Parenteral nutrition infections

Impla.nta.ble Ports. The safest method of accessing the vascular system is by means of a vascular access device (VAD) or port. Older VAD designs protmded through the skin. The totally implanted ports are designed for convenience, near absence of infection, and ease of implantation. Ports allow dmgs and fluids to be deUvered directiy into the bloodstream without repeated insertion of needles into a vein. The primary recipients of totally implanted ports are patients receiving chemotherapy, bolus infusions of vesicants, parenteral nutrition, antibiotics, analgesics, and acquired immune disease syndrome (AIDS) medications. 

An additional important component of therapy is nutrition. Intraabdominal infections often involve the GI tract directly or disrupt its function (paralytic ileus). The return of GI motility may take days, weeks, and occasionally, months. In the interim, enteral or parenteral nutrition as indicated facilitates improved immune function and wound healing to ensure recovery. 

Maintaining adequate nutritional status, especially during periods of illness and metabolic stress, is an important part of patient care. Malnutrition in hospitalized patients is associated with significant complications, including increased infection risk, poor wound healing, prolonged hospital stay, and increased mortality, especially in surgical and critically ill patients.1 Specialized nutrition support refers to the administration of nutrients via the oral, enteral, or parenteral route for therapeutic purposes.1 Parenteral nutrition (PN), also... 

Parenteral nutrition can be a lifesaving therapy in patients with intestinal failure, but the oral or enteral route is preferred when providing nutrition support ( when the gut works, use it ). Compared with PN, enteral nutrition generally is associated with fewer infectious complications (e.g., pneumonia, intraabdominal abscess, and catheter-related infections) and potentially improved outcomes.1-3 However, if used in appropriate patients (i.e., patients with questionable intestinal function or when the intestine cannot be used), PN can be used safely and effectively and may improve nutrient delivery.4 Indications for PN are listed in Table 97-1.1... 

The response in sepsis depends on the extent of infection. If severe, the loss of skeletal muscle can be large enough to impair physiological function and this increases mortality, for reasons given in Chapter 16. The loss can be as much as 150-200 g per day, despite adequate enteral or parenteral nutrition. Because this is detrimental to the recovery of the patient, there is considerable emphasis on development of treatments that could reduce this loss provision of... 

Paraneoplastic syndrome Parasitic infections Parenteral nutrition Postoperative cholestasis Primary biliary cholangitis Primary sclerosing cholangitis Protoporphyria Right ventricular failure Sepsis... 

In a study of catheter infection in patients treated with total parenteral nutrition a distant septic focus was present in 165 of 244 patients (188 of 269 catheters 70%). There was a colonization rate of 19% of the catheters of the patients with a distant septic focus, compared with 7.4% in patients without a distant septic focus. There was a high mortahty rate in patients with a distant septic focus and a colonized catheter sepsis was responsible for 33 of the 48 deaths (69%) in this group (33). 

Catheter infections in recipients of parenteral nutrition are of particular concern in children and can result in line removal, deep vein thrombosis, or an increased risk of hver disease. The incidence of catheter-related infections in 47 children receiving long-term parenteral nutrition has been studied retrospectively, one goal being to identify potential risk factors (35). The children had 125 catheters and 207 catheter-years. The average infection rate was 2.1/1000 parenteral nutrition days. The only factor identified was that early onset of infection after starting parenteral nutrition appeared to predict a poor prognosis. 

HIV-positive subjects are expected to be at even greater risk of line-related infection. A prospective study of 212 subjects with HIV infection with 327 central venous catheters has provided evidence of this enhanced risk (36). Over the period 1994-97, 33% were suspected as being infected, although only 61 episodes were diagnosed as catheter-related sepsis. Three variables affected the rate of sepsis parenteral nutrition, low numbers of circulating CD+ cells, and a high Apache score. 

Cahill SL, Benotti PN. Catheter infection control in parenteral nutrition. Nutr Chn Pract 1991 6(2) 65-7. 

Colomb V, Fabeiro M, Dabbas M, Goulet O, Merckx J, Ricour C. Central venous catheter-related infections in children on long-term home parenteral nutrition incidence and risk factors. Clin Nutr 2000 19(5) 355-9. 

Infection has long been recognized as a risk of parenteral nutrition and it has proved impossible to eliminate it (SEDA-22, 379). Once established, sepsis can increase the risk of fat overload syndrome. In an extensive study in Taiwan there was sepsis with positive blood cultures in 56 of 378 children receiving parenteral nutrition the risk factors were longer duration of parenteral nutrition, age under 3 months, the use of central venous catheters, gastrointestinal disease as an indication for parenteral nutrition, low birth weight, and short gestational age in prematurity (128). 

Sondheimer JM, Asturias E, Cadnapaphornchai M. Infection and cholestasis in neonates with intestinal resection and long-term parenteral nutrition. J Pediatr Gastroenterol Nutr 1998 27(2) 131-7. 

Shay DK, Fann LM, Jarvis WR. Respiratory distress and sudden death associated with receipt of a peripheral parenteral nutrition admixture. Infect Control Hosp Epidemiol 1997 18(12) 814-17. 

Parenteral route, which provides high-calorie nutrients administered through large veins such as the subclavian vein. This process is called total parenteral nutrition (TPN) or hyperalimentation. Parenteral is expensive, has a high rate of infection, and does not promote GI function, liver function, or weight gain. 

Three risks of a parenteral nutrition support therapy are pneumothorax, air embolism, and infection. 

Supportive care may include hydration, enteral tube or parenteral nutrition, nasogastric suctioning for ileus, bowel and bladder care, prevention and treatment of decubitus ulcers, prevention and treatment of deep venous thromboses, intensive care, mechanical ventilation, treatment of secondary infections, and monitoring for impending respiratory failure (36,38). 

Inflammatory conditions of the liver, in particular inflammatory hepatocellular cholestasis, are one of the most frequent causes of jaundice in the clinic. The major underlying denominator of this disorder is the inhibition of transporter expression and function by proinflammatory cytokines, which are either induced systemically or within the liver. Alcoholic hepatitis accounts for up to two-thirds of patients and is the most frequent trigger, followed by idiosyncratic drug reactions, sepsis or other extrahepatic bacterial infections, some variants of viral hepatitis, and total parenteral nutrition [95, 96]. 

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