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Increased use of specialized total parenteral nutrition (TPN) ward reduces both infection rate and cost of TPN
P.113 Increased use of specialized total parenteral nutrition (TPN) ward reduces both infection rate and cost of TPN I.W. Q&n*, P. Ispahanit, J. Kendall# and S.P. Allison’ bpartments of Medicine*, Microbiology, and Pharmacy#, Hospitab Nottingham, U.K.
University
The activities of an existing nutrition team (consisting of Physician, Nutrition Nurseand Pharmacist), using aspecializedTPN ward and standardized TPN regimes, were formally adopted by the hosptial in June 1966. This survey reviews the effect of this change in hospital policy on the numbers of aduft patients receiving and site of administration of TPN, along with the rate of TPN associated sepsis and cost TPN administration at different sites within a large teaching hospital. Records of TPN prescription and TPN associated sepsis (as confirmed by positive blood culture), in all adult patients of this hospital 18 months prior to and after this change were reviewed retrospectively. Data was analysed by Chi-squared test. sit8 Generalward TPNwwd lhfenslvacare"nlf
NunbrOfpOlfWh 7/6&12&Q l/674/88 12% 36 wa 20 55 56
msndwatbnoflPN(dlvs)) iin 7m&12/69 15.2 12.1 16.6 23.5 16.9 16.1
Muncosl mntla I*ofuws) (prl~dyr) tidy) 27.0% 16.6% E66 GeneralWard 1.45 3.5 E43 TPtiwd 7.O.b Et6 InfensivecareLnlf 3.6% 'P < 0.01. a l/676/88 7/F&12/89. b specraluedTPNward vmus alher wards
The advice of the nutrition team led to a reduction in the number of non-intensive care unit (1121)patients receiving TPN (by 15%) and increased the use of the TPN ward with reduced general ward TPN. There was no change in ITU TPN prescription. TPN associated sepsis rate was very low on the TPN ward, and therefore cost of diagnosis and treatment of sepsis was reduced. Furthermore, the daily cost of standard&d TPN prescriptions is lower on the TPN ward than on the general wards. This change in policy has reduced both the TPN associated infection rate and the cost of TPN in this hospital.
ConclusiomThe “all-in-one” system for TPN (with fat emulsion included) induces less precipitation on both VAP and PAC implantable infusion ports compared with traditional TPN regimens (multibottle systems) for a similar TPN regimen using an in vitro system.
P.115 Prospective randomised study comparing 12-hourly and continuous administration of peripheral parenteral nutrition H.J. Jaeger, M. J. Kerin, N.F. Cow, C. J. Mitchell and J. MacFie Departments of Surgery and Medicine, Scarborough Hospital, North Yorkshire, UK Phlebitis is a major obstacle to successful and prolonged peripheral parenteral nutriiion (PPN). Whilst many studies have concentrated on the effect of pharmacological manipulations few have evaluated the effects of elective change of intravenous cannula and intermittent infusion on the incidence of phlebitis. Fifty-one consecutive patients requiring PPN were randomised into three groups. Group 1: received PPN continuously through a cannula that was only changed if there was evidence of phlebitis at the infusion site. Group 2: received PPN continuously through a cannula which was electively changed every 24 hrs and Group 3: received the PPN over 12hrs after which the cannula was removed and reinserted in the contralateral arm the following day. All patients received 16OOkcal daily and 0.29 N/Kg/day. Infusion sites were inspected daily and a Maddox score (O-5) recorded. NoOfpatwnts No0f1nfusmdqs Cumulative Maddoxdays Medl~MadcbxScae lncKknca severep#ktlflS wddoX?ccw~3)
Of
Gmupi 17 115 64 0.73
mup2 17 169 69 0.41 7
7
Group3 17 157 32 0.25 3
This study demonstrates that the intermittent administration of PPN over 12 hrs has a lower incidence of phlebitis than continuous administration of PPN with or without elective change of cannula. We conclude that intermittent infusion of PPN with rotation of veins is the optimal method of administering TPN.
P.114 In vitro study comparing the “All-in-one” system with traditional TPN given through implantable infusion ports.
P.116 Percutaneous endoscopic gastrostomy (PEG) for long-term enteral nutrition: comparison of two different sizes
W. K&n”, H. Flaatten’: 0. Bentdal”‘and K. With: Oepr of Pharmacy* and Surgery”’ National Hospital, Oslo and Dqo of Anaesthesiobgy “Haukeland Hospital, Sergen; Norway.
R. Meisr, M. Thumshirn, R. Hoffmann, P. Bauerfeind and K. Gyr Department of Internal Medicine, Gastroentrology, Kantonsspital Liestal, University of Basle, CH-44 10 Liestat, Stvitzertand.
The “all in one” TPN bags have been claimed to give more precipitation and occlusion of subcutaneous infusion ports (SIP) than the traditional muitibottle TPN system. To investigate this, two different ports: PAC (Port-ACath) and VAP (Vascular Access Port) were given different TPN regimen using an in vitro system with a water-bath at 37°C: The three TPN regimen used were: A) The “all in one” bag (with lipids included). B) Simuftaneous infusion of aminoacids, lipid emulsion and glucose, and C) Infusion of aminoacids and fat emulsion followed by glucose infusion alone. All three TF’N regimen were identical using Syntamin 14, lntralipid 20% and glucose 24% with additives, and were given over seven hours. The ports were then flushed with saline and heparin-lock was installed. After 70 days use the ports were opened and analyzed. The results are given in the table.
PEG is nowadays often used for long-ten enteral nutriiion in patients (pt) with impaired or severely disordered esophageal transit. The aim of the study was to compare two sizes of PEG-tubes (CH 9 and CH 15, Freka, Fresenius, FRG) with respect to long-term durability. The PEG-tubes were introduced by two gastroenterologists; the tip of the tube was localized in the gastric corpus. Indications were cerebral vascular lesions (29) malignancy (6) polytraumatism (3) and various (14). Mean age of the pts was 75yrs (23-91).
ryPolporl
VAP PAC VAP PAC VAP PAC
lnfurknlWthOd
A A B B C C -=nopqeate
ReStlit% wof she CH9 CH15
~klthechmbuinmruthr*r
n 26 23
ww b.=l+sg 73+15 77+13
mhW@l 22(l-71) 14(l-29)
conpvutbnr n(w lab rrlv 3 (10.7) o@l (4.4) 1 (4.4)
1
The period of implantation was limited in 1&cases bythedeath of thepatient; no patient died due to complications of the PEG. The only early complication was 1 episodeof oozing hemorrhageduring 46hrsafter implantation (treated conservatively). The only late complication with CH 15 was leakage of the gastric stoma 10 days after implantation due to local infection (treated locally). With CH 9 a cicatricial granuloma at the site of the stoma occurred
(+I + ++ I:; + ++ ; + =pf.wpliafe. ++ =excxs.weprec,pifafe
64
University
The activities of an existing nutrition team (consisting of Physician, Nutrition Nurseand Pharmacist), using aspecializedTPN ward and standardized TPN regimes, were formally adopted by the hosptial in June 1966. This survey reviews the effect of this change in hospital policy on the numbers of aduft patients receiving and site of administration of TPN, along with the rate of TPN associated sepsis and cost TPN administration at different sites within a large teaching hospital. Records of TPN prescription and TPN associated sepsis (as confirmed by positive blood culture), in all adult patients of this hospital 18 months prior to and after this change were reviewed retrospectively. Data was analysed by Chi-squared test. sit8 Generalward TPNwwd lhfenslvacare"nlf
NunbrOfpOlfWh 7/6&12&Q l/674/88 12% 36 wa 20 55 56
msndwatbnoflPN(dlvs)) iin 7m&12/69 15.2 12.1 16.6 23.5 16.9 16.1
Muncosl mntla I*ofuws) (prl~dyr) tidy) 27.0% 16.6% E66 GeneralWard 1.45 3.5 E43 TPtiwd 7.O.b Et6 InfensivecareLnlf 3.6% 'P < 0.01. a l/676/88 7/F&12/89. b specraluedTPNward vmus alher wards
The advice of the nutrition team led to a reduction in the number of non-intensive care unit (1121)patients receiving TPN (by 15%) and increased the use of the TPN ward with reduced general ward TPN. There was no change in ITU TPN prescription. TPN associated sepsis rate was very low on the TPN ward, and therefore cost of diagnosis and treatment of sepsis was reduced. Furthermore, the daily cost of standard&d TPN prescriptions is lower on the TPN ward than on the general wards. This change in policy has reduced both the TPN associated infection rate and the cost of TPN in this hospital.
ConclusiomThe “all-in-one” system for TPN (with fat emulsion included) induces less precipitation on both VAP and PAC implantable infusion ports compared with traditional TPN regimens (multibottle systems) for a similar TPN regimen using an in vitro system.
P.115 Prospective randomised study comparing 12-hourly and continuous administration of peripheral parenteral nutrition H.J. Jaeger, M. J. Kerin, N.F. Cow, C. J. Mitchell and J. MacFie Departments of Surgery and Medicine, Scarborough Hospital, North Yorkshire, UK Phlebitis is a major obstacle to successful and prolonged peripheral parenteral nutriiion (PPN). Whilst many studies have concentrated on the effect of pharmacological manipulations few have evaluated the effects of elective change of intravenous cannula and intermittent infusion on the incidence of phlebitis. Fifty-one consecutive patients requiring PPN were randomised into three groups. Group 1: received PPN continuously through a cannula that was only changed if there was evidence of phlebitis at the infusion site. Group 2: received PPN continuously through a cannula which was electively changed every 24 hrs and Group 3: received the PPN over 12hrs after which the cannula was removed and reinserted in the contralateral arm the following day. All patients received 16OOkcal daily and 0.29 N/Kg/day. Infusion sites were inspected daily and a Maddox score (O-5) recorded. NoOfpatwnts No0f1nfusmdqs Cumulative Maddoxdays Medl~MadcbxScae lncKknca severep#ktlflS wddoX?ccw~3)
Of
Gmupi 17 115 64 0.73
mup2 17 169 69 0.41 7
7
Group3 17 157 32 0.25 3
This study demonstrates that the intermittent administration of PPN over 12 hrs has a lower incidence of phlebitis than continuous administration of PPN with or without elective change of cannula. We conclude that intermittent infusion of PPN with rotation of veins is the optimal method of administering TPN.
P.114 In vitro study comparing the “All-in-one” system with traditional TPN given through implantable infusion ports.
P.116 Percutaneous endoscopic gastrostomy (PEG) for long-term enteral nutrition: comparison of two different sizes
W. K&n”, H. Flaatten’: 0. Bentdal”‘and K. With: Oepr of Pharmacy* and Surgery”’ National Hospital, Oslo and Dqo of Anaesthesiobgy “Haukeland Hospital, Sergen; Norway.
R. Meisr, M. Thumshirn, R. Hoffmann, P. Bauerfeind and K. Gyr Department of Internal Medicine, Gastroentrology, Kantonsspital Liestal, University of Basle, CH-44 10 Liestat, Stvitzertand.
The “all in one” TPN bags have been claimed to give more precipitation and occlusion of subcutaneous infusion ports (SIP) than the traditional muitibottle TPN system. To investigate this, two different ports: PAC (Port-ACath) and VAP (Vascular Access Port) were given different TPN regimen using an in vitro system with a water-bath at 37°C: The three TPN regimen used were: A) The “all in one” bag (with lipids included). B) Simuftaneous infusion of aminoacids, lipid emulsion and glucose, and C) Infusion of aminoacids and fat emulsion followed by glucose infusion alone. All three TF’N regimen were identical using Syntamin 14, lntralipid 20% and glucose 24% with additives, and were given over seven hours. The ports were then flushed with saline and heparin-lock was installed. After 70 days use the ports were opened and analyzed. The results are given in the table.
PEG is nowadays often used for long-ten enteral nutriiion in patients (pt) with impaired or severely disordered esophageal transit. The aim of the study was to compare two sizes of PEG-tubes (CH 9 and CH 15, Freka, Fresenius, FRG) with respect to long-term durability. The PEG-tubes were introduced by two gastroenterologists; the tip of the tube was localized in the gastric corpus. Indications were cerebral vascular lesions (29) malignancy (6) polytraumatism (3) and various (14). Mean age of the pts was 75yrs (23-91).
ryPolporl
VAP PAC VAP PAC VAP PAC
lnfurknlWthOd
A A B B C C -=nopqeate
ReStlit% wof she CH9 CH15
~klthechmbuinmruthr*r
n 26 23
ww b.=l+sg 73+15 77+13
mhW@l 22(l-71) 14(l-29)
conpvutbnr n(w lab rrlv 3 (10.7) o@l (4.4) 1 (4.4)
1
The period of implantation was limited in 1&cases bythedeath of thepatient; no patient died due to complications of the PEG. The only early complication was 1 episodeof oozing hemorrhageduring 46hrsafter implantation (treated conservatively). The only late complication with CH 15 was leakage of the gastric stoma 10 days after implantation due to local infection (treated locally). With CH 9 a cicatricial granuloma at the site of the stoma occurred
(+I + ++ I:; + ++ ; + =pf.wpliafe. ++ =excxs.weprec,pifafe
64