Complications of home parenteral nutrition in a large pediatric series

doi:10.1016/j.transproceed.2003.10.040

Transplantation Proceedings

Volume 35, Issue 8, December 2003, Pages 3050-3051

https://doi.org/10.1016/j.transproceed.2003.10.040 Get rights and content

Abstract

When adequate nutrition cannot be provided by enteral route as a consequence of failure of intestinal functions, parenteral nutrition (PN) become the only way to maintain adequate nutrition; however, prolonged periods of PN can lead to severe complications. Furthermore, long hospital admissions for this form of nutrition can be detrimental for the child and the family. In the past 20 years, home parenteral nutrition (HPN) programs have been developed. The aim of our study was to retrospectively evaluate the kind and the frequency of complications in a HPN pediatric case series. We had 61 patients on HPN. Total duration of the program was 27,740 days (76 total years, mean 1.2 years per patient). We observed a total of 58 complications; mean 0.79 per patient per year with a prevalence of central venous cather–related complications (mechanical, 52%; infective, 26%). We had a very low incidence of metabolic complications (3%) and a low incidence of PN-related hepatic complications (19%). None of the complications described was the cause of death. Half of our patients have been able to stop the program. We had a low incidence (0.20 per patient per year) of septic episodes, lower than we had in patients on hospital PN in the same period (0.38 per patient per year). We had to replace 20 catheters, 18 of them for mechanical problems. Our study show that HPN still can be a valid alternative to small intestinal transplantation in patients affected by intestinal failure and that only patients with PN-related liver disease must be considered early candidates for combined liver–small bowel transplant.

Section snippets

Patients and methods

Since HPN programs have been started in our hospital (January 1990), we have discharged 61 patients. Mean age of patients at the beginning of the program was 4 years and 1 month (range, 8 months to 19 years). Total duration of the program was 27,740 days (76 total years, mean 1.2 years per patient). All patients were on total PN (>70% of their energy requirement given via PN). PN was in all cases infused in a central vein through a catheter (Broviac-type catheter in 51 patients and Porth-A-Cath

Results

We observed a total of 58 complications (mean 0.79 per patient per year) (Table 1). We had 30 mechanical complications (mean 0.41 per patient per year) with 19 catheter obstruction (64%), 3 catheter dislocations (10%), 7 catheter ruptures (23%), and 1 superior vena cava syndrome (3%). In 18 of 30 cases, the catheter needed to be replaced. We observed a total of 15 infective complications (mean 0.20 per patient per year): 13 bacterial sepsis and 2 tunnel infections. We needed to replace the

Discussion

In our case series, we observed an overall rate of HPN complications of 0.79 patient/year with a prevalence of CVC-related complications (mechanical, 52%; infective, 26%). We had a very low incidence of metabolic complications (3%) and a low incidence of PN-related hepatic complications (15%). None of the complications described was cause of death for our patients and the underlying disease of the patients was always the cause of deaths (33% of the patients). We have to underline that the

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Cited by (36)

Tunneled central venous catheters in pediatric intestinal failure: a single-center experience
2018, Journal of Surgical Research
Citation Excerpt :
With variable definitions for mechanical complications including break, malfunction, and occlusion, it is difficult to compare our study results with the published literature. We do know that mechanical complications are common, ranging from 25% to 75% of catheters placed.16-19 Many risk factors have been identified for mechanical complications including, but not limited to catheter tip position, catheter material, number of lumens, infusate, catheter dwell time, underlying illness, malposition, patient immobility, and age.20
Parenteral nutrition for intestinal failure (IF) often requires a tunneled central venous catheter (CVC). The purpose of this study was to characterize complications after CVC placement and contributors to line loss in pediatric IF patients.
An institutional review board–approved retrospective review of pediatric (<18 y) IF patients who had a silicone tunneled CVC newly inserted or exchanged from 2012 to 2016 in an IF center was conducted. Patient demographics, procedure service (surgery versus interventional radiology), procedure type (new versus exchange), vessel, and complications related to CVCs were evaluated. Complications included dislodgement, infection, break, occlusion/malfunction, and others. An ethanol-lock protocol for silicone CVCs in IF patients was instituted in January 2012.
Twenty-nine IF patients with tunneled CVCs were identified with 182 lines and 18,534 line d. Median age at line insertion was 17.1 mo (interquartile range [IQR] 7.6-31.5) with a median of five catheters (IQR 2-8) per patient. There were 19.2 complications per 1000 line d. Occlusions/malfunctions were the most common complication (6.0/1000 line d) followed by breaks (5.6/1000 line d). Median life of catheters was 51.5 d (IQR 21-129). On regression, adjusting for age, insertion service, and procedure type, shorter line life was associated with younger age (P = 0.04) and placement by interventional radiology (P < 0.01). Dislodgement was associated with newly placed lines relative risk 6.5 (95% CI 2.2-28.8).
CVCs in pediatric IF patients have frequent complications and short line lifetimes. Dislodgement of CVC was an unexpectedly common complication with loss of access in newly placed lines. There may be modifiable processes to mitigate CVC complications.
Central venous thrombosis in children with intestinal failure on long-term parenteral nutrition
2016, Journal of Pediatric Surgery
Citation Excerpt :
It is well known that although crucial for survival, CVCs are also the source of considerable morbidity and occasionally mortality. Published studies document the incidence of central line associated bloodstream infection to be anywhere between 1 and 11 per 1000 catheter days [11–15] and the incidence of catheter occlusion to be between 1 and 3.4 per 1000 catheter days [4,16,17]. Central vein thrombosis has been less well studied in this patient population, but is clinically relevant because it can lead to loss of venous access, resulting in the need for transplant referral [2,3,18].
Central venous thrombosis (CVT) is a serious complication of long-term central venous access for parenteral nutrition (PN) in children with intestinal failure (IF). We reviewed thse incidence of CVT and possible risk factors.
Children with IF on home PN (2010–2014) with central venous imaging were reviewed. Patient demographics, catheter characteristics and related complications, and markers of liver function were compared between children with and without CVT. Serum thrombophilia markers were reviewed for patients with CVT.
Thirty children with central venous imaging were included. Seventeen patients had thrombosis of ≥ 1 central vein, and twelve had ≥ 2 thrombosed central veins. Patients with and without CVT had similar demographics and catheter characteristics. Patients with CVT had a significantly lower albumin level (2.76 ± 0.38 g/dL vs. 3.12 ± 0.41 g/dL, p = 0.0223). The most common markers of thrombophilia in children with CVT were antithrombin, protein C and S deficiencies, and elevated factor VIII. There was a statistically significant correlation between a combined protein C and S deficiency and having > 1 CVT.
Children with IF on long-term PN are at high risk for CVT potentially owing to low levels of natural anticoagulant proteins and elevated factor FVIII activity, likely a reflection of liver insufficiency and chronic inflammation.
Long-term home parenteral nutrition in children with chronic intestinal failure: A 15-year experience at a single Italian centre
2011, Digestive and Liver Disease
Chronic intestinal failure is a condition causing severe impairment of intestinal functions; long-term total parenteral nutrition is required to provide adequate nutritional support.
This is a 15-year follow-up study of paediatric patients with intestinal failure receiving long-term home parenteral nutrition.
Thirty-six patients were included in the study, all aged <16 years. Total parenteral nutrition and home parenteral nutrition were administered respectively to 100.97 and 85.20 patients-year. Today, 12 out of 36 patients are still on parenteral nutrition. A total of 99 central venous catheters were inserted, for mean 2.75 catheters/patient. The overall incidence rates of catheter-related complications was 1.79 per 1000 days-catheter for sepsis and 3.37 per 1000 days-catheter for mechanical complications. Two multivariate Cox-models have been used to examine the role of some predictors for septic or mechanical complications. The only risk factor for septic complications was the indication for parenteral nutrition, and the only predictor of mechanical complications was the insertion period.
Our experience in the treatment of paediatric patients with gastrointestinal diseases confirms that long-term parenteral nutrition has become a safe and appropriate method in the treatment of severe chronic intestinal failure.
Vasopressor agents after experimental brain death: Effects of dopamine and vasopressin on vitality of the small gut
2010, Transplantation Proceedings
Both congenital and acquired short bowel syndrome frequently leads to the necessity for long-term parenteral nutrition, which in turn may lead to any of several complications or death. Transplantation of the small bowel from brain-dead organ donors has been successfully performed over the last years. However, systemic blood pressure and blood perfusion to the splanchnic area decrease rapidly after brain death, which comprises the vitality of the small bowel.
To evaluate the differences between dopamine and low-dose vasopressin on perfusion and vitality of the small bowel after brain death.
Fifteen pigs were randomized into 3 groups: vasopressin (n = 6), dopamine (n = 6), or control (n = 3). Brain death was induced via stepwise filling of an epidural balloon. When the hypotensive phase was achieved, vasopressin, maximum dose of 0.04 IU/kg/h, or dopamine, maximum dose of 20 μg/kg/min, was administered for 5 hours with the objective of increasing mean arterial blood pressure by 15 mm Hg.
Target blood pressure was achieved in the vasopressin group but not the dopamine group. Vasopressin reduced cardiac output, superior mesenteric artery (SMA) blood flow and oxygen delivery, and systemic oxygen delivery and consumption, and increased oxygen extraction. Dopamine increased SMA blood flow, and had no effect on systemic oxygen delivery or consumption.
Vasopressin reversed hypotension but compromised both the systemic and SMA blood flow. Vasopressin was associated with inadequate oxygen delivery, estimated from decreased oxygen delivery and increased oxygen extraction. These adverse effects were not observed with dopamine.
Evaluation of the total parenteral nutrition service at Universiti Sains Malaysia Hospital
2007, e-SPEN
Total parenteral nutrition (TPN) has been practised in Universiti Sains Malaysia Hospital (HUSM), Malaysia, since 1986. Unfortunately, there are no published data on the cost, complications and outcomes of patients treated with TPN in HUSM. This study was carried out to evaluate the cost, complications and outcomes of TPN.
Retrospective data were obtained from patient medical records, and 215 TPN cases from 2003 to 2005 were evaluated. The data were analyzed using SPSS version 11.
The demographics of the TPN cases were neonates 22.8%, pediatric 11%, adults 64.6%, males 52.6%, females 46.1%. Malays comprise 87.4%, Chinese 6.0% and Indians 1.9%. The average cost for TPN in neonates is RM 98±46, pediatric RM 210±121 and adult RM 398±103. TPN-associated complications were electrolyte complications (56.5%), acid–base imbalance (5.5%), renal complications (14.5%), liver complications (12.4%), hyperglycemia (9%), hyperlipidemia (0.7%) and hypoglycemia (0.7%). The outcomes were that 71.2% cases tolerated oral nutrition and 1.8% expired. The study showed a significant difference in the cost of TPN in each group of patients (P=0.000).
The cost and outcomes of TPN services in HUSM were similar to other centers, however, it was associated with relatively high TPN-related complications.
ACTG2 Variants in Pediatric Chronic Intestinal Pseudo-obstruction With Megacystis
2022, Journal of Neurogastroenterology and Motility

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Intestine transplantComplications of home parenteral nutrition in a large pediatric series

Abstract

Section snippets

Patients and methods

Results

Discussion

Clin Nutr

Clin Nutr

Nutr

Intestine transplant
Complications of home parenteral nutrition in a large pediatric series