Considerations for Fueling an Endurance Athlete With Home Parenteral Nutrition.

The goal of clinicians managing nutrition support for patients with home parenteral nutrition (HPN) is to adapt nutrition needs to best serve the consumers, so they may have the best quality of life despite specialized nutrition needs. Some HPN consumers may desire to participate in endurance athletics, which will require special considerations. This review is intended to outline key nutrition differences in endurance athletes that a nutrition support team should consider when providing HPN.

Hydration Strategy for Endurance Running in an Athlete Requiring Home Parenteral Nutrition.

PURPOSE: The purpose of this report is to share our experience with optimizing home parenteral nutrition (HPN) and hydration therapy for an HPN consumer who desired to run a marathon. METHODS: A 34-year-old woman with idiopathic gastroparesis necessitating HPN and intravenous (IV) hydration desired to train for a marathon. For short runs, prerun and/or postrun hydration were adequate, but a marathon (26.2 miles) would be too long to run without IV hydration. During training, we instructed our consumer to record weights (pre/post run), ambient temperature, running distance, and duration of time. These data were used to calculate her sweat rate and estimate hydration volume during the marathon. RESULTS: Ambient temperature was a significant factor influencing sweat rate. The estimate temperature for the marathon was 65 °F; therefore, our consumer would have an estimated sweat rate of approximately 720 mL/h. This exceeded the amount of fluid that could be infused during the marathon; therefore, we advised our consumer to overhydrate prior to the race. Initial postrace urine output was low and concentrated but returned to baseline after postrace hydration. Our consumer did not experience any symptoms of dehydration and had only minor muscle soreness. CONCLUSIONS: Our consumer was able to complete a marathon with IV hydration. We have shown that with careful preparation, calculation, and planning, our HPN consumer was able to adequately maintain her state of hydration and accomplish her goal of running a marathon.

Risk factors for the development of catheter-related bloodstream infections in patients receiving home parenteral nutrition.

BACKGROUND: Risk factors for development of catheter-related bloodstream infections (CRBSI) were studied in 125 adults and 18 children who received home parenteral nutrition (HPN). METHODS: Medical records from a national home care pharmacy were reviewed for all patients that had HPN infused at least twice weekly for a minimum of two years from January 1, 2006-December 31, 2011. Infection and risk factor data were collected during this time period on all patients although those patients who received HPN for a longer period had data collected since initiation of HPN. RESULTS: In adults, 331 central venous catheters (CVCs) were placed. Total catheter years were 1157. Median CVC dwell time was 730 days. In children, there were 53 CVCs placed. Total catheter years were 113.1. Median CVC dwell time was 515 days. There were 147 CRBSIs (0.13/catheter year;0.35/1000 catheter days). In children there were 33 CRBSIs (0.29/catheter year;0.80/1000 days; P < .001 versus adults). In adults, univariate analysis showed use of subcutaneous infusion ports instead of tunneled catheters (P = .001), multiple lumen catheters (P = .001), increased frequency of lipid emulsion infusion (P = .001), obtaining blood from the CVC (P < 0.001), and infusion of non-PN medications via the CVC (P < .001) were significant risk factors for CRBSI. Increased PN frequency was associated with increased risk of CRBSI (P = .001) in children, but not in adults. Catheter disinfection with povidone-iodine was more effective than isopropyl alcohol alone. There were insufficient patients to evaluate chlorhexidine-containing regimens. CONCLUSION: Numerous risk factors for CRBSI were identified for which simple and current countermeasures already exist.

Epidemiology of bloodstream infection associated with parenteral nutrition.

EPIDEMIOLOGY: Catheter-related bloodstream infections (CR-BSIs) occur in 1.3% to 26.2% of patients with central venous catheters used to administer parenteral nutrition (PN). Because of their nutritional components, PN solutions can support microbial growth. Contamination during preparation and handling is rare in hospitals and home-infusion pharmacies but may be difficult to control in a home setting. The risk of infection is increased in hospitalized patients because of malnutrition-associated immunosuppression, hyperglycemia exacerbated by dextrose infusion, microbial colonization/contamination of catheter hubs and the skin surrounding insertion site, and poor nursing care. During long-term catheter use for PN, an intraluminal biofilm, catheter-tip fibrin sheath or tail, or central venous thrombosis creates sites for microbial seeding and infection. Chronic conditions and psychosocial issues also increase the risk of infection. In hospitalized patients with BSIs, the most common organisms are coagulase-negative staphylococcus, Staphylococcus aureus, Enterococcus, Candida spp, Klebsiella pneumoniae, and Pseudomonas aeruginosa. In the long-term PN population, approximately 60% of CR-BSIs are caused by coagulase-negative Staphylococcus. TREATMENT: The best plan of care for a suspected or known infected catheter in a hospitalized patient is to reinsert a new central line after 48 hours of antibiotic treatment and negative blood cultures. In patients who receive long-term PN, hospitalization increases the risk of a nosocomial infection because the catheter can be contaminated by staff. A patient with fungemia must always be admitted and catheter removed. With gram-positive and gram-negative organisms, the catheter may not need to be removed. In most patients receiving PN at home, removing a long-term venous-access device is challenging. Peripheral vein access or peripherally inserted central catheters are needed until a new permanent device can be inserted after negative blood cultures are obtained. Evaluation of remote site infection also is necessary. Strategies to reduce or prevent infection include catheter lock therapy, daily evaluation of continued need for PN, enteral rather than PN support, and avoiding overfeeding. More studies are needed to demonstrate conclusively the benefits of immunonutrition, such as the use of omega-3 or glutamine supplements to reduce CR-BSIs in patients receiving PN.

Use of ethanol lock therapy to reduce the incidence of catheter-related bloodstream infections in home parenteral nutrition patients.

BACKGROUND: Catheter-related bloodstream infection (CRBSI) is a serious complication for home parenteral nutrition (HPN) patients. To reduce the incidence of infection in frequently infected HPN patients, prophylactic ethanol lock therapy (ELT) was initiated. METHODS: Nine patients were selected as candidates for ELT because of their history of recurrent CRBSI. Diagnosis of CRBSI was determined by symptoms correlating with positive peripheral and access device blood cultures. Medical-grade ethyl alcohol 25%-70% was instilled into the central venous access device and allowed to dwell for 2-4 hours. The incidence of CRBSI and catheter changes was compared before and after initiation of ELT. RESULTS: Nine patients experienced 81 CRBSIs (8.3 per 1,000 catheter-days) before starting ELT vs 9 infections (2.7 per 1,000 catheter-days: relative risk [RR], 0.325; confidence interval [CI] 95%, 0.17-0.64) after ELT. Catheter changes were also reduced from 69 (7.0 per 1000 days) before ELT to 1 (0.3 per 1,000 days: RR, 0.043; CI 95%, 0.01-0.25) after ELT. No significant adverse effects were noted, although some patients complained of transient dizziness and nausea. CONCLUSIONS: ELT shows promise in reducing the incidence of CRBSI in the frequently infected HPN population. Further studies are warranted.

Epidemiology of bloodstream infections in patients receiving long-term total parenteral nutrition.

GOALS: To describe the epidemiology and microbiologic characteristics of bloodstream infections (BSIs) in patients receiving long-term total parenteral nutrition (TPN). BACKGROUND: Home TPN therapy has been reported as a risk factor for BSI. However, little knowledge exists regarding the epidemiology of BSIs in this patient group. STUDY: A descriptive, observational epidemiologic study of patients receiving long-term TPN from January 1981 to July 2005 was performed. Variables analyzed include age, gender, time of follow-up, number of BSIs, microbiologic characteristics, underlying disease necessitating long-term TPN, catheter type, complications related to TPN, and clinical outcome. RESULTS: Forty-seven patients receiving long-term TPN were evaluated. The most frequent indication for long-term TPN was ischemic bowel disease (25.5%). The mean duration of follow-up was 4.5 years. Thirty-eight patients (80.9%) developed 248 BSIs while receiving TPN. More than 1 BSI episode occurred in 78.9% of these patients, and 23.8% of BSI episodes were polymicrobial. The most prevalent pathogen was coagulase negative staphylococci (33.5%). The most frequent complication among patients with BSI was central venous thrombosis (44.7%). Five patients were intravenous drug users. There were 11 deaths among the patients on long-term TPN, 4 of these were related to infection and 4 were related to intravenous drug use. CONCLUSIONS: The incidence of BSI is high, and a significant proportion of BSIs in long-term TPN patients are polymicrobial and due to multidrug-resistant bacteria and fungi. Careful management of the infusion line is required and interventions are needed to reduce the risk of catheter-related infections in this population.