Management of Home Parenteral Nutrition: Complications and Survival.

BACKGROUND AND AIMS: Parenteral nutrition (PN) has become an efficient, safe, and convenient treatment over years for patients suffering from intestinal failure. Home PN (HPN) enables the patients to have a high quality of life in their own environment. The therapy management however implies many restrictions and potentially severe lethal complications. Prevention and therapy of the latter are therefore of utmost importance. This study aims to assess and characterize the situation of patients with HPN focusing on prevalence of catheter-related complications and mortality. METHODS: Swiss multicentre prospective observational study collecting demographic, anthropometric, and catheter-related data by means of questionnaires every sixth month from 2017 to 2019 (24 months), focusing on survival and complications. Data were analysed using descriptive statistics. Logistic regression models were fitted to investigate association between infection and potential co-factors. RESULTS: Seventy adult patients (50% women) on HPN were included (≈5 patients/million adult inhabitants/year). The most common underlying diseases were cancer (23%), bariatric surgery (11%), and Crohn's disease (10%). The most prevalent indication was short bowel syndrome (30%). During the study period, 47% of the patients were weaned off PN; mortality rate reached 7% for a median treatment duration of 1.31 years. The rate of catheter-related infection was 0.66/1,000 catheter-days (0.28/catheter-year) while the rate of central venous thrombosis was 0.13/1,000 catheter-days (0.05/catheter-year). CONCLUSION: This prospective study gives a comprehensive overview of the adult Swiss HPN patient population. The collected data are prerequisite for evaluation, comparison, and improvement of recommendations to ensure best treatment quality and safety.

Repair of central venous access devices in intestinal failure patients is safe and cost-effective: A retrospective single centre cohort study.

INTRODUCTION: Patients with chronic intestinal failure (IF) require home parenteral nutrition (HPN). Central venous access is needed for prolonged use of PN, usually via a long term central venous access device (CVAD). Post insertion there may be mechanical complications with a CVAD such as catheter rupture or tear. Repair of damaged CVADs is possible to avoid risks associated with catheter replacement in patients with IF. However, catheter related blood stream infections (CRBSI) are a concern when CVAD's are accessed or manipulated. AIMS: To investigate the success of repair of CVADs in patients with IF on HPN, related to repair longevity and incidence of CRBSI following repair. METHOD: Nutrition team records of CVAD repairs carried out in patients with IF were reviewed retrospectively for the period April 2015 to March 2019. RESULTS: Nutrition Clinical Nurse Specialists carried out 38 repairs in 27 patients. Male n = 5, female n = 22; mean age 55 years. Catheter longevity before first repair (n = 27): median 851 days, IQR 137-1484 days. 30/38 (78.9%) of repairs were successful lasting ≥30days. Hospital admission was avoided in 76% of cases. 4 patients in the failed repair group underwent catheter re-insertion where 4 had a further, subsequently successful, repair, an overall success rate of 89.4% (34/38). 30-day CRBSI rate was 0.09/1000 catheter days in repaired catheters. In comparing costs, there is a potential cost saving of 2766GBP for repair compared to replacement of damaged CVADs. CONCLUSION: Repair of tunnelled CVADs in patients with IF is successful and safe with no increased risk of CRBSI. Significant cost savings may be made.

Prevalence of diabetes mellitus in patients with home enteral nutrition / Prevalencia de diabetes mellitus en pacientes con nutrición enteral domiciliaria

BACKGROUND: There are few data available in the literature on the prevalence of diabetes mellitus (DM) in patients with home enteral nutrition (HEN) via tube feeding. The objective was to analyze the prevalence of DM in patients receiving HEN, as well as evaluating the complications, the prescribed antidiabetic treatments and the nutrition regimen selected. DESIGN: This was a retrospective, single-center, observational study reviewing clinical histories. The population consisted of patients over 18 years of age who started HEN by tube between January 2016 and January 2018. Sociodemographic variables were recorded, as well as variables related to HEN. Additional variables were recorded in patients with DM. RESULTS: In the 198 study patients, followed up for a median of 104 days, the prevalence of DM was 31.8%, and patients with DM were older (71.3±11.5 vs. 64.2±15.8; p = 0.002) than those without DM. There were no differences between patients with and without DM as regards the prescription of HEN, its route and form of administration, and its complications. One hundred and thirty-two patients (66.7%) died during follow-up. The presence of DM did not increase the risk of death during follow-up (after adjusting for age, gender, and diagnosis). More than 85% of patients with DM received a specific formula for diabetes, and 84.1% of these patients received drug treatment. CONCLUSION: The prevalence of DM was high in patients receiving HEN, most of whom were prescribed specific enteral nutrition formulas. The presence of DM was not associated with greater morbidity and mortality or with differences in HEN regimens or indications

INTRODUCCIÓN: Existen pocos datos en la literatura sobre la prevalencia de la diabetes mellitus (DM) en los pacientes con nutrición enteral domiciliaria (NED) por sonda. El objetivo es analizar la prevalencia de los pacientes con DM en NED, las complicaciones, el tratamiento antidiabético y las pautas nutricionales escogidas. DISEÑO: Estudio observacional retrospectivo unicéntrico con revisión de historias clínicas. Población: pacientes mayores de 18 años que iniciaron NED y ambulatoria mediante sonda desde enero de 2016 a enero de 2018. Se recogieron variables sociodemográficas y relacionadas con la NED. En personas con DM se recogieron otras variables adicionales. RESULTADOS: Ciento noventa y ocho pacientes con una mediana de seguimiento de 104 días. La prevalencia de la DM fue del 31,8%, con mayor edad (71,3±11,5 vs. 64,2±15,8; p = 0,002) que los no DM. No encontramos diferencias entre personas con DM y sin ella respecto a la indicación de la NED, vía y forma de administración ni complicaciones mecánicas o infecciosas. Fallecieron 132 pacientes (66,7%) durante el seguimiento. La presencia de diabetes no incrementó el riesgo de fallecer durante el seguimiento (ajustado por la edad, el género y el diagnóstico). Más del 85% de los pacientes con DM recibieron una fórmula específica para diabetes. El 84,1% de los pacientes con DM recibieron tratamiento farmacológico. CONCLUSIÓN: En pacientes con NED por sonda, la prevalencia de DM fue elevada, y los pacientes recibieron mayoritariamente fórmulas nutricionales específicas. La presencia de diabetes no se asoció con una mayor morbimortalidad o diferencias en las pautas o indicaciones de la NED

ESPEN guideline on home parenteral nutrition.

This guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home parenteral nutrition (HPN) providers, as well as healthcare administrators and policy makers, about appropriate and safe HPN provision. This guideline will also inform patients requiring HPN. The guideline is based on previous published guidelines and provides an update of current evidence and expert opinion; it consists of 71 recommendations that address the indications for HPN, central venous access device (CVAD) and infusion pump, infusion line and CVAD site care, nutritional admixtures, program monitoring and management. Meta-analyses, systematic reviews and single clinical trials based on clinical questions were searched according to the PICO format. The evidence was evaluated and used to develop clinical recommendations implementing Scottish Intercollegiate Guidelines Network methodology. The guideline was commissioned and financially supported by ESPEN and members of the guideline group were selected by ESPEN.

Antimicrobial Locks in Patients Receiving Home Parenteral Nutrition.

Catheter-related bloodstream infection (CRBSI) is one of the most common and potentially fatal complications in patients receiving home parenteral nutrition (HPN). In order to prevent permanent venous access loss, catheter locking with an antimicrobial solution has received significant interest and is often a favored approach as part of the treatment of CRBSI, but mainly for its prevention. Several agents have been used for treating and preventing CRBSI, for instance antibiotics, antiseptics (ethanol, taurolidine) and, historically, anticoagulants such as heparin. Nonetheless, current guidelines do not provide clear guidance on the use of catheter locks. Therefore, this review aims to provide a better understanding of the current use of antimicrobial locking in patients on HPN as well as reviewing the available data on novel compounds. Despite the fact that our current knowledge on catheter locking is still hampered by several gaps, taurolidine and ethanol solutions seem promising for prevention and potentially, but not proven, treatment of CRBSI. Additional studies are warranted to further characterize the efficacy and safety of these agents.

Repair of Central Venous Catheters in Home Parenteral Nutrition Patients.

For patients receiving home parenteral nutrition (HPN), vascular access with a central venous catheter (CVC) is essential to safely administer parenteral nutrition (PN) to meet their nutrition and hydration needs. Unfortunately, despite rigorous training and prevention strategies, CVCs are susceptible to complications such as infection, occlusion, thrombosis, and mechanical failure. Much of the published research on CVC complications focuses on infections; however, catheter occlusions and mechanical failures also contribute significantly to catheter dysfunction and loss. Frequent CVC exchanges put HPN patients at risk of loss of vascular access, making it essential that any strategies that can salvage the CVC be implemented prior to removal. CVC repair is 1 technique that can be utilized to avoid CVC exchanges in certain situations. CVC repairs can be performed in the office or on the ward and are cost effective when compared with CVC replacement. When performed by trained clinical staff, the procedures are highly successful and associated with low risk.

Clinical outcomes of home parenteral nutrition patients using taurolidine as catheter lock: A long-term cohort study.

BACKGROUND & AIMS: Central venous access device (CVAD)-related complications, such as central-line associated bloodstream infections (CLABSIs), CVAD-related venous thromboses (CRVTs) and -occlusions frequently occur in home parenteral nutrition (HPN) patients. A preventive strategy to decrease the incidence of CLABSIs is the use of CVAD lock solutions, such as 2% taurolidine. The aim of this study was to evaluate long-term clinical outcomes of our HPN cohort while using taurolidine as lock solution. In addition, we explored risk factors associated with CVAD-related complications. METHODS: We conducted a retrospective analysis of complications (CLABSIs, CRVTs and CVAD occlusions) and adverse events in adult HPN patients while using taurolidine as lock solution. Patients with a benign underlying disease leading to intestinal failure were included between 2006 and 2017 at our tertiary referral centre for intestinal failure. Primary outcome was the effectiveness of taurolidine, as described by complication incidence rates. Secondary objectives were to assess adverse events of taurolidine, complication rates of patients who subsequently discontinued taurolidine and started using 0.9% saline alternatively, and risk factors associated with complications. RESULTS: In total, 270 HPN patients used taurolidine during 338521 catheter days. CLABSIs, CRVTs and CVAD occlusions occurred at a rate of 0.60 (CI95% 0.52-0.69), 0.28 (CI95% 0.23-0.34), and 0.12 (CI95% 0.08-0.16) events per 1000 catheter days, respectively. In 24 (9%) patients, mild to moderate adverse events resulted in discontinuation of 2% taurolidine. A subsequent switch to 0.9% saline resulted in an increased CLABSI rate (adjusted rate ratio 4.01 (95%CI 1.23-13.04), P = 0.02). Several risk factors were identified for CLABSIs (a lower age, nontunneled catheters, infusion frequency), CRVTs (site of vein insertion), and CVAD occlusions (type of CVAD). CONCLUSION: Complication rates remained low in the long-term, and use of taurolidine was generally safe. The identified risk factors may help to create new strategies to further prevent CVAD-related complications and improve HPN care in the future.

American Society for Parenteral and Enteral Nutrition Guidelines for the Selection and Care of Central Venous Access Devices for Adult Home Parenteral Nutrition Administration.

This document represents the American Society for Parenteral and Enteral Nutrition (ASPEN) clinical guidelines to describe best practices in the selection and care of central venous access devices (CVADs) for the infusion of home parenteral nutrition (HPN) admixtures in adult patients. The guidelines targeted adults >18 years of age in which the intervention or exposure had to include HPN that was administered via a CVAD. Case studies, non-English studies, or studies of CVAD no longer available in the United States were excluded. In total, 564 abstract citations, 350 from Medline and 214 from PubMed/non-MEDLINE databases, were scanned for relevance. Of the 564 citations, 13 studies addressed at least 1 of the 6 guideline-related questions, and none of the studies were prospective and randomized. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria were used to adjust the evidence grade based on assessment of the quality of study design and execution. Recommendations for the CVAD type, composition, or number of lumens to minimize infectious or mechanical complications are based on a limited number of studies and expert opinion of the authors, all very experienced in home infusion therapy. No studies were found that compared best solutions for routine flushing of lumens (eg, heparin versus saline) or for maintaining catheters in situ while treating CVAD mechanical or infectious complications. It is clear that studies to answer these questions are very limited, and further research is needed. These clinical guidelines were approved by the ASPEN Board of Directors.

Infectious complications in home parenteral nutrition: A long-term study with peripherally inserted central catheters, tunneled catheters, and ports.

OBJECTIVE: Home parenteral nutrition (HPN) has become a common therapy, with tunneled central venous catheters (CVCs) being the preferred route of administration. Peripherally inserted central catheters (PICCs) have been used increasingly, but whether they should be preferred over other types of CVCs is still controversial. The aim of this study was to evaluate catheter-related complications of CVC in patients receiving HPN. METHODS: All patients treated at our center for HPN from 2007 to 2017 were prospectively included. A specialized intravenous therapy team took care of these patients. Catheter-related bloodstream infections (CRBSI) were confirmed with positive, simultaneous, differential blood cultures drawn through the CVC and peripheral vein and then semiquantitative or quantitative culture of the catheter tip. RESULTS: In all, 151 patients received HPN during the 11-y study period. Of these patients, 95 were women (63%) and 55 were men (37%), with a mean age of 58 ± 13 y. Twenty-six were non-cancer patients (17%) and the remaining 125 patients had an underlying malignancy (83%). Regarding the CVC, 116 were PICCs, 18 Hickman, and 36 ports. Confirmed CRBSI per catheter-days showed 0.15 episodes per 1000 catheter-days for PICCs, 0.72 for Hickman, and 2.02 for ports. PICCs had less-confirmed CRBSIs per 1000 catheter-days than ports (φ = 0.54, P = 0.005), but no difference between PICCs and Hickman was found (φ = 0.32, P = 0.110). Confirmed episodes of CRBSI (2 versus 13%, χ2 = 6.625, P = 0.036) were more frequent with multilumen catheters. CONCLUSIONS: In our setting, single-lumen PICC and Hickman catheters showed low infectious complications.

Rate of Catheter-Related Bloodstream Infections Between Tunneled Central Venous Catheters Versus Peripherally Inserted Central Catheters in Adult Home Parenteral Nutrition: A Meta-analysis.

BACKGROUND: Tunneled central venous catheters (TCVCs) and peripherally inserted central catheters (PICC) are often used for the provision of home parenteral nutrition (HPN). There is no formal comparison being made to study the rate of catheter-related bloodstream infection (CRBSI) between TCVCs and PICC in HPN to recommend the use of 1 over the other. METHODS: An online MEDLINE, PubMed, and Scopus search was conducted. Studies reporting the rate of CRBSI in HPN patients were included. DerSimonian and Laird random effects meta-analyses were used to analyze comparative studies, whereas Begg and Pilote's random effects meta-analysis was used to pool and analyze single-arm studies. RESULTS: Seventeen studies (12 single-arm studies and 5 comparative studies) were included for analysis. Meta-analysis of comparative studies showed that PICC use was associated with a significantly lower rate of CRBSI (relative risk (RR) 0.40, 95% CI 0.19-0.83), whereas meta-analysis of single-arm studies revealed that the relative risk for CRBSI was not statistically significantly different from unity. CONCLUSION: TCVC is more commonly used in long-term HPN. Our analysis of comparative studies showed a lower rate of CRBSI in HPN patients using PICC compared with TCVC; however, analysis of single-arm studies showed that the rate of CRBSI was comparable in PICC and TCVC use. The decision to which type of catheter is most suited for HPN patients should hence be based on the duration of treatment, level of care, patients' dexterity, as well patients' underlying comorbidities that may potentially contribute to other catheter-related complications.

Central venous catheter repair is highly successful in children with intestinal failure.

PURPOSE: Damaged central venous catheters (CVCs) are commonly repaired to avoid line replacement and preserve vascular access. However, limited data suggest an increased risk for central line-associated bloodstream infections (CLABSIs) associated with the repair procedure. The purpose of this study was to describe outcomes of CVC repairs among parenteral nutrition (PN) dependent children with intestinal failure (IF). METHODS: A 2-year retrospective review was performed on children with IF on home PN > 6 months. Outcomes of interest were repair success and postrepair CLABSI incidence. Descriptive statistics included medians and frequencies. RESULTS: A total of 36 pediatric IF patients underwent 96 CVC repairs during the study period. The median CVC repair count was 1.5 repairs/patient (range, 1 to 16 repairs/patient) with >1 repair in half the patients. Ninety-four broken catheters (98%) were successfully repaired with restoration of function. Of the unsuccessful repairs (2%), the two catheters eventually required surgical removal and replacement. One repair (1%) was followed by a CLABSI with Enterococcus faecalis in an immunocompromised patient. CONCLUSION: CVC repair is a highly successful procedure with a low risk for infection. Catheter repair should be considered whenever possible as it may extend the lifetime of the catheter and decrease the risk for vascular access loss. LEVEL OF EVIDENCE: Treatment study; level IV.

To Pull or Not to Pull: Salvaging Central Line Catheters in Home Parenteral Nutrition.

PURPOSE OF REVIEW: Catheter-related blood stream infections (CRBSI) pose a significant risk to patients on home parenteral nutrition (HPN). Recurrent loss of catheters can lead to scarring and eventual loss of central access, a potentially fatal situation for patients dependent on HPN. RECENT FINDINGS: In the past, the standard of care to treat these infections required catheter removal. More recently, several studies have indicated that many CRBSI can be treated without removal of the catheter. Successful treatment without removal can be achieved by intentionally following a catheter salvage protocol. We define this as a previously defined protocol to accurately diagnose CRBSI, identify the organism(s) involved, and effectively treat not only the blood stream infection, but also sterilize the catheter. For patients on HPN with CRBSI, consider attempting line salvage if the patient is not suffering from severe sepsis, other infection related complications, or certain specific infections. Success rates vary depending on the organism causing the infection and the risks; benefits and chance of success should be considered when deciding to attempt line salvage.

Non-Antibiotic Antimicrobial Catheter Lock Solutions in Patients on Home Parenteral Nutrition.

Patients on home parenteral nutrition (HPN) are dependent on central venous access for long-term sustenance, and catheter-related bloodstream infections (CRBSIs) are a major cause of morbidity and mortality in this patient population. As such, there is much interest in finding new methods for preventing CRBSIs in patients on HPN. As it is thought that these infections are preceded by microbial colonization of the catheter, one approach is to use antimicrobial catheter lock solutions. Although antibiotic catheter lock solutions have been present for decades, their use has been mostly limited to the treatment of CRBSIs due to concern for promoting microbial resistance. Recently, however, with the advent of non-antibiotic antimicrobial catheter lock solutions, this approach is gaining popularity as a promising method to decrease rates of CRBSI in HPN patients.

Central Line in Long-term Parenteral Nutrition in Children: A European Survey.

BACKGROUND AND AIMS: The guidelines for the insertion and maintenance of the central venous catheter (CVC) in children on long-term parenteral nutrition (PN) were published 12 years ago and studies evaluating the outcomes are limited. Therefore, the aim of the present study was to perform a survey about criteria for CVC insertion and maintenance in intestinal failure/rehabilitation centers treating children on home PN. METHODS: An online cross-sectional survey based on previous European Society of Paediatric Gastroenterology, Hepatology and Nutrition PN guidelines was distributed electronically to the members of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition networking group, Network for Intestinal Failure and Transplantation in Europe and tertiary pediatric gastroenterology centers in Europe. RESULTS: Overall, 55 responses from 49 centers in 18 European countries and Israel were collected. The majority of respondents were from the United Kingdom (10, 19%), followed by Germany (7, 13%) and France (6, 11%). Eleven centers (21%) cared for >30 patients, 8 (15%) centers between 20 and 30 patients, 18 (34%) centers between 10 and 20 patients, and 16 (30%) <10 patients on home PN. There was a high variability in the majority of answers to the cross-sectional survey. CONCLUSIONS: CVC insertion and maintenance in children on home PN varies largely amongst centers in Europe. These differences could be at least partially explained by the lack of updated guidelines and limited evidence. There is an urgent need for collaborative research to make recommendations about the best possible practice.

Home Parenteral Nutrition in Adult Patients With Chronic Intestinal Failure: Catheter-Related Complications Over 4 Decades at the Main Danish Tertiary Referral Center.

BACKGROUND/AIMS: Catheter-related complications (CRCs) cause mortality and morbidity in patients dependent on parenteral support at home (HPN) due to intestinal failure (IF). This study describes the incidences of CRCs in an adult IF cohort over 40 years. It illustrates the evolution and consequences of CRCs, their association to demographic characteristics, and potential risk factors in an effort to provide the rationale for preventive precautions to the relevant patients with IF at risk. METHODS: All patients with IF discharged with HPN from 1970-2010 were included. Patient and treatment characteristics were extracted from the Copenhagen IF database. The incidences were given per 1000 central venous catheter (CVC) days. RESULTS: The 1715 CRCs occurred in 70% of the 508 patients with IF (56% of the 2191 CVCs). The incidence of catheter-related bloodstream infections (CRBSIs) was 1.43. Higher age, HPN administration by community home nurses, and prior CRBSIs significantly raised the hazard for CRBSIs. In the 1970s, catheters were generally replaced following CRBSIs, whereas catheter salvage was the norm in the 2000s. The incidences of mechanical complications, tunnel infections, and catheter-related venous thromboses were 0.80, 0.25, and 0.11, respectively. The overall CRC incidence was 2.58, decreasing the first 3 decades but peaking in the last (2.84). The deaths related to CRCs were low (0.018). CONCLUSION: Even in an experienced IF center of excellence, the incidence of CRCs increased over the 4 decades. This increase could be explained by the expansion of the indication of HPN to a more elderly and frail patient population.

Epidemiology and Risk Factors for Outpatient-Acquired Catheter-Related Bloodstream Infections in Children Receiving Home Parenteral Nutrition.

BACKGROUND: Few studies have examined the epidemiology and risk factors for the development of outpatient-acquired catheter-related bloodstream infections (CRBSIs) in children receiving home parenteral nutrition. This study aimed to (1) characterize the incidence, clinical presentation, and epidemiology of CRBSIs and (2) identify risk factors for CRBSIs in children receiving home parenteral nutrition. METHODS: A longitudinal database approved by our Institutional Review Board was created to prospectively track CRBSIs in the UCLA pediatric population from January to December 2012. Eligible patients included those < 18 years old receiving home parenteral nutrition. RESULTS: Thirty of 60 patients (50%) were diagnosed with 66 CRBSIs, for an overall CRBSI rate of 3.6 per 1000 catheter days. Of the CRBSIs, 73% were due to single microorganisms and 27% were polymicrobial. There was a significant difference in median (range) time for blood cultures to turn positive depending on type of CRBSIs (p = 0.03), with polymicrobial infections detected at 13.4 (8.7-24.3) hours, gram-negative infections at 16.5 (9-30.8) hours, and gram-positive infections at 18.9 (8.4-37.1) hours. The most common presenting symptom was fever (82%), followed by gastrointestinal symptoms (42%) and chills (29%). The only significant multivariate risk factor for CRBSIs was presence of a feeding tube (2.3-fold increase in CRBSI risk, p = 0.04). DISCUSSION: Outpatient-acquired CRBSIs are common in children receiving home parenteral nutrition. CRBSIs typically present with fever, but are also associated with gastrointestinal and/or respiratory symptoms. The presence of feeding tubes may predispose children on home parenteral nutrition to developing CRBSIs.

Documento de consenso de expertos de Andalucía y Extremadura sobre la nutrición parenteral domiciliaria / Home parenteral nutrition: a consensus document of experts from Andalucia and Extremadura

La nutrición parenteral en domicilio (NPD) es una técnica que ha permitido la supervivencia en la comunidad de aquellos pacientes con enfermedades graves resultantes en un fallo intestinal que hacía imposible su nutrición por otros métodos. Esta está indicada si existe un fallo intestinal documentado (entendido como la reducción de la función intestinal al mínimo hasta el punto de que se requiere suplementación intravenosa para mantener la salud y/o el crecimiento) con imposibilidad para la nutrición exclusiva por vía oral/enteral, posibilidad de manejo del enfermo en el domicilio y que no exista una expectativa corta de supervivencia, teniendo en cuenta la calidad de vida del paciente, el entorno familiar y la capacidad del paciente y/o de sus cuidadores de entrenamiento para la terapia de NPD. En los problemas de salud poco prevalentes, como es el fallo intestinal, en los cuales la evidencia científica disponible es de baja calidad, los documentos de consenso/expertos aportan valor en la toma de decisiones. Se suma a ello que la NPD es un proceso muy complejo y, a pesar de que existe una amplia experiencia en su aplicación e incluso guías de práctica clínica, en la práctica diaria se plantean incertidumbres acerca de su conveniencia, utilidad, uso racional y costes asociados. Por este motivo se ha realizado este documento de consenso, utilizando el método GRADE, con el que pretendemos definir nuestra posición con respecto al uso actual de la NPD en nuestro país y dar respuesta a una serie de preguntas que generan controversia en relación a este tratamiento (AU)

Home parenteral nutrition (HPN) is a technique that has allowed the survival in the community of those patients with serious diseases resulting in an intestinal failure that made their nutrition impossible by other methods. It is indicated if there is a documented intestinal failure (understood by the reduction of the intestinal function to the minimum to the point that intravenous supplementation is required to maintain health and/or growth) with impossibility for oral or enteral exclusive nutrition, provided that there is the possibility of managing the patient at home and that there is no short-term survival expectancy. It requires taking into account the patient’s quality of life, family environment and the capacity of the patient and/or their caregivers to be trained for HPN therapy. In low prevalence health topics, as intestinal failure, where the available scientific evidence is of poor quality, consensus documents add value in decision-making. Furthermore, HPN is a complex process and, although there is extensive experience in its application and even clinical practice guidelines, in daily practice there are uncertainties about its suitability, usefulness, rational use and associated costs. For this reason, this document of consensus has been carried out, using the GRADE method. With this document we intend to define our position with regard to the current use of HPN in our country and answer several controversial questions related to this treatment (AU)

Prevention of Subsequent Catheter-Related Bloodstream Infection Using Catheter Locks in High-Risk Patients Receiving Home Parenteral Nutrition.

INTRODUCTION: Catheter-related bloodstream infection (CRBSI) is a serious complication in patients receiving home parenteral nutrition (HPN). Antibiotic lock therapy (ALT) and ethanol lock therapy (ELT) can be used to prevent CRBSI episodes in high-risk patients. METHODS: Following institutional review board approval, all patients enrolled in the Mayo Clinic HPN program from January 1, 2006, to December 31, 2013, with catheter locking were eligible to be included. Patients without research authorization and <18 years old at the initiation of HPN were excluded. Total number of infections before and after ALT or ELT were estimated in all patients. RESULTS: A total of 63 patients were enrolled during the study period. Of 59 eligible patients, 29 (49%) were female, and 30 (51%) were male. The median duration of HPN was 3.66 (interquartile range, 0.75-8.19) years. The mean age ± SD at initiation of HPN was 49.89 ± 14.07 years. A total of 51 patients were instilled with ALT, and 8 patients were instilled with ELT during their course of HPN. A total of 313 CRBSI episodes occurred in these patients, 264 before locking and 49 after locking ( P < .001). Rate of infection per 1000 catheter days was 10.97 ± 25.92 before locking and 1.09 ± 2.53 after locking ( P < .001). DISCUSSION: The major findings of the present study reveal that ALT or ELT can reduce the overall rate of infections per 1000 catheter days. ALT or ELT can be used in appropriate clinical setting for patients receiving HPN.

Nutrición parenteral domiciliaria pediátrica / Pediatric home parenteral nutrition

No disponible

Sellado con antibióticos o antisépticos en pacientes pediátricos con nutrición parenteral domiciliaria. Puesta al día / Bactericide and antibiotic lock therapy in pediatric patients with home parenteral nutrition. Update

Introducción: la nutrición parenteral domiciliaria se ha convertido en un punto clave en el tratamiento de pacientes con fracaso intestinal crónico. A pesar de los importantes avances que se han producido en las últimas décadas, tanto en los accesos vasculares como en las soluciones empleadas, las infecciones asociadas a catéter venoso central siguen constituyendo una de las complicaciones más importantes. Dentro de las estrategias para la prevención o el tratamiento de estas infecciones se encuentra el empleo de sellados con antisépticos, como el etanol o la taurolidina, o de antibióticos. Objetivo: el objetivo de este artículo es revisar la evidencia disponible sobre el empleo de sellados con antisépticos o antibióticos en el manejo de pacientes pediátricos con nutrición parenteral domiciliaria. Material y métodos: el uso de sellados con etanol o taurolidina para prevenir el desarrollo de infecciones asociadas a catéter central estaría indicado en pacientes con nutrición parenteral domiciliaria que hayan tenido más de una infección en el año anterior o que se consideren pacientes de riesgo. Los sellados con antibióticos están indicados en el tratamiento de bacteriemias asociadas a catéter central producidas por S. coagulasa-negativo o gramnegativos, asociados a un tratamiento sistémico, siempre que sea posible, con el fin de salvar el catéter. Se debería llevar a cabo la retirada del mismo cuando existan signos de infección del punto de entrada o del trayecto subcutáneo, o cuando el germen responsable de la infección sea S. aureus o Candida. Conclusión: a pesar de que la fuerza de la evidencia sobre la eficacia del sellado en la prevención o el tratamiento de infecciones asociadas al catéter es limitada, tanto en el niño como en el adulto, cada vez existen más datos a usar esta alternativa en pacientes con nutrición parenteral domiciliaria en los que la atención y salvaguarda de los catéteres es primordial (AU)

Introduction: Home parenteral nutrition has become the mainstay for the support of patients with severe chronic intestinal failure. Despite the significant advances that have occurred in recent decades in terms of vascular access and parenteral solutions, catheter-related bloodstream infections remain one of the most important complications. Antiseptic lock therapies, as ethanol or taurolidine; and antibiotic lock therapies are used in order to prevent or treat these infections. Objective: The aim of this article is to review the available scientifi c evidence regarding the use of antiseptic and antibiotic lock therapies in the management of pediatric patients with home parenteral nutrition. Material and methods: The use of ethanol or taurolidine lock therapy would be suggested in order to prevent catheter-related bloodstream infections in patients with home parenteral nutrition who have suffered from more than one infection in the previous year or in at-risk patients. Antibiotic locks are used for the treatment of catheter-related bloodstream infections due to S. coagulase negative and gram-negative bacilli in conjunction with systemic antimicrobial therapy, for whom catheter salvage is the goal. Catheter removal is recommended when there are signs of exit site or tunnel infection or the infection is due to S. aureus or Candida species. Conclusion: Despite the fact that evidence based data on the topic is scarce, there are a growing number of publications that support the use of antibiotics or antiseptic locks for the prevention or treatment of catheter-related infections in home parenteral nutrition patients, in whom catheter maintenance is a cornerstone for survival (AU)