Ethanol Lock Therapy for Prevention of CLABSIs in HPN Patients

Wales WP, Kosar C, Carricato M, de Silva N, Lang K, Avitzur Y. Ethanol lock therapy to reduce the incidence of catheter-related bloodstream infections in home parenteral nutrition patients with intestinal failure: preliminary experience. J Pediatr Surg. 2011;46:951–956.

Catheter-related bloodstream infections (CRBSIs) are a major cause of morbidity and mortality in the home parenteral nutrition (HPN) patient population. In the pediatric literature, case reports have noted the success of ethanol “catheter lock” in the treatment and prevention of CRBSIs.

In this article, Wales et al reported on the technique of locking 1–3 cc of 70% ethanol into central venous catheters (CVCs) used for HPN in a pediatric population. Ethanol was “locked” within the CVC for 4 hours between daily PN infusion cycles and then flushed through into the bloodstream. Ten patients began treatment with ethanol lock. Previously, this group had experienced 91 CRBSIs, with a mean of 10+/- 6.2 infections per 1,000 catheter days (CDs). They also experienced 5.6 catheter replacements per 1,000 CDs. Post-institution of the ethanol lock technique, the CRBSI infection rate in this same group was 0.9+/- 1.8 per 1,000 CDs (p=.005 when compared to prior experience). CVC replacements were now 0.3/1,000 CDs (p=.038 when compared to prior experience).

Ethanol is an inexpensive antiseptic that is usually widely available. It works through protein denaturation of bacterial and fungal elements. Bench-top studies have shown that polyurethane and silicone CVCs can be immersed in 70% ethanol for 24 hours/day for 24 hours to 10 weeks without damage to the catheters.

This is one of a number of small, prospective observational studies noting a reduction in CRBSIs using the ethanol lock technique as compared to historical controls in the same patient population. To date, the reported complications to patients or CVCs while using this technique have been minimal. An appropriately powered prospective, randomized trial is necessary to confirm ethanol lock as an effective therapy for CVC infections. However, the number of reported small, positive trials to date in the literature would warrant its current use in patients at high risk for catheter infections.

Causes of Feelings of Burden for Caregivers of Pediatric HEN Patients

Calderón C, Gómez-López L, Martínez-Costa C, Borrcas Z, Moreno-Villero JM, Pedrón-Giner C. Feeling of burden, psychological distress and anxiety among primary caregivers of children with home enteral nutrition. J Pediatr Psychol. 2011 Mar;36(2):188–195.


For caregivers, the psychological impact of home care activities, such as home enteral nutrition (HEN), is determined by a number of factors. These include external forces (social support, the caregiver’s socioeconomic status, the doctor-patient relationship, knowledge of the disease, and home equipment needs); patient-dependent factors (illness severity, short-term prognosis, patient-caregiver relationship and patient psychological status); and caregiver-dependent factors (lifestyle, anxiety, ability to perform tasks, employment demands, and levels of grief and fear).

Calderón and colleagues examined the relationship between severe psychological factors and the burden experienced by caregivers of HEN pediatric patients. Fifty-six mothers who served as primary caregivers for their children on long-term HEN were evaluated for overall “caregiver burden” using standardized tools.

Researchers found that maternal age and family socioeconomic status were not significantly related to caregiver burden. Also, no specific patient diagnosis was related to caregiver burden. However, caregiver anxiety and psychological stress significantly increased the degree of caregiver burden. Although not demonstrated here, other studies have shown that the number and complexity of a patient’s disease did impact caregiver burden.

This study underscores the impact of the caregiver’s mental health and ability to cope with stress on their feelings of “burden.” These increased feelings of burden could result in marital discourse, resentment, reduced quality of life, and poorer overall care delivered by the caregiver. Health providers, including home care and home equipment providers, need to be fully aware of these issues and the potential impact they may have on the patient. Efforts should be made to assess caregiver burden during the course of a patient’s treatment in the home environment.

Hang Time for Enteral Formula

Lyman B, Gebhards S, Hensley C, Roberts C, San Pablo W. Safety of decanted enteral formula hung for 12 hours in a pediatric setting. Nutr Clin Prac. 2011;26:451-456.

Pancreatitis is often mild and self-limiting. However, in 20–30% of cases, it can cause systemic inflammatory distress syndrome (SIRS), multi-organ failure, and a mortality rate of 15–40%. In this “severe group,” pancreatitis is a very catabolic condition; therefore, nutrition support has been a cornerstone of therapy. The question always asked is how to “feed” the patient while “resting” the pancreas. Previous trials have demonstrated that enteral nutrition (EN) is superior to parenteral nutrition (PN) in the setting of acute pancreatitis because of reduced associated infectious complications and cost. This current study wanted to determine if the time to initiation of EN and the time to reach target nutrition goals impacted clinical outcomes in patients with severe acute pancreatitis (SAP).

A retrospective chart review was performed on 17 patients in an ICU with a diagnosis of SAP who were referred to a nutrition support team. These patients had at least one system in organ failure and an APACHE II score of >8. Patients were divided into 3 groups: A — never reached goal nutrition needs; B — reached goal nutrition needs after >3 days; and C— reached goal nutrition needs in <3 days. APACHE II scores were similar among the 3 groups. Nasojejunal (NJ) feeding tubes were placed endoscopically. Patients were fed using a semi-elemental tube feeding. ICU stay was significantly higher in group A (45.3 days) as compared to group B (19 days) and C (13 days) (p=.035). The percentage of patients with overall complications (e.g., sepsis, pancreatic necrosis, multiple organ failure) was similar among the 3 groups. The overall mortality rate was similar in the 3 groups (24%). There was a significant difference in the time to EN initiation between the survivors (8+/-3 days)(n=13) and non-survivors (17+/-13 days)(n=4) (p<.05) The average BMI in survivors was 34.2 and in non-survivors 44.8. Overall, it appears that patients with SAP benefit from early EN use by NJ feeding. Significantly obese patients appear to have reduced survival.

This study underscores the importance of early EN use in patients with SAP. These patients were able to get a NJ tube placed endoscopically in a time-efficient manner in order to begin EN therapy. In this patient group, severe obesity was associated with a decrease in survival. More work on obese patients is required to understand why this group has an increased incidence of death.

Glutamine as a Supplement to Parenteral Nutrition

Vaneck VW, Matarese LE, Robinson M, Sacks GS, Young LS, Kochevar M. A.S.P.E.N. position paper: parenteral nutrition glutamine supplementation. Nutr Clin Pract. 2011;26:479-494.

The A.S.P.E.N. Novel Nutrient Task Force examined the utility of glutamine in addition to parenteral nutrition (PN) for the hospitalized patient. Glutamine is the most common amino acid in the blood. During critical illness, the body becomes unable to produce enough glutamine to meet required needs.

Glutamine can be compounded into a PN solution as a free amino acid. However, because of its relative instability in this form, it must be added daily to the PN formulation. This requires a PN compounding center that has the resources and processes to complete this compounding with a physician’s order. Alternatively, glutamine dipeptides (L-alanyl L-glutamine and glycyl L-glutamine) are available in many locations outside of the U.S. These dipeptides are water- and heat-stable and have a shelf life of up to two years. When injected parenterally, these dipeptides are hydrolyzed to L-glutamine rapidly by peptidase, which is present in the vascular endothelium.

Using a PubMed search, the Task Force identified papers addressing parenteral glutamine. The recommendations of the Task Force were based on meta-analysis papers, published clinical guidelines, review articles, and a review of selected original articles when there was a discrepancy. Seventeen meta-analysis papers were found; seven were excluded for various reasons.

The Task Force determined that parenteral glutamine administration is associated with a decrease in infectious complications, a decrease in hospital length of stay, and possibly a decrease in mortality in critically ill, post-operative, or ventilator-dependent patients requiring PN. The heterogeneity of the populations in the studies, however, called for additional research to confirm the recommendations. The Task Force additionally pointed out that there may be a utility in positive blood culture reduction in bone marrow transplant patients with the use of parenteral glutamine. (There is not enough data to make recommendations in pediatric patients.) A dose of >.2 g/kg/day is suggested. There is no data to suggest that parenteral glutamine is harmful.

Enteral Nutrition and Severe Acute Pancreatitis

Hegazi R, Rana A, Graham T, Rolniak S, Conta P, Kandil H, O’Kefe J. Early jejunal feeding initiation and clinical outcomes in patients with severe pancreatitis. JPEN. 2011;35:91-96.

Pancreatitis is often mild and self-limiting. However, in 20–30% of cases, it can cause systemic inflammatory distress syndrome (SIRS), multi-organ failure, and a mortality rate of 15–40%. In this “severe group,” pancreatitis is a very catabolic condition; therefore, nutrition support has been a cornerstone of therapy. The question always asked is how to “feed” the patient while “resting” the pancreas. Previous trials have demonstrated that enteral nutrition (EN) is superior to parenteral nutrition (PN) in the setting of acute pancreatitis because of reduced associated infectious complications and cost. This current study wanted to determine if the time to initiation of EN and the time to reach target nutrition goals impacted clinical outcomes in patients with severe acute pancreatitis (SAP).

A retrospective chart review was performed on 17 patients in an ICU with a diagnosis of SAP who were referred to a nutrition support team. These patients had at least one system in organ failure and an APACHE II score of >8. Patients were divided into 3 groups: A — never reached goal nutrition needs; B — reached goal nutrition needs after >3 days; and C — reached goal nutrition needs in ±3 days. APACHE II scores were similar among the 3 groups. Nasojejunal (NJ) feeding tubes were placed endoscopically. Patients were fed using a semi-elemental tube feeding. ICU stay was significantly higher in group A (45.3 days) as compared to group B (19 days) and C (13 days) (p=.035). The percentage of patients with overall complications (e.g., sepsis, pancreatic necrosis, multiple organ failure) was similar among the 3 groups. The overall mortality rate was similar in the 3 groups (24%). There was a significant difference in the time to EN initiation between the survivors (8+/-3 days)(n=13) and non-survivors (17+/-13 days)(n=4) (p<.05) The average BMI in survivors was 34.2 and in non-survivors 44.8. Overall, it appears that patients with SAP benefit from early EN use by NJ feeding. Significantly obese patients appear to have reduced survival.

This study underscores the importance of early EN use in patients with SAP. These patients were able to get a NJ tube placed endoscopically in a time-efficient manner in order to begin EN therapy. In this patient group, severe obesity was associated with a decrease in survival. More work on obese patients is required to understand why this group has an increased incidence of death.

TPN and Vitamin D

Thompson P, Duerksen DR. Vitamin D deficiency in patients receiving home parenteral nutrition. JPEN. 2011;35:499-504.

Vitamin D is obtained through oral ingestion and by conversion of vitamin D in the skin from exposure to sunlight. Recently, it has been demonstrated that the daily recommendation for vitamin D intake is low for the general population. Patients on home parenteral nutrition (HPN) have very limited oral vitamin D intake or absorption. These patients often do not get outside into the sun for the time period necessary for adequate ultraviolet light exposure. They obtain most of their vitamin D (200 IU) from the multivitamin supplementation they receive in their PN prescription. The accepted method for monitoring a patient’s vitamin D status is through serum 25(OH)D serum levels.

Twenty-two long-term HPN patients had their vitamin D levels checked by 25(OH)D status. Most of the patients had been on HPN for >1 year. Their most common diagnosis for receiving HPN was gastrointestinal dysmotility (45%), malabsorption (36%), and GI obstruction (18%).Vitamin D insufficiency was defined as a serum level of 25(OH)D between 50 and 75 nmol/L, and deficiency was defined as a serum level <50 nmol/L. The mean 25(OH)D level was 42+/-22 nmol/l. Sixty-eight percent of the patients in this study had vitamin D insufficiency, and 27% had vitamin D deficiency. There did not appear to be a seasonal variation in vitamin D status. There appeared to be no correlation of small intestinal length and vitamin D status in patients with a diagnosis of short bowel syndrome.

One complication of patients on long-term HPN is metabolic bone disease (MBD). The etiology of this complication is multifactorial, with vitamin D as only one component of this complex problem. Intake of calcium, magnesium, and phosphorous, in addition to fluoride exposure, aluminum exposure, metabolic acidosis, and other factors, plays a role in the development of MBD. More work needs to be done to understand the optimal IV dose of vitamin D that is required in patients on long-term HPN. In addition, consideration needs to be given to the other factors listed previously as to their role in causing or worsening MBD in long-term HPN patients.

Central Venous Access Device Infections and Home Parenteral Nutrition

Cober MP, Kovacevich DS, Teitelbaum DH. Ethanol-lock therapy for the prevention of central venous access device infections in pediatric patients with intestinal failure. JPEN. 2011;35:67-73.       

Central venous access device (CVAD) infections are a problem in the home parenteral nutrition (HPN) patient. These infections include skin site infections and bloodstream infections. In fact, CVAD infection is one of the most common and most devastating complications of HPN. In this study, the Michigan group did a retrospective analysis of the use of the ethanol-lock therapy (locking the solution in the catheter between uses). The group used a 70% ethanol solution. The dwell time for the ethanol solution was 2 hours at a minimum. Patients had the ethanol drawn from the catheter and discarded prior to infusion. Catheter infections were diagnosed based on 2002 guidelines from the Centers for Disease Control and Prevention. Patients in the study were deemed at-risk (defined as having had 2 CVADs replaced because of infections or 2 previous infections from their current CVAD, or having limited remaining CVAD access). Fifteen patients, with an average age of 5.9 years, were followed over 16 months on average. Throughout the study period, 73% of patients remained infection-free. There was a statistically significant decrease in the number of BSIs (bloodstream infections) per 1,000 catheter days (8.0 BSIs before the ethanol lock technique was implemented, versus 1.3 BSIs afterward [p<.001]). None of the catheters was removed because of BSI. Two of the patients developed a tunnel infection. The incidence of CVAD repair for leakage or disruption was not significantly different than that noted before initiation of ethanol-lock therapy.

There has been some concern of catheter damage in CVADs composed of polyurethane and subjected to ethanol-lock or flush, although this has not been confirmed in clinical studies. Many interventions for CVAD infections have been examined over the years, including wound patches and biofilms (specialized devices to attach to catheters to maintain sterility), patient education, and antibiotic “lock,” among others. This study provides an alternative, and apparently successful, intervention for prevention of catheter infections in at-risk patients.

Study Evaluates 203 Home Enteral Nutrition (HEN) Patients

Klek S, Szybinski P, Sierzega M, et al. Commercial enteral formulas and nutrition support teams improve the outcome of home enteral tube feeding. JPEN. 2011;3:380-385. (The authors are from Krakow, Poland. Some of the authors are employed by Nutrimed Medical Corporation.)

This was an interesting study evaluating 203 home enteral nutrition (HEN) patients. To start, the patients were fed homemade diets (pureed table foods) for tube feeding for 12 months, with oversight by the family only. Following use of the homemade diets, the patients used commercial enteral tube feeding (ETF) for 12 months, with the guidance of a nutritional support team (NST). When the patients used the ETF with the guidance of an NST, as compared to when they used a homemade tube feeding with no NST, they had significantly reduced hospital admissions (0.21/year [p<.001] vs. 1.2/year), duration of hospitalizations (3.83 days [p<.001] versus 20.84 days), and duration of ICU stay (0.50 days [p<.001] versus 2.35 days). Also, the cost of hospitalization was significantly reduced in the commercial ETF group that was followed by an NST. In addition, the incidence of pneumonia, respiratory failure, urinary tract infection, and anemia were significantly reduced in the commercial ETF/NST oversight group (p<.05).

This study used the same patients for their own controls, thus creating a very good comparison study. Often when evaluating the use of a medical product, we look at the cost of the intervention only. In this case, the use of commercial tube feeding and NST guidance was most likely more costly initially than pureed table foods and oversight only by the family. However, the use of commercial ETF and NST guidance led to significantly improved clinical outcomes and a significant reduction in the cost of hospitalization. This study shows that tube feeding at home is not an intervention that should be viewed as “secondary” to the other therapies the patient may be receiving. Proper use of HEN can significantly impact patient clinical outcomes.