Algorithm 11.1. Identification and Treatment of Catheter Occlusion.
to infuse lipids even when dextrose and amino acid solution infuse, (b) difficulty flushing the central venous catheter (CVC), (c) inability to withdraw blood from the CVC or (d) blood back flow in the IV tubing. This may be secondary to thrombosis, malposition or by poor solubility of calcium, phosphorous or other divalent cations. In the absence of catheter malposition, there is an increased risk for the development of catheter thrombosis secondary to fibrin accumulation .
Administration of a small amount of a thrombolytic agent such as urokinase or tissue plasminogen activator (tPA) may clear the blockage located in the internal lumen of the catheter without causing a change in clotting times . Please refer to Table 11.5 for a protocol for administration of tPA. Prior to the administration of thrombolytics, additional physical findings such as neck or face edema, edema of the limb proximal to the CVC or pain along the CVC infusion tract should be assessed to exclude the possibility of superior vena cava syndrome. A radio-opaque dye study, chest radiograph+ or ultrasound may be useful to determine the presence of venous thrombosis and/or catheter malposition. If the catheter occlusion is not resolved with TPA or urokinase, and there is no evidence for malposition, then non-
Protocol for tPA administration
A. Preparation of enzyme:
1. Obtain tPA in a 50-mg vial.
2. Reconstitute enzyme according to instructions to provide 25 cc of enzyme at a concentration of 2 mg/ml.
3. Using sterile technique, divide the tPA into 1-cc aliquots (2mg). Place in sterile vials suitable for freezing.
5. When needed, remove vials from freezer and allow to thaw at room temperature.
6. Use immediately after thawing.
B. Technique for use:
1. Attempt to aspirate the occluded catheter lumen to remove heparin.
2. Inject 2 mg (1 ml) of tPA into the occluded catheter lumen.
3. Make up the remainder of the catheter lumen fill volume with saline (e.g., for a 1.9 catheter lumen use 1 ml tPA and 0.9 ml saline).
4. Wait 15 min, then inject 0.3 ml of saline to again move the active enzyme towards the tip of the catheter.
5. After another 15min, add another 0.3 ml to again move the active enzyme towards the tip of the catheter.
6. After a third 15-min period, try to aspirate the catheter.
7. If the catheter aspirates easily, forcefully flush several times with aspirated blood.
8. If the catheter cannot be aspirated easily, repeat the procedure.
9. If the second application of tPA is unsuccessful, refer the patient for catheter exchange.
thrombotic occlusion should be suspected; 0.1-N hydrochloric acid (HCl) or 0.1-N sodium hydroxide (NaOH) may be useful in clearing the mineral precipitate .(2) Prevention of recurrent catheter thrombosis: Patients susceptible to recurrent catheter thrombosis should receive prophylaxis with warfarin to achieve an INR equal to or greater than 1.6. Patients with severe malabsorption and short bowel syndrome may require higher doses of warfarin. Lipid emulsion and multivitamin formulations that contain vitamin K may also require increased doses of wafarin.
7.4. Infections (Algorithm 11.2)
CVCs typically become infected at three sites: (1) the site of skin entry, (2) the catheter hub and (3) a fibrin sheath coating the outside of the catheter inside the vein. Catheter sepsis is the greatest concern in patients receiving PN because the indwelling catheter is a potential conduit for organism entry from skin contamination. A skin site is usually the source for infection for a period of 10 days following line insertion . Afterwards the cathter hub should be implicated [18, 128-135]. A malnourished patient may be secondarily immunocompromised and thus become a good host for infection. Using aseptic techniques and following prescribed catheter care protocols are essential for minimizing infections.
A temperature greater than 38.5° C is considered to be a fever. If this occurs at any point during the administration of parenteral nutrition, close examination for a source should be undertaken. For example, in patients receiving cyclic TPN, a fever may only occur during an infusion. A small clot may be located at the catheter tip or the catheter may be colonized by bacteria or yeast; flushing the catheter may cause a transient bacteremia or fungemia. It is rare that a fever would develop secondary to an allergic reaction to nutrients or because of contaminated PN solutions. Blood cultures for bacteria and fungi should be obtained from the catheter and peripheral vein. A complete blood count, urinalysis and chest radiograph should be obtained as well to exclude other non-catheter sources of infection. Antibiotics to cover aerobic gram positive and gram negative organisms may be initiated prior to obtaining culture results if clinically suspected (i.e., rigors after flushing the catheter, persistent fevers spikes for more than 8 h or the patient progresses to septic shock). At this point, the PN solution should be held until the patient is afebrile. Vancomycin and an amino-glycoside or a third generation cephalosporin are usually started to cover the most common infecting organisms: Staphylococcus epider-midis, Staphylococcus aureus and Klebsiella pneumoniae . Though
Erythema of SQ tunnel tract
Treat for S. aureus with 1 wk IV antibiotics
May replace catheter in different site
Fever (may be only during infusion), Chills when fushing catheter or during infusion
1, Blood bacterial and fungal cultures from catheter + peripheral
2. CBC with smear (examine for bacteria/yeast)
IV antibiotics x 1-3 wks or antibiotic lock technique x 1 wk
Rx for coag. Neg. staph and Gram neg. organisms empirically; adjust antibiotics based on C&S + hold TPN for 24 hrs
Continue appropriate antibiotic
Fever resolves in 72 hrs
Continue No antibiotics
Catheter removed Ampho B 100-250 mg total
Tenderness, erythema or purulence of exit site (or on dressing)
Exit site infection
Empiric treatment for S. aureus with 2 wks IV antibiotics; adjust antibiotics based on C&S
Infection Infection present cured
Rx an additional 2 weeks with IV antibiotics
Recurrence within 6 wks of antibiotic discontinuation (same organism)
No further RX
Replace catheter once patient completely afebrile x 48-72 hrs, or blood culture negative in the absence of fever
Catheter removed i
Replace catheter in different site
Algorithm 11.2. Identification and Treatment of Catheter-Related infections.
controversial, most long-term tunneled catheters can be salvaged with in vivo treatment, such as the antibiotic lock technique. This technique is a controversial method for sterilizing the catheter lumen and involves instilling high concentrations of antibiotics with or without heparin into the catheter lumen for extended periods of time. The efficacy of the antibiotic-lock technique for S. epidermidis infection in an attempt to maintain central venous access in patients with otherwise poor access has been called into question . There are limited data using the antibiotic lock technique in cases of fungemia. Though there has been a successful case report in an adult, there have been multiple failures using the antibiotic lock technique. More studies will need to be performed to determine if this technique is useful. In general, the catheter should be removed in the presence of a fungal or mycobac-terial infection, or in the presence of infectious of the subcutaneous tunnel in long-term catheters.
Many metabolic complications have been observed in patients receiving PN. Most complications are caused by inappropriate nutrient administration, resulting in nutrient excesses or deficiencies or both. Overzealous nutrient administration may provide excess delivery of water and sodium (fluid overload), glucose (hyperglycemia, nonketotic hyperosmolar coma), amino acids (hyperammonemia, azotemia), lipids (hypertriglyceridemia, pancreatitis) and calcium (hypercalcemia, pancreatitis, renal stones) . Inadequate nutrient administration can cause deficiencies of glucose, electrolytes, vitamins, trace minerals and essential fatty acids .
Since the advent of peripheral nutrition in the late 1950s and the later development of total parenteral nutrition, parenteral nutrition has become an essential lifesaving measure in certain clinical scenarios by providing nutritional supplementation. Currently, there is increasing evidence that parenteral nutrition may not only have the ability to provide essential nutritional supplementation, but may be able to bolster the immune function of those patients who are immuno-suppressed and may alter the course of hepatic encephalopathy. Nevertheless, there are potential multiple complications (mechanical, vascular, infectious and metabolic) that can be avoided in most instances if the proper care is given. Unfortunately, there are insufficient controlled prospective data available. The use of PN still requires an integration of information from heterogeneous sources, including: pertinent clinical trials, clinical expertise in the illness or injury being treated, reasonable estimates of inadequate enteral intake and clinical expertise in nutritional therapy.
1. The best method for assessing the effectiveness of supplemental nutritional therapy is calculating a nitrogen balance in hospitalized patients.
2. There are multiple complications associated with the use of PN. These can be divided into mechanical, vascular, infectious, metabolic and gastrointestinal. The incidence of most complications is reduced with careful management and supervision by an experienced nutritional support team.
3. The concept that increasing the plasma aromatic amino acid ratio leads to decreased encephalopathy has been questioned by some investigators as brain uptake of BCAA in some cirrhotics may be similar to that of healthy controls and may be a better correlate of hepatic function than the degree of encephalopathy in others.
4. Recent studies have demonstrated that lipid emulsions containing medium chain triglycerides may have some advantages because of their positive effects on polymorphonuclear cells, macrophages and cytokine production, particularly in critically ill or immunocompro-mised patients.
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WHAT IT IS A three-phase plan that has been likened to the low-carbohydrate Atkins program because during the first two weeks, South Beach eliminates most carbs, including bread, pasta, potatoes, fruit and most dairy products. In PHASE 2, healthy carbs, including most fruits, whole grains and dairy products are gradually reintroduced, but processed carbs such as bagels, cookies, cornflakes, regular pasta and rice cakes remain on the list of foods to avoid or eat rarely.