Impact of a new guideline for central venous catheter care on sepsis in total parenteral nutrition: experience in Ramathibodi Hospital.

BACKGROUND: Total parenteral nutrition (TPN) is the essential treatment for hospitalized patients in whom normal enteral nutrition is inadequate or not feasible. However, TPN-related sepsis is the most serious and fatal complication of the treatment and the catheter is the most common cause of infection. Therefore, the Nutrition Support team in Ramathibodi Hospital has developed a new guideline for central venous catheter care for TPN patients and has used it for at least a year. OBJECTIVE: Survey the current incidence of TPN-related sepsis in the hospital, the predisposing factors of the TPN-related sepsis, and the pathogenic organisms of the sepsis. MATERIAL AND METHOD: Between July 1999 and February 2000, 52 TPN treatments (catheter count) in 40 surgical and medical patients were prospectively recruited. Microbiological studies were done in all cases of TPN-related sepsis. RESULTS: The incidence of TPN-related sepsis was 15% per catheter or 12.64/1000 catheter-days. Although no statistically significant predisposing factors were found for the sepsis, some factors such as postoperative TPN and short interval (< or = 2 days) for TPN line change (OR = 3.33, 95% CI = 0.33-30.34) showed a higher risk for TPN-related sepsis. The most common pathogenic organisms were Coagulase-negative staphylococci, Candida albicans, and gram-negative bacteria. The organisms were found from hemoculture in septic patients and were well correlated with those found in the catheter line. Thus, the significant pathogenic role of Coagulase-negative staphylococci emphasizes the importance of aseptic technique during catheterization. CONCLUSION: The Ramathibodi guideline rendered support for a good policy to improve and standardize the TPN treatment. Along with a practical guideline, the well-trained and highly responsible personnel would also be crucial to avoid the infectious complications.

Comparison of essential trace elements in blood of patients receiving Ramathibodi Standard Parenteral Nutrition with Ramatrace or a commercial formular.

OBJECTIVE: Commercially intravenous trace element product is very expensive compared to Ramatrace. Therefore, the present research was designed to compare the levels of zinc, copper chromium and manganese in the blood of patients receiving Ramathibodi Standard Parenteral Nutrition (STD) containing the Ramatrace or the commercial product. MATERIAL AND METHOD: Two groups of patients receiving STD were recruited. Group 1 (19 males and 11 females) received Ramatrace and Group 2 (19 males and 11 females) received a commercial product. Blood samples on day 0, day 3 and day 10 were measured for zinc, copper chromium and manganese levels by atomic absorption spectrophotometer (model 3100, Perkin Elmer). RESULTS: The present results showed that levels of zinc, copper, chromium and manganese were not significantly different between the two groups. On day 0, day 3 and day 10, the levels of zinc, copper and manganese in the blood of both groups were significantly increased (p < 0.05). Blood chromium levels of Group 1 were significantly increased from day 0 (0.14 +/- 0.02 microg/dL) to day 3 (0.23 +/- 0.02 microg/dL) but there was no significant difference between day 3 and day 10. In Group 2, the blood levels of chromium from day 0 to day 10 were significantly increased. CONCLUSION: In patients receiving STD, Ramatrace could improve the levels of zinc, copper, chromium and manganese as well as the commercial product. This may be one way to reduce the cost of treatment.

Initial experience and result of a Swedish adjustable gastric banding by laparoscopic approach in Thai cohorts.

BACKGROUND: Morbid obesity is a growing problem in Thailand. Several surgical procedures are available for weight reduction. The laparoscopic gastric banding has been shown to be an effective weight loss with a low post or perioperative complication. OBJECTIVE: The aim of this report was to evaluate the early preliminary outcome of the laparoscopic Swedish adjustable gastric banding operation in Thai cohort patients. MATERIAL AND METHOD: From November 2003 until March 2005, ten patients with a median age of 31 (range, 18-61) underwent laparoscopic Swedish adjustable gastric banding for morbid obesity at Ramathibodi Hospital. Demography, clinical course and outcome including excess weight loss and peri-operative complications were reviewed and studied. Descriptive statistics were used for data summary. RESULTS: There were 3 men and 7 women with a median preoperative body weight of 142.5 kg (range, 98-164 kg), and median body mass index (BMI) of 49.2 kg/m2 (range, 40.3-62.4 kg/m2). The operations were successful in 9 out of 10 patients with median operative time of 195 minutes (range, 125-275 minutes). One patient with a BMI of 62.4 had a failed operation due to poor operative exposure from a very large left lobe of the liver. None of the remaining patients required conversion to the opened technique. The mean hospital stay was 4 days with no perioperative mortality. There was no major post operative complication except one minor wound infection. The excess weight loss was within the range of 33.5% to 62.1% during the short-term follow-up (range, 1-15 months) CONCLUSION: The presented early preliminary result of the laparoscopic Swedish adjustable gastric banding showed a good technical success with a significant short-term weight loss. The authors believe this minimally invasive operation is appropriate for morbidly obese Thai patient. However a longer follow-up study is needed.