RESUMO
We describe cases of intestinal failure wherein inpatient admission was critical toward enteral autonomy. We performed a retrospective chart review of 6 children with long-term parenteral nutrition dependence who were weaned from parenteral nutrition after admission. Admissions included feeding and medication titration, interdisciplinary care, and a home parenteral nutrition team consultation.
RESUMO
OBJECTIVE: To compare extrahepatic adverse events during fish oil lipid emulsion (FOLE) or soybean oil lipid emulsion (SOLE) treatment in children with intestinal failure-associated liver disease (IFALD). STUDY DESIGN: In this multicenter integrated analysis, bleeding, bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), infections, and signs of lipid emulsion intolerance were compared between FOLE recipients (1 g/kg/d) (n = 189) and historical controls who received SOLE (≤3 g/kg/d) (n = 73). RESULTS: When compared with SOLE recipients, FOLE recipients had a lower gestational age (30.5 vs 33.0 weeks; P = .0350) and higher baseline direct bilirubin (DB) (5.8 vs 3.0 mg/dL; P < .0001). FOLE recipients had a decreased incidence of bleeding (P < .0001), BPD (P < .001), ROP (P < .0156), bacterial and fungal infections (P < .0001), and lipid intolerance signs (P < .02 for all). Patients with bleeding vs patients without bleeding had higher baseline DB; the ORs for baseline DB (by mg/dL) and treatment (FOLE vs SOLE) were 1.20 (95% CI: 1.10, 1.31; P ≤ .0001) and 0.22 (95% CI: 0.11, 0.46; P ≤ .0001), respectively. In preterm infants, a higher BPD (P < .0001) and ROP incidence (P = .0071) was observed in SOLE recipients vs FOLE recipients. CONCLUSIONS: Children with IFALD who received FOLE had fewer extrahepatic adverse events, including a decreased incidence of bleeding, preterm comorbidities, and lipid intolerance signs compared with children with IFALD who received SOLE. TRIAL REGISTRATION CLINICALTRIALS.GOV: NCT00910104 and NCT00738101.
Assuntos
Emulsões Gordurosas Intravenosas/efeitos adversos , Óleos de Peixe/efeitos adversos , Insuficiência Intestinal/terapia , Hepatopatias/etiologia , Nutrição Parenteral/efeitos adversos , Óleo de Soja/efeitos adversos , Emulsões Gordurosas Intravenosas/uso terapêutico , Feminino , Óleos de Peixe/uso terapêutico , Humanos , Lactente , Recém-Nascido , Insuficiência Intestinal/complicações , Masculino , Nutrição Parenteral/métodos , Estudos Retrospectivos , Óleo de Soja/uso terapêutico , Resultado do TratamentoRESUMO
OBJECTIVE: To compare the aspartate aminotransferase to platelet ratio index, liver transplantation, and mortality rates between children with intestinal failure-associated liver disease who received fish oil lipid emulsion (FOLE) or soybean oil intravenous lipid emulsion (SOLE). STUDY DESIGN: In this multicenter integrated analysis, FOLE recipients (1 g/kg/d) (n = 189) were compared with historical controls administered SOLE (≤3 g/kg/d) (n = 73). RESULTS: Compared with SOLE, FOLE recipients had a higher direct bilirubin level at baseline (5.8 mg/dL vs 3.0 mg/dL; P < .0001). Among FOLE recipients, 65% experienced cholestasis resolution vs 16% of SOLE recipients (P < .0001). The aspartate aminotransferase to platelet ratio index scores improved in FOLE recipients (1.235 vs 0.810 and 0.758, P < .02) but worsened in SOLE recipients (0.540 vs 2.564 and 2.098; P ≤ .0003) when baseline scores were compared with cholestasis resolution and end of study, respectively. Liver transplantation was reduced in FOLE vs SOLE (4% vs 12%; P = .0245). The probability of liver transplantation in relation to baseline direct or conjugated bilirubin (DB) was lower in FOLE vs SOLE recipients (1% vs 9% at DB of 2 mg/dL; 8% vs 35% at DB of 12.87 mg/dL; P = .0022 for both). Death rates were similar (FOLE vs SOLE: 10% vs 14% at DB of 2 mg/dL; 17% vs 23% at a DB of 12.87 mg/dL; P = .36 for both). CONCLUSIONS: FOLE recipients experienced a higher rate of cholestasis resolution, lower aspartate aminotransferase to platelet ratio index, and fewer liver transplants compared with SOLE. This study demonstrates that FOLE may be the preferred parenteral lipid emulsion in children with intestinal failure-associated liver disease when DB reaches 2 mg/dL. TRIAL REGISTRATION: Clinicaltrials.gov: NCT00910104 and NCT00738101.
Assuntos
Colestase/terapia , Emulsões Gordurosas Intravenosas/administração & dosagem , Óleos de Peixe/administração & dosagem , Nutrição Parenteral Total/efeitos adversos , Aspartato Aminotransferases/sangue , Estudos de Casos e Controles , Colestase/etiologia , Colestase/mortalidade , Feminino , Óleos de Peixe/farmacologia , Humanos , Lactente , Recém-Nascido , Enteropatias/complicações , Transplante de Fígado/estatística & dados numéricos , Masculino , Óleo de Soja/administração & dosagem , Óleo de Soja/efeitos adversosRESUMO
OBJECTIVES: To assess whether a 24-hour length of hospitalization and empiric antibiotic therapy to exclude central line-associated bloodstream infection (CLABSI) in children with intestinal failure is potentially as safe as 48 hours, which is the duration most commonly used but not evidence based. STUDY DESIGN: A prospective single-institution observational cohort study was conducted among pediatric patients with intestinal failure from July 1, 2015, through June 30, 2018, to identify episodes of suspected CLABSI. The primary end point was time from blood sampling to positive blood culture. Secondary end points included presenting symptoms, laboratory test results, responses to a parent/legal guardian-completed symptom survey, length of inpatient stay, costs, and charges. RESULTS: Seventy-three patients with intestinal failure receiving nutritional support via central venous catheters enrolled; 35 were hospitalized with suspected CLABSI at least once during the study. There were 49 positive blood cultures confirming CLABSI in 128 episodes (38%). The median time from blood sampling to positive culture was 11.1 hours. The probability of a blood culture becoming positive after 24 hours was 2.3%. Elevated C-reactive protein and neutrophil predominance in white blood cell count were associated with positive blood cultures. Estimated cost savings by transitioning from a 48-hour to a 24-hour admission to rule-out CLABSI was $4639 per admission. CONCLUSIONS: A 24-hour duration of empiric management to exclude CLABSI may be appropriate for patients with negative blood cultures and no clinically concerning signs. A multi-institutional study would more robustly differentiate patients safe for discharge after 24 hours from those who warrant longer empiric treatment.
Assuntos
Antibacterianos/administração & dosagem , Infecções Relacionadas a Cateter/prevenção & controle , Cateterismo Venoso Central/efeitos adversos , Enteropatias/terapia , Antibacterianos/efeitos adversos , Proteína C-Reativa/análise , Estudos de Casos e Controles , Infecções Relacionadas a Cateter/sangue , Infecções Relacionadas a Cateter/diagnóstico , Infecções Relacionadas a Cateter/economia , Cateterismo Venoso Central/instrumentação , Cateteres de Demora/microbiologia , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Enteropatias/economia , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Nutrição Parenteral/efeitos adversos , Nutrição Parenteral/métodos , Estudos Prospectivos , Inquéritos e Questionários , Fatores de TempoRESUMO
OBJECTIVE: To compare growth in children with intestinal failure-associated liver disease (IFALD) who received a fish oil intravenous lipid emulsion (FOLE) to those who received a soybean oil intravenous lipid emulsion (SOLE). STUDY DESIGN: This multisite, retrospective study pair-matched FOLE (n = 82) to SOLE recipients (n = 41) using baseline serum direct bilirubin levels and postmenstrual age. Study subjects received open-label FOLE (1 g/kg/day) until IFALD resolved or parenteral nutrition was stopped. Historical control subjects received SOLE (up to 3 g/kg/day). Growth measures (changes in body weight, height/length, and head circumference), prealbumin, triglycerides, and glucose were compared between groups over time using the Wilcoxon rank-sum test. RESULTS: Although changes in all of the growth measures were similar for both groups (P > .05), FOLE recipients demonstrated an overall improved growth trajectory. After 28 weeks, FOLE recipients had a mean body weight within a z score range of -1 to 1 indicating age-appropriate growth. FOLE recipients consistently had higher prealbumin, lower triglyceride, and more normal glucose concentrations over time compared with SOLE recipients. CONCLUSIONS: Children with IFALD who received FOLE had similar growth and fewer metabolic abnormalities compared with those who received SOLE. TRIAL REGISTRATION: Clinicaltrials.gov: NCT00910104 and NCT00738101.
Assuntos
Óleos de Peixe/administração & dosagem , Crescimento/efeitos dos fármacos , Enteropatias/terapia , Hepatopatias/terapia , Nutrição Parenteral/métodos , Estudos de Casos e Controles , Pré-Escolar , Ingestão de Energia , Emulsões Gordurosas Intravenosas , Ácidos Graxos , Feminino , Humanos , Masculino , Estudos RetrospectivosRESUMO
OBJECTIVES: To determine which factors confer the greatest risk of central line-associated bloodstream infection (CLABSI) in children with intestinal failure and fever presenting to an emergency department (ED), and to assess whether a low-risk group exists that may not require the standard treatment of admission for 48 hours on intravenous antibiotics pending culture results. STUDY DESIGN: This retrospective cohort study included children with intestinal failure and fever presenting to an ED over a 6-year period. Multivariable models were created using risk factors selected a priori to be associated with CLABSI as well as univariate predictors with P < .2. RESULTS: Among 81 patients with 278 ED encounters, 132 (47.5%) CLABSI episodes were identified. Multivariable models showed higher initial temperature in the ED (aOR, 1.99; 95% CI, 1.25-3.17) and low white blood cell count (aOR, 2.65; 95% CI, 1.03-6.79) and platelet count (aOR, 2.65; 95% CI, 1.20-5.87) relative to age-specific reference ranges were strongly associated with CLABSI. Among the 63 encounters in which the patient had none of these risk factors, the rate of CLABSI was 25.4%. CONCLUSIONS: Children with intestinal failure who present to the ED with fever have high rates of CLABSI. Although higher temperature in the ED, lower white blood cell count, and lower platelet count are strongly associated with CLABSI, patients without these risk factors frequently have positive blood cultures as well. Antibiotics should, therefore, be given to all children with intestinal failure and fever until CLABSI is ruled out.