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P316 TAUROLIDINE: THE LAST LINE OF DEFENCE FOR CATHETER RELATED BLOOD STREAM INFECTION IN HPN PATIENTS?
Nutritional techniques and formulations 1
163
P314 Outstanding abstract STABILITY OF TOTAL PARENTERAL NUTRITION ADMIXTURE BASED ON MEDIUM CHAIN/LONG CHAIN TRIGLYCERIDES VS. LONG CHAIN TRIGLYCERIDES. INFLUENCE OF HIGH ELECTROLYTE LOAD 1
1
2
1
D.C. Mirkovic , M.M. Antunovic , S.R. Ibric . Institute for Pharmacy, Military Medical Academy, 2 Institute for Pharmaceutical Technology, Faculty of Pharmacy, Belgrade, Serbia Rationale: There are various factors which cause instability in parenteral nutrition admixtures. One of the greatest risk factor is particle size of emulsion. This paper describes investigation of the droplet size distribution and of two kinds of TPN admixtures; one contains combination of medium chain and long chain triglycerides (MCT/LCT) and the second contains long chain triglycerides (LCT). Methods: The tested TPN admixtures were compounded in the hospital pharmacy on the base of commercial ingredients. There were amino acids 57.5 g, nitrogen 9 g, glucose 200 g, lipids 100 g and electrolytes. Whole volume of admixtures were about 1700 ml, and total energy 2030 kcal. Five controlled variables (concentration of Na+ was varied from 50 to 150 mmol, K+ from 75 to 100, Ca2+ from 10 to 20, Mg2+ from 10 to 20 mmol and quantity of lipid phase from 50 to 100 g were varied at two levels (high and low). Distribution of lipid globule size were determined by laser diffraction, using Microtrac, Leeds & Northrup apparatus and conducted at four intervals; immediately after preparation, after 12h at room temperature, and then at 24 and 72h during storage et 2 8º C. Statistical analysis was performed with Design Expert software. Calculation was evaluated according to 25 2 fractional factorial design. Analysis of variance (ANOVA) was used to calculate the significant differences of variations in the tested TPN admixtures. Results: In realized experiment, the maximum value of lipid droplet size was 3.175 mm (MCT/LCT) and 4.8175 mm (LCT). Factor effects indicate the influence of independent variables: the higher the factor effect in absolute value, the more influence it has on corresponding dependant variable. Conclusion: As well as offering physiologic advantages, MCT/ LCT emulsions show significantly better stability in All in One mixtures than to LCT emulsions. References [1] Driscoll DF. Physicochemical stability of two types of intravenous lipid emulsion as total nutrient admixtures. JPEN 2000;24:15. Disclosure of Interest: D. Mirkovic, MMA, Grant Research Support.
P315 Outstanding abstract PHYSICOCHEMICAL STABILITY OF STRUCTURED TRIGLYCERIDE EMULSIONS IN PARENTERAL NUTRITION ADMIXTURES G. Bersani1 , A.S. Stancari1 , S.M. Maselli1 , A.G. Guarguaglini1 , I.M. Mignini1 , L.P. Pironi2 , C.P. Puggioli1 , A.B. Bonoli3 . 1 Pharmacy Service, S. Orsola-Malpighi University Hospital, 2 Internal Medicine and Gastroenterology Department, 3 Chemical, Mining and Environmental Engineering Department, University of Bologna, Bologna, Italy Rationale: Structured triglyceride emulsions are interesterified mixtures of equimolar amounts of long chain and medium chain triglycerides with micellar structure, which can improve nitrogen balance in critically ill patients. The aim of this study is to check if micellar diameter is in the range of chylomicra (0.4 1 micron), as parenteral admixtures require to be safely infused to the patients. Methods: Stability studies were carried out on industrial structured triglyceride emulsion and on seven compounded admixtures with or without electrolytes. They were stored at three different temperatures: 4ºC (storage), 25ºC (compounding) and 37ºC (infusion), then they were analysed immediately (t = 0) and 24, 48, 72, 96 hours (t = 96) after compounding. Micelle diameter was determined by means of Laser Particle Sizer which uses Light scattering-Reverse Fourier Optics technique. Every sample was triple tested. Statistics were provided by T-test; they were regarded as significant data if p < 0.01. Results: Physicochemical stability did not change between t = 0 and t = 96 and there was no significant difference among tested admixtures, but only 80% of micelle diameter (d80) was in the range 0.5 1 micron, while the remaining 20% (d20) was in a larger range (2 3 micron) both in industrial structured triglyceride emulsion and in compounded admixtures. Conclusion: Parenteral infusion of lipid emulsions with particle diameter larger than chylomicra is a risk factor for the patients, because the least change in admixture storage conditions can let micellar diameter increase until 6 micron (pulmonary capillary vessels diameter); therefore clinicians must limit structure triglyceride admixtures prescription to the critically ill patients for whom benefit/risk ratio is favourable. Disclosure of Interest: None declared
P316 TAUROLIDINE: THE LAST LINE OF DEFENCE FOR CATHETER RELATED BLOOD STREAM INFECTION IN HPN PATIENTS? J. Sarveswaran1 , J. Wood1 , J. Smith1 , J. Scantlebury1 , H. Lynch1 , C. Donnellan1 , D. Burke1 . 1 Department of General Surgery, Leeds General Infirmary, Leeds, United Kingdom Rationale: Taurolidine has been identified in haemodialysis patients as a prophylactic therapy for catheter related sepsis. Trials are underway in evaluating its role in the prevention of catheter related blood stream infections (CRBSI) in Home Parenteral Nutrition (HPN) patients.
164
Poster presentations
The aim of this study was to evaluate our results with taurolidine in HPN patients. Methods: 2 of 28 HPN patients were identified with recurrent CRSBI (more than 2/year). One of these was a 47yr old male with short bowel syndrome (80 cms) secondary to mesenteric ischaemia who presented with 5 episodes of CRBSI in 2007. The latter two episodes resulted in prolonged ICU admissions. Potential sources of infection were excluded with each episode and line care was re-evaluated. Informed consent was taken and the patient was instructed on the use of Taurolock (2% taurolidine and 4% citrate) post infusion of PN, allowing an indwelling time of 12hrs for the Taurolock before reconnecting to PN bag. An assessment of this patient’s infection-free days on PN and number of catheters was made pre and post usage of Taurolock. Results: Prior to Taurolock, the patient presented with 5 CRSBI, each with different organisms. The table demonstrates the effects of Taurolock. Taurolock
No of CRSBI
Line removals
Feeding days
BMI
Pre Post
5 0
4 0
28, 30, 52, 70 170
17 23
Based Medicine (EBM) grading system and elaborating clinical answer. Results: By the 447 searches performed at PubMed, 4037 references were obtained (RI: 536, HD: 481, SBD: 379, IBD: 373, DI: 369, BN: 274, CI: 221, GIF: 168, PC: 136, AIDS: 44 and CA: 1056). After filters introduction 13.8% of this references remained and only 7% answer the questions. The level of evidence found for the indications was RI 2b (3) and 1b (2); HD 2b (6) and 1b (5); IBD 2b (1) and 1b (3); DI 2b (4); BN 1b (2); CI 2b (2) and 1b (3); PC 1b (1); CA 2b (18) and 1b (5); GIF, SBD and AIDs found none. Approximately 38% of the references were recommendation grade A. The nutrient that provides more answers was amino acid 25%. Conclusion: Although a large number of references about PN support have been obtained, less than a half was RCT and/or performed in humans and adults. This reflects the decreased probability to find a consistent answer for all questions stated. By the EBM principles and the appraised rules adopted, weren’t found enough knowledge to build a KNB. We look forward to apply the proposed methodology considering other study designs than RCT to complete the KNB. References
Conclusion: The use of taurolock in this patient has resulted in a substantial increase of continous infectionfree feeding days. The has also reduced the number of hospital admissions, increased his BMI and prevented line removals. These early results highlight a potential new role for Taurolidine in HPN patients.
Center of evidence based medicine Oxford, www.cebm.net/ index.asp?o = 1205 Scholosser RW; Koul R; Costello J. Asking well-built questions for evidence based practice in augmentative and alternative comunication. J Commun Disord. 2007 May-Jun 40(3): 255 38.
Disclosure of Interest: None declared
P318 A THREE YEAR EXPERIENCE OF A NUTRITIONAL SUPPORT TEAM AT A SINGLE CENTER: RETROSPECTIVE ANALYSIS OF 1584 PATIENTS
P317 SURVEYING KNOWLEDGE TO SUPPORT THE PARENTERAL NUTRITION WRITING-ORDER PROCESS AND PRESCRIPTION EVALUATION USING THE EVIDENCE BASED MEDICINE CONCEPT G.R. Vieira1 , M.G.F. Costa1 , C.F.F. Costa Filho1 . 1 Centro de Tecnologia Eletronica e da Informa¸ca ˜o, Universidade Federal do Amazonas, Manaus, Brazil Rationale: The selection of the best available information and its currently and safety use in clinical practice has submitted the professionals look forward a methodology that helps to objectively search, select, appraise and use such information. The first objective was to develop an optimal search strategy to retrieve the best current available evidence and classify by level of evidence and recommendation grade; the second was to built a knowledge base (KNB) to help the PN’s order-writing process. Methods: The methodology begins structuring clinical questions by PICO’s strategy template considering 11 PN indications (renal insifficiency RI, hepatic desease HD, short bowel syndrome SBS, inflammatory bowel desease IBD, diabetes DI, burns BN, critically ill CI, gastrointestinal fistula GIF, pancreatite PC and AIDS) plus a nutrient and outcome; selecting evidence sources; implementing search strategy; retrieving references found; appraising and classifying the evidences by the Center of Evidence
Disclosure of Interest: None declared
O. Abbasoglu1 , N. Doganci2 , P. Onar2 , K. Akcay2 , O. Isci2 , B.E. Arsava3 , D. Altintas3 , A. Topeli Iskit3 . 1 General Surgery, 2 Nutrition Support Team, 3 Internal Medicine, Hacettepe University, Ankara, Turkey Rationale: Improved organization of nutritional care may result in both clinical and economic benefits in the hospital service. The aim of this study was to evaluate the management, route and complications of nutritional support given by a nutritional support team in a referral hospital. Methods: This retrospective study analyzed 1584 patients who received either enteral or parenteral nutritional support from January 2005 to December 2007 in a single center. The demographic and clinical details were noted along with their complications. Results: Median age of patients was 57 years (range: 17 115). Median duration of nutritional support was 16 days (range: 1 251). Majority of patients (75%) received parenteral support. Of these 51% received central and 49% received peripheral parenteral nutrition. Among patients who received enteral nutrition, the most common route was postpyloric tube feeding (45%) which is followed by ostomy feeding (35%) and nasogastric tube feeding (20%). Overall serious complication rates in enteral and parenteral nutrition were 9.6% and 12.7% respectively. Hospital mortality rate was 21%.
163
P314 Outstanding abstract STABILITY OF TOTAL PARENTERAL NUTRITION ADMIXTURE BASED ON MEDIUM CHAIN/LONG CHAIN TRIGLYCERIDES VS. LONG CHAIN TRIGLYCERIDES. INFLUENCE OF HIGH ELECTROLYTE LOAD 1
1
2
1
D.C. Mirkovic , M.M. Antunovic , S.R. Ibric . Institute for Pharmacy, Military Medical Academy, 2 Institute for Pharmaceutical Technology, Faculty of Pharmacy, Belgrade, Serbia Rationale: There are various factors which cause instability in parenteral nutrition admixtures. One of the greatest risk factor is particle size of emulsion. This paper describes investigation of the droplet size distribution and of two kinds of TPN admixtures; one contains combination of medium chain and long chain triglycerides (MCT/LCT) and the second contains long chain triglycerides (LCT). Methods: The tested TPN admixtures were compounded in the hospital pharmacy on the base of commercial ingredients. There were amino acids 57.5 g, nitrogen 9 g, glucose 200 g, lipids 100 g and electrolytes. Whole volume of admixtures were about 1700 ml, and total energy 2030 kcal. Five controlled variables (concentration of Na+ was varied from 50 to 150 mmol, K+ from 75 to 100, Ca2+ from 10 to 20, Mg2+ from 10 to 20 mmol and quantity of lipid phase from 50 to 100 g were varied at two levels (high and low). Distribution of lipid globule size were determined by laser diffraction, using Microtrac, Leeds & Northrup apparatus and conducted at four intervals; immediately after preparation, after 12h at room temperature, and then at 24 and 72h during storage et 2 8º C. Statistical analysis was performed with Design Expert software. Calculation was evaluated according to 25 2 fractional factorial design. Analysis of variance (ANOVA) was used to calculate the significant differences of variations in the tested TPN admixtures. Results: In realized experiment, the maximum value of lipid droplet size was 3.175 mm (MCT/LCT) and 4.8175 mm (LCT). Factor effects indicate the influence of independent variables: the higher the factor effect in absolute value, the more influence it has on corresponding dependant variable. Conclusion: As well as offering physiologic advantages, MCT/ LCT emulsions show significantly better stability in All in One mixtures than to LCT emulsions. References [1] Driscoll DF. Physicochemical stability of two types of intravenous lipid emulsion as total nutrient admixtures. JPEN 2000;24:15. Disclosure of Interest: D. Mirkovic, MMA, Grant Research Support.
P315 Outstanding abstract PHYSICOCHEMICAL STABILITY OF STRUCTURED TRIGLYCERIDE EMULSIONS IN PARENTERAL NUTRITION ADMIXTURES G. Bersani1 , A.S. Stancari1 , S.M. Maselli1 , A.G. Guarguaglini1 , I.M. Mignini1 , L.P. Pironi2 , C.P. Puggioli1 , A.B. Bonoli3 . 1 Pharmacy Service, S. Orsola-Malpighi University Hospital, 2 Internal Medicine and Gastroenterology Department, 3 Chemical, Mining and Environmental Engineering Department, University of Bologna, Bologna, Italy Rationale: Structured triglyceride emulsions are interesterified mixtures of equimolar amounts of long chain and medium chain triglycerides with micellar structure, which can improve nitrogen balance in critically ill patients. The aim of this study is to check if micellar diameter is in the range of chylomicra (0.4 1 micron), as parenteral admixtures require to be safely infused to the patients. Methods: Stability studies were carried out on industrial structured triglyceride emulsion and on seven compounded admixtures with or without electrolytes. They were stored at three different temperatures: 4ºC (storage), 25ºC (compounding) and 37ºC (infusion), then they were analysed immediately (t = 0) and 24, 48, 72, 96 hours (t = 96) after compounding. Micelle diameter was determined by means of Laser Particle Sizer which uses Light scattering-Reverse Fourier Optics technique. Every sample was triple tested. Statistics were provided by T-test; they were regarded as significant data if p < 0.01. Results: Physicochemical stability did not change between t = 0 and t = 96 and there was no significant difference among tested admixtures, but only 80% of micelle diameter (d80) was in the range 0.5 1 micron, while the remaining 20% (d20) was in a larger range (2 3 micron) both in industrial structured triglyceride emulsion and in compounded admixtures. Conclusion: Parenteral infusion of lipid emulsions with particle diameter larger than chylomicra is a risk factor for the patients, because the least change in admixture storage conditions can let micellar diameter increase until 6 micron (pulmonary capillary vessels diameter); therefore clinicians must limit structure triglyceride admixtures prescription to the critically ill patients for whom benefit/risk ratio is favourable. Disclosure of Interest: None declared
P316 TAUROLIDINE: THE LAST LINE OF DEFENCE FOR CATHETER RELATED BLOOD STREAM INFECTION IN HPN PATIENTS? J. Sarveswaran1 , J. Wood1 , J. Smith1 , J. Scantlebury1 , H. Lynch1 , C. Donnellan1 , D. Burke1 . 1 Department of General Surgery, Leeds General Infirmary, Leeds, United Kingdom Rationale: Taurolidine has been identified in haemodialysis patients as a prophylactic therapy for catheter related sepsis. Trials are underway in evaluating its role in the prevention of catheter related blood stream infections (CRBSI) in Home Parenteral Nutrition (HPN) patients.
164
Poster presentations
The aim of this study was to evaluate our results with taurolidine in HPN patients. Methods: 2 of 28 HPN patients were identified with recurrent CRSBI (more than 2/year). One of these was a 47yr old male with short bowel syndrome (80 cms) secondary to mesenteric ischaemia who presented with 5 episodes of CRBSI in 2007. The latter two episodes resulted in prolonged ICU admissions. Potential sources of infection were excluded with each episode and line care was re-evaluated. Informed consent was taken and the patient was instructed on the use of Taurolock (2% taurolidine and 4% citrate) post infusion of PN, allowing an indwelling time of 12hrs for the Taurolock before reconnecting to PN bag. An assessment of this patient’s infection-free days on PN and number of catheters was made pre and post usage of Taurolock. Results: Prior to Taurolock, the patient presented with 5 CRSBI, each with different organisms. The table demonstrates the effects of Taurolock. Taurolock
No of CRSBI
Line removals
Feeding days
BMI
Pre Post
5 0
4 0
28, 30, 52, 70 170
17 23
Based Medicine (EBM) grading system and elaborating clinical answer. Results: By the 447 searches performed at PubMed, 4037 references were obtained (RI: 536, HD: 481, SBD: 379, IBD: 373, DI: 369, BN: 274, CI: 221, GIF: 168, PC: 136, AIDS: 44 and CA: 1056). After filters introduction 13.8% of this references remained and only 7% answer the questions. The level of evidence found for the indications was RI 2b (3) and 1b (2); HD 2b (6) and 1b (5); IBD 2b (1) and 1b (3); DI 2b (4); BN 1b (2); CI 2b (2) and 1b (3); PC 1b (1); CA 2b (18) and 1b (5); GIF, SBD and AIDs found none. Approximately 38% of the references were recommendation grade A. The nutrient that provides more answers was amino acid 25%. Conclusion: Although a large number of references about PN support have been obtained, less than a half was RCT and/or performed in humans and adults. This reflects the decreased probability to find a consistent answer for all questions stated. By the EBM principles and the appraised rules adopted, weren’t found enough knowledge to build a KNB. We look forward to apply the proposed methodology considering other study designs than RCT to complete the KNB. References
Conclusion: The use of taurolock in this patient has resulted in a substantial increase of continous infectionfree feeding days. The has also reduced the number of hospital admissions, increased his BMI and prevented line removals. These early results highlight a potential new role for Taurolidine in HPN patients.
Center of evidence based medicine Oxford, www.cebm.net/ index.asp?o = 1205 Scholosser RW; Koul R; Costello J. Asking well-built questions for evidence based practice in augmentative and alternative comunication. J Commun Disord. 2007 May-Jun 40(3): 255 38.
Disclosure of Interest: None declared
P318 A THREE YEAR EXPERIENCE OF A NUTRITIONAL SUPPORT TEAM AT A SINGLE CENTER: RETROSPECTIVE ANALYSIS OF 1584 PATIENTS
P317 SURVEYING KNOWLEDGE TO SUPPORT THE PARENTERAL NUTRITION WRITING-ORDER PROCESS AND PRESCRIPTION EVALUATION USING THE EVIDENCE BASED MEDICINE CONCEPT G.R. Vieira1 , M.G.F. Costa1 , C.F.F. Costa Filho1 . 1 Centro de Tecnologia Eletronica e da Informa¸ca ˜o, Universidade Federal do Amazonas, Manaus, Brazil Rationale: The selection of the best available information and its currently and safety use in clinical practice has submitted the professionals look forward a methodology that helps to objectively search, select, appraise and use such information. The first objective was to develop an optimal search strategy to retrieve the best current available evidence and classify by level of evidence and recommendation grade; the second was to built a knowledge base (KNB) to help the PN’s order-writing process. Methods: The methodology begins structuring clinical questions by PICO’s strategy template considering 11 PN indications (renal insifficiency RI, hepatic desease HD, short bowel syndrome SBS, inflammatory bowel desease IBD, diabetes DI, burns BN, critically ill CI, gastrointestinal fistula GIF, pancreatite PC and AIDS) plus a nutrient and outcome; selecting evidence sources; implementing search strategy; retrieving references found; appraising and classifying the evidences by the Center of Evidence
Disclosure of Interest: None declared
O. Abbasoglu1 , N. Doganci2 , P. Onar2 , K. Akcay2 , O. Isci2 , B.E. Arsava3 , D. Altintas3 , A. Topeli Iskit3 . 1 General Surgery, 2 Nutrition Support Team, 3 Internal Medicine, Hacettepe University, Ankara, Turkey Rationale: Improved organization of nutritional care may result in both clinical and economic benefits in the hospital service. The aim of this study was to evaluate the management, route and complications of nutritional support given by a nutritional support team in a referral hospital. Methods: This retrospective study analyzed 1584 patients who received either enteral or parenteral nutritional support from January 2005 to December 2007 in a single center. The demographic and clinical details were noted along with their complications. Results: Median age of patients was 57 years (range: 17 115). Median duration of nutritional support was 16 days (range: 1 251). Majority of patients (75%) received parenteral support. Of these 51% received central and 49% received peripheral parenteral nutrition. Among patients who received enteral nutrition, the most common route was postpyloric tube feeding (45%) which is followed by ostomy feeding (35%) and nasogastric tube feeding (20%). Overall serious complication rates in enteral and parenteral nutrition were 9.6% and 12.7% respectively. Hospital mortality rate was 21%.