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Proton pump inhibitors in patients with high output stomas and enterocutaneous fistulae. Do they really help? An audit of a specialty clinic practice
Abstracts / Clinical Nutrition ESPEN 10 (2015) e174ee212
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to calculate relative risk (RR) of PN-aCVC sepsis given various patient variables. 56% were male. Mean age of patient receiving PN was 65.7 years, for a period of 14.16 days. Mean pre-feed body mass index (BMI) was 24.81 kg/ m2. 90 patients received PN centrally via PICC or temporary 3-lumen CVC (as opposed to peripherally). There were 6 confirmed PN-aCVC line infections, equivalent to 4.46 infections/1000 PN days. Comparison of baseline statistics between patients with and without confirmed PN-aCVC sepsis revealed no significant difference between age, pre-feed BMI or baseline albumin. PN-aCVC sepsis positive patients had a longer feed length (36.67 days vs 13.54 days, p ¼ 0.0007). The table demonstrates multivariate logistic regression for RR of line sepsis given various patient characteristics.
Characteristic
Relative risk of PN-aCVC sepsis (95% CI)
Age Sex (male vs female) Albumin at start of PN PN length >14 days CVC (vs PICC) ITU patient (vs Non ITU)
1.04 0.75 1.04 23.86 0.03 45.59
(0.95 e 1.14) (0.09 e 6.61) (0.85 e 1.28) (1.36 e 419.98) (0.001 e 0.59) (1.59 e 1337.55)
Significance (p-value) 0.42 0.80 0.70 0.03 0.02 0.03
Six month mortality in the entire cohort was 27%. Age above 65 (RR 3.17, 95%CI 1.05 e 9.86, p ¼ 0.05) and baseline albumin less than 20 (RR 5.21, 95%CI 1.19-22.91, p ¼ 0.02) was associated with increased risk of mortality, although confirmed PN-aCVC sepsis was not related to increased mortality. In summary, PN-aCVC sepsis is not an infrequent occurrence in patients receiving short-term PN. Feed length > 14 days, feed received via PICC line, and patient location in ITU have been isolated as potential predisposing factors for this outcome. With this in mind, the aim is that high risk patients are identified earlier, and that vigilance for suspected line sepsis is raised. Although overall mortality is high in the PN cohort, this is probably a reflection of the type of patient receiving PN at our centre (tertiary referral centre for complex upper GI cancer and HPB surgery) rather than the rates of line sepsis. 1. Catheter application, insertion vein and length of ICU stay prior to insertion affect the risk of catheter-related bloodstream infection’.van der Kooi et al. J Hosp Infect. 2012 Mar;80(3):238-44. OC13. PROTON PUMP INHIBITORS IN PATIENTS WITH HIGH OUTPUT STOMAS AND ENTEROCUTANEOUS FISTULAE. DO THEY REALLY HELP? AN AUDIT OF A SPECIALTY CLINIC PRACTICE N.D. Appleton 1, W.D. Neithercut 2, C. Edwards 3, M. Duncan 3, C.J. Walsh 1. 1Department of Surgery; Wirral University teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Wirral, CH49 5PE, UK; 2 Department of Clinical Biochemistry; Wirral University teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Wirral, CH49 5PE, UK; 3Nutrition Support Team, Wirral University teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Wirral, CH49 5PE, UK Patients with high output stomas and proximal enterocutaneous fistulae (ECF) are prone to fluid and electrolyte losses. Hypomagnesaemia can be a particular problem. Proton pump inhibitors (PPIs) are advocated to help reduce fluid losses in these patients(1-3). Recently however PPIs have been linked with hypomagnesaemia in other clinical settings(4-6). We therefore wondered whether PPIs may actually potentiate hypomagnesaemia in this patient group? During October 2012, we audited the outcomes of nine patients (8 high output stomas: 1 ECF) who were attending a dedicated clinic for management of their fluid and electrolyte losses. Daily outputs and plasma magnesium were recorded before and after cessation of PPIs used specifically to reduce GI losses. There was no significant increase in serum magnesium on stopping the PPI. On PPI - mean serum magnesium¼0.59mmol/L, SE: 0.40 compared to
being off PPI - mean serum magnesium¼0.64mmol/L, SE:0.40, t(8)¼1.42, p¼0.226). However, average daily stoma output whilst on PPIs of 1550mls (SE:147.67) was seen to significantly reduce to 1344mls (SE:130.29) when off the PPI (t(8)¼2.11, p<0.05). Our findings do not support current thinking with regard to PPIs used to reduce stoma/fistula output in this patient cohort. Consideration should be given to stopping PPIs in patients with problematic high output stomas or ECF’s with or without refractory hypomagnesaemia. 1. Carlson G, Gardiner K, McKee R, MacFie J & Vaizey C (2010) Surgical Intestinal Failure Working Party on behalf of the Association of Surgeons of Great Britain and Ireland 2. Nightingale JMD (2003) Proc Nutr Soc 62, 703-10. 3. Baker ML, Williams RN & Nightingale JMD (2011) Colorectal Dis 13, 1917 4. Hess MW, Hoenderop JGJ, Bindels RJ & Drenth JP (2012) Aliment Pharmacol Ther 36, 405-13. 5. Cundy T & Mackay J (2011) Curr Opin Gastroenterol 27, 180-5. 6. Mackay JD & Bladon PT (2010) Q J Med 103, 387-395. OC14. PUMP INFUSION PRESSURES IN PATIENTS ON LONG TERM PARENTERAL NUTRITION: A NOVEL APPROACH AND MONITORING TECHNIQUE TO ANTICIPATE CATHETER OCCLUSION. S.M. Gabe 1,*, M. Small 1, M. Kallis 2, A. Tsoukalis 3, J.C. Cascailh 4. 1LennardJones Intestinal Failure Unit, St Mark’s Hospital, Watford Road, Harrow, Middlesex, HA1 3UJ, United Kingdom; 2Inspiration Healthcare Ltd, Earl Shilton, United Kingdom; 3Micrel Medical Devices SA, Athens, Greece; 4 Micrel Medical Devices SA, Vence, France Parenteral nutrition (PN) pumps apply a pressure to infuse PN into a vein at a consistent flow rate & alarms when the infusion pressure is above a preset limit. With a venous occlusion it is likely that the pressure would rise over days or weeks, culminating in an occlusion. This has not been studied as pumps have not been developed to record, display or export this information. Collaboration between industry & clinicians has led to the development of a unique system to assess infusion pressures We developed a method for infusion pressures to be continuously recorded on the Mini RythmicTM PN pump & exported anonymously using GPRS technology to a secure MicrelcareTM server. Patients recorded PN fluid type, difficulty flushing and occlusion alarms 7 patients consented to use the Mini Rythmic PN pump to measure their infusion pressures. Only patients with single lumen catheters were considered (Vygon 6.6Fr Lifecath). Patients with repaired or femoral catheters were excluded. The underlying aetiology of intestinal failure was: 4 Crohn’s, 1 mesenteric ischaemia, 1 scleroderma and 1 sclerosing peritonitis. Central venous catheter (CVC) access was via the internal jugular vein in all patients (3 RIJ, 4 LIJ) and the average time between CVC placement and the start of pressure measurement was 30 (0-62) months. Records were obtained for a total of 636 infusions over 559 days. The average infusion pressure was 0.28±0.08 (range 0.11-0.87) bar & did not increase with the infusion rate (r2¼0.22). A small increase in infusion pressure was noted during an infusion which was significantly higher for 3:1 PN (containing lipid) compared to 2:1 PN or electrolyte bags [p<0.001] (maximum pressure difference during the infusion 0.07 ± 0.06, 0.04 ± 0.07, 0.04 ± 0.04 bar for electrolytes, 2:1 PN and 3:1 PN, respectively). In one patient 2 unusual pressure spikes occurred on different days with the pressure rising to 1.48 bar & then settling. CT venography 3 weeks later demonstrated SVC stenosis & she underwent venoplasty. These spikes were not seen in the other patients This is the first time that infusion pressures have been recorded in patients on long term PN. The technology offers real time monitoring of pump performance, infusion pressures & volume infused. This pilot study describes the infusion pressure normal range. We have also noted subtle differences in pressure in a patient 3 weeks before the diagnosis of SVC stenosis. The internal limits for the occlusion alarm varies between pump manufacturers but is generally around 1-2 bar. This setting is helpful for patients to detect when the catheter has become compressed or twisted
* Corresponding author.
e182
to calculate relative risk (RR) of PN-aCVC sepsis given various patient variables. 56% were male. Mean age of patient receiving PN was 65.7 years, for a period of 14.16 days. Mean pre-feed body mass index (BMI) was 24.81 kg/ m2. 90 patients received PN centrally via PICC or temporary 3-lumen CVC (as opposed to peripherally). There were 6 confirmed PN-aCVC line infections, equivalent to 4.46 infections/1000 PN days. Comparison of baseline statistics between patients with and without confirmed PN-aCVC sepsis revealed no significant difference between age, pre-feed BMI or baseline albumin. PN-aCVC sepsis positive patients had a longer feed length (36.67 days vs 13.54 days, p ¼ 0.0007). The table demonstrates multivariate logistic regression for RR of line sepsis given various patient characteristics.
Characteristic
Relative risk of PN-aCVC sepsis (95% CI)
Age Sex (male vs female) Albumin at start of PN PN length >14 days CVC (vs PICC) ITU patient (vs Non ITU)
1.04 0.75 1.04 23.86 0.03 45.59
(0.95 e 1.14) (0.09 e 6.61) (0.85 e 1.28) (1.36 e 419.98) (0.001 e 0.59) (1.59 e 1337.55)
Significance (p-value) 0.42 0.80 0.70 0.03 0.02 0.03
Six month mortality in the entire cohort was 27%. Age above 65 (RR 3.17, 95%CI 1.05 e 9.86, p ¼ 0.05) and baseline albumin less than 20 (RR 5.21, 95%CI 1.19-22.91, p ¼ 0.02) was associated with increased risk of mortality, although confirmed PN-aCVC sepsis was not related to increased mortality. In summary, PN-aCVC sepsis is not an infrequent occurrence in patients receiving short-term PN. Feed length > 14 days, feed received via PICC line, and patient location in ITU have been isolated as potential predisposing factors for this outcome. With this in mind, the aim is that high risk patients are identified earlier, and that vigilance for suspected line sepsis is raised. Although overall mortality is high in the PN cohort, this is probably a reflection of the type of patient receiving PN at our centre (tertiary referral centre for complex upper GI cancer and HPB surgery) rather than the rates of line sepsis. 1. Catheter application, insertion vein and length of ICU stay prior to insertion affect the risk of catheter-related bloodstream infection’.van der Kooi et al. J Hosp Infect. 2012 Mar;80(3):238-44. OC13. PROTON PUMP INHIBITORS IN PATIENTS WITH HIGH OUTPUT STOMAS AND ENTEROCUTANEOUS FISTULAE. DO THEY REALLY HELP? AN AUDIT OF A SPECIALTY CLINIC PRACTICE N.D. Appleton 1, W.D. Neithercut 2, C. Edwards 3, M. Duncan 3, C.J. Walsh 1. 1Department of Surgery; Wirral University teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Wirral, CH49 5PE, UK; 2 Department of Clinical Biochemistry; Wirral University teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Wirral, CH49 5PE, UK; 3Nutrition Support Team, Wirral University teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Wirral, CH49 5PE, UK Patients with high output stomas and proximal enterocutaneous fistulae (ECF) are prone to fluid and electrolyte losses. Hypomagnesaemia can be a particular problem. Proton pump inhibitors (PPIs) are advocated to help reduce fluid losses in these patients(1-3). Recently however PPIs have been linked with hypomagnesaemia in other clinical settings(4-6). We therefore wondered whether PPIs may actually potentiate hypomagnesaemia in this patient group? During October 2012, we audited the outcomes of nine patients (8 high output stomas: 1 ECF) who were attending a dedicated clinic for management of their fluid and electrolyte losses. Daily outputs and plasma magnesium were recorded before and after cessation of PPIs used specifically to reduce GI losses. There was no significant increase in serum magnesium on stopping the PPI. On PPI - mean serum magnesium¼0.59mmol/L, SE: 0.40 compared to
being off PPI - mean serum magnesium¼0.64mmol/L, SE:0.40, t(8)¼1.42, p¼0.226). However, average daily stoma output whilst on PPIs of 1550mls (SE:147.67) was seen to significantly reduce to 1344mls (SE:130.29) when off the PPI (t(8)¼2.11, p<0.05). Our findings do not support current thinking with regard to PPIs used to reduce stoma/fistula output in this patient cohort. Consideration should be given to stopping PPIs in patients with problematic high output stomas or ECF’s with or without refractory hypomagnesaemia. 1. Carlson G, Gardiner K, McKee R, MacFie J & Vaizey C (2010) Surgical Intestinal Failure Working Party on behalf of the Association of Surgeons of Great Britain and Ireland 2. Nightingale JMD (2003) Proc Nutr Soc 62, 703-10. 3. Baker ML, Williams RN & Nightingale JMD (2011) Colorectal Dis 13, 1917 4. Hess MW, Hoenderop JGJ, Bindels RJ & Drenth JP (2012) Aliment Pharmacol Ther 36, 405-13. 5. Cundy T & Mackay J (2011) Curr Opin Gastroenterol 27, 180-5. 6. Mackay JD & Bladon PT (2010) Q J Med 103, 387-395. OC14. PUMP INFUSION PRESSURES IN PATIENTS ON LONG TERM PARENTERAL NUTRITION: A NOVEL APPROACH AND MONITORING TECHNIQUE TO ANTICIPATE CATHETER OCCLUSION. S.M. Gabe 1,*, M. Small 1, M. Kallis 2, A. Tsoukalis 3, J.C. Cascailh 4. 1LennardJones Intestinal Failure Unit, St Mark’s Hospital, Watford Road, Harrow, Middlesex, HA1 3UJ, United Kingdom; 2Inspiration Healthcare Ltd, Earl Shilton, United Kingdom; 3Micrel Medical Devices SA, Athens, Greece; 4 Micrel Medical Devices SA, Vence, France Parenteral nutrition (PN) pumps apply a pressure to infuse PN into a vein at a consistent flow rate & alarms when the infusion pressure is above a preset limit. With a venous occlusion it is likely that the pressure would rise over days or weeks, culminating in an occlusion. This has not been studied as pumps have not been developed to record, display or export this information. Collaboration between industry & clinicians has led to the development of a unique system to assess infusion pressures We developed a method for infusion pressures to be continuously recorded on the Mini RythmicTM PN pump & exported anonymously using GPRS technology to a secure MicrelcareTM server. Patients recorded PN fluid type, difficulty flushing and occlusion alarms 7 patients consented to use the Mini Rythmic PN pump to measure their infusion pressures. Only patients with single lumen catheters were considered (Vygon 6.6Fr Lifecath). Patients with repaired or femoral catheters were excluded. The underlying aetiology of intestinal failure was: 4 Crohn’s, 1 mesenteric ischaemia, 1 scleroderma and 1 sclerosing peritonitis. Central venous catheter (CVC) access was via the internal jugular vein in all patients (3 RIJ, 4 LIJ) and the average time between CVC placement and the start of pressure measurement was 30 (0-62) months. Records were obtained for a total of 636 infusions over 559 days. The average infusion pressure was 0.28±0.08 (range 0.11-0.87) bar & did not increase with the infusion rate (r2¼0.22). A small increase in infusion pressure was noted during an infusion which was significantly higher for 3:1 PN (containing lipid) compared to 2:1 PN or electrolyte bags [p<0.001] (maximum pressure difference during the infusion 0.07 ± 0.06, 0.04 ± 0.07, 0.04 ± 0.04 bar for electrolytes, 2:1 PN and 3:1 PN, respectively). In one patient 2 unusual pressure spikes occurred on different days with the pressure rising to 1.48 bar & then settling. CT venography 3 weeks later demonstrated SVC stenosis & she underwent venoplasty. These spikes were not seen in the other patients This is the first time that infusion pressures have been recorded in patients on long term PN. The technology offers real time monitoring of pump performance, infusion pressures & volume infused. This pilot study describes the infusion pressure normal range. We have also noted subtle differences in pressure in a patient 3 weeks before the diagnosis of SVC stenosis. The internal limits for the occlusion alarm varies between pump manufacturers but is generally around 1-2 bar. This setting is helpful for patients to detect when the catheter has become compressed or twisted
* Corresponding author.