Catheter salvage from central line-related bloodstream infections in pediatric intestinal failure.

OBJECTIVES: Patients with intestinal failure require central venous access which puts them at risk for central line-associated bloodstream infections (CLABSI). Maintaining vascular patency is critical for this population to receive nutrition support. When CLABSIs occur line salvage can help maintain vascular access. The aim of this study is to assess factors associated with safe and successful central venous catheter salvage. METHODS: Retrospective cohort study of patients with intestinal failure at two tertiary care institutions between 2012 and 2020. The study examined the rates of attempted salvage, factors associated with successful salvage, and complications associated with salvage attempts. RESULTS: Over the study period, 76 patients with intestinal failure were include while central venous access was in place. There were a total of 94 CLABSIs. Salvage was more likely to be attempted when patients were under the direct care of an intestinal rehabilitation service (95% vs. 68%, p = 0.04). The overall successful salvage rate was 91.6% (n = 77). Gram-positive, Gram-negative, and polymicrobial infections had successful salvage rates of 97%, 92%, and 94% respectively. The successful salvage rate for fungal infections was 40%. There was no difference in 30-day complication rates for hospital readmission, intensive care unit admission, and death between patients who underwent salvage attempt and those who did not. CONCLUSIONS: Central line salvage can be safely attempted for many infections in patients with intestinal failure, leading to vascular access preservation.

Refractory Pediatric Fibrostenotic Eosinophilic Esophagitis Treated With Dupilumab.

Eosinophilic esophagitis (EoE) is a progressive inflammatory disease of the esophagus. Untreated or uncontrolled disease over time can lead to the development of fibrosis and formation of strictures. Once the patient develops strictures, it is difficult to treat with the available medical therapies and will often require esophageal dilations. The Food and Drug Administration recently approved dupilumab for the treatment of EoE in patients older than 12 years. The clinical trials excluded patients with esophageal strictures. We describe a case of EoE with fibrostenotic stricture who had stricture resolution while on dupilumab therapy.

Making the case for multidisciplinary pediatric aerodigestive programs.

Multidisciplinary pediatric aerodigestive centers have been proposed to address the needs of children with complex multi-system problems affecting the respiratory and upper gastrointestinal tracts. The setup of a multidisciplinary service allows for the complex coordination needed between different subspecialties. This allows for rapid communication and family-centered decision making and agreement on further diagnostic and/or therapeutic next steps such as offering triple endoscopy when indicated. Triple endoscopy entails performing rigid upper airway assessment, flexible bronchoscopy and upper gastrointestinal endoscopy and has been linked to reduced time to diagnosis/treatment, reduced costs and anesthesia exposure. This review summarizes the available literature on the structure and benefits of multidisciplinary pediatric aerodigestive services.

Polygenic Infantile Juvenile Polyposis Syndrome Managed With Sirolimus and Endoscopic Polypectomy.

In the following clinical case of infantile juvenile polyposis syndrome (JPS), administration of a pharmacologic agent sirolimus was associated with reduced disease burden without need for bowel resection. The positive impact included improvement in protein-losing enteropathy, decreased intestinal blood loss, and improved weight gain. In addition, the number of polyps resected per unit time and frequency of upper and lower endoscopic evaluation needed dropped after initiation of sirolimus. This case report describes a positive clinical outcome and discusses the use of sirolimus with aggressive polypectomy as a potential treatment for the rare disease entity of polygenic infantile JPS. Through this case, we aim to emphasize that while administration of this drug may mitigate many sequelae of infantile JPS, it does not appear to eliminate the need for aggressive polypectomy.

Anticipated impact of recent ethanol lock shortage and price increase on practice among pediatric intestinal rehabilitation programs across the United States.

BACKGROUND: Ethanol lock use has been associated with significantly lower rates of central line-associated bloodstream infection (CLABSI) in children with intestinal failure. Concerns have been raised among intestinal rehabilitation program providers regarding the impact of recent changes in cost and availability of ethanol locks in the US. METHODS: We conducted a survey among the members of the North American Society For Pediatric Gastroenterology, Hepatology & Nutrition Intestinal Rehabilitation Special Interest Group (NASPGHAN IR-SIG) regarding practice changes among providers to tackle this issue and the anticipated effect on CLABSI rates. RESULTS: The results show that the vast majority of US participants use ethanol locks in their population with intestinal failure, with most anticipating or already experiencing reduction in access to ethanol locks. Most worrisome is that more than half of participating programs expect an increase in CLABSI rates in this vulnerable patient population as a consequence of limited access to ethanol locks. CONCLUSION: Further multicenter prospective studies to assess the efficacy of alternative locking agents, besides ethanol, are needed in order to have readily available and affordable options for CLABSI prevention in the future.

Impact of central venous catheter repair in pediatric intestinal failure.

OBJECTIVES: Patients with intestinal failure (IF) require long-term parenteral nutrition through central venous catheters (CVCs). When damaged, catheter replacement or repair is considered. Limited literature exists on repair outcomes in this population. We aimed to assess the impact of repair on durability of exiting CVCs and infection rates. METHODS: This was a retrospective cohort study of pediatric IF patients with tunneled silicone CVCs over 10 years. Outcomes were evaluated by assessing CVC longevity, repair success, replacement, and postrepair infection rates. RESULTS: One hundred thirty-eight repairs and 45 replacements were conducted in 37 patients with repair and replacement rates of 4.7 and 1.5 per 1000 catheter days, respectively. Twenty patients (54%) required ≥1 repair. For CVCs requiring repair, median CVC durability without and with repairs were at 123 and 391 days, respectively (P < .0001). Overall repair success rate was 96% with significantly lower success in the emergency department at 81% (P = .007). The 7-day postrepair infection rate was 2.2% without specific risk factors identified. Most repairs (76%) were performed by the Pediatric Gastroenterology division. Variability in practice was noted among services, including frequency of periprocedural antibiotic use and performance of temporary repairs before permanent repairs. A gradual increase in CVC repair rate was noted over time. CONCLUSIONS: Our study showed that CVC repair is effective in prolonging CVC durability in pediatric IF patients without increasing infection rates. Incorporating a temporary repair as a step before permanent repair may offer a route to address potential intraluminal thrombosis before permanent repair.

Transient End-Tidal Carbon Dioxide Elevation During Pediatric Upper Endoscopy With Carbon Dioxide Insufflation: Is It True Hypercapnia?

BACKGROUND: Endoscopic insufflation, long performed using air, is being replaced by carbon dioxide (CO2) at many pediatric centers, despite limited published data on its use in children. We have previously demonstrated that CO2 use during esophagogastroduodenoscopy (EGD) in non-intubated children is associated with transient elevations of end-tidal CO2 (EtCO2). This observation raised concerns about possible CO2 inhalation and systemic absorption. Here, we investigate this concern by concurrently measuring both EtCO2 and transcutaneous CO2 (tCO2) during upper endoscopic procedures in children. AIM: To determine if elevations in EtCO2 levels seen in non-intubated children undergoing CO2 insufflation during EGD are associated with elevated systemic CO2 levels. METHODS: Double-blinded, prospective, randomized clinical trial. Children were randomized 1:1 to receive either CO2 or air for endoscopic insufflation. EtCO2 was sampled with a CO2-sampling nasal cannula and tCO2 was monitored using the Radiometer transcutaneous monitoring device. RESULTS: Fifty nine patients were enrolled; 30 patients in the CO2 insufflation group and 29 in the air group. All patients underwent a procedure involving an EGD. Transient elevations in EtCO2 (defined as >60 mmHg) were observed only in the CO2 insufflation group. This contrasted with the similar elevations of tCO2 between the CO2 and air insufflation groups. None of these events were of clinically significant magnitude or duration. CONCLUSION: This study demonstrates that the observed transient elevations in EtCO2 seen during EGD in non-intubated children receiving CO2 insufflation are most likely measurements of eructated CO2 without evidence of excessive systemic absorption of CO2.

30% Ethanol Locks Are Effective in Preventing Central Line-Associated Bloodstream Infections in Pediatric Intestinal Failure: A Pilot Study.

BACKGROUND: Complications related to central venous lines (CVLs) are common in intestinal failure (IF), including central line-associated bloodstream infections (CLABSIs). Replacing heparin with 70% ethanol locks can reduce infection rates; however, concerns exist about potential negative effects on catheter integrity. We hypothesized that a lower ethanol concentration combined with citrate would prevent catheter-related complications, including CLABSIs. METHODS: This was a retrospective cohort study in pediatric IF patients assessing rates of CLABSIs, catheter repair, catheter replacement, and thrombolytic (alteplase) use for suspected catheter-related thromboses comparing heparin, 70% ethanol, and 30% ethanol-2.8% citrate locks. RESULTS: Six patients were included with a total of 8777 catheter days. All patients utilized silicone single-lumen CVLs for venous access. The rate of CLABSIs was highest with heparin at 13.9 events per 1000 catheter days, which significantly dropped to 1.6 per 1000 catheter days on 70% ethanol (P = .02) and remained significantly low at 0.4 per 1000 catheter days when transitioning to 30% ethanol-2.8% citrate locks as compared with heparin (P = .01). No statistically significant differences were noted among the groups in rates of catheter repair and replacement and alteplase use. CONCLUSION: This pilot study provides supportive evidence that a lower ethanol lock concentration may be effective in maintaining a low rate of CLABSIs in pediatric IF patients using silicone CVLs. Although this study did not show significant positive impact on catheter integrity and durability, there are other potential benefits to using lower ethanol concentrations including reduced systemic ethanol exposure in children.

Impact of a Medical Scribe Program on Outpatient Pediatric Gastroenterology Clinic.

OBJECTIVES: Medical scribes may offer a route to improve physician productivity and workflow efficiency with reduced physician time for documentation. To our knowledge, there is no prior literature on medical scribe impact on outpatient pediatric gastroenterology clinic operations. The primary aim of our study was to address this knowledge gap. METHODS: Data were collected on encounters conducted by pediatric gastroenterology physicians at a tertiary center, during a summer scribe program. Scribes were trained and attended clinics in a nonrandomized fashion. Clinic efficiency was assessed by patient flow, tracked via the electronic medical record system. Medical note complexity codes, associated work relative value units (wRVUs), and note delinquency were compared between encounters with and without scribes. Patient satisfaction survey scores were compared between groups. RESULTS: One thousand nine hundred seventy encounters were included. Documented medical note complexity (and wRVUs), note delinquency, patient satisfaction, and perceived overall quality of service were similar between groups. Clinic time for established encounters was statistically shorter with scribes (median 18 vs 21 minutes, P = 0.01), a 14% reduction. No significant difference was noted in new encounter clinic time. The time to note completion was shorter for new encounters with scribes (2 vs 3 days, P = 0.048). More notes were finalized by the third day postencounter when a scribe was present (63% vs 57%, P = 0.02). CONCLUSIONS: The presence of medical scribes was associated with significantly more efficient clinic flow for established encounters and modest improvements in note completion rate. There were no measurable negative effects on documented medical note complexity or patient satisfaction scores.

COVID-19 pandemic and challenges in pediatric gastroenterology practice.

The current coronavirus pandemic is imposing unpreceded challenges to the practice of pediatric gastroenterology. These are highlighted in their impact on performing aerosol-generating endoscopy procedures and the need to accommodate longer room turnaround time for disinfection, ensuring appropriate and consistent safety measures for patients, staff and providers, and emphasizing the importance for screening patients for active coronavirus disease (COVID) infection before endoscopy when possible. Pediatric patients are less likely to exhibit severe COVID-related symptoms so survey-based screening would not be a sensitive measure to identify patients with active infections. To address the restrictions of patients coming for face to face clinic encounters, there has been rapid expansion of telehealth services in a very short time period with several difficulties encountered. To survive these challenges, pediatric gastroenterology practices need to adapt and accept flexibility in clinical operations with ongoing commitment to safety for patients and healthcare workers.

Is Carbon Dioxide Insufflation During Endoscopy in Children as Safe and as Effective as We Think?

OBJECTIVES: Distension of the gastrointestinal lumen is crucial for visualization and advancement during endoscopic procedures. An increasing number of pediatric centers now use carbon dioxide (CO2) preferentially over air as many adult studies and a few pediatric studies have concluded that CO2 is better tolerated than air, especially for colonoscopy. AIMS: The aim of the study was to determine if CO2 is as safe and as effective as air and if it reduces abdominal discomfort and distension in children undergoing upper endoscopy and colonoscopy. METHODS: Double blinded, prospective, randomized clinical study. Patient- and nursing-reported outcomes of pain and distension were recorded. End tidal CO2 (EtCO2) was monitored continuously with a CO2-sampling nasal cannula for patients undergoing procedural sedation and via the endotracheal tube for those who were intubated. RESULTS: One hundred seventy-eight patients with 180 procedures were enrolled, 91 procedures were randomized to receive CO2, and 89 to air. Groups did not differ significantly with respect to nursing-assessed abdominal discomfort, change in girth from baseline, or endoscopist-perceived ease of inflation. Use of CO2 was associated with transient spikes in the EtCO2 (≥60 mmHg) in a significant number of patients during sedated upper endoscopy without endotracheal intubation. There was a reduction of bloating and flatulence for all procedures in the CO2 group. CONCLUSIONS: The benefits of using CO2 for insufflation were minimal in our patients. The observed transient elevations of EtCO2 during sedated upper endoscopy raise concerns of possible systemic hypercarbia. The wisdom of its routine use for all pediatric endoscopic procedures is questioned.

Successful Colonoscopy-assisted Cecostomy Tube Replacement to Salvage Lost Cecostomy Tract Access in Children.

OBJECTIVES: Cecostomy tubes are commonly used for antegrade enema delivery in children with spinal defects and anorectal malformations to help address chronic constipation and fecal incontinence. Once surgically or radiologically placed, cecostomy tubes require changes by a percutaneous approach, which may be unsuccessful requiring repeat laparoscopy or open surgery to re-establish the cecostomy tract. The role of colonoscopy assistance to salvage lost cecostomy access in children who fail percutaneous replacement is not well described. The primary aim was to describe the safety and effectiveness of a colonoscopy-assisted approach to re-establish lost cecostomy access in children. METHODS: This was a retrospective cohort study of the methods, success and complication rates associated with colonoscopy assisted cecostomy tube replacement in children between 2000 and 2017 at a pediatric tertiary care center. RESULTS: Ninety-five patients with 841 attempted procedures were included with only 1% of procedures requiring endoscopic assistance. These included 7 colonoscopy-assisted cecostomy tube replacement procedures in 6 patients (median age 9.2 years, median weight 26.3 kg, 33% girls). The most common reason for using colonoscopy assistance was a failed percutaneous approach. The colonoscopy-assisted approach was successful in all cases without documented complications. CONCLUSIONS: Colonoscopy-assisted cecostomy tube replacement is safe and highly successful in re-establishing lost cecostomy access in children after failed attempts with percutaneous or fluoroscopic-guided approaches.

Safety and Efficacy of the Push Endoscopic Technique in the Management of Esophageal Food Bolus Impactions in Children.

OBJECTIVES: Adult-based guidelines support the use of the pull (extraction) endoscopic technique in managing esophageal food bolus impactions (FBIs) but allow the consideration of the push (advancement) technique with caution based on available published literature. The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition guidelines mention the use of gentle endoscopic pushing for disimpaction but elaborate that this technique has not been studied in children. Our study aimed at assessing the safety and efficacy of the push technique in managing pediatric esophageal FBIs. METHODS: This was a retrospective cohort study of all pediatric patients presenting with esophageal FBIs to a pediatric tertiary care center from 2003 to 2016. RESULTS: Two hundred forty-two procedures for esophageal foreign body removal were reviewed. Thirty-nine procedures for managing esophageal FBIs were included in a total of 23 patients (1-4 procedures per patient). The most common underlying diagnoses were eosinophilic esophagitis and repaired tracheoesophageal fistula. The cohort had a median age of 8 years and median weight of 34.4 kg. Initial endoscopic disimpaction methods included 20 push and 19 pull technique attempts with success rates of 65% and 68%, respectively (P = 1.0). Unsuccessful attempts using 1 technique were successfully accomplished using the other technique. Patients initially managed by either of the 2 disimpaction techniques did not differ in age, weight, sex, or underlying diagnoses. No procedure-related complications were reported at our center. CONCLUSION: The present study shows that the push technique is as safe and effective as the pull technique in managing esophageal FBIs in pediatric patients.

Systematic Review and Meta-Analysis of the Utilization of Ethanol Locks in Pediatric Patients With Intestinal Failure.

BACKGROUND: Intestinal failure is a chronic condition related to loss of bowel length and/or function, resulting in dependence on central venous catheters for fluids and nutrition. Catheter use can be associated with significant complications, including catheter-related bloodstream infections (CRBSIs), which can lead to loss of vascular access, advancing intestinal failure associated-liver disease and death. Our objective was to evaluate the effectiveness and safety of ethanol locks as compared with standard heparin locks in pediatric intestinal failure. METHODS: Databases, including MEDLINE and EMBASE, were searched until March 2017. Titles and abstracts were reviewed independently and relevant articles reassessed by full-text review. The main outcome was the rate of CRBSIs, while secondary outcomes were catheter replacement and repair. RESULTS: Nine observational studies were included. The mean difference in rate of CRBSIs was 6.27 per 1000 catheter days (95% CI, 4.89-7.66) favoring ethanol locks, with a 63% overall reduction in infection rate. The mean difference in catheter replacement rate (per 1000 catheter days) was 4.56 (95% Cl, 2.68-6.43) favoring ethanol locks. The overall effect on catheter repair rate (per 1000 catheter days) was -1.67 (95% CI, -2.30 to -1.05), indicating lower repair rate with heparin locks. CONCLUSION: Sufficient evidence was noted showing that ethanol locks reduced CRBSIs and catheter replacements. Our findings raise questions about the effect of the ethanol lock on catheter integrity based on the noted increase in repair rate. This requires further prospective evaluation and may support selective application of ethanol locks to patients with documented CRBSIs.

Differences in Durability, Dislodgement, and Other Complications With Use of Low-Profile Nonballoon Gastrostomy Tubes in Children.

BACKGROUND: Nonballoon low-profile gastrostomy tubes (GTs) are used for enteral nutrition support in a subset of pediatric patients with feeding difficulties when use of balloon GTs is problematic. Different nonballoon low-profile tube types are available, but comparative studies are lacking. MATERIALS AND METHODS: This was a retrospective cohort study comparing complications and outcomes between different low-profile nonballoon GTs at a pediatric tertiary care center over 10 years. RESULTS: We identified 43 patients with 160 tube placement procedures, including 93 (58%) BARD tubes (type A) and 67 (42%) Mini-ONE tubes (type B). Accidental tube dislodgment occurred exclusively with type B (33% vs 0%, P < .0001) with dislodgment occurring at a median of 54 days after placement. Type A GTs were more likely to be changed due to leakage (47% vs 8%, P < .0001). Minor gastrostomy site bleeding was more likely to be seen with type A tube changes (46% vs 7%, P < .0001). Patient sedation or site dilation was rarely needed in either group. Time to tube change was longer in the type B GTs (BARD) ( P = .016) with a median tube survival in the type A and type B groups at 432 and 284 days, respectively, with a hazard ratio of 1.89 (95% confidence interval, 1.2-2.99), but once confounders were accounted for, the effect of tube type was no longer statistically significant. CONCLUSION: Our study shows that differences exist with use of various low-profile nonballoon GTs. This should be taken into consideration when counseling families about the most appropriate tube type for their children.

Is Total Pancreatectomy with Islet Autotransplantation A Reasonable Choice for Pediatric Pancreatitis?

Chronic pancreatitis is an emerging and poorly understood disease in childhood. Total pancreatectomy with islet cell autotransplantation is being proposed as a treatment for chronic pancreatitis and recent studies report a more favorable outcome in children compared to adults. Herein, we review the therapeutic alternatives for pediatric chronic pancreatitis, focusing primarily on TP/IAT.

Difficulty Achieving Vitamin D Sufficiency With High-Dose Oral Repletion Therapy in Infants With Cholestasis.

OBJECTIVES: Oral high-dose repletion vitamin D therapy, also known as stoss therapy, can be effective in the treatment of nutritional vitamin D deficiency rickets in infants and young children without liver disease and in patients with cystic fibrosis. There is no literature about this approach in infants with new-onset cholestasis. METHODS: This was a retrospective chart review of infants with cholestasis from March 2010 to March 2012 at a pediatric tertiary care center. Four cases satisfied the inclusion criteria, and were described in detail. RESULTS: All of the patients received oral high-dose repletion therapy with ergocalciferol (vitamin D2) 300,000 IU daily for 2 to 3 days. Follow-up vitamin D levels approximately 4 weeks later showed failure to achieve sufficiency levels (>20 ng/dL) in any patient. CONCLUSIONS: Unlike infants without liver disease, use of oral high-dose repletion therapy may not be adequate as treatment of vitamin D deficiency in the setting of cholestasis.