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StayCurrentMD
Multidisciplinary Approach: Intestinal Failure Innovations
hosted by Dr. Todd Ponsky
Chapter 5 of 7 · Medical Management
Lock therapy
Ethanol Locks and Antibiotic Lock Therapy
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Intestinal failure teams should include equal members from neonatology, surgery, GI, nutrition, social work, and psychology
Intestinal failure is defined by inadequate bowel length OR adequate length with poor absorptive function preventing growth
Gastroenterologists should be involved when NICU patients are unable to absorb appropriate nutrition to maintain growth
Patients with residual bowel of only 5-10 centimeters require very early family counseling about life with intestinal failure and potential transplantation
Patients no longer leave Cincinnati NICU with cholestasis due to improved management protocols
The traditional view that extreme short gut in premature infants is not survivable is now completely archaic with good management
Lipid minimization protocols and reduction of trace elements in TPN help prevent cholestasis
Rotavirus vaccination in NICU reduced readmission rates from nearly 30% to almost zero for rotavirus-positive admissions
Weekly joint rounds with surgeons, gastroenterologists, dietitians, and neonatologists help identify protocol deviations and build family rapport
Breast milk provides not just immunostimulatory benefits but also motility effects and healing properties through oligosaccharides
Cincinnati reduced central line infection rates from 12 per 1000 catheter days to less than 2 per 1000 through standardized care
Subclavian approach for central lines has higher risk of stenosis compared to jugular approach
If parents report child looks funny, smells funny, or behaves funny with a central line, treat as line infection until proven otherwise
Kids who get line infections do not do as well as those who do not
Line infections cause visible drops in growth curves that take time to recover from
Emergency room protocols should flag intestinal failure patients with central lines and fevers for immediate evaluation in trauma/acute care rooms
Ethanol locks use 70% ethanol as a dwell during TPN windows, requiring patients to be on cycled TPN
Ethanol locks work better with 6.6 French catheters; smaller PICC lines tend to occlude with ethanol
In UK, taurolidine locks are predominantly used instead of ethanol locks for line infection prevention
Line care education is crucial; recurrent infections warrant revisiting line care practices before implementing locks
Fungal line infections are pulled more promptly due to severity, but some centers treat through even fungal infections in patients with limited vascular access
Phytosterols share the cholesterol heterodimer transporter in hepatocytes, which is down-regulated by endotoxemia
Limiting lipid intake to 1g/kg/day in at-risk patients reduces cholestasis rate to less than 5%
For patients developing cholestasis on 1g/kg/day lipids, dose may be reduced to 1g/kg every other day despite risk of essential fatty acid deficiency
With lipid restriction protocols, cholestasis rarely comes out of Cincinnati NICU
Symptomatic essential fatty acid deficiency is not seen with lipid restriction protocols
Higher glucose infusion rates lead to less efficient caloric use and more fat deposition rather than optimal growth
Intestinal failure patients should not be expected to maintain 50th percentile growth; continued advancement along a growth curve is the appropriate goal
Surgeons should measure bowel length at time of resection, not ex vivo, as bowel lengthens significantly after removal
Patients with less than 10% bowel resection still typically require 2-3 months of parenteral nutrition
Feed absorption and ability to wean TPN while maintaining growth are the best measures of bowel function
With improved management, children can achieve linear growth above 50th percentile if they have genetic potential
Upper GI studies can identify some anastomotic problems but cannot rule them out; absence of findings does not exclude mechanical issues
Low anastomotic strictures may show dilation on barium studies but delayed films reveal poor outflow
Some anastomoses are not strictured but kinked or twisted, creating functional problems that resolve with surgical revision
Radiologists may interpret dilated bowel as motility issue when mechanical obstruction is actually present
Endoscopy is valuable for visualizing anastomosis diameter when imaging is inconclusive
Children with anastomotic problems typically show noticeable improvement after surgical revision
Application of STEP procedure to all children with dilated bowel should be viewed with skepticism; more important to determine why bowel is dilating
MRI enterography is limited in pediatric intestinal failure due to need for sedation, difficulty with contrast administration, and poor imaging of air-filled dilated bowel
Manometric assessment is often more confusing than helpful in short bowel syndrome as motility abnormalities are not well described
Post-gastric tube feeding with gastric decompression can demonstrate distal bowel function and avoid unnecessary surgeries
Distal feeding may improve foregut emptying over time through feedback mechanisms
At University of Michigan, when each surgeon or gastroenterologist cared for 2-3 patients individually, 1-year mortality was 30-40%
After developing a team approach at Michigan, mortality dropped to about 5% per year
PICC lines have approximately half the complication-free survival of Broviacs according to IR literature
Polyurethane catheters do not change elastic characteristics when exposed to ethanol according to in vitro studies
Some centers achieve good results with ethanol locks 3 times weekly (Monday, Wednesday, Friday) rather than daily
High doses of soy-based lipids containing phytosterols have the strongest association with irreversible liver disease
Neonatologists often maintain higher lipid doses (2-3g/kg/day) due to concerns about depriving infants of linoleic acid and affecting brain development