Infectious Complications in Home Parenteral Nutrition: A Systematic Review and Meta-Analysis Comparing Peripherally-Inserted Central Catheters with Other Central Catheters

Femorally inserted central catheters with exit site at mid-thigh: A low risk alternative for central venous catheterization

BACKGROUND

Femorally inserted central catheters are increasingly used, especially after the COVID-19 pandemic, also thanks to widespread of tunneling techniques that allow the exit site to be moved away from the groin.

METHODS

In this retrospective observational study, femorally inserted catheters, with exit site at mid-thigh and the tip in Inferior vena cava or in Inferior vena cava at the junction with right atrium, have been observed and complications have been analyzed. All catheters were inserted by trained Nurses of a tertiary hospital Vascular Access Team.

RESULTS

In 142 catheters (126 inserted via common femoral vein and 16 inserted via superficial femoral vein) and 3060 catheter days, we observed an infection rate of 1.3 events/1000 catheter days (all of them in oncologic patients and up to 30 days of catheterization), 2 cases of thrombotic events (1.41%) and 17 cases of accidental removal (11.97%). Other rare complications, as primary malposition, tip migration, arterial pseudoaneurysm, have been recorded. The average length of catheters inserted, from the exit site to the tip, was 47.6 ± 2.4 cm.

CONCLUSION

The attention to the correct position of the tip, the exit site at mid-thigh and the new techniques during insertion make these femoral catheters as safe as other central vascular access devices. For this kind of central access device, a catheter at least 50 cm long is needed.

Ready-to-Use Multichamber Bags in Home Parenteral Nutrition for Patients with Advanced Cancer: A Single-Center Prospective Study

Home parenteral nutrition (HPN) is increasingly prescribed for patients with advanced cancer. This therapy improves free-fat mass, quality of life and survival, but it is not free from complications, especially catheter-related bloodstream infections (CRBSIs). The use of commercial multichamber bags in HPN has not been extensively explored in oncologic patients and their association with complications is not well known. In this prospective cohort study, we included 130 patients with advanced cancer and HPN. We compared the effects of individual compounded bags (n = 87) vs. commercial multichamber bags (n = 43) on complications. There were no differences in any complication, including thrombosis (p > 0.05). There were 0.28 episodes of CRBSI per 1000 catheter days in the individual compounded bag group and 0.21 in the multichamber bag group (p > 0.05). A total of 34 patients were weaned off HPN, 22 with individual bags and 12 with multichamber bags (p = 0.749). Regarding survival when on HPN, the group with individual bags showed a median of 98 days (95% CI of 49-147), whereas those with multichamber bags showed a median of 88 days (95% CI of 43-133 (p = 0.913)). In conclusion, commercial multichamber bags for HPN in patients with advanced cancer are non-inferior when compared to individual compounded bags in terms of complications.

Identifying the impact of the Zone Insertion MethodTM (ZIMTM): A randomized controlled trial

BACKGROUND

In 2011, Dawson proposed the Zone Insertion MethodTM (ZIMTM) to identify the optimal peripherally inserted central catheters (PICCs) insertion site in the upper arm. However, data on the effectiveness and safety of the ZIMTM in guiding PICC placement in Chinese population is limited.

METHODS

In this randomized controlled trial, 120 cancer patients were randomly assigned to the upper portion of the red zone (RZ), the green zone (GZ) and the lower portion of the yellow zone (YZ) groups (at a 1:1:1 ratio). The aim was to compare the degree of patient comfort and the incidence of major PICC complications among the three insertion zones based on the ZIMTM in a Chinese Cancer Center. (Clinical Trials. Gov number, ChiCTR1900024111).

RESULTS

A total of 118 catheters were inserted in 118 patients (2 patients were lost to follow-up). After the 1-month follow-up, patients randomly assigned to the YZ group had a higher degree of comfort with a lower score than those assigned to the other two zone groups: 30.21±3.16 in the YZ group versus 31.65±2.51 in the RZ group and 31.59±2.92 in the GZ group (P=.046). The incidence of thrombosis (10/40, 25%) and occlusion (4/40, 10%) in the RZ, which were significantly higher than those in the other two zone groups (χ2 =7.368, P=.02; χ2 =5.778, P =.03), whereas the risk in the GZ group was similar to that in the YZ group. The incidence of contact dermatitis in the GZ group was significantly higher than that of the other two zone groups (χ2=12.873, P=.001).

CONCLUSIONS

This study found that the lower portion of YZ seems to be another suitable PICC insertion site for a higher degree of comfort and a lower risk of occlusion and thrombosis, which broadens the choice of PICC insertion sites in the upper arm for clinical practice.

Intestinal failure among adults and children: Similarities and differences

Intestinal failure (IF) is a complex medical condition that is caused by a constellation of disorders, resulting in the gut's inability to adequately absorb fluids and nutrients to sustain hydration, growth, and survival, thereby requiring the use of parenteral fluid and/or nutrition. Significant advancements in intestinal rehabilitation have resulted in improved survival rates for individuals with IF. There are distinct differences, however, related to etiology, adaptive potential and complications, and medical and surgical management when comparing children with adults. The purpose of this review is to contrast the similarities and differences between these two distinct groups and provide insight for future directions, as a growing population of pediatric patients will cross into the adult world for IF management.

Glucagon-like peptide-2 analogues for Crohn’s disease patients with short bowel syndrome and intestinal failure

Short bowel syndrome (SBS) with intestinal failure (IF) is a rare but severe complication of Crohn’s disease (CD), which is the most frequent benign condition that leads to SBS after repeated surgical resections, even in the era of biologics and small molecules. Glucagon-like peptide-2 analogues have been deeply studied recently for the treatment of SBS-IF. These drugs have a significant intestinotrophic effect and the potential to reduce the chronic dependence of SBS-IF patients on parenteral support or nutrition. Teduglutide has been approved for the treatment of SBS-IF, and apraglutide is currently in clinical development. The use of these drugs was examined with a focus on their use in CD patients.

Association Between ABO Blood Group and Venous Thromboembolism Risk in Patients With Peripherally Inserted Central Catheters: A Meta-analysis and Systematic Review

Background

Previous studies have evaluated the association between ABO blood group and venous thromboembolism (VTE) risk in patients with peripherally inserted central catheters (PICCs). However, it remains unclear whether ABO blood groups are associated with PICC-associated VTE risk. Therefore, we conducted a meta-analysis of related studies to elucidate the potential role of ABO blood group as a risk factor for PICC-associated VTE.

Methods

All detectable case–control and cohort studies comparing the role of ABO blood group as a risk factor for PICC-associated VTE were collected for this analysis by searching PubMed, Embase, CNKI, Web of Science, and Wanfang. We conducted a meta-analysis of the eligible studies and computed the summary risk estimates with random or fixed effects models.

Results

A total of four studies involving 7,804 patients were included. Meta-analysis of the studies showed that the risk of PICC-associated VTE was significantly higher in blood types A [odds ratio (OR)=1.54, 95% CI=1.17–2.03), p=0.002], B (OR=2.35, 95% CI=1.71–3.23, p<0.0001), and AB (OR=2.55, 95% CI=1.68–3.88, p<0.0001) and lower in blood types O (OR=0.58, 95% CI=0.45–0.74, p<0.0001). Subgroup analysis based on ethnicity demonstrated that blood type O may be a genetic protective factor for PICC-associated VTE in Asians. Among Caucasians, individuals with blood types B and AB have a higher risk of PICC-associated VTE. Blood types A, B, and AB are risk factors for PICC-associated VTE in Asians.

Conclusions

Blood type O is associated with a decreased risk of PICC-associated VTE, especially in Asian populations. Moreover, blood types A, B, and AB are risk factors for PICC-associated VTE.

Evidence-based recommendations of the Andalusian Group for Nutrition Reflection and Investigation (GARIN) for the management of adult patients with short bowel syndrome

Introduction

In order to develop evidence-based recommendations and expert consensus for the nutritional management of patients with short bowel syndrome (SBS), we conducted a systematic literature search using the PRISMA methodology plus a critical appraisal following the GRADE scale procedures. Pharmacological treatment with antisecretory drugs, antidiarrheal drugs, and somatostatin contributes to reducing intestinal losses. Nutritional support is based on parenteral nutrition; however, oral intake and/or enteral nutrition should be introduced as soon as possible. In the chronic phase, the diet should have as few restrictions as possible, and be adapted to the SBS type. Home parenteral nutrition (HPN) should be individualized. Single-lumen catheters are recommended and taurolidine should be used for locking the catheter. The HPN's lipid content must be greater than 1 g/kg per week but not exceed 1 g/kg per day, and omega-6 fatty acids (ω6 FAs) should be reduced. Trace element vials with low doses of manganese should be used. Patients with chronic SBS who require long-term HPN/fluid therapy despite optimized treatment should be considered for teduglutide treatment. All patients require a multidisciplinary approach and specialized follow-up. These recommendations and suggestions regarding nutritional management in SBS patients have direct clinical applicability.

Analysis of risk factors of PICC-related bloodstream infection in newborns: implications for nursing care

Background

It is necessary to analyze the characteristics and risk factors of catheter-related bloodstream infection (CRBSI) in newborns with peripherally inserted central catheter (PICC).

Methods

Newborns undergoing PICC catheterization in the neonatal department of our hospital from January 1, 2020 to January 31, 2021 were included. The characteristics of newborns with and without CRBSI newborns were compared and analyzed. Logistic regression analyses were performed to evaluate the risk factors of CRBSI in newborns with PICC.

Results

Three hundred eighty-six newborns with PICC were included, of whom 41 newborns had the CRBSI, the incidence of CRBSI in newborns with PICC was 10.62%. There were significant differences regarding the birth weight, durations of PICC stay, 5-min Apgar score, site of PICC insertion of PICC between CRBSI and no CRBSI group (all P < 0.05), and there were no significant differences regarding the gender, gestational age, cesarean section, mechanical ventilation and length of hospital stay between CRBSI and no CRBSI group (all P > 0.05). Escherichia coli (26.08%) and Staphylococcus aureus (23.92%) were the most common CRBSI pathogens in newborns with PICC. Logistic regression analysis indicated that birth weight ≤ 1500 g (OR 1.923, 95% CI 1.135–2.629), durations of PICC stay ≥ 21 days (OR 2.077, 95% CI 1.024–3.431), 5-min Apgar score ≤ 7 (OR 2.198, 95% CI 1.135–3.414) and femoral vein insertion of PICC (OR 3.044, 95% CI 1.989–4.306) were the independent risk factors of CRBSI in neonates with PICC (all P < 0.05).

Conclusion

For newborns with low birth weight, longer durations of PICC stay and femoral vein PICC insertion, they may have higher risks of CRBSI, and medical staff should take targeted measures to reduce the development of CRBSI.

Complications of tunneled peripherally inserted and tunneled-cuffed central catheters in home parenteral nutrition

OBJECTIVES

We sought to compare complications associated with tunneled peripherally inserted central catheters (tPICCs) and tunneled-cuffed centrally inserted central catheters (tCICCs) in adult home parenteral nutrition (HPN).

METHODS

The study (2017-2019) identified 257 people with type III chronic intestinal failure requiring HPN. The data were analyzed for tPICC- and tCICC-related complications. The rate of catheter-related complications was recorded as the number of complications analyzed per 1000 d of catheter use, and rates were compared using the Mann-Whitney Wilcoxon test.

RESULTS

A total of 273 venous access devices were included to the analyses: 150 (55%) non-cuffed tPICCs and 123 (45%) tCICCs. In-dwelling time for tPICCs and tCICCs were 23 045 and 43 789 catheter d, respectively. Median (interquartile range) catheter days and duration of HPN, for tPICCs and tCICCs, were respectively 119 (166) and 324 (314) d and 108 (159) and 324 (322) d. The overall complication rates per 1000 catheter d for tPICCs and tCICCs were 1.52 and 0.8, respectively (P = 0.565). On analysis, there was no statistical difference between complication rates per 1000 catheter d. The removal rate and conversion ratio due to complications were similar for tPICCs and tCICCs.

CONCLUSIONS

Both tPICCs and tCICCs have similar complication rates per 1000 d. This study highlights that tCICCs, the preferred and currently used venous access devices in HPN, can be effectively and safely replaced by tPICCs, depending on the indications.

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.

Comparative Complication Rates of 854 Central Venous Access Devices for Home Parenteral Nutrition in Cancer Patients: A Prospective Study of Over 169,000 Catheter-Days

BACKGROUND

Whether peripherally inserted central catheters (PICCs) are appropriate as safe and durable venous access devices (VADs) is still controversial. The aim of this 7-year, prospective cohort study was to compare the incidence rate differences of catheter-related complications (CRCs) among 4 types of central VADs in cancer patients receiving home parenteral nutrition (HPN).

METHODS

We enrolled all adult cancer outpatients who were candidates for HPN and who had a central VAD inserted during the study period, focusing on the incidence rate of CRCs.

RESULTS

We evaluated 854 central VADs (401 PICCs, 137 nontunneled centrally inserted central catheters [CICCs], 118 tunneled-cuffed CICCs, and 198 ports) in 761 patients, for a total of 169,116 catheter-days. Overall, the rate of total CRCs was 1.08/1000 catheter-days. The incidence of catheter-related bloodstream infections was low (0.29/1000), particularly for PICCs (0.08/1000; P < .001 vs tunneled-cuffed CICCs) and for ports (0.21/1000; P < .019 vs tunneled-cuffed CICCs). The rates of mechanical complications (0.58/1000) and of catheter-related symptomatic thrombosis (0.09/1000) were low and similar for PICCs, tunneled-cuffed CICCs, and ports. In terms of duration and removal rate due to complications, PICCs were like tunneled-cuffed CICCs and ports. Altogether, PICCs had fewer total complications than tunneled-cuffed CICCs (P < .001), there was no difference in total complications between PICCs and ports.

CONCLUSION

PICCs had significantly better outcomes than tunneled-cuffed CICCs and were safe and durable as ports. Our extensive, long-term study suggests that PICCs can be successfully used as safe and long-lasting VADs for HPN in cancer patients.