AUSTRALIAN SOCIETY FOR PARENTERAL AND ENTERAL NUTRITION

NEWSLETTER, APRIL 1997

DISCLAIMER

The views and opinions expressed in this Newsletter are not necessarily the views and opinions of the Australian Society of Parenteral and Enteral Nutrition. Reports and articles on techniques, procedures and products is provided for the information of the Members of the Society and their inclusion does not imply any endorsements from the Australian Society of Parenteral and Enteral Nutrition. No liability can or will be accepted by AuSPEN or its agents for the third party use of information in this Newsletter.


NEWS FROM COUNCIL

Julie Bines

President of AuSPEN

Over the past 6 months the AuSPEN Council has been active in a number of areas important to the function of the Society and to the Membership.

NUTRITION

The negotiations for the journal 'Nutrition' have remained a key issue. As Members will be aware, in 1996 the AuSPEN subscription to the journal Nutrition was suspended pending negotiations regarding changes to the Journal. At this time the Journal underwent many important changes including a change in Publisher and increase from bi-monthly to monthly editions. This was to have a significant impact on the cost of the Journal to the members of AuSPEN. Membership surveys and opinions expressed during discussion at the last two Annual General meetings of AuSPEN have strongly supported the Journal subscription as part of the benefits of Membership of AuSPEN.

After prolonged negotiations with Elsevier - the new Publisher of the Journal - an agreement has been reached for AuSPEN Members to receive the Journal at a cost of U$40 (Aus$55) per year fixed for 3 years. This cost will be included as part of the Annual Membership Subscription to the Society but as a result will necessitate an increase in Annual Membership Subscription rate from $75 to $100. For this Members will receive a number of benefits including the new initiative of a quarterly AuSPEN Newsletter and now monthly issues of the journal Nutrition. The increase in Membership Subscription Fee will be discussed at the next Annual General meeting in October 1997 and if passed will take effect in 1998.

Members should be receiving the first issues of Nutrition very soon as they are currently in transit from the Publisher. The editions of the Journal will recommence from January 1997. Members will be aware that they have not received the 1996 editions despite having contributed $40 of their annual membership subscription in 1996 for this intended purpose. Unfortunately this has been necessary due to:

Members who are interested in obtaining 1996 copies of the journal Nutrition can apply directly to the publisher.

HOME ENTERAL NUTRITION STANDARDS AND GUIDELINES

A subcommittee of AuSPEN is currently re-writing the standards and guidelines for Home Enteral Nutrition. This has been hastened by the recent State and Federal Government interest in funding issues in Home Enteral Nutrition. The subcommittee would welcome any contribution from members on this issue.

INTERNATIONAL COUNCIL ON PARENTERAL AND ENTERAL NUTRITION

Twice a year the executive members of the international societies of Parenteral and Enteral Nutrition meet to discuss relevant national and international issues. It is an excellent opportunity to interact, learn and establish ties with societies with similar interests. The last meeting of this Council was in San Francisco in January 1997 during the ASPEN Annual Scientific Meeting. At this meeting the importance of AuSPEN and our sister societies in the Asian-Pacific region was highlighted.

We look forward to a bright and fulfilling 1997.

See you in Freemantle.


CONTACT ADDRESSES

Dr Julie Bines, President of AuSPEN,

  • Dept. of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne.
  • Ph +61-3-9345-5060. Fax +61-3-9345-6240
  • email bines@cryptic.rch.unimelb.edu.au

    Dr Margaret Allman, Honorary Secretary of AuSPEN,

  • Human Nutrition Unit, Biochemistry Dept.,The University of Sydney, Sydney 2006.
  • Ph +61-2-9351-3758 Fax +61-2-9351-6022
  • email m.allman@biochem.usyd.edu.au

  • 1997 AuSPEN SCIENTIFIC MEETING - PERTH

    Dr Paul Woods, ICU, Sir Charles Gairdner Hospital, WA

    The 23rd Annual Scientific Meeting of the Society will be hosted in Perth October 1997 (23rd - 25th inclusive) at the Esplanade Hotel in Fremantle. We are totally committed to making this a very successful meeting.

    Abstracts for the free paper session will be called for in May. Your scientific contribution to the programme, either with a poster or paper presentation is highly valued and encouraged by the Society. It is a great opportunity to contribute to the meeting and share the your work with other participants. The Society offers awards / prizes for the best paper and best poster and you may be eligible for a Travel Award. The programme is shaping up well and is almost finalised.

    Main Programme Topics

    Guest Speakers :

    We are privileged to have excellent international guest speakers:

    Peter Furst from Stuttgart who has been a speaker at previous AuSPEN meetings He is Head of the Institute for Biological Chemistry and Nutrition at the University of Hohenheim in Stuttgart. He has published widely and lectured on amino acids, dipeptides, glutamine, new strategies in clinical nutrition, growth factors and the intestine

    In Fremantle his provisional lecture topics are:

    Gary Zaloga, Professor of Anaesthesia and Medicine, Head of Section on Critical Care, The Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, North Carolina. He has published extensively on calcium and magnesium in critical illness, early enteral feeding, access to the enteral route and biogenic dietary amines.

    In Fremantle his provisional lecture topics are:

    Stan Zlotkin Professor of Paediatrics and Nutrition at the University of Toronto and Attending Staff in the Division of Gastroenterology and Nutrition at the Hospital for Sick Children. He is the Raine Visiting Professor in Paediatrics for 1997 and we are fortunate that his visit to Perth will coincide with the AuSPEN meeting He has published extensively on many aspects of paediatric and infant nutrition and has a special interest in iron metabolism and the prevention of deficiency.

    In Fremantle he will talk on:

    The international faculty is well supported by a number of excellent local speakers enabling us to present a programme of great variety with something of interest for everyone.

    A small number of topics and speakers are remain to be confirmed and the topics of the main speakers may be adjusted as the programme becomes more complete.

    Workshop(s)

    Workshops are planned for Thursday afternoon which, due to the time difference, will still allow many delegates to fly in on Thursday morning and be able to attend the afternoon sessions. Our international speakers have agreed to participate in the workshop(s).

    Venue

    The Esplanade Hotel in Fremantle is an outstanding conference venue with recent refurbishments enhancing all aspects of the hotel, including the convention facilities and accommodation. Social functions are being planned to make the most of these opportunities and we can guarantee you will enjoy them. We will be especially encouraging everyone to attend the Thursday night cocktail party and the Friday night dinner which we intend to make memorable occasions. We hope to see you all here?

    The Conference Organising Committee for Perth 1997:

    Please contact any of the above if you have particular queries about the Conference. A second 'flyer' is under preparation and will be mailed out shortly.


    A REPORT ON THE 79th ANNUAL MEETING OF THE AMERICAN DIETETIC ASSOCIATION HELD IN SAN ANTONIO, TEXAS, USA. October 21-24. 1996

    Prepared by Margaret Allman-Farinelli PhD APD

    This meeting covered a diversity of research, education, dietetic practice and professional areas of concern to dietitians and it is impossible to report,on all of them. Hence this report concentrates on one session which should be of most interest to AuSPEN members. Dr Steven Heymsfield (Professor of Medicine, St Luke's-Roosevelt Hospital, New York) was awarded Honorary Membership of the ADA; firstly, in recognition of his support and mentoring of dietitians; secondly, for his outstanding contribution to research in body composition and enteral nutrition; and finally for his leadership roles in nutrition organisations including the presidency of ASPEN. He presented in a symposium entitled "Energy Metabolism: To BEE or not to BEE".

    The symposium began with Dr Carol Ireton-Jones RD (Nutrition Therapy Specialist, Preferred Nutrition Therapists, Texas) who discussed the evolution and application of equations used to predict basal energy expenditure (BEE). There now have been about 200 equations published. The Harris Benedict equation published in 1919 is still one of the most widely employed however, 24 different forms have been published and give results which may differ by up to 55% from the original. Most practitioners have never sighted the original paper which was formulated using 239 normal subjects, measurement of energy expenditure after 30 minutes of rest and linear regression analysis. Validation of various equations was recently published by Garrel (Nutrition in Clinical Practice, 11: 99-103, 1996) and found Harris Benedict to be 75% accurate as compared with 90% accuracy using the World Health Organisation equations. It was reinforced that when deciding to use equations to construct feeding regimens that you must look at how the equation was derived including the patient population, the methodology and statistical analysis. It was noted that the majority of equations are derived using people of normal weight and that the requirements for obese people are not adequately researched. Assumptions and guesstimates are made based on "ideal" weight but it is usually forgotten that around 25% of extra weight is lean body mass. Dr Ireton-Jones has published equations including obese individuals (Journal of Burn Care and Rehabilitation 13: 330-3, 1992).

    The theme of inadequate investigation of the requirements of the obese patients on nutrition support was continued by Dr Heymsfield. He suggested we have the technology for prospective multi-centre trials and they only require coordination. An overview of methods of measuring energy expenditure was presented, i.e. direct calorimetry and indirect calorimetry in chambers or with carts or doubly-labelled water. The four components of energy expenditure are basal metabolic rate (usually measured in practice as resting energy expenditure, REE ), physical activity, thermic effect of food and, in the case of patients, the thermogenic effect of the injury. Factors for injury were derived and published a number of years ago. However, they are over estimates and need to be researched and reformulated. When patients are fed 24 hours per day the thermic effect is incorporated into the REE measurements. In the papers already published most patients had EE measured when they were being fed 4,000 kcal per day and the thermic effect of this load results in higher REE. The more you feed and the faster the infusion rate the greater will be the REE.

    New methods of measuring body composition have made it easier to discern energy requirements because one can base them on lean body mass (fat-free mass) only. Adipose tissue is inert. The greatest challenge is to devise non-invasive methods for measuring the energy expenditure of individual organs given the obvious differences between skeletal muscle (in the patient at rest) and the brain.

    Laura Matarese, RD, (Manager, Nutrition Support Dietetics, Cleveland Clinic Foundation) presented a guide to the use of indirect calorimetry, in particular metabolic carts in the hospital setting but also measurement using ventilator systems. It appears to be routine practice in many centres for the dietitian to be responsible for the conduct and interpretation of these measurements. Most use the Weir equation to derive energy expenditure from the oxygen consumption and carbon dioxide production. It was emphasised that clinical judgement should be exercised in the interpretation of the measurement. Also if the conditions in which to conduct the measurements were less than ideal they are a waste of time and an energy prediction equation would be better. The RQ (respiratory quotient) can be used as a quality control mechanism. An RQ in the range .85 to .95 is desirable and indicaties a variety of fuels are being oxidised. For example if the RQ was 1.2 and the REE 1,800 kcal and the patient was being fed 3,000 kcal it is obvious the patients is being over fed and laying down fat. However, if the patient had an RQ of 1.2 and REE of 1,500 kcal and being fed 1,600 kcal it is likely the measurement was invalid.

    In summary the speakers outlined the usefulness of indirect calorimetry to determine energy requirements and the use of appropriate equations when this was not possible. Technology has enabled good measurement of energy expenditure to plan parenteral and enteral feeding programs. All speakers emphasised that it was important not to be obsessed with the use of equations or indirect calorimetry to dictate nutrition support. There is no replacement for good clinical judgement and monitoring patient response to the nutrition supplied. Despite the ability to measure requirements e.g. of obese, it may be inappropriate to provide the REE of 4,000 kcal to the ICU patient as to give more than 2,000 kcal results in too large a fluid load and may make it impossible to maintain euglycaemia.


    FBBC NUTRITION RESEARCH GROUP

    Maree Ferguson, Queensland University of Technology and the Wesley Hospital Brisbane.

    The FBBC (Ferguson, Bauer, Banks, Capra) Nutrition Research Group was established in Brisbane in 1995. The group consists of Maree Ferguson, Judy Bauer, Merrilyn Banks and Dr Sandra Capra. Maree Ferguson is a full-time PhD student at the Centre for Public Health Research, Queensland University of Technology (QUT). The title of her thesis is "The Development of an Efficient and Effective Nutrition Screening and Support Model for Hospital Inpatients at Risk of Malnutrition". Judy Bauer is currently the Nutrition Services Co-ordinator at The Wesley Hospital in Brisbane. She has a Master of Health Science for which wrote a thesis on "Nutrition Screening - Development of an Admission Nutrition Screening Tool". Merrilyn Banks is currently the Director of Nutrition and Dietetic Services at the Redcliffe Hospital and has Master of Health Science for which she wrote a thesis titled "Nutrition Screening and Prevalence of Malnutrition in an Australian Public Hospital: Validation of a Level 1 Admission Screen". Dr Sandra Capra is currently a Senior Lecturer at the School of Public Health, QUT. Sandra supervises many students working on varied research topics including food service management, measuring client satisfaction, measuring outcomes and introducing better ways of conducting practice.

    The aims of the group are:

    PREVIOUS RESEARCH

    The group has spent the past three years conducting research on nutrition screening. Judy Bauer initiated the research on nutrition screening by developing a simple nutrition screening tool to identify patients at risk of malnutrition on admission to The Wesley Hospital. Merrilyn Banks then validated this tool against subjective global assessment (SGA) at Redcliffe Hospital.

    Maree Ferguson has recently further validated the tool against SGA at The Wesley Hospital. This lead to the development of the FBBC malnutrition screening tool (c). In that study, she also collected data on anthropometric (TSF, AMC, BMI), biochemical (albumin, prealbumin, CRP, TLC, WCC, Hb, Hct) and functional (grip strength) parameters in an attempt to measure nutritional status. SGA was chosen as the method of assessing patients for malnutrition. The group has also looked at the effect of coding for malnutrition under 'Casemix Funding'.

    CURRENT RESEARCH

    Currently the group is investigating the impact of nutrition screening and support on outcomes such as patient satisfaction, quality of life, nutritional status, clinical outcome and costing. Hospital inpatients are being divided into two groups: (1) those that are not screened and, (2) those that are screened by the FBBC malnutrition screening tool. Patients will then be further divided depending upon whether they are at risk of malnutrition or not.

    Nutritional status will be evaluated by SGA on admission and discharge. Clinical outcomes including short-term outcomes such as length of stay, morbidity and mortality during hospital stay; and long-term outcomes such as mortality and unscheduled rehospitalisation during the period one month post discharge will also be determined. Quality of life will be assessed on admission and discharge using the EORTC instrument. Patient satisfaction will be assessed on discharge using a tool we have developed.

    A cost analysis will be conducted retrospectively, comparing time spent and type of nutrition support provided by nutrition assistants and/or nutrition consultants with outcome results, to determine which is the best method of nutrition care delivery, in terms of outcomes and cost.

    ACTIVITIES

    The group has developed a tool which can be used to measure patient satisfaction with nutrition services. They have also developed an adapted SGA form. The group has five papers currently under review for publication on the above research and they have developed a malnutrition screening and assessment resource manual.

    The group has been invited to conduct a Nutrition Screening and Assessment Workshop in Sydney by the DAA NSW branch in April, and in Mackay by the DAA North QLD Branch in September. They are also holding a workshop at the National DAA Conference in Hobart in May.

    The Sydney workshop will cover the following topics: nutrition parameters, nutrition assessment tools, subjective global assessment (background, video and case studies), rationale for implementing nutrition screening, malnutrition and casemix, development of the FBBC malnutrition screening tool, and implementation of nutrition screening.

    Please contact Maree Ferguson or Judy Bauer (07) 3232 7918 if you would like further information about any of the workshops or the resource manual.

    Please contact the DAA NSW branch (02) 9267 2302 if you would like to register for the Nutrition Screening and Assessment Workshop in Sydney. The workshop is being held at the St George Community Centre on April 19 from 9.00 am to 4.30 pm.


    WHAT IS GROWING AT THE END OF THE TRACT ?

    Cate Law, TPN Clinical Nurse Consultant, Royal Hobart Hospital

    INTRODUCTION

    Infection and sepsis are well documented complications of central venous catheterisation.

    Pathogens can either;

    It is now hospital policy to send all central catheter tips for microscopy and culture to provide surveillance of the incidence of these complications .

    Previous International studies estimate the percentage of Bacteraemia caused by C.V.Cs to be between 2% - 9 %,(1-5) and the incidence of all C.V.C infections to be between 4-8 %. The wide variation in incidence is partly due to diverse variation in defining catheter related infections,(6).

    Total Parenteral Nutrition fluids containing lipids and high concentration glucose, are an excellent culture media for bacteria, this may predispose the patient to a greater risk of catheter related sepsis. However with the commitment of a hospital T.P.N team, the annual statistics for C.V.C infections with T.P.N therapy within our Hospital has been kept within these international standards.

    
                                       TABLE 1.
    
                          Combined Proven and Probable Catheter
                           Sepsis and Colonisation Percentages.
    
                                  1992   =     1.4%
                                  1993   =     0.6%
                                  1994   =     1.0 %
                                  1995   =     4.4%
    

    In 1995 all hospital procedures relating to Central Venous Catheters were reviewed. The emphasis in staff education was on correct handwashing and cleansing the lumen with Alcoholic-Chlorhexidine or Povidone-Iodine before any line connection / disconnection.

    A larger education base has been established with the C.V.C "Competentcy" assessors available on each ward. 'Definitions Of Catheter Sepsis' have been revised by the T.P.N team and approved by the Infection Control Department.

    AIMS OF STUDY

    METHOD

    From January to December 1995 the Microbiology Department cultured 583 Central Venous Catheter (subclavian,femoral and jugular) tips. 66 of these were found to be positive.The following data were collated from clinical examination, patient notes and pathology reports.

    This information enabled positive tips to be classified into one of the three categories of "Definitions of Catheter Sepsis".

    Definitions of Catheter Sepsis

    RESULTS

    
                                         TABLE 2.
    
                         Proven Catheter Sepsis    1.3 %
                         Possible Catheter Sepsis  3.4 %
                         Colonisation             12.6 %
    
                         **  3 tips were obviously contaminated
                         prior to transfer to Microbiology,
                         e.g "dropped on floor ". These tips were
                         not included in the results.
    
    
    
                                         TABLE 3.
    
                             COMMON PATHOGENS IDENTIFIED.
    
                    Staphylococcus epidermidi                  56   %
                    Staphylococcus aureus                      10.4 %
                    Klebsiella pneumoniae                       8.9 %
                    Staphylococcus warneri                      4.4 %
                    Candida albicans                            2.9 %
                    Enterococcus faecalis                       4.4 %
                    Pseudomonas aeruginosa                      2.9 %
                    Other-                                     10.0 %
    
                    The 'Other' group included the following organisms
    
                    Staphylococcus auriculari
                    Staphylococcus capitus
                    Enterobacter cloacae
                    Enterobacter aerogenosa
                    M.R.S.A
                    Serratia marcescens
                    Proteus mirabilis
                    Staphylococcus cohnii
                    Streptococcus viridans
                    Escherichia coli
    
    
                                       TABLE 4.
    
                       NUMBER OF TIPS RETURNED SORTED BY WARDS
    
               WARD            NUMBER OF TIPS      NUMBER POSITIVE WHEN
                                                     SENT FOR CULTURE
    
               Surgical             62                     9
               Medical              51                     6
               Cardiothoracic      196                    21
               Neurosurgery         53                     2
               Intensive Care       43                    15
               Orthopaedics         38                     5
               Oncology              4                     0
               Paediatrics          10                     0
               Obstetrics            4                     1
               Burns                 4                     2
    
                          TOTALS   465                    61 (13%)
    
    
    

    DISCUSSION

    The incidence of Proven or Probable Catheter Sepsis 1.3% - 3.4% has not increased, and is a satisfactory achievement.

    High colonisation figures are a cause for concern as the distal tip of the catheter should remain free of infection. In most cases haemogenous spread was not the cause of colonisation, as many of the patients had other sites of infection an d the C.V.C organisms cultured were different from these sites. The contamination most probably occurred from catheter exit site infection from skin flora or from direct introduction of organisms into the closed sterile system.

    The high percentage of Staphylococcus epidermidi is a common pathogen implicated in C.V.C infection, therefore 56 % is not surprising.

    The difficulty in preserving an intact dressing has been demonstrated and this may account for the number of Jugular lines contaminated with skin flora. Different dressings have been trialed, however the emphasis must be placed on preventing "tugging" on the intravenous lines. Countertraction using tape is sufficient in preventing the weight of the lines from lifting the dressing, and preventing introduction of skin flora from the movement of the catheter.

    If patients are to shower, the C.V.C dressing must be protected as it is not waterproof.In hospital areas that use pressure transducers and manipulate the catheter by adding multiple lines or bloodletting, care must be taken with stringent handwashing and the wearing of sterile gloves. Maintaining minimal connections and keeping them free of old blood is an integral measure when maintaining a sterile system.

    Patients with severe illness or loss of defence mechanisms are predisposed to infection, however, we have observed that some wards with immunosuppressed patients have lower than average incidences of catheter infections.

    In some instances of catheter infection, some unusual practices have been documented. One catheter had been instantly contaminated as it was reguidewired through an existing infected site. Two positive tip cultures had been documented as "leaking" catheters for 48 hours before removal.

    Modifying factors of high colonisation are;

    The safe working life of a catheter is approximatley four weeks. T.P.N catheters have been successfully placed for this period of time without complications. The length of time a catheter is in-situ usually increases the likelihood of infection but some of the catheter tips were cultured positive after four days. Two catheters were left in situ and capped, but not used for 48 hours.

    Importance should be placed on maintaining the catheter whilst it is required and recognizing that peripheral access should be used if central access is not indicated.

    CONCLUSION.

    Proven and Probable Catheter Sepsis are often recognized and treated. By placing positive C.V.C tips into the three Categories, it can be deduced from the number of colonisations that catheters can harbour microorganisms and place the patient at risk without the individuals necessarily showing signs of infection.

    T.P.N therapy revolves around a patent, infection free catheter therefore these "high risk" catheters remain a worthwhile tool for comparing overall C.V.C infection rates in the Hospital. Validity of ward colonisation percentages may improve with increased compliance of sending all tips for culture.

    Further education will include promotion of hospital procedures and policies, and correct dressing technique especially countertraction on lines to prevent infection from skin flora.

    REFERENCES

  • 1. Maki DG. Nosochomial bacteraemia- an epidemiological overview. Am J Med 1981; 70: 719-32.
  • 2. Maki DG. Ringer M, Alvarado CJ. Prospective randomised trial of Povidone- Iodine, alcohol, and Chlorhexidine for prevention of infection associated with central venous and arterial catheters. Lancet 1991,338: 339-43.
  • 3. Sitzmann JV, Townsend TR, Siler MC,Bartlett JG. Septic and technical complications of central venous catheterisation- a prospective study of 20 consecutive patients. Ann Surg 1985;202: 766-70.
  • 4. Cleri DJ, Corrado ML, Seligman SJ. Quantitive culture of intravenous catheters and intravenous inserts. J Infect Dis 1980; 141: 781-6.
  • 5. Cooper GL, Hopkins CC. Rapid diagnosis of intravascular catheter- associated infection by gram staining of catheter segments. N Eng J Med 1985; 312: 1142-7.
  • 6. Elliot T.S.J, Faroqui MH, Armstrong RF, Hanson GC. Guidelines for good practice in central venous catheterization. Journal of Hospital Infection 1994;28: 163-176.

    INCIDENCE OF CVC RELATED INFECTIONS IN INTENSIVE CARE

    Joey Penfold, S McKinley, R Ward and S Finfer

    Intensive Therapy Unit, Royal North Shore Hospital, Sydney

    INTRODUCTION

    Use of central venous catheters (CVCs) in intensive care units is associated with significant risk of infection which may possibly be reduced by changes in nursing practice. To study the influence of changes in practice on the infection rate the baseline infection rate must first be known.

    STUDY OBJECTIVE

    To determine a baseline incidence of CVC-related infection and sepsis, and the causative organisms, as a prelude to randomised studies of nursing practice.

    DEFINITIONS

  • Local Catheter Related Infection : The prescence of > 15 colony forming units (CFU's) on semiquantitative culture.

  • Catheter Related Bacteraemia : Isolation of the same organism (identical species, antibiogram and plasmid profile) from the catheter tip and blood.

  • Catheter Related Septicaemia : Isolation of the same organism (identical species, antibiogram and plasmid profile) from the catheter tip and the blood, with clinical sepsis of no other apparent source.

    METHODS

    The study period was six months. All CVCs inserted in the intensive care unit, which were expected to remain in situ for at least 72 hours were studied. CVCs inserted in the Emergency Department or Operating Theatres were excluded. Daily clinical data collection was performed whilst the CVC was in-situ and on removal all CVC tips were sent for semi-quantitative culture.

    Catheters were inserted at the bedside using the Seldinger technique, under strict aseptic conditions. Operators were required to wash hands and forearms for three minutes with antiseptic soap (Hibiclens G, ICI Aust.), dry with a sterile towel, don a sterile gown and gloves. The insertion site was prepared with povidone iodine and fully draped with sterile towels leaving the insertion site exposed.

    Polyurethane catheters were inserted percutaneously and then covered with a polyurethane dressing, (Opsite, Smith and Nephew Ltd, Hull, England). Catheters were changed every seven days, dressings were changed on the third or fourth day after insertion.

    RESULTS

    Data collection was completed on 119 CVCs.

  • CVC-related infection was identified in 31 (26.1%)
  • CVC-related bacteraemia was identified in 5 (4.2%)

    Infecting organisms were

  • Coagulase Negative Staphylococci 11 out of 119 (9.2%)
  • Staphylococcus Aureus 9 out of 119 (7.6%)
  • Enterococci 3 out of 119 (2.5%)
  • Gram Negative Bacilli 11 out of 119 (9.2%)
  • Two organisms were cultured from 12 CVCs
  • Three organisms were cultured form 3 CVCs

    CONCLUSION

    A clinically significant incidence of CVC related infection was found. The causative organisms were as expected with a predominance of gram positive cocci. There is substantial scope to reduce the incidence of infection with changes in nursing practice.

    (This is an extended abstract based upon the authors' work originally presented at the 21st Australian and New Zealand Scientific Meeting on Intensive Care, Melbourne, October 1996. The Editor would like to acknowledge Joey Penfold and her co-authors for agreeing to prepare this item for the AuSPEN Newsletter)


    THE CLINICAL MANAGEMENT OF A SEPTIC PATIENT ON TPN

    Dr Alan Street, Royal Melbourne Hospital.

    This is a copy of the abstract of the paper presented at the 1996 Annual Scientific Meeting of AuSPEN.

    Alan currently holds the position of Deputy Director, Victorian Infectious Diseases Service at the Royal Melbourne Hospital, and Sessional Physician, Department of Microbiology and infectious Diseases at the Alfred Hospital. He graduated from the University of Melbourne in 1980 and from the Royal College of Physicians in 1988. He has completed post-graduate training at the Royal Melbourne Hospital, Fairfield Infectious Diseases Hospital and Duke University Medical Center, North Carolina, USA. His major interest are HIV/AIDS - antiviral therapy, management of opportunistic infections, infections of immunocompromised patients, tuberculosis and rational antibiotic use.

    Infection of long-term indwelling intravenous (IV) devices such as those used in TPN patients is an area where controversies abound. The key question confronting the clinician faced with suspected or confirmed IV line infection is whether the line has to be removed or not. Other important issues concern the prevention of these infections, and the best diagnostic test for establishing that the infection arises from the IV line and not from another focus.

    The spectrum of organisms causing IV line infections is well characterised - most infections are due to Staph. aureus and coagulase-negative staphylococci while gram negative organisms (enteric bacilli, pseudomonas & related organisms) and fungi (usually Candida species, occasionally unusual lipophilic organisms such as Malessezia) account for the remainder. Fungal infections in TPN patients can arise from contaminated infusion fluids as well as skin contamination.

    Practices vary regarding prevention and diagnosis of these infections. The nature of the dressing (transparent plastic versus gauze) and the skin disinfectant used have influenced infection rates in some but not all studies. The 'gold standard' for diagnosis of IV line-related bacteraemia is considered to be isolation of the same organism from both the blood and the catheter tip in the absence of any other focus. Quantitative cultures that compare bacterial counts in blood drawn through the central line with peripheral blood counts may have a role in diagnosing these infections, and avoid the need to remove the line.

    Does an infected long-term indwelling IV line always have to be removed? First principles tell us that the infection will not be eradicated if the foreign body stays in place. But clinical experience suggests that this is not always the case, and some infections, especially those caused by skin flora organisms such as coagulase negative staphylococci and diphtheroids, can be successfully treated in selected patients without catheter removal. However, the line should be removed immediately if patients are clinically unstable at presentation, or if fever persists or blood cultures remain positive 48 hours after starting treatment. Infection of the subcutaneous tunnel, or isolation of specific organisms such as Staph. aureus, Pseudomonas aeruginosa or Stenotrophomonas maltophilia also mandates immediate line removal. Line-related fungaemia can occasionally be managed successfully with medical therapy along, but relapses or persistent infections are frequent and the line will usually have to be removed.


    INTERNET NEWS

    This Newsletter is now viewable on the World Wide Web :

    http://www.southcom.com.au/~hartley/home.htm.

    This is an experiment in electronic publishing of AuSPEN material and the Editor would be delighted to get some feedback on what Members think of the idea and how it could be developed. Having learnt the techniques of converting text to HTML format the process of electronic publishing is not particularly difficult. One problem, however, lies in how different hypertext browsers - such as Netscape and Internet Explorer - convert scientific symbols and mathematical expressions. The designers of HTML have produced codes to cover more possibilities than we in our various professions will ever use but not all browsers are capable of interpreting them correctly; they were designed before these newer codes were introduced. Once both browsers and HTML have settled into a standard, electronic publishing will become as reliable as the printed text. In the meantime we will have to tolerate some of the ambiguities and refer to the source text from the author whenever an browser makes a questionable interpretation.

    Compuserve is another channel of electronic information. I recently accessed their 'Health Database Plus Power Search' and in response to my query 'parenteral nutrition' was given a list of 88 journal articles to select from. Downloading a fairly lenghty one on hypertriglyceridaemia cost $1.50. Compuserve can be accessed in all capital cities for the price of a local call and can provide a more structured access to electronic information than an internet service provider. Consequently it could be of interest to readers who feel that they would prefer a consistent user interface. Medline is accessible via Compuserve. An email account is included in a Compuserve subscription.

    The Society of Hospital Pharmacists of Australia have a web site :

    http://www.vicnet.au/~shpa/shpa1.htm


    PUBLICATION DATES FOR 1997

    The Newsletter will be published in July and October this year. If contributors could get items to the Editor by the middle of the third week of the month preceeding that will assist greatly with the planning of the issue. If copy is not ready at that time but will be by the end of that month please let me know so that I can reserve the space.

    Contributions on any relevant subject are always very welcome. Reports on meetings that you may have attended are always a very useful item.

    For the next issue I am eager to receive contributions from Pharmacists or Clinicians

    Send contributions to :

  • Dr Tom Hartley, 36 Pregnells Road, Sandfly, Tasmania 7150, Australia.
  • Phone +61-3-6239-6475 or +61-3-6222-8780
  • Fax +61-3-6231-3145
  • email hartley@southcom.com.au


    NEW BOOKS

    Metabolic Regulation. A Human Perspective. K N Frayn. Frontiers in Metabolism Vol 1. Portland Press UK, 1996. 284p. $Aus 39.75.

    Understanding the Control of Metabolism. D Fell. Frontiers in Metabolism Vol 2. Portland Press UK, 1996. 300p. $Aus 39.75.

    Channelling in Intermediary Metabolism. Edited by L Agius and H S A Sherratt. Portland Press Research Monograph #9. Portland Press UK, 1996. 352p. $Aus 146.50

    Nutrient Regulation of Insulin Secretion. Edited by P R Flatt. Portland Press Monograph #1. Portland Press UK, 1992. 427p. $Aus 125.50.

    The Significance of Circulating Peptides in Mammalian Protein Metabolism. Edited by G Grimble and C Blackwell. Portland Press Proceedings Series #11. Portland Press UK, 1997. 200p. $Aus 136.00.

    Nutrition Support. Theory and Therapeutics. S A Shikora and G I Blackburn. Chapman and Hall UK, 1996. 608p. $Aus 115.25.

    Origins and Consequences of Obesity. CIBA Foundation Symposium Series. Wiley UK, 1996. 300p. $Aus 110.00


    FROM THE JOURNALS

    This was a very popular item in the January Newsletter and there was a strong demand for reprints. If you wish to receive reprints then please send a stamped self addressed envelope to the Editor. A large envelope is required eg 23 X 15 cm or larger. This offer is only available to requests from within Australia.

    Feeding Tubes in Prevention of Pneumonia. Roubenoff & Mayer, Letter to the Editor, Lancet, v349, p433, 8/2/97

    Clinical and Analytical Requirements and Needs of Glucose Measurements on Whole Blood, Wandrup, Blood Gas News, (1996), v5, #6, 3-8. (Deals with the new generation of Near Patient Testing blood glucose electrodes)

    Obesity, Part of the Metabolic Syndrome. Caterson. Clinical Biochem. Revs., (1997), v 18, #i, 11- 21

    Reducing Vitamin A Deficiency. Potter. BMJ, (1997), v 314, 317-318, 1/2/97.

    Dietary Selenium : Time to Act. Rayman. BMJ, (1997), v314, 387-388, 8/2/97.


    MEETINGS CALENDAR

    April 19th. Nutrition Screening & Assessment Workshop. To be presented by the FBBC Nutrition Research Group. Organised by the NSW Branch of the Dietitians Association of Australia. Enquiries to Marcelle Middleton 02-9350-2752. Topics - Nutrition Assessment - Nutrition Screening; Development, Validation and Use of the FBBC Malnutrition Screening Tool; SGA - Subjective Global Assessment.

    May 1st - 3rd. Malnutrition in the Hospitalized Patient, Joslin Auditorium, Beth Israel Deaconess Medical Center, Boston. Sponsored by Harvard Medical School and Beth Israel Deaconess Medical Center. Contact Susan Klug Branco, Continuing Education Coordinator, Deaconess Hospital, One Autumn Street, Suite 1B, Boston, MA 02215. (617) 632-0811. Fax 617-632- 7825. E-mail: sbranco@west.bidmc.harvard.edu.

    May 5th - 7th. Nutrition and Immunity, Atlanta. Sponsored by the American Cancer Society, Centers for Disease Control and Prevention, Emory University, and ILSI Research Foundation in cooperation with the Food and Agriculture Organization, ILSI Europe, ILSI North America, and the World Health Organization. Contact Conference on Nutrition and Immunity, International Life Sciences Institute, 1126 Sixteenth Street, NW, Washington, DC 20036-4810. Fax 202-659-3859. E-mail: meetings@dc.ilsi.org. State "Nutrition and Immunity" on all correspondence.

    May 14th - 17th. 16th Dietitians Association of Australia National Conference : 'Nutrition Unplugged : Back to Basics'. Wrest Point Convention Centre, Hobart, Tasmania. This conference will ignore diversions and go 'back to basic' to question fundamental beliefs in the practice of nutrition. In addition to the conference programme there will be many and varied opportunities for meeting with your peers and other interesting people. An important part of every conference is networking - this will be no exception. Further information contact : Conference Secretariat, Mures Convention Management, Victoria Dock, Hobart, TAS 7000. Ph +61-03-6234-1424 Fax +61-03-6234-4464.

    May 15th - 16th. Frontiers in Therapeutic Endoscopy, Washington, DC. Postgraduate course offered during Digestive Diseases Week by the American Society for Gastrointestinal Endoscopy. Contact ASGE/PG Registration Manager, 6900 Grove Road, Thorofare, NJ 08086-9447. (609) 848-1000 ext 208.

    May 25th - 28th. Bioavailability '97 Symposium, Wageningen, Netherlands. Sponsored by the Graduate School VLAG (Advanced Studies in Nutrition, Food Technology, Agrobiotechnology and Health Sciences) in cooperation with the Working Party on Food Chemistry of the Federation of European Chemical Societies, the Federation of European Nutrition Societies, the European Academy of Nutrition Sciences, and the International Life Sciences Institute (Europe). Contact LA Duym, Department of Human Nutrition, Wageningen Agricultural University, PO Box 8129, 6700 EV Wageningen, Netherlands. 31 317 483054. Fax 31 317 483342. E-mail: lous.duym@secret ariaat.voed.wau.nl. Internet: http://www.wau.nl/vlag/ bioava.html.

    June 1997 : Medical Research Week, organised by local State Branches of the Australian Society for Medical Research.

    June 8th - 11th Designing, Preparing, and Delivering Research Diets, Pennington Biomedical Research Center, Baton Rouge, LA. Sponsored by the National Heart, Lung, and Blood Institute. Contact Marlene Windhauser, Pennington Biomedical Research Center, 6400 Perkins Road, Baton Rouge, LA 70808. (504) 763-2663. Fax 504-763-2525. E-mail: windhamm@mhs.pbrc.edu.

    June 12th -14th Dietary Factors in Cancer Prevention: Molecular Mechanisms and Applications, Piscataway, NJ. Sponsored by the Environmental and Occupational Health Sciences Institute and the Cancer Institute of New Jersey. Contact Mitchel Rosen, Centers for Education and Training, Environmental and Occupational Health Sciences Institute, 45 Knightsbridge Road, Piscataway, NJ 08854-3923. (908) 235-5062. Fax 908-235-5133. E-mail: mrosen@umdnj.edu.

    July 23 - 26, 1997. Sixth World Congress on Clinical Nutrition : Antioxidants and Disease, Banff, Alberta, Canada. Contact Tapan Basu, Dept of Agricultural Food and Nutritional Sciences, University of Alberta, Edmonton, AB T6G 2P5, Cananda. (403)492- 4921 . Fax 403-492-9130.

    July 20th - 23rd. 2nd World Congress of Allied Health Professionals :'Sustainable Health Care in the 21st Century. A Global Perspective'. University of Wolverhampton, Priorslee Hall, Telford, Shropshire, England. email n.birch@wlv.ac.uk

    July 27 - Aug 1 : 16th International Congress of Nutrition . Montreal. Contact Congress Secretariat, IUNS '97, National Research Council Canada, Building M-19, Montreal Road, Ottawa, ON, Canada K1A OR6. (613)993-7271. Fax 613-993-7250.

    September 7th - 11th : Tachykinins in Health and Disease. Cairns, Queensland. Home Page = http://iuphar.pharmacology.unimelb.edu.au/iupar/meeting_970907.h tml

    October 1st - 5th. VIIIth Biennial Meeting of the International Society for Free Radical Research. Contact. Mr Merce Ferrer, Pacifico SA, E Granados, 44 Pral., 08008 Barcelona Spain. Tel +34-3-4545400. Fax +34-3-4517438

    October 16th - 19th : 22nd Australia & New Zealand Intensive Care Society Scientific Meeting, Wrest Point Convention Centre, Hobart, Tasmania. Keynote Speakers : Prof. Michael Pinsley, Dr Stephen Crawford and Ms Karin Mitchell-Supplee. Contact Cartherin Gordon, 22nd Annual Scientific Meeting, PO Box 255, SANDY BAY 7006. Ph 03-6222-8013, Fax 03-6222-8010. Email anzics97@mail.mpx.com.au

    October 24th - 25th. 23rd Annual Scientific Meeting of AuSPEN, at the Esplanade Hotel, Fremantle, Western Australia. Contact Dr Paul Woods, +61-9-346-3333 Ext 1010 or Fax +61-9-386-8541 or Susan Adler Conference Planning Ph/Fax +61-9-384-4213

    November 13th - 17th. 23rd Annual Scientific Meeting of the Society of Hospital Pharmacists of Australia, Adelaide Convention Centre, South Australia. Further details from Dave Cosh, Pharmacy Dept, Repatriation General Hospital, Daw Park, SA 5041. Ph 08-2751-799 Fax 08-3740-225 email scoshdg@rgh.sa.gov.au, or from Hartley Management Group Pty Ltd, PO Box 20, Kent Town, SA 5071, Ph 08-363-4399, Fax 08-3634-577, email sgt@ozemail.com.au.

    November 30th - December 2nd. 21st Annual Scientific Meeting of the Nutrition Society of Australia, Brisbane, Queensland. Further information contact Joan Breakey, 75, Bishop Road, BEACHMERE. Ph +61-7-496-8207 email : breakey@ozemail.com.au


    JANUARY 1997 PRIZE CROSSWORD PUZZLE

    The winner of the Digitor 4K DataBank was Jane Luddington, Pharmacy Dept. Westmead Hospital.


    tfh : 24th April 1997