CLB-08730; No. of pages: 2; 4C: Clinical Biochemistry xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Clinical Biochemistry journal homepage: www.elsevier.com/locate/clinbiochem
Short Communication
Delivering safe and effective parenteral nutrition John W.L. Puntis Leeds General Infirmary, UK University of Leeds, UK
Introduction Since Wilmore and Dudrick's 1968 landmark case report of successful long-term intravenous feeding in a child with short bowel syndrome/intestinal failure, parenteral nutrition (PN) has been continually refined over time. It is now both more safe and also much more widely used, with the premature newborn being the largest single patient group and representing one of the main causes of increasing demand.
Multidisciplinary nutrition support Multidisciplinary nutritional support teams function in order to ensure that PN is used only when needed, and in a way that minimises risk [1]. Benefits include reduced catheter sepsis and mechanical complications, less biochemical disturbance, cost containment from reduced waste, and promotion of enteral nutritional support when more appropriate. Much PN is short-term (as in the newborn) but requires a sound organisational framework to be both safe and effective, with close pharmacist involvement and agreed protocols including necessary monitoring. Serious complications during limited periods of PN are rare, but very occasional prescription transcription or compounding errors, and microbiological contamination have devastating consequences and highlight potential risks involved.
Small bowel transplantation or long-term PN? In terms of survival, long-term PN remains a better option for patients with chronic intestinal failure than small bowel transplantation. This is because in transplantation the five year graft survival rate is only around 50%, largely because of unresolved difficulties with immuno-suppression to prevent rejection. Home PN (HPN) offers a good quality of life for children, if not for their parents. However, some important problems remain, and a key focus of management is prevention of those life threatening complications that become the principle indications for small bowel (+/− liver) transplantation. Most commonly this is intestinal failure associated liver disease (IFALD), but recurrent central venous catheter related blood stream
E-mail address: [email protected].
infection (CRBSI), and extensive venous thrombosis jeopardising future venous access are also important triggers. Preventing complications Recent investigations suggest that PN is not always managed as well as it could be [2], and both European guidelines and national reviews have sought to address this issue [3,4]. A number of advances in practice have also reduced the risk both of IFALD, and of CRBSI (an antecedent to both IFALD and thrombosis). These include the use of newer lipid emulsions containing fish oil, and antibacterial ‘line locks’ (taurolidine; ethanol) [5]. Prevention of venous thrombosis is more challenging, but minimising the need for CVC replacement by avoiding infection, and using selected and highly skilled surgeons or interventional radiologists most likely play a role [6]. Intestinal failure associated liver disease (IFALD) The risk factors for IFALD relate to both patient characteristics and management of the IF. The former include age, degree of liver maturation (prematurity), cause of IF, site and frequency of infection (gastrointestinal tract, central venous catheter), small bowel bacterial overgrowth, and enteral feed tolerance. Treatment related factors include the composition of PN, its mode of administration (continuous/cyclical), the duration of PN dependency, the surgical interventions and their anatomical consequences (intestinal obstruction, disruption of the enterohepatic circulation, resection of the terminal ileum or the ileocaecal valve), and the need for antibiotics (liver/renal toxicity). The pathogenesis of IFALD is therefore multifactorial. The composition of newer fish oil containing lipid emulsions (LE) has several potential advantages, including a high concentration of α-tocopherol (4–8 fold more than soybean oil LE), and absence of plant sterols. Moreover, fish oil is a source of docosahexaenoic acid (DHA, important for neurodevelopment and visual function), and of eicosapentaenoic acid (EPA). EPA favourably modulates inflammation, directly by decreasing the production of pro-inflammatory cytokines, and indirectly by increasing secretion of the antiinflammatory cytokine IL-10 by hepatic macrophages. Recommendations for avoiding IFALD include giving a balanced energy supply of fat and dextrose (usually 15–30% of non-protein calories as fat) in order to sustain protein accretion and growth, but avoiding
http://dx.doi.org/10.1016/j.clinbiochem.2014.05.024 0009-9120/© 2014 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.
Please cite this article as: Puntis JWL, Delivering safe and effective parenteral nutrition, Clin Biochem (2014), http://dx.doi.org/10.1016/ j.clinbiochem.2014.05.024
2
J.W.L. Puntis / Clinical Biochemistry xxx (2014) xxx–xxx
excess energy intake. Reducing, or temporarily discontinuing LE should be considered in the presence of hyperbilirubinaemia, and both decreasing intake of soybean oil derived ω−6 LE and using fish oil containing LE seem to be promising interventions.
patients may point to underlying family difficulties in managing complex care, and the need for increased social care support.
References Catheter related blood stream infection Scrupulous aseptic technique when accessing the CVC remains the key to avoiding infection. Interventions shown to definitely decrease the risk of catheter sepsis all involve protecting the external catheter from intraluminal bacterial contamination. There is little or no evidence that translocation of bacteria from the bowel lumen into the bloodstream is an important cause of CRBSI or that surgical interventions such as bowel lengthening affect this process. Antimicrobial ‘line locks’ are used to fill the CVC lumen when not in use during cyclical PN. The two agents investigated in children are taurolidine [5], and alcohol. Taurolidine, with citrate to prevent thrombus (TauroLock®), works by binding to the cell walls of organisms and preventing their adhesion to biological surfaces. It has a wide range of anti-microbial activity, including fungi, without causing resistance. Retrospective studies suggest a major effect in reducing risk of infection. Frequent CRBSI in HPN
[1] Agostoni C, Axelsson I, Colomb V, et al. The need for nutrition support teams in pediatric units: a commentary by the ESPGHAN committee on nutrition. J Pediatr Gastroenterol Nutr 2005;41:8–11. [2] Koletzko B, Goulet O, Hunt J, et al. Guidelines on parenteral nutrition of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), supported by the European Society of Pediatric Research (ESPR). J Pediatr Gastroenterol Nutr 2005;41(Suppl. 2). [3] Mason DG, Puntis JWL, McCormick K, Smith N. Parenteral nutrition for neonates and children: a mixed bag. Arch Dis Child 2011;96:209–10. [4] Improving practice and reducing risk in the provision of parenteral nutrition for neonates and children. A report from the paediatric Chief Pharmacists Group. http:// www.nppg.scot.nhs.uk/Minimising%20risk%20in%20PN%20for%20children.pdf; 2011. [5] Chu H-P, Brind J, Tomar R, Hill S. Significant reduction in central venous catheterrelated blood stream infections in children on HPN after starting treatment with taurolidine line lock. J Pediatr Gastroenterol Nutr 2012;55:403–7. [6] Wells JM, Jawaid WB, Bromley P, Bennett J, Arul GS. A dedicated consultant-led vascular access team significantly reduces out-of-hours and emergency permanent central venous access insertions. J Pediatr Surg 2010;45:419–21.
Please cite this article as: Puntis JWL, Delivering safe and effective parenteral nutrition, Clin Biochem (2014), http://dx.doi.org/10.1016/ j.clinbiochem.2014.05.024
Contents lists available at ScienceDirect
Clinical Biochemistry journal homepage: www.elsevier.com/locate/clinbiochem
Short Communication
Delivering safe and effective parenteral nutrition John W.L. Puntis Leeds General Infirmary, UK University of Leeds, UK
Introduction Since Wilmore and Dudrick's 1968 landmark case report of successful long-term intravenous feeding in a child with short bowel syndrome/intestinal failure, parenteral nutrition (PN) has been continually refined over time. It is now both more safe and also much more widely used, with the premature newborn being the largest single patient group and representing one of the main causes of increasing demand.
Multidisciplinary nutrition support Multidisciplinary nutritional support teams function in order to ensure that PN is used only when needed, and in a way that minimises risk [1]. Benefits include reduced catheter sepsis and mechanical complications, less biochemical disturbance, cost containment from reduced waste, and promotion of enteral nutritional support when more appropriate. Much PN is short-term (as in the newborn) but requires a sound organisational framework to be both safe and effective, with close pharmacist involvement and agreed protocols including necessary monitoring. Serious complications during limited periods of PN are rare, but very occasional prescription transcription or compounding errors, and microbiological contamination have devastating consequences and highlight potential risks involved.
Small bowel transplantation or long-term PN? In terms of survival, long-term PN remains a better option for patients with chronic intestinal failure than small bowel transplantation. This is because in transplantation the five year graft survival rate is only around 50%, largely because of unresolved difficulties with immuno-suppression to prevent rejection. Home PN (HPN) offers a good quality of life for children, if not for their parents. However, some important problems remain, and a key focus of management is prevention of those life threatening complications that become the principle indications for small bowel (+/− liver) transplantation. Most commonly this is intestinal failure associated liver disease (IFALD), but recurrent central venous catheter related blood stream
E-mail address: [email protected].
infection (CRBSI), and extensive venous thrombosis jeopardising future venous access are also important triggers. Preventing complications Recent investigations suggest that PN is not always managed as well as it could be [2], and both European guidelines and national reviews have sought to address this issue [3,4]. A number of advances in practice have also reduced the risk both of IFALD, and of CRBSI (an antecedent to both IFALD and thrombosis). These include the use of newer lipid emulsions containing fish oil, and antibacterial ‘line locks’ (taurolidine; ethanol) [5]. Prevention of venous thrombosis is more challenging, but minimising the need for CVC replacement by avoiding infection, and using selected and highly skilled surgeons or interventional radiologists most likely play a role [6]. Intestinal failure associated liver disease (IFALD) The risk factors for IFALD relate to both patient characteristics and management of the IF. The former include age, degree of liver maturation (prematurity), cause of IF, site and frequency of infection (gastrointestinal tract, central venous catheter), small bowel bacterial overgrowth, and enteral feed tolerance. Treatment related factors include the composition of PN, its mode of administration (continuous/cyclical), the duration of PN dependency, the surgical interventions and their anatomical consequences (intestinal obstruction, disruption of the enterohepatic circulation, resection of the terminal ileum or the ileocaecal valve), and the need for antibiotics (liver/renal toxicity). The pathogenesis of IFALD is therefore multifactorial. The composition of newer fish oil containing lipid emulsions (LE) has several potential advantages, including a high concentration of α-tocopherol (4–8 fold more than soybean oil LE), and absence of plant sterols. Moreover, fish oil is a source of docosahexaenoic acid (DHA, important for neurodevelopment and visual function), and of eicosapentaenoic acid (EPA). EPA favourably modulates inflammation, directly by decreasing the production of pro-inflammatory cytokines, and indirectly by increasing secretion of the antiinflammatory cytokine IL-10 by hepatic macrophages. Recommendations for avoiding IFALD include giving a balanced energy supply of fat and dextrose (usually 15–30% of non-protein calories as fat) in order to sustain protein accretion and growth, but avoiding
http://dx.doi.org/10.1016/j.clinbiochem.2014.05.024 0009-9120/© 2014 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.
Please cite this article as: Puntis JWL, Delivering safe and effective parenteral nutrition, Clin Biochem (2014), http://dx.doi.org/10.1016/ j.clinbiochem.2014.05.024
2
J.W.L. Puntis / Clinical Biochemistry xxx (2014) xxx–xxx
excess energy intake. Reducing, or temporarily discontinuing LE should be considered in the presence of hyperbilirubinaemia, and both decreasing intake of soybean oil derived ω−6 LE and using fish oil containing LE seem to be promising interventions.
patients may point to underlying family difficulties in managing complex care, and the need for increased social care support.
References Catheter related blood stream infection Scrupulous aseptic technique when accessing the CVC remains the key to avoiding infection. Interventions shown to definitely decrease the risk of catheter sepsis all involve protecting the external catheter from intraluminal bacterial contamination. There is little or no evidence that translocation of bacteria from the bowel lumen into the bloodstream is an important cause of CRBSI or that surgical interventions such as bowel lengthening affect this process. Antimicrobial ‘line locks’ are used to fill the CVC lumen when not in use during cyclical PN. The two agents investigated in children are taurolidine [5], and alcohol. Taurolidine, with citrate to prevent thrombus (TauroLock®), works by binding to the cell walls of organisms and preventing their adhesion to biological surfaces. It has a wide range of anti-microbial activity, including fungi, without causing resistance. Retrospective studies suggest a major effect in reducing risk of infection. Frequent CRBSI in HPN
[1] Agostoni C, Axelsson I, Colomb V, et al. The need for nutrition support teams in pediatric units: a commentary by the ESPGHAN committee on nutrition. J Pediatr Gastroenterol Nutr 2005;41:8–11. [2] Koletzko B, Goulet O, Hunt J, et al. Guidelines on parenteral nutrition of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), supported by the European Society of Pediatric Research (ESPR). J Pediatr Gastroenterol Nutr 2005;41(Suppl. 2). [3] Mason DG, Puntis JWL, McCormick K, Smith N. Parenteral nutrition for neonates and children: a mixed bag. Arch Dis Child 2011;96:209–10. [4] Improving practice and reducing risk in the provision of parenteral nutrition for neonates and children. A report from the paediatric Chief Pharmacists Group. http:// www.nppg.scot.nhs.uk/Minimising%20risk%20in%20PN%20for%20children.pdf; 2011. [5] Chu H-P, Brind J, Tomar R, Hill S. Significant reduction in central venous catheterrelated blood stream infections in children on HPN after starting treatment with taurolidine line lock. J Pediatr Gastroenterol Nutr 2012;55:403–7. [6] Wells JM, Jawaid WB, Bromley P, Bennett J, Arul GS. A dedicated consultant-led vascular access team significantly reduces out-of-hours and emergency permanent central venous access insertions. J Pediatr Surg 2010;45:419–21.
Please cite this article as: Puntis JWL, Delivering safe and effective parenteral nutrition, Clin Biochem (2014), http://dx.doi.org/10.1016/ j.clinbiochem.2014.05.024
