- Email: [email protected]
Antibiotic prophylaxis for children undergoing percutaneous endoscopic gastrostomy (PEG)
M2175
and did not change with lENS. Measured resting energy expenditure' (mean• was 1367 • 126 kcal/d. Body fat was 25.1% by Dexa, 18.4% by bioelectnc impedance and 26.8% by anthmpometry; prealbumin and albumin averaged 8.9 mg/dl and 2.8 grrddl. Trends were noted toward improvement in these parameters with IENS but did not reach significance. Transfernn increased within 2 weeks, was sustained through day 56, then declined aher stopping IENS (table). WBC and mouocyte counts significantly increased by day 56 and increases in total T lymphocytes and CD4 counts were sustained through day 112. Trail A test improved significantly after day 0, while trail B and symbol search pertormance were unchanged. One patient was hospitalized briefly ibr confusion after omitting lactulose, but was able to resume lENS. One patient withdrew because of liver transplantation on d W 21. Conclusion: IENS was well tolerated in cirrbotic patients with controlled HE; cognitive function, liver function and leukocyte counts all were stable or improved. Satety and efficacy of long term IENS for improving quality of life, clinical outcomes and survival of patients w~th advanced cirrhosis merit further evaluation.
Prognostic Factors Affecting Early and Late Survival in Adult Patients on Home Pareuteral Nutrition Roser Vega Dimitrios Polymeros, Cinzia Papadia, Ruth Hodgson, Alastair Forbes, Simon Gabe Home parenteral nutrition (HPN) LS known as an eft~'ctive therapy in patients with either transient or permanent intestinal failure (IF) Prognostic factors of long term survival, are not well established. Airo: To report long-term survival probabilities in patients on HPN and to identity' the potential prognostic factors Methods: A total of 142 adult patients on HPN followed regnlaHy in St Mark's Hospital from 1980 to 2002 were retrospectively reviewed. Kapkm-Meier nmthod was used lot calculation of survival probabilities. To identity" independent factors atf;ecting survival, a univariate and muhivanate Cox regression model was used. Results: average age of patients starting HPN was 52 years (16-79), 56 male and 86 female Tbe a~5~v~geduration of HPN was 5 years (001-22.5), gi~ng a total of 717 patient-years experience. Crohn's disease was present in 32% of the cases, followed by inte~tk~l pseudoobstmction (15%), and mesenteric nita,rction (14%). In addition, 4% had active malignancy Short bowel s}mdmme (SBS) as a cause of IF was prevalent in 58% of cases and the presence oi permanent stoma was found in 51% The survival probabilities at 2 5, 10, 15 and 20 years were 79%, 68%, 66%, 48% and 14% respectively. In the univanate analysis age, SBS, active malignancy, Cmhn's disease, radiation enteritis, systemic sclerosis, intestinal obstruction, non functional intestine and a high rate of central venous catheter (Ca.~C)infectinns were negatwely related wkh survival. However, multivariate analysis demonstrates that only acuve malignancy is a s~gnificant prognostic factor (relative risk (RR) of &ath 17 (95% C[: 5-56)). Prognostic factors tbr early, mortality (0-2 years) were development of chronic cbolestasis non CVC-intections, SBS, intestimal obstruction and CVC infection ~ t h a RR of 31 (95% CI: 3.3-298), 20 (95% CI: 4.03-105), 13 (2.6-67), 6.2 (95% Cl: 153-25.37) and 1,94 (95% CI: 1.37-2.73), respectively. No prognostic factors were identified tot late mortality (> 10 years) in this population Conclusions: The survival curve of HPN patients receiving has notable decreases in early (0-2 years) and late (> 10 years) survival. Tim only" factor refinancing overall survival is the presence of active malignancy. However, em'ly mortality relates to the development of complications (chronic cholestasis and infections) as well as intestnial morpholo~' (obstruction and SBS). These observations should be considered When considering the timing and suitability of small bowel transplantation.
~yo(~) Tmnsf~v~ (mg/dl) 171 13 Trail test A (see) 7714 WBC (xl0001mm3) 4,6 0.5 CD4/mm3 677 109 * p < 0,01 by paired t test (2 tailed) compared to time 0
D~ S (L=)st)
Day~lZ(f~)
202~16" 441(7' 5.3~0.5" 733 139
18023 5117" 5,0 0,7 770 104"
M2178 Antibiotic Prophylaxis For Children Undergoing Percutaneous Endoscopic Gastrostomy (PEG) David J. Rawat, Anshu Srivastava, Simon Keady, Robert Heuschkel, Simon Murch, Michael Thomson Introduction: Peristomal wound infection is the most common complication of PEG for which use of antibiotic pmphylams is recommended. However, guidelines for use of antibiotics for PEG in children remain controversial. Aim: To evaluate whether a single dose antibiotic regime is effective in reducing the risk of peristomal infection in children undergoing PEG. Methods: 36 children undergoing PEG insertion were prospectwely rvahiated. Children with known immune compromise or who received antibiotics one week preceding the procedure were excluded. Patients were consecutively allocated either a single dose of intravenous Cefiriaxone(5Omg/kg) per procedure (groupl) or 48 hours of intravenous Cefiriaxone(50mg/ kgday) and Metronidazole(7.Smg/kg tds) (group 2). Group 1:9 boys, 9 girls median age 23 months (8 - 166). Group 2 : 1 0 boys, 8 girls median age 17 months(4 - 205)~ For 2 weeks after gastrostomy, the peristomaI area was evaluated using a validated wound score I-IV. Infection up to degree III was regarded as minor. Results: 32/36 underwent PEG insertion by standard techinque and 4/36 by rapid one step insertion. 19% had wound refections and there were no severe complications, in group 1, 3/18 (1 swab- positive) had minor wound infections, 2 requiring antibiotic therapy. 4/18 (3 swab- positive) in group 2 had minor wound infections requiring antibiotic treatment. Duration of hospital stay was increased in only 1 child in group 2, Staphylococcus aureus was the most comnmn bacteria isolated. Conclusion: Single dose intravenous Ceftnaxone is as effective as dual antibiotic therapy, in the reduction of peristomal infections after PEG irksertion in children.
M2176 Home Parenteral Nutrition Is Cost-Saving with Low Consumption of Acute Care Resources S Gadowsky, D. Armstrong, A. Childs, J K Marshall BACKGROUND: Home parenteral nutrition (HPN) is increasingly available, but there are no rigormls, current estimates of its economic impact in a Canadian health care setting. AIM: To esnmate total per diem direct medical costs in a consecutive cohort of patients disa barged from hospital to receive HPN METHODS: Itemized per diem direct medical costs were derwed ~br the final week of inpatient (IP) care from detailed review of hospital charts, administrative databases, and Ontario provincial tee schedules. Estimated hospital hotel costs were weighted according to daily patient acuity profiles. Total per diem direct medical costs were then compiled fbr the first month of outpatient (OP) care from review of patient community care fdes, medical supply company invoices, HPN program charts, hosDtal databases, and pmnary care records. All 1P costs incurred after discharge (e.g. for readmission) were atmbnted to OP care. The perspective of a provincial Ministry of Health was assumed, with costs converted to 2002 equivalents using the Consumer Price Index (C$1 = US$0.64). RESULTS: TwentDnine HPN patients were evaluated (mean age 5L 18 female; fistulae (11), obstructiorddysmotility (9), malabsorption (9)) All survived at least one month from discharge, Mean -+. SD per diem costs were lower at home (C$405 • 129) than in hospital (C$574 • 144; p < 0 0001) The mayor components (proportion, 95% CI) of OP costs were intravenous sohnions (0.38, 033-0.43), conmmnity caregiver contracts (0.19, O. 16-0.22) and medical supplies (0.13, 0.11-0.15). The proportion of OP costs attributable to acute care hospital resources was 0.09 (0.03-0.15), with 9 hospital readmissions (total 59 inpatient days) and 7 ER visits. Thus, 6.8% of patient day's in the first month of HPN were spent in acute care. Only 2 admissions were judged to be HPN-related. CONCLUSIONS: HPN is cost-saving in Canada The care of HPN patients and their nutrition in the communBy is complex, but consumption of acute hospital resources is low. Regardless of whether ongoing research indicates that HPN maintains or improves patient outcomes or quality of life, there sfamld be no fiscal barrier to the prowsion of HPN to appropriate patients. Support: Hamilton Health Sciences Foundation Operati~g Grant
M2179 Nutritional Support In Intensive Care Units - National Survey of Current Practice In The U.K Nell Kapoor, Helen Cooper, Paul O'toole ALMS: 1) To establish attitudes and current practice regarding nutritional support in the 1CU setting. 2) To explore factors determining choice of feeding route. METHODS: A validated questionnaire was sent to 324 ICUs in the U.K It comprised an attitudinal survey assessing unit policy and opinion in relation to nutritional support, and a 'snap-shot" survey of current inpatients to determine how this policy was implemented in practice RESULTS: Completed questionnaires were returned by 112 units (35%), responsible for the care of 617 inpatients on the day oftbe survey. 416 patients (67%) were receiving artificial nutrition, 85% were on some form of enteral nutrition (EN) alone, 9% were receiving parenteral nutrition (PN) alone and 6% were on a combination of EN and PN. Nasogastric (NG) feeding accounted for 90% of the EN group. In the attitudinal survey, most respondents (83%) agreed that NG feeding generally allowed patients to meet their nutritional requirements. However, frequent problems with NG feeding were reported in practice, with 30% needing tube replacement, 24% having absorption problems and 24% having unplanned interruptions to their feed. 51% of respondents agreed that those who fail NG will usually tolerate nasojejunal (NJ) feeding, yet only 15 patients had NJ tubes (2 with supplemental PN) Only 25% of units claimed to use NJ feeding regularly,, while 18% units never use it, Of the 39 patients on PN, only 64% appeared to have an accepted contraindicatinn to NJ feeding NJ tubes were placed endoscopicalb/m 6/13 patients with 3 placed blindly, 2 with thioroscopy and 2 during surgery. 45 units reported difficulty in arranging endoscopic NJ tube placement. 62/109 units felt that a reliable NJ tube placement service would probably decrease their use of PN. CONCLUSIONS: EN is firmly established as the preferred choice for nutritional support in 1CU patients. NG remains the main f:eeding route but is frequently associated with problems that may limit nutrient delivery. Man),'units have diftkuhy an'anging endoscopic NJ tube placement. Better access to the technique might decrease the use of PN
M2177 Short Term Safety and Efficacy of an Immune Enhancing Nutritional Supplement (IENS) in Patients with Advanced Cirrhosis and HEpatic Encephalopathy (He) Souheil G Abou-kssi, Edith Gavis, leslie Williams, Amy Haselbush, Adfl Habib, Anastasios A. Mihas, Douglas M. Heuman Background: Malnutrition is common in patients vnth advam:ed hepatic cirrhosis and worsens susceptibility' to infection. IENS in surgery and traunm improves bealing and reduces septic complications, lENS could be of benefit in cirrhosis, but the high arginine and glutamine content risk aggravating hyq~erammonemia and HE. Aim: to determine efficacy and safety of an oral IENS in outpatients witb advanced cirrhosis and controlled HE, Methods: We prospectively studied 9 men with hepatic cirrhosis, CTP class B or C, ages 40 - 60. Four bad been hospitalized for HE and all Md experienced symptoms of HE; in all HE was well controlled with lactulose at enrollment Patients ingested tbree packets per day of Impact Recover (Novartis) containing per packet 240 Kcal, 17 g pmteni, 4 g arginine, 5 g glutamine, 390 mg nucleotides and 420 mg n3Jatty acids, lENS was stopped after 56 day's. On day's 0, 14, 28, 42, 56, 84 and 112 patmnts underwent laboratory and psychometric testing and neurological assessment. Results: Mean (hido) CTP = 9 (7-11) and MELD = 14 (7-24)
A-431
AGA Abstracts
and did not change with lENS. Measured resting energy expenditure' (mean• was 1367 • 126 kcal/d. Body fat was 25.1% by Dexa, 18.4% by bioelectnc impedance and 26.8% by anthmpometry; prealbumin and albumin averaged 8.9 mg/dl and 2.8 grrddl. Trends were noted toward improvement in these parameters with IENS but did not reach significance. Transfernn increased within 2 weeks, was sustained through day 56, then declined aher stopping IENS (table). WBC and mouocyte counts significantly increased by day 56 and increases in total T lymphocytes and CD4 counts were sustained through day 112. Trail A test improved significantly after day 0, while trail B and symbol search pertormance were unchanged. One patient was hospitalized briefly ibr confusion after omitting lactulose, but was able to resume lENS. One patient withdrew because of liver transplantation on d W 21. Conclusion: IENS was well tolerated in cirrbotic patients with controlled HE; cognitive function, liver function and leukocyte counts all were stable or improved. Satety and efficacy of long term IENS for improving quality of life, clinical outcomes and survival of patients w~th advanced cirrhosis merit further evaluation.
Prognostic Factors Affecting Early and Late Survival in Adult Patients on Home Pareuteral Nutrition Roser Vega Dimitrios Polymeros, Cinzia Papadia, Ruth Hodgson, Alastair Forbes, Simon Gabe Home parenteral nutrition (HPN) LS known as an eft~'ctive therapy in patients with either transient or permanent intestinal failure (IF) Prognostic factors of long term survival, are not well established. Airo: To report long-term survival probabilities in patients on HPN and to identity' the potential prognostic factors Methods: A total of 142 adult patients on HPN followed regnlaHy in St Mark's Hospital from 1980 to 2002 were retrospectively reviewed. Kapkm-Meier nmthod was used lot calculation of survival probabilities. To identity" independent factors atf;ecting survival, a univariate and muhivanate Cox regression model was used. Results: average age of patients starting HPN was 52 years (16-79), 56 male and 86 female Tbe a~5~v~geduration of HPN was 5 years (001-22.5), gi~ng a total of 717 patient-years experience. Crohn's disease was present in 32% of the cases, followed by inte~tk~l pseudoobstmction (15%), and mesenteric nita,rction (14%). In addition, 4% had active malignancy Short bowel s}mdmme (SBS) as a cause of IF was prevalent in 58% of cases and the presence oi permanent stoma was found in 51% The survival probabilities at 2 5, 10, 15 and 20 years were 79%, 68%, 66%, 48% and 14% respectively. In the univanate analysis age, SBS, active malignancy, Cmhn's disease, radiation enteritis, systemic sclerosis, intestinal obstruction, non functional intestine and a high rate of central venous catheter (Ca.~C)infectinns were negatwely related wkh survival. However, multivariate analysis demonstrates that only acuve malignancy is a s~gnificant prognostic factor (relative risk (RR) of &ath 17 (95% C[: 5-56)). Prognostic factors tbr early, mortality (0-2 years) were development of chronic cbolestasis non CVC-intections, SBS, intestimal obstruction and CVC infection ~ t h a RR of 31 (95% CI: 3.3-298), 20 (95% CI: 4.03-105), 13 (2.6-67), 6.2 (95% Cl: 153-25.37) and 1,94 (95% CI: 1.37-2.73), respectively. No prognostic factors were identified tot late mortality (> 10 years) in this population Conclusions: The survival curve of HPN patients receiving has notable decreases in early (0-2 years) and late (> 10 years) survival. Tim only" factor refinancing overall survival is the presence of active malignancy. However, em'ly mortality relates to the development of complications (chronic cholestasis and infections) as well as intestnial morpholo~' (obstruction and SBS). These observations should be considered When considering the timing and suitability of small bowel transplantation.
~yo(~) Tmnsf~v~ (mg/dl) 171 13 Trail test A (see) 7714 WBC (xl0001mm3) 4,6 0.5 CD4/mm3 677 109 * p < 0,01 by paired t test (2 tailed) compared to time 0
D~ S (L=)st)
Day~lZ(f~)
202~16" 441(7' 5.3~0.5" 733 139
18023 5117" 5,0 0,7 770 104"
M2178 Antibiotic Prophylaxis For Children Undergoing Percutaneous Endoscopic Gastrostomy (PEG) David J. Rawat, Anshu Srivastava, Simon Keady, Robert Heuschkel, Simon Murch, Michael Thomson Introduction: Peristomal wound infection is the most common complication of PEG for which use of antibiotic pmphylams is recommended. However, guidelines for use of antibiotics for PEG in children remain controversial. Aim: To evaluate whether a single dose antibiotic regime is effective in reducing the risk of peristomal infection in children undergoing PEG. Methods: 36 children undergoing PEG insertion were prospectwely rvahiated. Children with known immune compromise or who received antibiotics one week preceding the procedure were excluded. Patients were consecutively allocated either a single dose of intravenous Cefiriaxone(5Omg/kg) per procedure (groupl) or 48 hours of intravenous Cefiriaxone(50mg/ kgday) and Metronidazole(7.Smg/kg tds) (group 2). Group 1:9 boys, 9 girls median age 23 months (8 - 166). Group 2 : 1 0 boys, 8 girls median age 17 months(4 - 205)~ For 2 weeks after gastrostomy, the peristomaI area was evaluated using a validated wound score I-IV. Infection up to degree III was regarded as minor. Results: 32/36 underwent PEG insertion by standard techinque and 4/36 by rapid one step insertion. 19% had wound refections and there were no severe complications, in group 1, 3/18 (1 swab- positive) had minor wound infections, 2 requiring antibiotic therapy. 4/18 (3 swab- positive) in group 2 had minor wound infections requiring antibiotic treatment. Duration of hospital stay was increased in only 1 child in group 2, Staphylococcus aureus was the most comnmn bacteria isolated. Conclusion: Single dose intravenous Ceftnaxone is as effective as dual antibiotic therapy, in the reduction of peristomal infections after PEG irksertion in children.
M2176 Home Parenteral Nutrition Is Cost-Saving with Low Consumption of Acute Care Resources S Gadowsky, D. Armstrong, A. Childs, J K Marshall BACKGROUND: Home parenteral nutrition (HPN) is increasingly available, but there are no rigormls, current estimates of its economic impact in a Canadian health care setting. AIM: To esnmate total per diem direct medical costs in a consecutive cohort of patients disa barged from hospital to receive HPN METHODS: Itemized per diem direct medical costs were derwed ~br the final week of inpatient (IP) care from detailed review of hospital charts, administrative databases, and Ontario provincial tee schedules. Estimated hospital hotel costs were weighted according to daily patient acuity profiles. Total per diem direct medical costs were then compiled fbr the first month of outpatient (OP) care from review of patient community care fdes, medical supply company invoices, HPN program charts, hosDtal databases, and pmnary care records. All 1P costs incurred after discharge (e.g. for readmission) were atmbnted to OP care. The perspective of a provincial Ministry of Health was assumed, with costs converted to 2002 equivalents using the Consumer Price Index (C$1 = US$0.64). RESULTS: TwentDnine HPN patients were evaluated (mean age 5L 18 female; fistulae (11), obstructiorddysmotility (9), malabsorption (9)) All survived at least one month from discharge, Mean -+. SD per diem costs were lower at home (C$405 • 129) than in hospital (C$574 • 144; p < 0 0001) The mayor components (proportion, 95% CI) of OP costs were intravenous sohnions (0.38, 033-0.43), conmmnity caregiver contracts (0.19, O. 16-0.22) and medical supplies (0.13, 0.11-0.15). The proportion of OP costs attributable to acute care hospital resources was 0.09 (0.03-0.15), with 9 hospital readmissions (total 59 inpatient days) and 7 ER visits. Thus, 6.8% of patient day's in the first month of HPN were spent in acute care. Only 2 admissions were judged to be HPN-related. CONCLUSIONS: HPN is cost-saving in Canada The care of HPN patients and their nutrition in the communBy is complex, but consumption of acute hospital resources is low. Regardless of whether ongoing research indicates that HPN maintains or improves patient outcomes or quality of life, there sfamld be no fiscal barrier to the prowsion of HPN to appropriate patients. Support: Hamilton Health Sciences Foundation Operati~g Grant
M2179 Nutritional Support In Intensive Care Units - National Survey of Current Practice In The U.K Nell Kapoor, Helen Cooper, Paul O'toole ALMS: 1) To establish attitudes and current practice regarding nutritional support in the 1CU setting. 2) To explore factors determining choice of feeding route. METHODS: A validated questionnaire was sent to 324 ICUs in the U.K It comprised an attitudinal survey assessing unit policy and opinion in relation to nutritional support, and a 'snap-shot" survey of current inpatients to determine how this policy was implemented in practice RESULTS: Completed questionnaires were returned by 112 units (35%), responsible for the care of 617 inpatients on the day oftbe survey. 416 patients (67%) were receiving artificial nutrition, 85% were on some form of enteral nutrition (EN) alone, 9% were receiving parenteral nutrition (PN) alone and 6% were on a combination of EN and PN. Nasogastric (NG) feeding accounted for 90% of the EN group. In the attitudinal survey, most respondents (83%) agreed that NG feeding generally allowed patients to meet their nutritional requirements. However, frequent problems with NG feeding were reported in practice, with 30% needing tube replacement, 24% having absorption problems and 24% having unplanned interruptions to their feed. 51% of respondents agreed that those who fail NG will usually tolerate nasojejunal (NJ) feeding, yet only 15 patients had NJ tubes (2 with supplemental PN) Only 25% of units claimed to use NJ feeding regularly,, while 18% units never use it, Of the 39 patients on PN, only 64% appeared to have an accepted contraindicatinn to NJ feeding NJ tubes were placed endoscopicalb/m 6/13 patients with 3 placed blindly, 2 with thioroscopy and 2 during surgery. 45 units reported difficulty in arranging endoscopic NJ tube placement. 62/109 units felt that a reliable NJ tube placement service would probably decrease their use of PN. CONCLUSIONS: EN is firmly established as the preferred choice for nutritional support in 1CU patients. NG remains the main f:eeding route but is frequently associated with problems that may limit nutrient delivery. Man),'units have diftkuhy an'anging endoscopic NJ tube placement. Better access to the technique might decrease the use of PN
M2177 Short Term Safety and Efficacy of an Immune Enhancing Nutritional Supplement (IENS) in Patients with Advanced Cirrhosis and HEpatic Encephalopathy (He) Souheil G Abou-kssi, Edith Gavis, leslie Williams, Amy Haselbush, Adfl Habib, Anastasios A. Mihas, Douglas M. Heuman Background: Malnutrition is common in patients vnth advam:ed hepatic cirrhosis and worsens susceptibility' to infection. IENS in surgery and traunm improves bealing and reduces septic complications, lENS could be of benefit in cirrhosis, but the high arginine and glutamine content risk aggravating hyq~erammonemia and HE. Aim: to determine efficacy and safety of an oral IENS in outpatients witb advanced cirrhosis and controlled HE, Methods: We prospectively studied 9 men with hepatic cirrhosis, CTP class B or C, ages 40 - 60. Four bad been hospitalized for HE and all Md experienced symptoms of HE; in all HE was well controlled with lactulose at enrollment Patients ingested tbree packets per day of Impact Recover (Novartis) containing per packet 240 Kcal, 17 g pmteni, 4 g arginine, 5 g glutamine, 390 mg nucleotides and 420 mg n3Jatty acids, lENS was stopped after 56 day's. On day's 0, 14, 28, 42, 56, 84 and 112 patmnts underwent laboratory and psychometric testing and neurological assessment. Results: Mean (hido) CTP = 9 (7-11) and MELD = 14 (7-24)
A-431
AGA Abstracts