Surgical shunts and TIPS for variceal decompression in the 1990s.

BACKGROUND: In the 1990s, liver transplantations and transjugular intrahepatic portosystemic shunts (TIPS) have become the most common methods to decompress portal hypertension. This center has continued to use surgical shunts for variceal bleeding in good-risk patients who continue to bleed through endoscopic and pharmacologic treatment. This article reports this center's experience with surgical shunts and TIPS shunts from 1992 through 1999. METHODS: Sixty-three patients (Child A, 43 patients; Child B, 20 patients) received surgical shunts: distal splenorenal, 54 patients; splenocaval, 4 patients; coronary caval, 1 patient; and mesocaval, 4 patients. Sixty-two patients had refractory variceal bleeding, and 1 patient had ascites with Budd-Chiari syndrome. Two hundred patients (Child A, 24 patients; Child B, 62 patients; Child C, 114 patients) received TIPS shunts. One hundred forty-nine patients had refractory variceal bleeding, and 51 patients had ascites, hydrothorax, or hepatorenal syndrome. Data were collected by prospective databases, protocol follow-up, and phone contact. RESULTS: The 30-day mortality rate was 0% for surgical shunts and 26% for TIPS shunts; the overall survival rate was 86% (median follow-up, 36 months) for surgical shunts and 53% (median follow-up, 40 months) for TIPS shunts. For surgical shunts, the portal hypertensive rebleeding rate was 6.3%; the overall rebleeding rate was 14.3%. For TIPS shunts, the overall rebleeding rate was 25.5% (30-day, 9.4%; late, 22.4%). There were 4 reinterventions for surgical shunts (6.3%); the reintervention rate for TIPS shunts in the bleeding group was 33%, and the reintervention rate in the ascites group was 9.5%. Encephalopathy was severe in 3.1% of the shunt group and mild in 17.5%; this was not systematically evaluated in the TIPS shunts patients. CONCLUSIONS: Surgical shunts still have a role for patients whose condition was classified as Child A and B with refractory bleeding, who achieve excellent outcomes with low morbidity and mortality rates. TIPS shunts have been used in high-risk patients with significant early and late mortality rates and have been useful in the control of refractory bleeding and as a bridge to transplantation. The comparative role of TIPS shunts versus surgical shunt in patients whose condition was classified as Child A and B is under study in a randomized controlled trial.

Diagnosing gastrointestinal malignancies.

OBJECTIVES: To provide an overview of imaging studies that can be used to help diagnose gastrointestinal malignancies and a brief description of tumor markers specific for these cancers. DATA SOURCES: Published professional articles, textbooks, and clinical procedural manuals. CONCLUSIONS: Diagnosing gastrointestinal malignancies can be problematic due to the relative lack of signs and symptoms, especially early in the disease process. While clinical suspicion may lead to a tentative diagnosis, imaging studies and tumor markers can provide confirmation of the suspected malignancy. IMPLICATIONS FOR NURSING PRACTICE: An understanding of the requirements of imaging studies and tumor markers will allow for better preparation of the patient by the nurse for the test and can assist the nurse in helping the patient understand the need for and results of the diagnostic work-up.

Case management in home total parenteral nutrition: a cost-identification analysis.

BACKGROUND: Home parenteral nutrition (HPN) requires intensive medical case management by practitioners with expertise in the provision of nutrition support. There is expenditure of considerable time and resources for management of these patients not covered by any of the traditional reimbursement mechanisms. The costs associated with this unreimbursed input and follow-up are most often borne by the Nutrition Support Team or individual practitioners. Reimbursement by home care agencies to physicians for management of patients after discharge cannot be done because this may be construed as a "kick-back" for referral of patients to particular home care agencies. METHODS: Time and costs associated with management of HPN patients after discharge from the hospital were assessed using a cost-identification analysis of 24 different factors. Daily activity logs were kept by the Nutrition Support Team members over a 2-week period. Costs of space and furnishings were calculated. RESULTS: On average, a total of 25 h/d was spent by members of the Nutrition Support Team on our HPN patients. Variable activities accounted for 5640.1 hours of time with fixed support at 890.3 hours. This computes to a total annual personnel cost of $168,482 ($1982 per patient). If costs of furnishings and space are also included, the overall cost of all resources was $175,989 per year or $2070 per patient. CONCLUSION: Significant and currently nonreimbursed costs are involved in HPN patient management. These costs are most often absorbed by the Nutrition Support Team and should be considered when evaluating total costs of HPN.

Recurrent small bowel obstruction secondary to a dilated Kock pouch: a case report.

We report a case of recurrent bowel obstruction caused by a hugely dilated Kock pouch. The approximate capacity of the pouch was at least 1300 ml. Frequent emptying of the pouch resulted in resolution of the obstructing symptoms.

Long-term silastic catheters and chest pain.

There are multiple reports in the literature of vascular erosion in the innominate vein or superior vena cava from the use of temporary central venous catheters. Catheter malposition is likely to precede the development of superior vena cava perforations, a catastrophic complication of central venous catheters. Catheter malposition after initial adequate placement is a very unusual long-term complication and delayed recognition of this complication may have disastrous consequences. Should the catheter change position so the tip is angled toward the sidewall, the repetitive movement of the catheter tip that occurs with respiratory excursion and the cardiac cycle may lead to endothelial injury and eventual erosion of the vein. These problems are thought to be alleviated in the patient receiving long-term intravenous therapy by using a soft Silastic catheter, which may not cause as much damage to the endothelium of the vein. We report three patients with left-sided long-term indwelling Silastic catheters that had changed position over time who presented with chest pain upon infusion of their total parenteral nutrition solutions. In each case, chest x-ray revealed that the tip of the catheter had migrated and was directed against the sidewall of the superior vena cava. In each case, catheter removal and replacement with a new catheter into the right side (subclavian and jugular systems) led to prompt relief of the patient's symptoms.

Standardized enteral orders attain caloric goals sooner: a prospective study.

Standardized enteral nutrition order forms were introduced listing the enteral formulary, the advancement schedule of formulae, and whether feedings should be given continuously or intermittently. The efficiency of these forms was evaluated prospectively by counting the number of days needed to reach the patient's estimated caloric needs in a total of 113 patients studied 3 months before (pre-group) and 3 months after (post-group) the introduction of the form. When the standardized enteral order forms were used, patients in the post-group reached their caloric goals 3.1 days sooner than did those in the pre-group. Use of standardized enteral nutrition order forms decreases the time needed to reach a patient's estimated caloric needs, thereby achieving effective nutritional therapy sooner.

Bacteriological safety of closed enteral nutrition delivery system.

One of the most commonly reported side effects of enteral tube feedings is diarrhea, at times attributed to the bacterial contamination of tube feedings. A closed enteral delivery system has recently been devised. It consists of a cardboard Tetrapack containing the sterile enteral nutrition formula and and independent sterile administration set; together these constitute a closed Tetrapack-administration set enteral delivery system. The bacteriological safety of this system was evaluated in vitro under controlled laboratory conditions in a series of studies. There was no or bacteriologically insignificant bacterial contamination of the enteral nutrition formula, even with repeated use of one administration set for multiple containers over 24 h. Bacteriological growth in the enteral nutrition formula was directly related to the duration of the hanging time of a Tetrapack container. No bacterial growth occurred with hanging times less than 18 h; insignificant bacterial growth occurred by 24 h. A progressive time-related increase in bacterial growth occurred between 24 and 48 h. Our data indicate that the newly developed closed Tetrapack-administration set enteral delivery system is, and will remain, bacteriologically sterile if each Tetrapack container is allowed to hang for no longer than 24 h.

Culture methods to evaluate central venous catheter sepsis.

Sepsis is a frequent complication of central venous catheters, but the diagnosis of catheter sepsis is not always clear-cut. A variety of culture methods is available to determine catheter-related septicemia. Each method has advantages and disadvantages for the clinician to consider. This article reviews qualitative, quantitative, and other culture methods applicable to both blood and the device.

Standardized TPN order form reduces staff time and potential for error.

The Nutrition Support Team developed a standardized parenteral nutrition (PN) order form for the newly introduced total nutritional admixture (TNA) system. The new order form (TNA-Form) is oriented toward the physician, providing prescription guidelines and standing orders for the initiation and discontinuation of PN. The form replaced an older one (TPN-Form) originally designed for pharmacy use. Over two 4-month periods, the usefulness of the new TNA-Form was compared with that of the old TPN-Form, with reviews of the completeness and safety of all PN prescriptions. When prescription errors, errors of dosage, or errors of omission occurred, the pharmacist queried the physician. The number and the nature of the prescription errors per PN order were recorded daily for each patient. With the old TPN-Form, there were 634 prescription errors in 682 patients (93% total error rate). This rate decreased to 116 prescription errors in 1017 patients (11% total error rate) with the new TNA-Form. There were fewer errors in all categories concerning glucose and lipid concentrations, trace elements and vitamins, the use of heparin, infusion rate, and electrolyte concentrations. It was concluded that the new TNA-Form led to a substantial decrease in overall PN prescription errors, particularly errors of omission, resulting in safer, more efficacious, and more uniform provision of PN. The new TNA-Form provided the secondary benefit of an educational tool for housestaff. Because of its broad-based benefits, it was subsequently adopted by two other hospitals in the community.

Nutrition support nursing: a specialty practice: historical development.

Nutrition Support Nursing as an area of specialization within nursing emerged from the development of new technology that enabled patients to be fed totally by vein and from the realization that this complex, new therapy could not be administered safely and effectively without the involvement of nurses who had special expertise. This paper will examine how a specialty organization has developed and evolved over two decades, characterized by dramatic changes in the health care system. The involvement of nurses in nutrition support facilitated the early research in this area and was instrumental in developing a strong nursing role in the care of these patients.

Intestinal obstruction from cecal bezoar; a complication of fiber-containing tube feedings.

Dietary fiber increases stool bulk, regulates bowel transit time, and decreases intraluminal pressure. Because these actions constitute a natural way to stop diarrhea, a frequent problem with tube feedings, enteral tube feeding manufacturers have marketed several fiber-containing formulae. While bulk-forming agents such as fiber may not be appropriate for every tube-fed patient, we were unable to find any published contraindications to the use of fiber-containing enteral products. We present the case of a seriously ill man who received a fiber-containing tube feeding while also getting intestinal motility-suppressing medications. A large fiber bezoar developed, with resultant mesenteric hemorrhage. We conclude that fiber-containing tube feedings are contraindicated in certain types of patients.

Evaluation of nutritional status.

Most of the methods used for nutritional assessment provide information regarding body composition abnormalities. In addition to clinical evaluation, straight-forward physical measurements (such as body weight, anthropometric measures) and biochemical or immunological determinations are used. Sophisticated laboratory measurements are, at present, useful primarily for research purposes. Based on the results of nutritional assessment, a diagnosis as to type of malnutrition (and its treatment) may be made. Nutritional assessment criteria are also used to evaluate the effectiveness of nutritional support.

Cannulation of inferior vena cava for long term central venous access.

Nineteen patients had a Silastic (silicone rubber) catheter placed into the inferior vena cava (IVC) by way of a vein of a lower extremity. All patients needed long term venous access but had conditions precluding access to the superior vena cava (SVC) or access sites of the upper torso. Precautions regarding operative technique for the placement of the catheter include incisions through healthy skin, maintenance of aseptic technique at the site of access, an atraumatic subcutaneous tunnel at least 25 centimeters in length and a long acting local analgesic effect. Catheters were in situ for a total of 2,215 days (a mean of 111 days per catheter). Catheters were also used to administer intravenously medications, blood and blood products, chemotherapeutic agents, parenteral nutrition and for sampling of blood. Four complications occurred: one instance each of catheter sepsis and infection of the subcutaneous tract and two of thromboses of the IVC. No deaths occurred. The complication rate was 0.18 per cent per catheter-day. Long term access to the IVC is feasible without undue concern in conditions in which access to the SVC is precluded but long term central access is essential.

Refinement of central venous cannulation technique.

A further refinement of the improved Seldinger technique of central venous cannulation is described. The method entails inserting the guidewire through a previously created side hole in a standard 5ml plastic syringe. The problems of needle dislodgement, air embolism and blood loss are virtually eliminated with this technique.

[The bacteriological diagnosis of catheter-related sepsis. The advantages of quantitative blood cultures]. / Diagnóstico bacteriológico de sepsis por catéter. Ventajas de los hemocultivos cuantitativos.

If sepsis due to a catheter is suspected in a patient receiving parenteral nutrition, the doctor responsible for the patient usually withdraws the catheter and sends the point to the bacteriological laboratory for examination. This operation is usually accompanied by the extraction of several blood samples for haemoculture. With this attitude, it has been observed that most of the catheters withdrawn are sterile or if they are contaminated, they are not the cause of the sepsis. This leads to a series of unnecessary expenses and risks. This problem has prompted us to design a clinical study for the prospective investigation of the efficiency of quantitative haemocultures in the diagnosis of sepsis due to the catheter. During an 8-month period, all the patients who received parenteral nutrition in our centre were followed up by members of the nutritional support unit and participated in the study. In the face of the clinical suspicion of sepsis due to the catheter, blood was obtained for haemoculture, both through the catheter and from the peripheral veins. However, the catheters were not withdrawn until after the results of the cultures, between 16 and 24 hours following the extraction. A count of colonies in blood proceeding from the catheter which was five times or more greater than the count in the peripheral blood was interpreted as sepsis due to the catheter and the catheter was withdrawn. Differences between both counts (central and peripheral) which were less were interpreted as sepsis with a different origin to the catheter and in this case, the catheter was not withdrawn. A total of 26 catheters were evaluated using this method.(ABSTRACT TRUNCATED AT 250 WORDS)

The benefits of Isolator cultures in the management of suspected catheter sepsis.

Until recently, when a patient receiving total parenteral nutrition (TPN) was suspected of having catheter-related sepsis, the catheter was removed and the tip and the patient's blood was cultured. Using this method at our institution, greater than two thirds of the central venous catheters (CVC) removed were sterile, or if colonized, proved not to be the source of sepsis. This practice led to the unwarranted removal of numerous catheters and posed a clinical dilemma because it necessitated replacement of the catheter with its attendant risks, cost, and inconvenience. To address this problem, we instituted a protocol for determining in situ catheter-related sepsis based on a quantitative blood culture method using lysis centrifugation (Isolator; Dupont Co., Wilmington, Del.). When catheter-related sepsis was clinically suspected, quantitative blood cultures were obtained simultaneously via a peripheral (PER) vein and through the CVC suspected as the source of sepsis. The CVC, however, remained in situ pending culture results (approximately 16 to 24 hours). A CVC colony of greater than or equal to five times the PER colony count was considered significant and the catheter was removed. Equivocal colony counts between the CVC and PER cultures were interpreted as incriminating a source of sepsis other than the CVC. An 8-month prospective study was undertaken to evaluate the efficacy of this method for determining in situ catheter sepsis. One hundred third-eight patients received TPN by means of 160 catheters. In 113 patients no sepsis-related problems were noted. In the remaining 25 patients, 28 catheters were suspected as the source of sepsis. Twenty-six catheters were evaluated by the Isolator culture method. In eight instances significant differences in colony counts between the CVC and PER cultures were seen, implicating the CVC as the source of infection. In all these cases the CVC was removed and the patients underwent defervescence. In 18 cases, the CVC samples revealed either no growth or insignificant differences between the CVC and PER colony counts. Nine of these CVCs were removed without clinical improvement. The remaining nine catheters were left in place, and another source of sepsis was ultimately identified and treated. These results confirm the use of the quantitative blood culture method for determining in situ catheter-related sepsis. In all cases, when the catheter was incriminated by culture data, removal of the CVC led to patient improvement.(ABSTRACT TRUNCATED AT 400 WORDS)