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Systematic Review and Meta-Analysis of the Utilization of Ethanol Locks in Pediatric Patients With Intestinal Failure.
Rahhal, R, Abu-El-Haija, MA, Fei, L, Ebach, D, Orkin, S, Kiscaden, E, Cole, CR
JPEN. Journal of parenteral and enteral nutrition. 2018;(4):690-701
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Abstract
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.
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Comparison of complications associated with peripherally inserted central catheters and Hickman™ catheters in patients with intestinal failure receiving home parenteral nutrition. Six-year follow up study.
Christensen, LD, Holst, M, Bech, LF, Drustrup, L, Nygaard, L, Skallerup, A, Rasmussen, HH, Vinter-Jensen, L
Clinical nutrition (Edinburgh, Scotland). 2016;(4):912-7
Abstract
BACKGROUND & AIM: Patients with intestinal failure (IF) are dependent on parenteral nutrition delivered through central access such as Hickman™ catheters. The peripherally inserted central catheter (PICC) is becoming increasingly popular for the purpose. The aim of the present study was to compare complication rates between the two types of catheters. PATIENTS AND METHODS Over a six-year period (2008-2014), we included 136 patients with IF receiving home parenteral nutrition (HPN). These patients had a total of 295 catheters (169 Hickman™ catheters and 126 PICCs). Data were collected by reviewing their medical records. Incidences are given per 1000 catheter days. Data are given as means ± standard deviation (SD) and compared using independent student's t-tests, Mann-Whitney-Wilcoxon, and X(2)-tests. A survival analysis for time to the first infection was conducted using Cox regression. RESULTS The total number of catheter days was 54,912 days for Hickman™ catheters (mean dwell time 325 ± 402) and 15,974 days for PICCs (mean dwell time 127 ± 121), respectively. The incidence of catheter-related blood stream infection (CRBSI) per 1000 catheter days was significantly lower for Hickman™ catheters compared to PICCs (0.56 vs. 1.63, p < 0.05). The mean time to first CRBSI was significantly shorter for PICCs compared to Hickman™ catheters (84 ± 94 days vs. 297 ± 387 days, p < 0.05), which was confirmed with a cox analysis corrected for age and gender. A total of 75 catheters were removed due to CRBSI, 49 Hickman™ catheters and 26 PICCs respectively. In addition, PICCs were more often removed due to local infection/phlebitis and mechanical causes (p < 0.001). CONCLUSION We found a higher risk and shorter time to first CRBSI in PICCs compared to Hickman catheters supporting that PICCs should mainly be chosen for planned HPN up to 3-6 months. We therefore conclude that the choice of catheter must still be determined on an individual basis.
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Comparison of neutral and positive enteral contrast media for MDCT enteroclysis.
Aiyappan, SK, Kalra, N, Sandhu, MS, Kochhar, R, Wig, JD, Khandelwal, N
European journal of radiology. 2012;(3):406-10
Abstract
OBJECTIVE To compare neutral and positive enteral contrast media for MDCT enteroclysis (MDCTE) in various small bowel diseases. MATERIALS AND METHODS 40 patients with suspicion of small bowel diseases were divided randomly into two equal groups. In one group, water was used as neutral enteral contrast and in other group, 2% water soluble iodinated contrast was used as positive enteral contrast. All MDCTE were done on a 16-slice multidetector row CT unit. The findings of MDCTE were compared with the standards of reference. RESULTS There were 12 cases of abdominal tuberculosis (30%), 5 cases of bowel masses (12%), 4 cases of Crohn's disease (10%), 3 cases of small bowel adhesions (7%), 2 cases of midgut volvulus (5%), 2 cases of segmental enteritis (5%) and 12 of all cases (30%) were normal. There was no statistically significant difference between neutral and positive enteral contrast with regards to bowel distention, contrast reflux and evaluation of duodenum. Abnormal bowel wall enhancement was appreciated only with use of neutral enteral contrast (n=12). Evaluation of ileocaecal junction was possible in all 20 patients (100%) with positive enteral contrast but in only 17 patients (85%) with neutral enteral contrast. Overall sensitivity and specificity of MDCTE with use of neutral contrast medium (100 and 88% respectively) was greater for evaluation of small bowel diseases, when compared to MDCTE using positive enteral contrast medium (92.8 and 83.3% respectively). CONCLUSIONS Water is a good enteral contrast medium for MDCT enteroclysis examination and allows better evaluation of abnormal bowel wall enhancement. Ileocaecal junction evaluation is better with positive enteral contrast medium.
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Are bowel purgatives and prokinetics useful for small-bowel capsule endoscopy? A prospective randomized controlled study.
Postgate, A, Tekkis, P, Patterson, N, Fitzpatrick, A, Bassett, P, Fraser, C
Gastrointestinal endoscopy. 2009;(6):1120-8
Abstract
BACKGROUND Capsule endoscopy (CE) is limited by incomplete small-bowel transit and poor view quality in the distal bowel. Currently, there is no consensus regarding the use of bowel purgatives or prokinetics in CE. OBJECTIVE To evaluate the usefulness of bowel purgatives and prokinetics in small-bowel CE. DESIGN Prospective single-blind randomized controlled study. SETTING Academic endoscopy unit. PATIENTS A total of 150 patients prospectively recruited. INTERVENTION Patients were randomized to 1 of 4 preparations: "standard" (fluid restriction then nothing by mouth 12 hours before the procedure, water and simethicone at capsule ingestion [S]); "standard" + 10 mg oral metoclopramide before the procedure (M); Citramag + senna bowel-purgative regimen the evening before CE (CS); Citramag + senna + 10 mg metoclopramide before the procedure (CSM). MAIN OUTCOME MEASUREMENTS Gastric transit time (GTT) and small-bowel transit time (SBTT), completion rates (CR), view quality, and patient acceptability. SECONDARY OUTCOME MEASURES positive findings, diagnostic yield. RESULTS No significant difference was noted among groups for GTT (median [minutes] M, CS, and CSM vs S: 17.3, 24.7, and 15.1 minutes vs 16.8 minutes, respectively; P = .62, .18, and .30, respectively), SBTT (median [minutes] M, CS, and CSM vs S: 260, 241, and 201 vs 278, respectively; P = .91, .81, and .32, respectively), or CRs (85%, 85%, and 88% vs 89% for M, CS, and CSM vs S, respectively; P = .74, .74, and 1.00, respectively). There was no significant difference in view quality among groups (of 44: 38, 37, and 40 vs 37 for M, CS, and CSM, vs S, respectively; P = .18, .62, and .12, respectively). Diagnostic yield was similar among the groups. CS and CSM regimens were significantly less convenient (P < .001), and CS was significantly less comfortable (P = .001) than standard preparation. CONCLUSIONS Bowel purgatives and prokinetics do not improve CRs or view quality at CE, and bowel purgatives reduce patient acceptability.
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A 3-month double-blind randomised study comparing an olive oil- with a soyabean oil-based intravenous lipid emulsion in home parenteral nutrition patients.
Vahedi, K, Atlan, P, Joly, F, Le Brun, A, Evard, D, Perennec, V, Roux-Haguenau, D, Bereziat, G, Messing, B
The British journal of nutrition. 2005;(6):909-16
Abstract
Intravenous lipid emulsions (ILE) have demonstrated advantages including prevention of essential fatty acid (EFA) deficiency; however, too much EFA can down regulate fatty acid elongation leading to an imbalance of nutritional compounds in plasma and cell membranes. An olive oil-based ILE containing long-chain triacylglycerols (LCT) with a low content (20 %) of PUFA was administered for home parenteral nutrition (HPN) and compared with a conventional soyabean oil-based ILE (PUFA content, 60 %). Thirteen patients (26-92 years) with stable intestinal failure were randomised after a 1-month run-in period with a medium-chain triacylglycerols-LCT-based ILE, to receive 3 months of HPN with either olive oil- (n 6) or soyabean oil-based (n 7) ILE. The nutritional impact and safety of HPN, oral intakes and absorption rates, phospholipid fatty acids in plasma and lymphocyte cell membrane were assessed. The only clinical event reported was one case of pneumonia (soya group). In both groups, 20 : 3n-9:20 : 4n-6 ratios remained within normal ranges (0.03-0.07). There was a significant increase of gamma-linolenic acid (gamma-LA) in plasma and lymphocyte cell membrane (P=0.02) and of oleic acid in plasma (P<0.01) in the olive compared with the soya group. A significant correlation was found between gamma-LA (day 90 - day 0) in plasma and PUFA parenteral intakes (P=0.02), but neither with fat intakes nor with fat absorption rates. In conclusion, plasma and lymphocyte EFA pattern remained in normal ranges without EFA deficiency with both lipid emulsions, despite a lower content of n-3 and n-6 series with the olive oil-based ILE.