in concentration of nutrients in the solution may cause serious, life-threatening complications. Metabolic complications like electrolyte abnormalities, refeeding syndrome, hyperglycemia, hypertriglyceridemia and many hepatobiliary dysfunctions like steatosis, cholestasis, hepatic dysfunction and gallbladder dysfunction are all associated with the use of total parenteral nutrition.&#x0D;

Factors associated with cholestasis after surgery for congenital duodenal atresia

Background: This study assessed the characteristics of neonates with duodenal atresia (DA) who developed transient postoperative cholestasis which resolved spontaneously, without identifiable congenital anomalies or surgical complications, and identified potential risk factors for cholestasis. Methods: Neonates with DA who underwent surgery at our institution between January 2009 and July 2022 were retrospectively reviewed. Demographic factors, intraoperative findings, placement of a trans-anastomotic tube (TAT), and postoperative outcomes were compared between patients who developed cholestasis (conjugated hyperbilirubinemia &gt;2.0 mg/dL) after surgery (Group A) and those who did not (Group B). This report is a retrospective cohort study and complies with the STROBE statement. Results: Among 19 neonates with DA, 6 (31.6%) developed cholestasis after surgery, with the highest direct bilirubin value being 4.3 (2.4-6.5) mg/dL (median, [range]) on postoperative day 14.5 (2-23) that persisted for 67 (47-116) days until spontaneous resolution. Neonates in Group A had a significantly younger gestational age (36.6 vs. 38.0 weeks) (median) (p=0.038), a higher rate of Down syndrome (66.7 vs. 15.4%) (p=0.046), a higher rate of TAT placement (66.7 vs. 15.4%) (p=0.046), and longer administration of total parenteral nutrition (15.5 vs. 7.0 days) (p=0.027) than those in Group B. Conclusion: Transient cholestasis after surgery for DA seemed to be associated with prematurity, Down syndrome, parenteral nutrition, and TAT placement.

Hypertriglyceridemia as a Cause of Continuous Renal Replacement Therapy Circuit Clotting: A Case Series

Introduction: Hypertriglyceridemia is a rarely reported cause of early continuous renal replacement therapy (CRRT) circuit clotting. Methods: We have identified and will present 11 published cases in the literature where hypertriglyceridemia has led to CRRT circuit clotting or dysfunction. Results: The majority of cases (8/11) are related to propofol use leading to hypertriglyceridemia. The other cases (3/11) are due to total parenteral nutrition administration. Conclusion: Due to the propensity of propofol use for critically ill patients in intensive care units, and the rather common occurrence of CRRT circuit clotting, hypertriglyceridemia may be underappreciated and undiagnosed. The exact pathophysiology behind hypertriglyceridemia-induced CRRT clotting has not been fully elucidated, although there are some hypotheses which include fibrin and fat droplet deposition (identified after electron microscopic examination of the hemofilter), increased blood viscosity, and development of a procoagulant state. Premature clotting poses a multitude of problems including inadequate treatment time, increased costs, increasing nursing workload, and patient blood loss. With earlier identification, discontinuation of the inciting agent, and possible therapeutic management, we could expect improvement in CRRT hemofilter patency and decreased costs.

A retrospective study on use of palliative care for patients with alcohol related end stage liver disease in United States.

BACKGROUNDPalliative care (PC) has been shown to be beneficial in end stage liver disease (ESLD), yet the hospitalization data for PC utilization is unknown.AIMTo identify the trend of PC utilization for the special population of alcohol-associated ESLD patients, factors affecting its use and ascertain its impact on healthcare utilization. METHODSWe analyzed around 78 million discharges from the 2007-2014 national inpatient sample and 2010-2014 national readmission database including adult patients admitted for decompensated alcohol-associated cirrhosis. We identified patients with PC consultation as a secondary diagnosis. Odds ratios (OR) and means were adjusted for confounders using multivariate regression analysis models.RESULTSOut of the total 1421849 hospitalizations for decompensated liver cirrhosis, 62782 (4.4%) hospitalizations had a PC consult, which increased from 0.8% (1258) of all alcohol-associated ESLD hospitalizations in 2007 to 6.6% in 2014 (P < 0.01). Patient and hospital characteristics associated with increased odds of PC utilization were advanced age, lower income, Medicaid coverage, teaching institution, urban location, length of stay > 3 d, prolonged ventilation, and administration of total parenteral nutrition (all P < 0.01). Palliative encounters in alcohol-associated ESLD and acute-on-chronic liver failure (ACLF) score were associated with increased odds of discharge to a rehabilitation facility, but significantly lower odds of 30-d readmissions (aOR: 0.35, 95%CI: 0.31-0.41), lower total hospitalization charges and lower mean hospitalization days (all P < 0.01).CONCLUSIONInpatient PC is sparingly used for patients with decompensated alcohol related liver disease, however it has increased over the past decade. PC consultation is associated with lower 30-d readmission rates on multivariate analysis, and lower hospitalization cost and length of stay in patients with ACLF score ≥ 2.

Hepatic Function in Premature Lambs Supported by the Artificial Placenta and Total Parenteral Nutrition.

The artificial placenta (AP) promotes organ development and reduces organ injury in a lamb model of extreme prematurity. This study evaluates hepatic outcomes after AP support with total parenteral nutrition (TPN) administration. Premature lambs (116-121 days estimated gestational age; term = 145) were cannulated for 7 days of AP support. Lambs received TPN with SMOFlipid (n = 7) or Intralipid (n = 5). Liver function and injury were compared between the two groups biochemically and histologically. Groups were compared by ANOVA with Tukey's multiple comparisons or linear-mixed effects models. From baseline to day 7, total bilirubin (Intralipid 2.6 ± 2.3 to 7.9 ± 4.4 mg/dl; SMOFlipid 0.3 ± 0.1 to 5.5 ± 2.3 mg/dl), alanine aminotransferase, and gamma-glutamyl transferase increased in both groups ( p < 0.001 for all). Direct bilirubin (0.3 ± 0.2 to 1.8 ± 1.4 mg/dl; p = 0.006) and AST (27 ± 5 to 309 ± 242 mg/dl; p < 0.001) increased in SMOFlipid group (not measured in Intralipid group). On liver histology, Intralipid showed more cholestasis than SMOFlipid; both groups showed more than tissue controls. The Intralipid group alone showed hepatocyte injury and had more congestion than controls. Lambs supported by the AP with TPN administration maintain normal hepatic function and sustain minimal hepatic injury. SMOFlipid is associated with decreased cholestasis and hepatic injury versus Intralipid.

The role of 2 - Octyl-Isocyanacrylate Glue, as a microbial barrier in peripherally inserted central catheter port VADS. A review of the literature

Abstract&#x0D; Introduction: The implanted port catheters in chemotherapy which are connected to a Peripherally Inserted Central Catheter (PICC Ports) are used daily in clinical nursing practice, enabling the administration of intravenous fluids, blood, drugs and Total Parenteral Nutrition. The 2-octyl-isocyanoacrylate glue as an alternative intervention in preventing wound infection during PICC port insertion.&#x0D; Aim: The aim of the present review was to explore the use of 2-octylisocyanacrylate glue as a microbial barrier in wound trauma and in peripherally central catheter insertion.&#x0D; Methods: An electronic research was conducted in 4 databases. Sixty five papers focusing on the use of glue in surgical trauma closure and healing were analyzed.&#x0D; Results: The literature demonstrates significant benefits of the 2-octyl-isocyanacrylate glue in comparison to other tissue adhesives, when placed on skin incisions. The 2-octyl-isocyanacrylate glue seems to provide an effective barrier to microbial penetration by Gram-positive and Gram-negative motile and non-motile species.&#x0D; Conclusions: The use of the 2-octyl-isocyanacrylate seems to be an effective method for skin closure and healing in patients undergoing PICC Port implantation whilst causing no side effects such as allergies, skin irritation or pain during the procedure.

Age Disparities in End of Life Symptom Management Among Patients with Epithelial Ovarian Cancer.

To evaluate the symptoms of women with epithelial ovarian cancer (EOC) during their last admission before death and analyze invasive palliative management administered in relation to symptom control and survival. A retrospective review of Israeli patients with EOC, primary peritoneal cancer (PPC) and tubal cancer, admitted to our department prior to death between 2008-2018. Basic palliative treatment was defined as administration of IV fluids, analgesics, oxygen, antiemetics, antibiotics and/or blood transfusions. Procedures regarded as invasive included: peritoneal or pleural fluid drainage; placement of an indwelling catheter, administration of total parenteral nutrition (TPN), chemotherapy and ventilation. 82 patients were included. Most suffered from weakness and fatigue, gastrointestinal complaints, pain and shortness of breath. 34 patients (41.5%) required only basic palliative treatment to alleviate their symptoms; however, in 48 patients (58.5%) invasive interventions were needed. Patients treated with invasive procedures were younger at death by almost 9 years (mean age of 65.73 ± 9.5 vs. 74.78 ± 9.8; p = 0.001). There were significantly more women with platinum sensitive disease in the invasive interventions group compared to the basic palliative care (60.42% vs. 32.35%; p = 0.012). No survival difference was found between the groups from diagnosis to death, relapse to death, last chemotherapy to death and last admission to death. EOC patients suffer from high disease burden and multiple symptoms before death. We found that physicians tend to use more invasive care in dying younger patients. However, this aggressive treatment does not prolong survival. Futile treatments influencing quality of life should be avoided.

Preliminary Exploration of Transpedal Lymphangiography With High-Dose Ethiodized Oil Application in the Treatment of Postoperative Chylothorax.

Objective: To preliminarily explore the safety and effectiveness of transpedal lymphangiography (TL) with high-dose ethiodized oil application (>20 ml) in the treatment of high-output postoperative chylothorax.Methods: From 1 July 2020 to 1 July 2021, a total of 7 patients with high-flow postoperative chylothorax (> 1,000 ml/d) were retrospectively reviewed in a single center. Clinical data, including surgery types, technical and treatment success of TL, and adverse events of TL, were collected and analyzed.Results: Seven patients (5 cases of non-small cell lung cancer; 2 cases of esophageal carcinoma) with a median age of 62 years (range: 30–70 years) occurred postoperative chylothorax after tumor resection with mediastinal lymphadenectomy. All patients received conservative treatment including total parenteral nutrition and somatostatin administration for a median of 20 days (range: 15–31 days) that failed to cure the chylothorax, so TL was performed as a salvage. Before TL, the median daily chyle output was 1,500 ml/day (range: 1,100–2,000 ml/day). The technical success rate of TL was 100% (7/7), with the median volume of ethiodized oil of 27.6 ml (range: 21.2–30.0 ml) injected in TL. Ruptured thoracic duct was identified in 5 patients (5/7, 71%) in fluoroscopy and chest CT after TL. The treatment success rate of TL was 86% (6/7). In 6 patients, the thoracic drainage was removed after a median of 7 days (range: 4–13 days) from TL performance. No adverse event of TL was reported.Conclusion: Transpedal lymphangiography with high-dose ethiodized oil application (>20 ml) is a feasible, safe, and effective modality for the treatment of high-flow (> 1,000 ml/day) postoperative chylothorax.

769. Risk Factors of Central Line-associated Bloodstream Infection in an Academic Medical Center

BackgroundCentral line-associated bloodstream infections (CLABSI) are one of the leading healthcare-acquired infections (HAI) with significant morbidity and mortality. We aimed to identify risk factors of CLABSI at an academic medical center to determine high-risk populations and target interventions.MethodsThis is an observational retrospective cohort study at William P. Clements Jr. University Hospital from January 1, 2017 to December 31, 2020. Retrospective chart review was conducted to identify demographics and co-morbidities of hospitalized patients diagnosed with CLABSI as defined by National Healthcare Safety Network (NHSN). Infections due to mucosal barrier injuries were excluded. Means were compared using independent-samples T-test and proportions were compared using chi-square.ResultsNinety-three CLABSI events were identified with an increase in the standardized infection ratio from 0.38 in 2017 to 0.74 in 2020 (Figure 1). Bacterial organisms were identified in 71 (76%) cases while fungal organisms were identified in 22 (24%) (Table 2). There was no significant difference in the timing of CLABSI after line insertion (p=0.09) or organism identified (p=0.61) in PICC lines (n=33, 34%) vs all other central lines (n=60, 67%). When comparing immunocompromised patients with CLABSI (n=47, 51%) vs non-immunocompromised (n=46, 50%), there was a significant difference in the indication for line (chemotherapy), but no difference was seen in the number of line days prior to event (p=0.57), line type (p=0.17), or organism identified (p=0.94). Of all CLABSI, 46% (n=43) were in the intensive care unit (ICU) with significantly more Candida species (p=0.018) identified compared to non-ICU patients with CLABSI (n= 50, 54%). Figure 1. CLABSI Rate and SIR from 2017 to 2020 by Quarter ConclusionCandida species were more likely to be found in ICU patients with CLABSI as compared to non-ICU counterparts with further investigation in the ICU population revealing lack of flushing after administration of total parenteral nutrition. Otherwise, this observational cohort of CLABSI events did not identify any difference in immunosuppression status or line type. Given this information, infection prevention efforts will continue to be directed towards proper central line maintenance and removal when no longer indicated.Disclosures All Authors: No reported disclosures

Substantial Variation in Peripherally Inserted Central Catheter Use and Outcomes in Patients with Hematologic Malignancies: A Multi-Center Study

Background:Use of peripherally inserted central catheters (PICCs) has grown rapidly in patients with hematologic malignancies. Studies demonstrating the safety of PICCs in hematologic malignancies, however, are largely single-center, retrospective designs focused on the outpatient setting. Little is known about inpatient PICC use in patients with hematologic malignancies and how such use varies across hospitals.Methods:Data was prospectively collected between November 2013 and December 2019 from a cohort of patients admitted at one of 42 Michigan hospitals participating in the Michigan Hospital Medicine Safety Consortium (HMS). Patients had a diagnosis of a hematologic malignancy and had a PICC placed during their hospital stay. Adult medical patients admitted to a general ward or intensive care unit were eligible for data collection and data were collected from the medical record using a standardized template. The indications for PICC placement, catheter characteristics, and associated complications from 17 hospitals with more than 25 discrete patients with hematologic malignancy were included in a comparative analysis. Major complications were defined as central line associated bloodstream infection (CLABSI), catheter occlusion, and venous thromboembolism (VTE). Differences across hospitals were tested using the Kruskal-Wallis test for continuous variables and Pearson chi-square test for categorical variables.Results:A total of 2092 PICCs placed in 1798 patients were included in the analysis with a median (IQR) dwell time of 15 (6-30) days. Most patients were male (n=1242, 59.4%), white (n=1720, 82.2%), and 50 to 69 years old (n=950, 45.4%). Patients were primarily admitted to large hospitals (≥375 beds: n=1429, 68.8%) that were teaching centers (n=1600, 76.5%) in metropolitan locations (n=2000, 95.6%). Leukemia (n=752, 36.0%) and non-Hodgkin's lymphoma (n=409, 19.6%) were the most represented malignancies. The most common primary indication for PICC placement was administration of chemotherapy (n=1180, 56.4%). The majority of PICCs were double lumen (n=1457, 69.6%), most often placed by vascular access nurses (n=1520, 72.7%). A concurrent central venous catheter was present at the time of PICC placement in 12.2% (n=264) of patients. A major complication event occurred in over 1 in 4 PICCs placed (n=562, 26.9%). Catheter occlusion occurred in 17.8% (n=372), CLABSI in 8.2% (n=171), and VTE in 3.8% (n=80) of PICCs respectively.There was wide variation in PICC indications, characteristics, and outcomes across hospitals. Placement of PICCs for chemotherapy varied from 33.3% to 85.3% (p<0.001). Similarly, there was a wide range of placement for antibiotics (2.8% to 32.4%, p<0.001), transfusion of blood products (0.0% to 9.7%, p<0.001), medications requiring central access (0% to 26.7%, p<0.001), difficult access and blood draws (1.8% to 33.3%, p<0.001), and administration of total parenteral nutrition (0.0% to 14.3%, p=0.002). There was significant variation in the number of lumens used: single (5.6% to 37.9%, p<0.001), double (51.9% to 93.0%, p<0.001), or triple (0.0% to 30.8%, p<0.001). The incidence of major complications spanned from 9.7% to 40.8% (p=0.001). Rate of catheter occlusion had the widest range (0.0% to 36.7%, p<0.001). The differences between rates of VTE (0.0% to 8.7%, p=0.29) and CLABSI (1.4% to 15.9%, p< 0.20) were not statistically significant. Patient mortality ranged from 2.8% to 19.4% (p<0.001).Conclusion:Appropriate venous access is critical to the care of patients with hematologic malignancy. This study demonstrates wide variation in the practice patterns and outcomes for PICCs in patients with hematologic malignancies across hospitals in Michigan. Further work is necessary to further understand and improve decision making around choosing vascular access in this vulnerable population. [Display omitted] DisclosuresZhang: SIMR, Inc: Ended employment in the past 24 months, Research Funding; AmerisourceBergen: Current Employment. Sood: Bayer: Consultancy.

Seorang Anak Laki-Laki dengan Kolestasis, Cytomegalovirus dan Anemia: Laporan Kasus

Introduction: Cholestasis can cause obstruction of substances that should be secreted into the duodenum for further digestive process. Causes of intrahepatic cholestasis in children less than 2 months of age include idiopathic neonatal hepatitis; infections such as Cytomegalovirus (CMV), Human Immunodeficiency Virus (HIV), toxoplasmosis, Urinary Tract Infection (UTI), sepsis; and metabolic disorders, resulting from long-term administration of Total Parenteral Nutrition, and part of a syndrome. The infection can be transmitted either vertically or horizontally. Objective: This case report aims to determine congenital infections that can occur in children during pregnancy. Method: This study is a case report that applies a descriptive observational method about a 2.5-month-old boy being treated at Dr. Kariadi Semarang with a diagnosis of cholestasis, cytomegalovirus, normochromic microcytic anemia. Data was obtained from primary and secondary sources. Results and discussion: This case report explains that transmission of CMV infection can occur from mother to fetus during pregnancy, thus causing congenital infection. This infection becomes a chronic infection in children, thus affecting Hb levels in the blood and causing anemia. Examination of bilirubin, liver enzymes, and ultrasound of the abdomen confirmed the diagnosis of cholestasis. A head CT scan and ABR test are important for long-term monitoring. Conclusion: Infections that occur in patients due to cytomegalovirus may be acquired intrauterine. Complete investigations are needed to establish the diagnosis, so that appropriate therapy can be given. Long-term monitoring is important for the presence of intracranial calcifications as well as hearing loss.