The incidence and management of complications of venous access in home parenteral nutrition (HPN): A 19 year longitudinal cohort series

Abstract

Backgrounds and AimsLong term central venous access for Home Parenteral Nutrition (HPN) is associated with catheter related complications. The most studied and well known of these is Catheter Related Blood Stream Infection (CRBSI).This paper looks at other venous access complications, including blocked and damaged catheters, catheter related thrombosis and CRBSI. This paper will also present treatment outcomes for each of these complications. This paper will also examine if there are any correlating patient or catheter related factors that can help predict future catheter related complications. By demonstrating the treatment outcomes for each line complication, it is hoped this will contribute to the literature that could be used for standard setting in complications related to long term central venous access. MethodsHPN data was analysed from the Greater Glasgow and Clyde (GGC) Home Parenteral Nutrition Database (HPN) which is a comprehensive, prospectively maintained electronic record of all HPN patients treated in GGC. The time period of data collection was 1998-2017. Descriptive statistics were used to report data frequency, age, and catheter days' distributions. Data were not normally distributed and so non-parametric tests were used.Spearman's Rho correlation was used to measure correlation between two numeric groups. Catheter complications were reported as a rate in count data, meaning that more than one event could be recorded per patient, with 1,000 catheter days as the person-time denominator. Poisson means test and Fisher exact tests were used to compare different rates, as complications were treated as count data increasing over variable total time periods. P < 0.05 with 95% confidence interval (CI) was considered significant in all tests. Comparisons between binary data sets used 2 sample t-test to compare the groups. ResultsFrom 169 patients, 101 (59.8%) were female and 68 (40.2%) were male. The age when first starting HPN ranged from 16 to 79 years old with a median of 56 years. Total catheter days was 173,151 derived from 408 catheter insertions on 169 patients. 282 complications occurred in 85 patients over the study period. An overall catheter complication rate of 1.62/1000 days was found. 84 patients did not experience a single complication. There were 171 proven catheter infections in 66 patients over the study period. Infection rate from the entire period of report was 1.35 infections/1000 catheter days. This decreased over time. Infection was found to be correlated with length of time on HPN, catheter location, catheter diameter and use of Taurolock-Hep100. Thrombosis (n=16) was associated with total time on HPN(r 2 = 0.187, P <0.05) and the number of infections (r 2 = 0.207 P <0.05). Damage was strongly associated with increasing time on HPN with (r 2 of 0.494 and P <0.005). Blockage was not associated with any patient or catheter factors. Overall catheter salvage rate for CRBSI by antibiotic treatment was 61.87%.Success varied according to organism cultured. Catheter salvage was less succe...

Short‐Bowel Syndrome: Epidemiology, Hospitalization Trends, In‐Hospital Mortality, and Healthcare Utilization

“…As a result of heightened awareness and continuous efforts for infection prevention, rates of CLABSI have significantly improved 70,84,90–92 . Our study confirms that sepsis is the most important modifiable risk factor to prevent in‐hospital mortality in patients with SBS, and therefore, home PN programs should continue their efforts to maintain the lowest possible infection rates 93,94 …”

“…70,84,[90][91][92] Our study confirms that sepsis is the most important modifiable risk factor to prevent in-hospital mortality in patients with SBS, and therefore, home PN programs should continue their efforts to maintain the lowest possible infection rates. 93,94 Liver disease is also a common complication in patients with IF. 72 Studies have reported that abnormal levels of liver enzymes have been observed in many patients receiving home PN; however, specific diagnostic criteria for the diagnosis of IFALD is lacking, which has resulted in variability in the reported prevalence.…”

Comparing success rates in central venous catheter salvage for catheter-related bloodstream infections in adult patients on home parenteral nutrition: a systematic review and meta-analysis

“…A low degree of heterogeneity at 23% ( P = 0.21) was seen in studies that used ALT and a moderate heterogeneity at 61% ( P < 0.01) in studies that only used systemic antibiotics. A sensitivity analysis performed by excluding the 2 studies ( 34 , 53 ) having <10 patients did not produce pooled salvage proportions that differed from those of the main analysis. Mixed-effects logistic regression analysis showed that the combination of systemic antibiotics with ALT was superior to systemic antibiotics alone (OR: 1.75; 95% CI: 1.21, 2.53; P = 0.003).…”

“…Most studies defined CRBSIs according to the CDC ( 17 , 35 , 39 , 43–45 , 52 ) or IDSA ( 15 , 16 , 31 , 32 , 36 , 50 ) guidelines; the other studies used either nonstandard definitions or did not report the definition used ( 33 , 34 , 37 , 41 , 48 , 49 , 51 , 53 , 54 ). Two studies reported a slightly modified definition, but were still considered as appropriate and were counted as using the CDC definition ( 24 , 38 ).…”

“…Two studies reported a slightly modified definition, but were still considered as appropriate and were counted as using the CDC definition ( 24 , 38 ). Reported salvage rates differed widely among studies: 9 studies reported overall salvage rates ( 17 , 24 , 34 , 38 , 40 , 47 , 49 , 52 , 54 ), whereas 18 studies reported successful salvage rates (e.g., exclusion of S. aureus for salvage) ( 15 , 16 , 31–33 , 35–37 , 41 , 42–46 , 48 , 50 , 51 , 53 ) ( Supplemental Table 2 ). One study did not mention the method of salvage ( 39 ).…”