Central Venous Catheter Thrombosis Associated With 70% Ethanol Locks in Pediatric Intestinal Failure Patients on Home Parenteral Nutrition

Abstract

Central venous catheter (CVC) ethanol locks may reduce catheter-related bloodstream infection (CRBSI). Four children with intestinal failure on home parenteral nutrition (HPN) were selected for 70% ethanol locks because of their high rate of CRBSI. The 70% ethanol locks were instilled at a volume equal to the estimated internal volume of the CVC. Two children (aged 4 and 11 years) received 70% ethanol locks as CRBSI prophylaxis; another 2 children (aged 10 and 11 years) received 70% ethanol locks as adjunctive treatment for CRBSI. All 4 children developed either visible thrombosis in the CVC or CVC occlusion. To the authors' knowledge, this is the first report of CVC thrombosis associated with ethanol lock therapy in the pediatric HPN population. Although none of the CVCs were removed due to occlusion, these events raise serious concerns about the use of high-concentration ethanol locks.

Ethanol Causes Protein Precipitation—New Safety Issues for Catheter Locking Techniques

“…In pediatric patients on total parenteral nutrition a standardized procedure to minimize systemic effects revealed difficulties in withdrawing ELs (70–100%), as well as vascular access occlusion or visible line thrombosis. [25], [26], [28], [50] The vast majority of studies suggest flushing ELs at the end of dwell time to prevent clotting inside the catheter, most likely because ethanol is considered to resolve lipid residues in CVCs used for total parenteral nutrition, although the underlying rationale was not given. [12], [27], [39], [43], [51]–[55] Introduction of irreversibly precipitated protein particles into the systemic circulation might occur not only when the ethanol lock solution is injected as a bolus, but also following every single instillation of ethanol due to gravity induced leakage of precipitate, thus indicating physical incompatibility of high ethanol concentrations.…”

Sellado con antibióticos o antisépticos en pacientes pediátricos con nutrición parenteral domiciliaria. Puesta al dí

“…Y, aunque no hay evidencia de que esa precipitación sea clínicamente relevante, se desaconseja su uso combinado. Hay varios casos publicados, sobre todo de oclusión del catéter, en relación con el uso de etanol (42,43). Sin embargo, también es cierto que existen otros 15 estudios publicados en los que no se refiere mayor tasa de disfunción u oclusión del catéter en el grupo de etanol.…”

Use of Ethanol Lock Therapy for Children with Intestinal Failure on Long-Term Parenteral Nutrition

“…Kayton et al had 3 out of 12 patients develop catheter thrombosis while using daily ethanol locks for 12 h at a time (Kayton et al 2010), and Mouw et al reported 1 out of 10 children developing catheter thrombosis when using ethanol locks daily for 4-14 h (Mouw et al 2008). A recently published case series noted that clot developed in the CVCs of 4 patients managed with ethanol lock anywhere from 3 to over 400 days after starting the lock therapy (Wong et al 2012). In our own retrospective review of 10 children with intestinal failure treated daily with 70 % ethanol lock for at least 4 h at a time, there were 2 patients who developed catheter thrombosis (Wales et al 2011).…”