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Introduction: Manual feeding by parents using a syringe, a widespread practice in Sweden since the 1980s, favors parents' involvement in childcare tasks. This approach is used in our neonatal unity since 2007., Objective: To study the behavioral changes of preterm children during nasogastric tube feeding: manual milk administration by parents (MAP) versus electric syringe administration (ESA) over a 30-minute period., Method: This is a randomized, crossover study conducted in the neonatology unit of Toulouse. Preterm children under 33 weeks of age and over 7 days of life were included. A video recording was performed to assess the children's behavioral response, using the Dsilna score. The reviewer was blinded., Results: 15 preterm children with a median gestational age of 30.1 weeks and a median birth weight of 1.210 g were included from March to October 2012. The facility, environment, and state of alertness of children were similar in both groups. Signs of well-being were significantly more prevalent in the MAP group versus the ESA group (36.2 (±8.0) versus 30.7 (±9.5)), (p = 0.04), particularly "hand-to-mouth, mouth gestures, seeking suction and sucking". Although not significant, motor withdrawal signs were more apparent and fluctuating in the ESA group. Qualitative analysis of NIDCAP observations confirms this data., Conclusion: There are behavior changes of preterm children during nasogastric tube feeding. This pilot study showed previously undescribed results: MAP is associated with more common well-being signs and could be more widely used in neonatal units., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background & Aims: A retrospective evaluation was undertaken in intestinal failure (IF) patients with long term CVCs to evaluate differential time to positivity (DTP) against paired quantitative blood cultures (PP) for the diagnosis of CRBSI., Methods: A list of patients with a diagnosis of CRBSI was obtained from the intestinal failure unit database for a five year period, 2013 to 2017. Microbiology records were reviewed to obtain further information about blood culture and pour plate examinations. Organisms and times of collection, loading and positivity were recorded. Patients with a contemporaneous set of central and peripheral PP and blood cultures were included in an analysis of the sensitivity of DTP compared to PP., Results: There were 61 (45.5%) episodes in 56 patients where complete sets of central and peripheral blood cultures and PP were received. All 61 episodes had positive central blood cultures, 59 (96.7%) had positive central line PP and 17 (27.9%) had positive peripheral PP. Using PP as the gold standard, DTP sensitivity was 96.0% for 50 episodes where PP were consistent with CRBSI. Sensitivity increased to 100% for 17 episodes where there were no delays in either collection or loading of blood cultures., Conclusions: This is the first evaluation to support the use of DTP as a sensitive test in diagnosing CRBSI in patients with IF and provides confidence to IF centers where pour plate cultures are not available., Competing Interests: Conflict of interest The authors declare no conflict of interest. The results presented in this paper have not been published previously., (Copyright © 2019 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Background & Aims: Patients with Intestinal failure (IF) on long-term nutritional support (IF Type 3) through parenteral nutrition (PN) require invasive venous access to provide nutritional compounds. Central venous catheters (CVC) are at risk of complications including microbial infections and occlusion. Occlusions can be resolved by administering parenteral solutions to achieve patency. However, we report an alternative methodology for salvaging occluded CVCs and achieving patency using endoluminal brushing., Methods: Patients admitted with a CVC occlusion to one of the two national IF centres in the UK, were entered into a prospectively managed database and the data were then analysed retrospectively. The study used data from patients who had CVC occlusions from December 2003 to March 2006 (Cohort 1) and from April 2006 to September 2010 (Cohort 2). Cohort 1 included occluded CVCs managed using endoluminal brushing and the split of cohorts was determined by the availability of endoluminal brushes. Cohort 2 included occluded CVCs managed using a 'standard' technique of urokinase with or without adjuncts such as Ethanol, Hydrochloric acid or Sodium hydroxide. If therapy failed, the CVC was removed. Data were recorded on success of achieving patency and occurrence of re-occlusion., Results: 66 episodes of CVC occlusion from 44 patients occurred in Cohort 1, compared to 68 episodes in 45 patients in Cohort 2. There was no difference in gender, age, median time on TPN prior to occlusive episode or disease aetiology. The number of CVCs where patency was achieved was 57 (86%) in Cohort 1 compared to 34 (50%) in Cohort 2 (p < 0.0001). Consequently, the number of CVCs replaced were 9 (14%) in Cohort 1 compared to 34 (50%) in Cohort 2 (p < 0.0001). There were no complications associated with endoluminal brushing or 'standard' therapy., Conclusion: This is the first report of the safe and effective use of endoluminal brushing to manage occluded CVCs in patients requiring long-term parenteral nutrition., (Copyright © 2014 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Background & Aims: Catheter-related-blood-stream-infection (CRBSI) might be prevented by optimal catheter connector antisepsis in children with intestinal failure on parenteral nutrition (PN). We changed the disinfectant used from isopropanol 70% to chlorhexidine 2% in 70% isopropanol, which leaves a residue of chlorhexidine on the connector., Methods: We conducted this before/after study in children treated with PN for >28 days. Episodes of CRBSI were recorded for all 42 children treated for >28 days during May-November 2006 before introducing chlorhexidine and for all 50 children treated in May-November 2007 after chlorhexidine was introduced. The number of hospital-acquired CRBSI and number of PN days was counted for each period. The rate of CRBSI/1000 catheter days and the proportion of patients that experienced at least one CRBSI during the two periods were compared., Results: There were 3.1 CRBSI/1000 catheter days prior to using chlorhexidine and 0.4 CRBSI/1000 catheter days after it was introduced, p = 0.03. Prior to chlorhexidine 10/42 (24%) patients experienced at least one episode of CRBSI, compared to 3/50, (6%) after introducing it (p = 0.02). The survival rate in both periods was similar, but after chlorhexidine significantly more children made a full recovery and a lower proportion of children had irreversible intestinal failure (p = 0.01)., Conclusions: Our results support the use of 2% chlorhexidine not only to reduce risk of sepsis for central venous catheter connector antisepsis in catheters used for intravenous nutrition, but also to improve the patients' chances of recovering intestinal function., (Copyright © 2013 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Background and Aims: Peripheral intravenous nutrition (PIVN) delivered via a finebore midline offers a viable alternative to central venous feeding. The major complication is the onset of peripheral vein thrombophlebitis (PVT). Feed additives such as heparin and hydrocortisone have been advocated in its prevention. Concern over the safety of heparin has prevented its widespread use; this study examines its true benefit., Methods: A randomised, double-blind trial comparing the addition of either, Heparin 1500 units or hydrocortisone 15 mg or a combination of the two to full intravenous nutrition (IVN) (2500 ml, 13 g of nitrogen, 1190 m0sm/k) was performed. All feeds were delivered via a finebore midline inserted via an antecubital fossa vein. Feeding was terminated in the event of complication or cessation of intended nutritional support., Results: One hundred and twenty-three episodes of feeding occurred in 110 patients. The incidence of peripheral vein thrombosis was similar in each group (Heparin 30% (12/41), hydrocortisone 33% (14/42), combination 31% (13/41) chi(2) test P>0.05). There was a significant difference in total catheter survival with the addition of heparin to the feeds, either alone (11 days (SEM 1.79) or in combination with hydrocortisone (11.7 days (SEM 1.39) compared with those receiving only hydrocortisone (6.9 days (SEM 0.73) P=0.002 and 0.030, respectively))., Conclusion: When intravenous feeds are delivered in to a peripheral vein via a fine-bore midline, the addition of heparin to the feed extends the total period of feeding attainable.

Aims: 1) To establish the relationship between the kind of microorganism that colonizes parenteral nutrition catheters and several risk factors related to catheterization and patient characteristics. 2) To investigate the risk factors associated to bacteremia episodes originated in these colonized catheters., Method: An observational, non-controlled, retrospective and cohorts study of the parenteral nutrition catheters implanted between 1988 and 1994 in our hospital. Risk factors were studied in 6 multiple-logistic regression models., Results: 3632 catheters were studied. Incidences of colonization and bacteremia per 1000 days of catheterization were 17.56 and 3.93, respectively. Coagulase-negative staphyloccoci (CNS) were the most frequently isolated microorganisms. The colonization risk factors were: insertion site for all the microorganisms except fungi, catheterization time for CNS and fungi, hospitalization area, sex and age for CNS model, the existence of other infectious foci for Gram negative bacilli (GNB), S. aureus and other microorganisms, hypoalbuminemia for GNB model, and neoplasm for other microorganisms. The bacteremia risk factors were jugular insertion site, catheterization time greater than 10 days, catheter's hub colonization, and catheter colonization by gram-negative bacilli, fungi and S. aureus., Conclusion: Risk factors for catheter colonization vary depending on the microorganism which colonizes the catheter., (Copyright 2001 Harcourt Publishers Ltd.)

Unlabelled: Percutaneous central venous catheterization for parenteral feeding is a permanent problem in the management of very low birth weight neonates. Usually, 23-gauge catheters (diameter: 0.6 mm) are used. In our unit, we have started to use 27-gauge catheters (diameter 0.35 mm) since 1995. The aim of this study was to report our experience with this materiel., Subject and Methods: Between September 1, 1997 and January 30, 2000, 352 catheter implantations were performed using 27-gauge infusing sets in 200 premature infants (gestational age less than or equal to 33 weeks [mean 29.2], weight less than or equal to 1,500 g [mean: 1, 152.5 g]). Data were reviewed retrospectively with the view to determine the modality of use and complications. Peculiar insertion modalities were prospectively evaluated in the 50 last included infants (92 catheters)., Results: In 97% of cases, the physician needed no help to insert the catheter. In 99.5% of cases (199 neonates), the insertion was successful (the procedure failed in one case). The mean duration procedure was 26 min (range 10 to 85 min). The mean age at insertion of the first catheter was 29 hours (range 0 to 216). Mean catheter maintenance duration was 15 days (range 1 to 53). In 31 cases, documented sepsis related to the catheter were noted (8.8% or 5.8 infections for 1,000 catheter-days). Endocarditis was observed in one case. A pericardial effusion was diagnosed in two cases. No death related to the catheter was noted., Conclusion: In our experience, 27-gauge catheter implantation is an easy and safe procedure. We noted no major maintenance problems. Complications were not observed more frequently than those usually encountered with 23-gauge catheters. We conclude that 27-gauge catheter utilization is an attractive alternative for percutaneous central venous catheterization, in very low birth weight neonates.

Background & Aims: Vitamins A and E are the most light-sensitive vitamins. Vitamin A is degraded by photolysis, while vitamin E degrades by photo-oxidation. The composition of the parenteral nutrition mixture and the container could therefore influence degradation during daylight administration. The aim of this study was therefore to determine the influence of fat emulsion and the type of bag on the photo-degradation of vitamins A and E in Parenteral Nutrition (PN) mixtures during simulated infusion in daylight., Methods: Representative adult PN mixtures, with and without fat emulsion, were prepared. Samples for analysis were taken from infusates and each bag during simulated infusion. Degradation of vitamins A and E was determined by stability-indicating HPLC analysis., Results: Results indicated that vitamin A loss proceeded rapidly during infusion, resulting in up to 80% loss in 6 hours, even with light protection of the bag. The presence of fat emulsion did not provide significant light protection. Vitamin E degradation was substantial if mixtures were prepared in EVA bags but was largely prevented if PN mixtures were compounded and stored in multi-layered bags., Conclusions: It is recommended that all PN bags should be light-protected during infusion in daylight. The use of multi-layered bags will prevent vitamin E losses during infusion., (Copyright 2000 Harcourt Publishers Ltd.)

Objective: To review the literature related to venous access for parenteral infant feeding., Data Sources: Sources included medical, nursing, and nutrition literature from 1900 to 1994., Study Selection: One hundred ten studies were reviewed. Studies were selected based on historical significance and contribution to current practice., Data Extraction: Data relating to the development of parenteral nutrients or evolution of parenteral techniques were extracted., Data Synthesis: The central venous catheter was a significant development in meeting the nutritional needs of hospitalized infants., Conclusion: Delivery of parenteral nutrition through percutaneous, peripherally inserted central venous catheters provides the least trauma and greatest benefit.

To reduce the likelihood of thrombophlebitis during intravenous feeding through a peripheral vein, the osmolality of the solution is usually reduced by disproportionately raising the lipid content and lowering the carbohydrate, electrolyte, and aminoacid concentrations. The possibility that delivery system rather than feed is the main influence on the development of thrombophlebitis was examined in a randomised comparison of a fine-bore silicone catheter against a short 'Teflon' cannula. The nutrient solution given through a peripheral vein was a standard feed used for infusion into a central vein (osmolality 1250 mOsmol/kg, 13 g nitrogen, 200 g glucose [800 kcal], and lipid emulsion [1000 kcal]). 27 patients received the infusion through a fine-bore silicone rubber catheter (diameter 23 G, length 15 cm) and 23 through a teflon catheter (diameter 20 G, length 3.2 cm). The median duration of feeding was 5 days in each of the two groups. Thrombophlebitis developed in all patients in the teflon group but in only 2 (7%) of the silicone group. The first silicone catheter for a patient lasted a median of 128.5 h, compared with 40 h for the first teflon cannula (p less than 0.001). The results show that when a nutrient solution of osmolality 1250 mOsmol/kg is delivered through a peripheral vein with an ultrafine-bore silicone catheter, the risk of thrombophlebitis is low. For many patients intravenous feeding may thus be given through a peripheral instead of a central vein without compromising the nutritional adequacy of the feed.

A totally implantable system for venous access (Port-A-Cath, Pharmacia, Nu-tech) has now entered clinical use. This system consists of a silastic catheter secured to a stainless steel reservoir with a locking ring. The system has been shown to have several advantages when compared with earlier venous access systems. However, the advantages of total implantation have also disposed the system to new complications. Two cases are presented of patients who had this system placed and developed in-situ separation of the catheter from the reservoir. The catheter was removed surgically from the subcutaneous tissues in one patient and with a Dormain basket in the second because complete migration of the catheter into the central venous system had occurred. In neither patient could the precise cause for the separation be ascertained. However, it can be appreciated that if chemotherapeutic agents were infused in these patients the results would have been disastrous. It is recommended that if blood cannot be easily aspirated after gentle to and fro flushes with a 10 ml syringe, a chest radiograph be obtained prior to the infusion of any substance to check for continuity in the system. Any breaks in the system should be immediately repaired since migration of the catheter into the venous system can occur.

Fifty silastic (Hickman) right atrial catheters were implanted in 43 patients receiving cytotoxic chemotherapy or parenteral nutrition. The mean catheter survival was 72 days (range 2-316 days), but 17 catheters were removed before treatment was complete. Thirteen catheters were removed for septic complications. It is concluded that the Hickman catheter will provide venous access for prolonged periods, but its benefits must be weighed against the risks of septic complications which may occur frequently in the absence of uniform care and maintenance of the catheter.