Central venous catheter infection in Canadian home parenteral nutrition patients: a 5-year multicenter retrospective study.

HIGHLIGHTS: A lower central venous catheter (CVC) infection rate suggests an improvement in practice and education. CVC infection remains a complication that often requires significant health care resources. Use of tunneled CVC and patient education on catheter care reduces CVC infection rates. OBJECTIVES: CVC infection is one of the most frequent, life-threatening complications in home parenteral nutrition (HPN) patients. Our objective was to conduct a 5-year retrospective chart review regarding CVC infections in 3 adult HPN programs. METHODS: Data were collected from the Canadian HPN Registry and patient charts that include demography, infection diagnosis, blood cultures, and treatments. RESULTS: Results are reported as median (range) ± standard error of mean or population frequency. Eighty-one charts were reviewed. Mean age was 51.98 ± 1.71 years. Short bowel syndrome (54.3%) was the primary diagnosis, with 36 months (range, 1324 months) median length of HPN therapy. Forty-seven subjects (58%) had infections over a 5-year period. Of these, there were 144 sepsis events. There was positive correlation (r=0.423; P<0.001) between number of infections and HPN duration. The median length of time the CVC was in place was 281 (range, 14-4380) days. There were 66.7% tunneled CVCs; 25.9% peripherally inserted central catheters (PICCs), and 7.4% implanted venous port. In this sample, there was no association between line infection and catheter type. Most patients presented with fever (58.3%) and chills (38.2%). Blood cultures were done (89.6%), and coagulase negative Staphylococcus was the resulting pathogen present in 25.7%. Patients with bloodstream infection were treated for 17.9 ± 1.2 days with combination antibiotics (22.2%). Overall, the CVC infection rate was 0.97 per 1000 catheter days. CONCLUSION: We found the standard approach to infection prevention is comparable to reports in literature. However, a subset of patients with multiple CVC infections require education with an emphasis on preventive techniques in order to reduce the incidence of infection.

Effect of Discontinuation of Manganese Supplementation From Home Parenteral Nutrition Solutions on Whole-Blood Levels and Magnetic Resonance Imaging of the Brain: A 5-Year Cohort Study.

BACKGROUND: Manganese (Mn) is included in current premixed multiple trace element (TE) additives for home parenteral nutrition (HPN). However, there is a risk of oversupplementation of Mn due to contamination from PN additives. Oversupplementation can produce Mn toxicity with neurologic symptoms and abnormalities on brain magnetic resonance imaging (MRI). In 2009, we reported that whole-blood Mn levels were above the upper limit of normal in 16 HPN patients, with 81% having MRI findings. Subsequently, we removed Mn supplementation from all our HPN patients. We present a 5-year follow-up here. METHODS: This is a prospective cohort study on 11 of the surviving 16 patients on HPN. All patients had Mn removed from PN and had yearly monitoring of blood Mn levels. Eight patients had a repeat MRI to evaluate for resolution of basal ganglia deposits. Patient demography, clinical history, and bloodwork were recorded. RESULTS: Five of 6 patients who initially had elevated Mn levels had normal levels on follow-up. All patients who had Mn levels measured serially had a decrease in levels; the mean percent decrease of Mn was 38.1% (range, 10.1%-53.8%). Two patients had elevated Mn despite the absence of supplementation. Six of 8 patients who had repeat MRIs had complete resolution abnormalities. CONCLUSIONS: Removal of Mn as an additive in HPN solutions resulted in resolution of MRI abnormalities in most patients. Over 5 years, all patients except for 1 maintained normal blood Mn levels. Therefore, Mn levels should be monitored and supplementation be individualized.

Quality of life analysis during transition from stationary to portable infusion pump in home parenteral nutrition patients: a Canadian experience.

BACKGROUND: Quality of life (QOL) of patients receiving home parenteral nutrition (HPN) may be impacted by device technology. Historically, our HPN patients used pole-mounted pumps which can hinder activities and affect QOL. METHODS: Patients receiving HPN with a pole-mounted pump completed Short Form 36 (SF-36®) and pump-specific questionnaires. Patients were then enrolled in a 2-month prospective crossover open study. Patients were randomized to use a pole-mounted pump or a portable pump. After 1 month, each arm crossed over. Measurements were repeated at 4 and 8 weeks. RESULTS: Participants included 5 males, 15 females; age 52.8 ± 3.3 (mean ± SEM) years; 50% had short bowel syndrome; received HPN for 83.3 ± 15.9 months; infused HPN over 11.2 ± 0.3 hours/day; 4.3 ± 0.4 days/week. Portable pump users scored 53.75 ± 5.64, 61.25 ± 6.14, and 40.31 ± 4.94 in SF-36v2 physical, social, and health vitality, respectively, while the stationary pump users scored 45.50 ± 4.82, 55.00 ± 5.97, and 35.31 ± 4.63, respectively (NS). They reported ease of movement between rooms (4.11 ± 0.21 vs 1.44 ± 0.20; P = .001); when traveling (5.00 ± 0.00 vs 3.00 ± 0.45; P < .02) (1 = very difficult, 5 = very easy); 5.0% were sleep disturbed with the portable compared to 42.1% with pole-mounted pump (P < .04). Overall, patients were significantly happier with the portable vs pole-mounted pump (4.53 ± 0.19 vs 2.68 ± 0.22; P < .001) (1 = very unhappy, 5 = very happy). CONCLUSION: Our HPN patients reported improved happiness and satisfaction regarding ease of use and function with a portable vs pole-mounted pump.

Home parenteral nutrition in patients with systemic sclerosis: a retrospective review of 12 cases.

OBJECTIVE: To evaluate the effect of home total parenteral nutrition (HTPN) on the nutritional and functional status of patients with systemic sclerosis (SSc). METHODS: Retrospective review of SSc patients from the HTPN database at the University Health Network, Toronto, Canada, from 1998 to 2010. RESULTS: In total 12 subjects (9 females, 3 males) with SSc were identified. At initiation of HTPN, the age was 48.75 ± 3.94 years and the median body mass index was 16.8 kg/m(2) (range 12.3-21.3). This significantly increased to 18.3 kg/m(2) (17.0-21.7) at 6 months and to 19.7 kg/m(2) (17.0-24.6) at 12 months. The mean Karnofsky score at baseline was 58.00 ± 3.27, and the score at 12 months of 39.00 ± 13.29 did not change significantly. CONCLUSION: HTPN improved the nutritional status of these patients with SSc but it did not improve their functional status.

Monitoring parenteral nutrition in hospitalized patients: issues related to spurious bloodwork.

BACKGROUND: Monitoring hospitalized patients receiving parenteral nutrition requires regular bloodwork. However, blood specimens, if not drawn appropriately, may be contaminated by parenteral nutrition, leading to spurious results and unnecessary medical interventions. The objective was to determine, in a large academic center, the frequency of spurious bloodwork, unnecessary medical interventions, and contributing factors. METHODS: This was a 1-year prospective cohort study monitoring hospitalized patients receiving parenteral nutrition and their bloodwork. Sudden unexplained changes in serum levels of glucose, potassium, and sodium were identified. Subsequent medical interventions were tracked. Factors affecting blood collection, such as technique, shifts, nursing units, nursing, and patient demography, were assessed and compared with those of a control group. RESULTS: Out of 201 patients, 34 had 63 incidents of spurious bloodwork. This led to 23 medical interventions. The most frequent problem was the failure to clamp the parenteral nutrition infusion prior to blood collection or too short a time between clamping and drawing. There was an increased occurrence of spurious bloodwork drawn by nurses with < 10 years of experience due to failure in following blood collection policy. Cost of spurious bloodwork and subsequent interventions for 63 incidents was approximately $3480 (CAD) per year. This excluded physician time. CONCLUSIONS: Spurious bloodwork was due to parenteral nutrition contamination by incorrect blood draw techniques. This led to a policy amendment to incorporate a "wait time" between stopping the parenteral nutrition infusion and drawing blood and to an institution-wide nursing reeducation.

Telehealth videoconferencing: improving home parenteral nutrition patient care to rural areas of Ontario, Canada.

BACKGROUND: Telehealth videoconferencing is a medium for health care professionals to communicate and care for patients living in remote areas. The aim of this study was to provide a survey to examine management outcome of home parenteral nutrition (HPN) patients when followed by telehealth as an alternative modality of care. METHODS: Twenty-six individuals who were identified to benefit from tele-health were invited to participate in a satisfaction survey. The survey was sent to patients by postal mail. The survey also documented the incidence of line sepsis and other medical HPN complications. A cost analysis was also performed according to technology, human resources, and infrastructure. RESULTS: Eighty-one telehealth videoconference sessions have been held since the inception of telehealth in 2002. Of the current telehealth patients, 13 were eligible for the survey. The satisfaction survey response rate was 11/13 (84.6%). The average line sepsis rate for the 13 patients was 0.89/1000 catheter-days. All patients were generally satisfied with videoconferencing as an alternative method of communication and care for new consultation, patient and family education, and follow-up. Travel time and costs to the patients, their families, and the health care system were significantly less. For example, a patient who resides 611 km from Toronto would cost CDN (Canadian) 724.00 dollars for flight and accommodation to meet with the team at the HPN clinic in Toronto. CONCLUSION: Telehealth incorporated the cost-saving ability for HPN patients to maintain proper medical care, support, and collaboration of specialists inaccessible to their local community. Thus, its strongly positive role in HPN care deserves further consideration for a national application.

Line sepsis in home parenteral nutrition patients: are there socioeconomic risk factors? A Canadian study.

BACKGROUND: Line sepsis complicates home parenteral nutrition (HPN). This study examined nonmedical risk factors that may contribute to line sepsis and compared 2 HPN programs with different administrative structures (Ontario and British Columbia [BC]) in terms of line sepsis and patient satisfaction. METHODS: A survey was developed to evaluate possible correlation between line sepsis and (1) patients' perceptions of HPN care, (2) family support, (3) community support, and (4) socioeconomic status. Data were analyzed by categorizing into high- and low-risk groups using a cutoff point. A second method analyzed the incidences of line sepsis as a continuous variable. RESULTS: Sixty-eight patients responded to the survey: 33 from Ontario (62%), 35 from BC (44%). Community agency, socioeconomic and educational status were not significant in determining line sepsis. Patients who had (1) medication or blood work done through the catheter, (2) a higher number of dependents, or (3) had a trained family member involved in HPN were in the high-risk category for line sepsis, in addition to patients who were part-time students or receiving social assistance. When comparing the provinces, there was no difference in line sepsis. However, significant differences between the provinces include (1) BC patients rate their level of care lower; (2) Ontario patients rely more on family members for HPN; and (3) Ontario patients have more community support. CONCLUSIONS: Line sepsis may be increased by some nonmedical risk factors. However, when comparing the 2 programs, rates of line sepsis were not influenced by different administrative structures.

Influence of multivitamin regimen on urinary oxalate in home parenteral nutrition patients.

BACKGROUND: High urinary oxalate levels have been associated with high ascorbic acid intakes. An alteration in the vitamin regimen for home parenteral nutrition (HPN) patients because of product discontinuation resulted in provision of 500 mg instead of 100 mg ascorbic acid per HPN day. This regimen was associated with high urinary oxalate levels. PURPOSE: To determine if a switch from a multivitamin regimen containing 500 mg to one containing 100 mg of ascorbic acid daily would reduce urinary oxalate levels. METHODS: A 24-hour urine collection for oxalate was analyzed before switching the vitamin regimen back to 100 mg ascorbic acid and repeated 2 months after the change. A paired t test was conducted to compare measurements at baseline and at 2 months. RESULTS: Overall, 18 patients completed both phases of this observational study. The initial urinary oxalate of 517 +/- 63 micromol/day decreased to 425 +/- 47 micromol/day after 2 months (p = .05). However, after applying the exclusion criteria, only 6 patients could be included. The baseline urinary oxalate of 649 +/- 106 micromol/day decreased to 391 +/- 57 micromol/day after 2 months (p = .006). CONCLUSIONS: A change in the parenteral regimen of HPN patients from 500 mg ascorbic acid to 100 mg ascorbic acid is associated with a decrease in urinary oxalate levels. This suggests that a moderate dose of parenteral ascorbic acid (100 mg/day) may limit urinary oxalate appearance in HPN patients.