0148-6071/90/1402-0148$02.00/0
JOURNALO F PARENTERAL AND ENTERNAL NUTRITION Copyright 0 1990 by the American Society for Parenteral and Enteral Nutrition
Vol. 14, No. 2 Printed in IJ.S.A
Catheter-Related Complications in 35 Children and Adolescents with Gastrointestinal Disease on Home Parenteral Nutrition EBERHARD SCHMIDT-SOMMERFELD, M.D.,* GLENNSNYDER,B.A.,? THOMAS M. ROSSI,M.D.,? EMANUEL LEBENTHAL, M.D.3
AND
From the * Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, T h e University of Chicago Medical Center, Chicago, Illinois; t Children's Hospital, Buffalo, New York; and $ T h e Department of Pediatrics, Hahnemann University, Philadelphia, Pennsylvania
ABSTRACT. A 7-year experience with home parenteral nutrition (HPN) in 35 children and adolescents suffering from severe gastrointestinal diseases is reported. The average duration of HPN was 577 days with a mean of 2.9 catheters per patient. There was a total of 82 episodes of proven catheterrelated sepsis, an average of 1.5 septic episodes per patient year. In about half of these instances, the catheter had to be removed. Coagulase-negative and -positive staphylococci were the most common organisms isolated. All four Candida infections led t o removal of the catheter. Children requiring HPN
from early infancy had a higher frequency of catheter-related infections than those started on HPN after the first year of life. In four cases, clinically significant thrombotic complications occurred. The results suggest that even under optimal conditions of catheter placement and with extensive education in aseptic catheter handling, infection is still relatively common in children receiving HPN. However, there was no mortality related to this complication. (Journal of Parenteral and Enteral Nutrition 14:148-151, 1990)
The first successful long-term treatment of a child with total parenteral nutrition ( T P N ) was reported 20 years ago.' Since t ha t time, T P N has become a generally accepted method of treatment for children with gastrointestinal disease who are unable to digest an d absorb sufficient nutrients through their digestive tracts. Initially, central venous catheters were made of polyethylene vinyl and complications like perforation of the great veins, extrusion, migration and infection were quite common. With the advent of soft an d flexible silastic silicone rubber catheters' which can be anchored in the subcutaneous tissue, some of these problems have been eliminated. Infectious complications have been reduced by improved insertion techniques and more careful handling of the catheters. T h e recognition t hat the speed of infusion can be increased, allowing limitation of infusions to the night hours, advanced the concept of home parenteral nutrition (HPN ) in the late 1 9 7 0 ~ . ~ In the following we report a 6-year experience with H P N in 35 children, focusing on catheter-related complications.
diagnoses are listed in Table 11: 74% required H P N for complications of inflammatory bowel disease (IBD) such a s intestinal obstruction, enterocutaneous fistula, perianal disease, severe growth failure or failure of medical treatment; 23% had short bowel syndrome (SBS), and one patient had a motility disorder of the gut. The total duration of H P N for the 35 patients was 20,178 days with a n average of 577 days per patient (range 58-2, 633 days). One year after the study period, five of the 35 patients still required H P N , whereas 29 patients were exclusively on enteral nutrition. One patient with SBS died during the study period due to liver failure. H P N was administered through a single lumen Broviac silastic catheter2 placed with the tip in the superior (33 patients) or inferior vena cava (two patients). The catheters were introduced percutaneously into a n internal jugular, subclavian or femoral vein in the operating room under general anesthesia. A subcutaneous tunnel was fashioned 3 to 4 cm from the venous entrance in order to assure sufficient distance between vessel and insertion site. T h e catheter placement was confirmed fluoroscopically a t the time of insertion. The catheter was held in place by a nonabsorbable skin suture. T h e infusion solution consisted of 15 to 25% dextrose, amino acids (1-3 g/kg/day), ions, minerals, trace elements, vitamins and heparin (1 IU/ml). Generally, 150 to 200 nonprotein calories were given per g of nitrogen. However, the amount of fluid and calories given varied with the needs of the individual patients and depended on the amount of oral intake tolerated. In patients who received little or nothing orally, a n intravenous fat infusion (2-3 g/kg) was given once weekly to daily by a separate pump through a Y-piece connected to the catheter. During the hospitalization, the rate of infusion was increased and the infusion time was gradually decreased
PATIENTS A N D METHODS
The medical charts of 35 patients who participated in the Home Parenteral Nutrition Program of the Children's Hospital of Buffalo for a 6-year period (19801985) were reviewed with particular attention to catheter-related complications. At the start of H P N , the patients were 2 months to 23 years old (Table I). Their Received for publication, October 31, 1988. Accepted for publication, August 4, 1989. Reprint requests: Emanuel Lebenthal, M.D., Professor and Chairman Department of Pediatrics, mail stop #402, Hahnemann University, Broad and Vine, Philadelphia, PA 19102-11920.
148
March/Aprill990
149
CATHETER COMPLICATIONS I N CHILDREN ON H P N
from 24 hr/day to a 10-12 hr period at night under weekly monitoring of plasma electrolytes, BUN, Ca, Mg, P albumin, cholesterol, and urinary specific gravity and glucose. To avoid reactive hypoglycemia, the infusion rate was reduced by 50% increments for two 30-min periods during the last hr of infusion. After each infusion period, the catheter was flushed with heparinized saline (100 U/ml) and capped. Instruction in catheter care and home parenteral nutrition administration was performed according to standard nursing procedures developed at our hospital by specialized nursing personnel. The specifics of the technique have been previously p u b l i ~ h e d .After ~ discharge from the hospital, the patients received their prescribed infusion solutions from a commercial pharmaceutical company every 2 weeks and were seen regularly (usually monthly) in the Gastroenterology Clinic of the Children’s Hospital of Buffalo where blood was drawn from the catheter for a metabolic profile. When patients presented with fever and were suspected to have sepsis, blood cultures were obtained through the catheter and a peripheral vein. The patients were then admitted to the hospital and were administered Oxacillin (100 mg/kg/day divided every 6 hr) and Gentamicin (7.5 mg/kg/day divided every 8 hr) through the Broviac catheter. Antibiotic therapy was continued for 14 days. The specific antibiotic regimen was adjusted based upon the organism cultured and its sensitivity pattern. RESULTS
A total of 101 catheters were inserted, giving a mean of 2.9 catheters per patient (range 1-22). The average life-span of a catheter was 200 days (range 1-1099 days). Table I11 lists the complications leading to catheter removal. TABLE I Aae distribution of 35 pediatric patients at onset of HPN Aee
No
1-12 months 1-6 years 6-12 years 12-18 years 18+ years
6 2 5 19 3
TABLE I1 Diagnosis of 35 pediatric patients on HPN No.
Diagnosis
Short-bowel syndrome Volvulus Necrotizing enterocolitis Jejunal atresia Gastroschisis Aganglionosis Cjejunostomy) Intestinal pseudoobstruction Inflammatory bowel disease (IBD) Crohn’s disease Ulcerative colitis Chronic granulomatous disease with colitis Collazen disease with IBD
8 (23%)
2 3 1 1 1 1 26 (74%)
20 4 1 1
TABLE I11 Complications leading to removal of the catheter No.
Complication
Infection Sepsis Local Large vessel thrombosis Occlusion or breakage Accidental removal
39 (59%) 37 2 4 (6%)* 16 (24%) 9 (14%)
* Two with sepsis. TABLE IV Organisms cultured from patients with sepsis No
Orcanism
Staphylococcus aureus Staphylococcus coagulase neg. S. epidermidis S. hominis S. hemolyticus Streptococcus jaecalis Streptococcus pneumoniae Gram-negative rods E. coli Klebsiella Pseudomonas Neisseria meningitidis, Gr. B Gram-positive bacilli* Candida albicans ~~
22 (26%) 26 (31%) 21 3 2 8 (10%) 2 17 (20%)
8 8 1 1
4 4 (5%)
~~
* Not further specified.
Infection The most frequent reason for catheter removal was infection which could not be eliminated by antibiotic or antimycotic therapy. In two cases, the catheter had to be removed because of severe infection at the exit site. There were a total of 101 episodes of clinically suspected sepsis thought to be related to the catheter, which led to the initiation of broad spectrum antibiotic therapy. Blood cultures were positive in 82 cases. The majority of these showed bacterial or fungal growth both from central venous blood obtained through the catheter and from peripheral blood. There was an average of 1.5 episodes of proven sepsis per patient year, which corresponds to an infection rate of 411000 catheter days. Of the 82 episodes with positive blood cultures, 37 required removal of the catheter. Six catheters were judged to be no longer needed a t the time the patient was admitted for treatment, and in 12 cases, the catheter was removed because of a severely ill-appearing child. In 19 of 82 septic episodes (23%), catheter removal was prompted by persistence of the organism for greater than 48 hours, despite appropriate antibiotic therapy. No patient died from sepsis. The organisms cultured from central and/or peripheral blood are shown in Table IV. In two instances, two different organisms were cultured. Coagulase negative and positive staphylococci were the most common pathogens (31 and 26%, respectively). Gram-negative rods accounted for 20% of the positive cultures. The incidence of catheter removal due to failure to eliminate bacteremia by antibiotics was not related to any particular strain. However, there were four candida infections which invariably led to removal of the catheter. Fifteen patients (43%) having a total of 19 catheters were free from any catheter-related infection. All of them had IBD and were
150
SCHMIDT-SOMMERFELD ET AL
Vol. 14, No. 2
older than 8 years of age at the onset of HPN. The longest time a single catheter was in place without causing infection was 10 months. Two patients with SBS who required HPN from early infancy and had the longest duration of H P N in the study group (86 and 70 months) had more than 20 catheter related infections and accounted for about half of the total number of infections. There was no relationship between the type of organism cultured and patient age, nor was there a relationship between the number of infections and age, duration of H P N or diagnosis. However, there was a significant difference in the frequency of catheter related infections between patients requiring H P N since early infancy (mean 4.0 infections per year) and those started on H P N after 1 year of age (mean 0.8 infections per year, p < 0.01, Wilcoxon non parametric rank test). All patients of the former group suffered from SBS, whereas the latter group consisted mostly of patients with IBD (Table V).
Thrombosis Two patients presented with chest pain while on HPN. Chest x-rays and scintigraphic studies of the lungs suggested multiple pulmonary infarctions. The patients were treated with anticoagulants. One patient with SBS and severe liver disease developed superior vena cava thrombosis with radiological evidence of left lung embolism. In another patient, calcifications in the right femoral and iliac veins extending to the inferior vena cava were found and proved to be associated with thrombotic obstruction of these vessels (Fig. 1). Thrombotic complications occurred irrespective of the site of catheter insertion. DISCUSSION
It is believed that catheter sepsis is caused by invasion of organisms from the skin along the course of the catheter or by access of organisms to the closed infusion system through breaks or improper handling.5 Contaminated infusates, however, have not been implicated as a significant cause of infection.6 Our results show that, even under optimal conditions of catheter placement and after extensive education of parents and/or patients in catheter handling, infection is still a relatively common complication in HPN patients. The frequency of infections in our patients (57%) is comparable with that recently reported by Vargas et a17 in a larger population of children (42%).However, the mean number of infectious episodes per affected patient (four us two episodes) and the number of septic episodes per patient year (1.5 TABLE V Relationship between age at onset of HPN, diagnosis, and frequency of catheter related infections Age at onset of H I "
(1 month 1-6 years 6-12 years >12 vears
No. of patients
SBS
IBD
NO.
NO.
5
5
3 4
3
0 0
1 0
3 23
23
No. Of infections per year, mean* (ranee) , -
4.0 (1.8-7.7)
1.4 (1.0-1.8) 0
0.9 (0-4.3)
FIG.1. A plain x-ray of the right femoral joint ( A ) and a CT-scan of the pelvis ( B )performed 10 days after removal of an infected catheter from an 8-year-old boy with a short-bowel syndrome requiring home parenteral nutrition. The arrows point to a calcified catheter track within the thrombosed right femoral and iliac veins extending to the inferior vena cava. us 0.5 episodes) were higher in our patient population than in theirs. In adults, the incidence of HPN related sepsis varies from 0.1 to 0.9 episodes per year of treatment.',' Our somewhat higher incidence of infection may in part be due to the extraordinarily high frequency of sepsis (about half of all infectious episodes) that occurred in two of our patients. These children were obviously at high risk for catheter related infections because they had required HPN since early infancy. One can only speculate upon the reason why early onset of HPN is associated with a higher overall risk for infection. A greater susceptibility to infection and/or thrombotic lesions in the great veins during infancy may play a role and the etiologic relationship between these two factors"' may continue even later in the course of treatment. Moreover, all of our patients with a high frequency of infection suffered from short-bowel syndrome, an entity which is frequently associated with chronic liver disease" which may also predispose the patient to infection. In our population, the most common organisms cultured were coagulase positive and negative staphylococci.
MarchlAprill990
CATHETER COMPLICATIONS I N CHILDREN ON H P N
Candida infections were less common. This is in agreement with recent reports7,'' and indicates th at a change in the prevalence of organisms responsible for catheter sepsis has taken place since the early 1970s when fungi were reported t o be the main cause of catheter related infections in parenterally alimented children13-l4 a n d adults.5 There is reasonable agreement in the literature that a catheter should be removed once a fungal organism is detected as the cause of infection. We were unable to effectively treat our four patients with candida sepsis using antimycotic agents. With regard to bacterial infections, catheter removal is not generally held to be necessary.15 Elimination of the organism(s) has been accomplished without removal of the catheter in 75% of cases.I5 This figure is in close agreement with our experience: The organism could not be eliminated by antibiotics in only 23% of septic episodes. However, in 12 instances, the catheter was removed even before effective antibiotic treatment was achieved because of the severity of illness. Thrombosis of the large veins was not a rare complication (10% of our patients) of H P N and led to pulmonary embolism in three instances. However, surgical intervention was not necessary and no patient died from this complication. In comparison, the frequency of clinically significant thrombosis in a n adult population receiving H P N was reported to be about 5%."' However, another study using routine venography reported central venous thrombosis in 50% of adult patients on long-term HPN." In conclusion, our study indicates th at children receiving long-term H P N have a considerable incidence of catheter-related complications. However, no mortality was associated with the use of parenteral nutrition in the home setting. ACKNOWLEDGMENTS
The authors wish to thank Dr. M. M. Riddlesberger from the Department of Radiology, Children's Hospital of Buffalo for kindly providing the x-rays.
151
REFERENCES
1. Witmore DW, Dudrick SJ: Growth and development of an infant
receiving all nutrients exclusively by vein. JAMA 203:860, 1968. 2. Broviac J W , Cole JJ, Scribner BH: A silicone rubber right atrial catheter for prolonged parenteral aimentation. Surg Gynecol Obstet 136:602-606, 1973. 3. Fleming CR, McGill DB, Berkner S: Home parenteral nutrition as primary therapy in patients with extensive Crohn's disease of the small bowel and malnutrition. Gastroenterology 73:1077-1081, 1977. 4. Rossi TM, Morrison-Willard E: Home Parenteral Nutrition. In Total Parenteral Nutrition: Indications, Utilization, Complications and Pathophysiologic Considerations, Lebenthal E, (ed). Raven Press, New York, pp 253-276, 1986. 5. Ryan JA, Abel RM, Abbott WM, et al: Catheter complications in total parenteral nutrition. N Engl J Med 290:757-761, 1974. 6. Flores L: Hyperalimentation and sepsis. McGaw Clinical Digest Vol. 1 No. 2, Glendale, CA, Medical Department, McGaw Laboratories, August 1972. 7. Vargas J H , Ament ME, Berquist WE: Long-term home parenteral nutrition in pediatrics. Ten years of experience in 102 patients. J Pediatr Gastroenterol Nutr 6:24-37, 1987. 8. Mughal M, Irving M: Home parenteral nutrition in the United Kingdom and Ireland. Lancet 2:383-387, 1986. 9. Fleming CR, Witske DJ, Beart RW: Catheter-related complications in patients receiving home parenteral nutrition. Ann Surg 192:593599,1980. 10. Stillman RM, Soliman F, Garcia L, Sawyer PN: Etiology of catheter-associated sepsis. Correlation with thrombogenicity. Arch Surg 112:1497-1499, 1977. 11. Stanko RT, Nathan G, Mendelow H, Adibi SA: Development of hepatic cholestasis and fibrosis with massive loss of intestine supported by prolonged parenteral nutrition. Gastroenterology 92:197-202, 1987. 12. Downey S, Ament ME, Vargas J et al: Improved survival in very short small bowel of infancy with use of long-term parenteral nutrition. J Pediatr 107:521-525, 1985. 13. Heird WC, Driscoll JM, Schullinger J N et al: Intravenous alimentation in pediatric patients. J Pediatr 80:351-372, 1972. 14. Boeckman CR, Krill CE: Bacterial and fungal infections complicating parenteral alimentation in infants and children. J Pediatr Surg 5:117-125, 1970. 15. Decker MD, Edwards KM: Central Venous Catheter Infections. Pediatr Clin North Am 35:579-612, 1988. 16. Ladefoged K, Efsen F, Christofferson JK, Jamum S: Long-term parenteral nutrition. 11. Catheter-related complications. Scand J Gastroenterol 16:913-919, 1981.
JOURNALO F PARENTERAL AND ENTERNAL NUTRITION Copyright 0 1990 by the American Society for Parenteral and Enteral Nutrition
Vol. 14, No. 2 Printed in IJ.S.A
Catheter-Related Complications in 35 Children and Adolescents with Gastrointestinal Disease on Home Parenteral Nutrition EBERHARD SCHMIDT-SOMMERFELD, M.D.,* GLENNSNYDER,B.A.,? THOMAS M. ROSSI,M.D.,? EMANUEL LEBENTHAL, M.D.3
AND
From the * Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, T h e University of Chicago Medical Center, Chicago, Illinois; t Children's Hospital, Buffalo, New York; and $ T h e Department of Pediatrics, Hahnemann University, Philadelphia, Pennsylvania
ABSTRACT. A 7-year experience with home parenteral nutrition (HPN) in 35 children and adolescents suffering from severe gastrointestinal diseases is reported. The average duration of HPN was 577 days with a mean of 2.9 catheters per patient. There was a total of 82 episodes of proven catheterrelated sepsis, an average of 1.5 septic episodes per patient year. In about half of these instances, the catheter had to be removed. Coagulase-negative and -positive staphylococci were the most common organisms isolated. All four Candida infections led t o removal of the catheter. Children requiring HPN
from early infancy had a higher frequency of catheter-related infections than those started on HPN after the first year of life. In four cases, clinically significant thrombotic complications occurred. The results suggest that even under optimal conditions of catheter placement and with extensive education in aseptic catheter handling, infection is still relatively common in children receiving HPN. However, there was no mortality related to this complication. (Journal of Parenteral and Enteral Nutrition 14:148-151, 1990)
The first successful long-term treatment of a child with total parenteral nutrition ( T P N ) was reported 20 years ago.' Since t ha t time, T P N has become a generally accepted method of treatment for children with gastrointestinal disease who are unable to digest an d absorb sufficient nutrients through their digestive tracts. Initially, central venous catheters were made of polyethylene vinyl and complications like perforation of the great veins, extrusion, migration and infection were quite common. With the advent of soft an d flexible silastic silicone rubber catheters' which can be anchored in the subcutaneous tissue, some of these problems have been eliminated. Infectious complications have been reduced by improved insertion techniques and more careful handling of the catheters. T h e recognition t hat the speed of infusion can be increased, allowing limitation of infusions to the night hours, advanced the concept of home parenteral nutrition (HPN ) in the late 1 9 7 0 ~ . ~ In the following we report a 6-year experience with H P N in 35 children, focusing on catheter-related complications.
diagnoses are listed in Table 11: 74% required H P N for complications of inflammatory bowel disease (IBD) such a s intestinal obstruction, enterocutaneous fistula, perianal disease, severe growth failure or failure of medical treatment; 23% had short bowel syndrome (SBS), and one patient had a motility disorder of the gut. The total duration of H P N for the 35 patients was 20,178 days with a n average of 577 days per patient (range 58-2, 633 days). One year after the study period, five of the 35 patients still required H P N , whereas 29 patients were exclusively on enteral nutrition. One patient with SBS died during the study period due to liver failure. H P N was administered through a single lumen Broviac silastic catheter2 placed with the tip in the superior (33 patients) or inferior vena cava (two patients). The catheters were introduced percutaneously into a n internal jugular, subclavian or femoral vein in the operating room under general anesthesia. A subcutaneous tunnel was fashioned 3 to 4 cm from the venous entrance in order to assure sufficient distance between vessel and insertion site. T h e catheter placement was confirmed fluoroscopically a t the time of insertion. The catheter was held in place by a nonabsorbable skin suture. T h e infusion solution consisted of 15 to 25% dextrose, amino acids (1-3 g/kg/day), ions, minerals, trace elements, vitamins and heparin (1 IU/ml). Generally, 150 to 200 nonprotein calories were given per g of nitrogen. However, the amount of fluid and calories given varied with the needs of the individual patients and depended on the amount of oral intake tolerated. In patients who received little or nothing orally, a n intravenous fat infusion (2-3 g/kg) was given once weekly to daily by a separate pump through a Y-piece connected to the catheter. During the hospitalization, the rate of infusion was increased and the infusion time was gradually decreased
PATIENTS A N D METHODS
The medical charts of 35 patients who participated in the Home Parenteral Nutrition Program of the Children's Hospital of Buffalo for a 6-year period (19801985) were reviewed with particular attention to catheter-related complications. At the start of H P N , the patients were 2 months to 23 years old (Table I). Their Received for publication, October 31, 1988. Accepted for publication, August 4, 1989. Reprint requests: Emanuel Lebenthal, M.D., Professor and Chairman Department of Pediatrics, mail stop #402, Hahnemann University, Broad and Vine, Philadelphia, PA 19102-11920.
148
March/Aprill990
149
CATHETER COMPLICATIONS I N CHILDREN ON H P N
from 24 hr/day to a 10-12 hr period at night under weekly monitoring of plasma electrolytes, BUN, Ca, Mg, P albumin, cholesterol, and urinary specific gravity and glucose. To avoid reactive hypoglycemia, the infusion rate was reduced by 50% increments for two 30-min periods during the last hr of infusion. After each infusion period, the catheter was flushed with heparinized saline (100 U/ml) and capped. Instruction in catheter care and home parenteral nutrition administration was performed according to standard nursing procedures developed at our hospital by specialized nursing personnel. The specifics of the technique have been previously p u b l i ~ h e d .After ~ discharge from the hospital, the patients received their prescribed infusion solutions from a commercial pharmaceutical company every 2 weeks and were seen regularly (usually monthly) in the Gastroenterology Clinic of the Children’s Hospital of Buffalo where blood was drawn from the catheter for a metabolic profile. When patients presented with fever and were suspected to have sepsis, blood cultures were obtained through the catheter and a peripheral vein. The patients were then admitted to the hospital and were administered Oxacillin (100 mg/kg/day divided every 6 hr) and Gentamicin (7.5 mg/kg/day divided every 8 hr) through the Broviac catheter. Antibiotic therapy was continued for 14 days. The specific antibiotic regimen was adjusted based upon the organism cultured and its sensitivity pattern. RESULTS
A total of 101 catheters were inserted, giving a mean of 2.9 catheters per patient (range 1-22). The average life-span of a catheter was 200 days (range 1-1099 days). Table I11 lists the complications leading to catheter removal. TABLE I Aae distribution of 35 pediatric patients at onset of HPN Aee
No
1-12 months 1-6 years 6-12 years 12-18 years 18+ years
6 2 5 19 3
TABLE I1 Diagnosis of 35 pediatric patients on HPN No.
Diagnosis
Short-bowel syndrome Volvulus Necrotizing enterocolitis Jejunal atresia Gastroschisis Aganglionosis Cjejunostomy) Intestinal pseudoobstruction Inflammatory bowel disease (IBD) Crohn’s disease Ulcerative colitis Chronic granulomatous disease with colitis Collazen disease with IBD
8 (23%)
2 3 1 1 1 1 26 (74%)
20 4 1 1
TABLE I11 Complications leading to removal of the catheter No.
Complication
Infection Sepsis Local Large vessel thrombosis Occlusion or breakage Accidental removal
39 (59%) 37 2 4 (6%)* 16 (24%) 9 (14%)
* Two with sepsis. TABLE IV Organisms cultured from patients with sepsis No
Orcanism
Staphylococcus aureus Staphylococcus coagulase neg. S. epidermidis S. hominis S. hemolyticus Streptococcus jaecalis Streptococcus pneumoniae Gram-negative rods E. coli Klebsiella Pseudomonas Neisseria meningitidis, Gr. B Gram-positive bacilli* Candida albicans ~~
22 (26%) 26 (31%) 21 3 2 8 (10%) 2 17 (20%)
8 8 1 1
4 4 (5%)
~~
* Not further specified.
Infection The most frequent reason for catheter removal was infection which could not be eliminated by antibiotic or antimycotic therapy. In two cases, the catheter had to be removed because of severe infection at the exit site. There were a total of 101 episodes of clinically suspected sepsis thought to be related to the catheter, which led to the initiation of broad spectrum antibiotic therapy. Blood cultures were positive in 82 cases. The majority of these showed bacterial or fungal growth both from central venous blood obtained through the catheter and from peripheral blood. There was an average of 1.5 episodes of proven sepsis per patient year, which corresponds to an infection rate of 411000 catheter days. Of the 82 episodes with positive blood cultures, 37 required removal of the catheter. Six catheters were judged to be no longer needed a t the time the patient was admitted for treatment, and in 12 cases, the catheter was removed because of a severely ill-appearing child. In 19 of 82 septic episodes (23%), catheter removal was prompted by persistence of the organism for greater than 48 hours, despite appropriate antibiotic therapy. No patient died from sepsis. The organisms cultured from central and/or peripheral blood are shown in Table IV. In two instances, two different organisms were cultured. Coagulase negative and positive staphylococci were the most common pathogens (31 and 26%, respectively). Gram-negative rods accounted for 20% of the positive cultures. The incidence of catheter removal due to failure to eliminate bacteremia by antibiotics was not related to any particular strain. However, there were four candida infections which invariably led to removal of the catheter. Fifteen patients (43%) having a total of 19 catheters were free from any catheter-related infection. All of them had IBD and were
150
SCHMIDT-SOMMERFELD ET AL
Vol. 14, No. 2
older than 8 years of age at the onset of HPN. The longest time a single catheter was in place without causing infection was 10 months. Two patients with SBS who required HPN from early infancy and had the longest duration of H P N in the study group (86 and 70 months) had more than 20 catheter related infections and accounted for about half of the total number of infections. There was no relationship between the type of organism cultured and patient age, nor was there a relationship between the number of infections and age, duration of H P N or diagnosis. However, there was a significant difference in the frequency of catheter related infections between patients requiring H P N since early infancy (mean 4.0 infections per year) and those started on H P N after 1 year of age (mean 0.8 infections per year, p < 0.01, Wilcoxon non parametric rank test). All patients of the former group suffered from SBS, whereas the latter group consisted mostly of patients with IBD (Table V).
Thrombosis Two patients presented with chest pain while on HPN. Chest x-rays and scintigraphic studies of the lungs suggested multiple pulmonary infarctions. The patients were treated with anticoagulants. One patient with SBS and severe liver disease developed superior vena cava thrombosis with radiological evidence of left lung embolism. In another patient, calcifications in the right femoral and iliac veins extending to the inferior vena cava were found and proved to be associated with thrombotic obstruction of these vessels (Fig. 1). Thrombotic complications occurred irrespective of the site of catheter insertion. DISCUSSION
It is believed that catheter sepsis is caused by invasion of organisms from the skin along the course of the catheter or by access of organisms to the closed infusion system through breaks or improper handling.5 Contaminated infusates, however, have not been implicated as a significant cause of infection.6 Our results show that, even under optimal conditions of catheter placement and after extensive education of parents and/or patients in catheter handling, infection is still a relatively common complication in HPN patients. The frequency of infections in our patients (57%) is comparable with that recently reported by Vargas et a17 in a larger population of children (42%).However, the mean number of infectious episodes per affected patient (four us two episodes) and the number of septic episodes per patient year (1.5 TABLE V Relationship between age at onset of HPN, diagnosis, and frequency of catheter related infections Age at onset of H I "
(1 month 1-6 years 6-12 years >12 vears
No. of patients
SBS
IBD
NO.
NO.
5
5
3 4
3
0 0
1 0
3 23
23
No. Of infections per year, mean* (ranee) , -
4.0 (1.8-7.7)
1.4 (1.0-1.8) 0
0.9 (0-4.3)
FIG.1. A plain x-ray of the right femoral joint ( A ) and a CT-scan of the pelvis ( B )performed 10 days after removal of an infected catheter from an 8-year-old boy with a short-bowel syndrome requiring home parenteral nutrition. The arrows point to a calcified catheter track within the thrombosed right femoral and iliac veins extending to the inferior vena cava. us 0.5 episodes) were higher in our patient population than in theirs. In adults, the incidence of HPN related sepsis varies from 0.1 to 0.9 episodes per year of treatment.',' Our somewhat higher incidence of infection may in part be due to the extraordinarily high frequency of sepsis (about half of all infectious episodes) that occurred in two of our patients. These children were obviously at high risk for catheter related infections because they had required HPN since early infancy. One can only speculate upon the reason why early onset of HPN is associated with a higher overall risk for infection. A greater susceptibility to infection and/or thrombotic lesions in the great veins during infancy may play a role and the etiologic relationship between these two factors"' may continue even later in the course of treatment. Moreover, all of our patients with a high frequency of infection suffered from short-bowel syndrome, an entity which is frequently associated with chronic liver disease" which may also predispose the patient to infection. In our population, the most common organisms cultured were coagulase positive and negative staphylococci.
MarchlAprill990
CATHETER COMPLICATIONS I N CHILDREN ON H P N
Candida infections were less common. This is in agreement with recent reports7,'' and indicates th at a change in the prevalence of organisms responsible for catheter sepsis has taken place since the early 1970s when fungi were reported t o be the main cause of catheter related infections in parenterally alimented children13-l4 a n d adults.5 There is reasonable agreement in the literature that a catheter should be removed once a fungal organism is detected as the cause of infection. We were unable to effectively treat our four patients with candida sepsis using antimycotic agents. With regard to bacterial infections, catheter removal is not generally held to be necessary.15 Elimination of the organism(s) has been accomplished without removal of the catheter in 75% of cases.I5 This figure is in close agreement with our experience: The organism could not be eliminated by antibiotics in only 23% of septic episodes. However, in 12 instances, the catheter was removed even before effective antibiotic treatment was achieved because of the severity of illness. Thrombosis of the large veins was not a rare complication (10% of our patients) of H P N and led to pulmonary embolism in three instances. However, surgical intervention was not necessary and no patient died from this complication. In comparison, the frequency of clinically significant thrombosis in a n adult population receiving H P N was reported to be about 5%."' However, another study using routine venography reported central venous thrombosis in 50% of adult patients on long-term HPN." In conclusion, our study indicates th at children receiving long-term H P N have a considerable incidence of catheter-related complications. However, no mortality was associated with the use of parenteral nutrition in the home setting. ACKNOWLEDGMENTS
The authors wish to thank Dr. M. M. Riddlesberger from the Department of Radiology, Children's Hospital of Buffalo for kindly providing the x-rays.
151
REFERENCES
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