Each issue of the CoramClick provides an in-depth focus on timely and practical solutions. In this issue of the Click, we are focusing on intestinal failure and intestinal transplant. Full, printable issues of the Click are available in the CoramClick archive for easy reference!

	Intestinal Failure Intestinal failure can be a temporary or permanent clinical condition, resulting in malabsorption. Intestinal failure may also require prolonged and potentially long-term dependence on parenteral nutrition.		Bug of the Month: Catheter-related Infections Intravenous catheters are a mainstay of high-tech infusion services. However, there are catheter-related risks, including complications such as local and systemic infections, septic thrombophlebitis and endocarditis.
	Intestinal Transplant Intestinal transplantation is a significant, and often the only remaining, treatment option for many patients with irreversible intestinal failure.		Do You Know? How many people in the United States are estimated to have short bowel syndrome? 5,000 to 10,000 10,000 to 20,000 20,000 to 30,000
	Common ICD-9 Codes and V Codes A list of certain ICD-9 codes and V codes for intestinal failure and intestinal transplant.		Resource Center Featuring the Oley Foundation, the American Society for Parenteral and Enteral Nutrition and the American Dietetic Association.
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Intestinal Failure

Introduction
A functional stomach, duodenum, jejunum, ileum and colon are necessary for adequate absorption of food and fluids. When part of the intestinal tract is missing or does not function appropriately, maldigestion and malabsorption may occur – potentially resulting in malnutrition.

Intestinal failure (IF) has been defined as the loss of intestinal absorptive capacity secondary to gastrointestinal disease or resection of the bowel, resulting in shortened bowel or short bowel syndrome (SBS). SBS is the loss of gut mass or function leaving the patient unable to meet nutritional needs by oral diet alone. This can be a temporary or permanent clinical condition resulting in malabsorption and may require prolonged and potentially long-term dependence on parenteral nutrition (PN). Clinical symptoms of IF are chronic diarrhea, dehydration, electrolyte disturbances and malnutrition. The diagnoses for IF vary by age. For adults, Crohn’s disease, mesenteric infarct and jejunoileal bypass are the leading causes of SBS and IF; in children, volvulus, necrotizing enterocolitis and mesenteric ischemia are the leading causes.

Management of SBS
The management goals of a patient with SBS are to maintain hydration, nutrition status and prevent complications immediately after surgery. Over time, the remaining gastrointestinal tract experiences a time of adaptation which may allow some patients to absorb nutrients via the small bowel and decrease or eliminate dependence on PN. The key factors that affect the patient’s ability to be weaned partially or completely from PN include length of small bowel and the presence or absence of the colon as well as the presence or absence of the ileocecal valve.

PN is utilized in the initial phase of recovery to maintain fluid and electrolyte balance, and to meet nutritional needs. Adequate hydration, as well as provision of adequate calories, protein, fat, vitamins and minerals is vital in the early stages to prevent malnutrition related complications and to promote growth in children.

Management of the SBS patient includes individualized nutrition management through oral nutrition or tube feeding as well as PN. The patient’s gastrointestinal anatomy needs to be evaluated to determine the ability to tolerate oral/enteral nutrition. When the colon is present, less small intestinal length is needed. The presence of the ileocecal valve helps control transit time and therefore allows nutrients a longer exposure time to the cell wall for improved absorption. Without a colon, the patient is at increased risk for dehydration. Patients with resections of the small intestine that are greater than 75 percent usually require PN. These factors form the basis for nutritional management and recommendations. A registered dietitian can work with the patient to perform a complete nutritional assessment and then base the diet, tube feeding or PN recommendations according to the medical, surgical and nutritional history. Patients need intensive monitoring to ensure the nutritional intake is balanced whether the patient is being fed orally, by tube feeding, by PN or all three. In many cases, the small intestine adapts and there is an increased ability to absorb nutrients and fluids over time despite the shorter length.

In addition to nutritional management, other therapeutic options must be evaluated including medical and surgical modalities. Anti-diarrheal medications slow motility allowing for increased absorption potential and decreased fluid output. Proton pump inhibitors may help by controlling gastric secretions, reduce output and may enhance absorption of nutrients. Specific nutrients and experimental medication may be used to enhance absorption and adaptation such as glutamine, glucagon like peptide (GLP-2) and growth hormone. Surgical interventions such as bowel lengthening procedures and small bowel transplantation may be considered for these patients.

Nutritional management should focus on adequate hydration, macronutrients and micronutrients, as well as normal growth and development for children. While some patients rely on long-term or lifetime PN, others may be able to decrease their dependence on PN with dietary modifications, medical and surgical interventions.

Intestinal Transplant

Intestinal transplantation is a significant, and often the only remaining, treatment option for many patients with irreversible intestinal failure. In fact, 242 patients are currently waiting for this opportunity. Since the first successful intestinal transplant in 1988, over 1,500 procedures have been performed with 514 patients still surviving with a functional intestine. Success rates continue to improve as research remains focused on optimizing immunosuppressive regimens, improving supportive care and evaluating national allocation policies – to positively impact both survival and quality of life.

An intestinal transplant may involve the whole intestine or an intestinal segment. At times an intestinal transplant may be performed in conjunction with a liver or multi-visceral transplant. Intestinal transplantation may be considered for patients who have a diagnosis of irreversible intestinal failure (70 percent have short bowel syndrome), and who are dependent on parenteral nutrition (PN) with one or more life-threatening complications from PN (e.g. recurrent episodes of central line sepsis, loss of venous access, thrombosis of central veins, parenteral nutrition related liver disease, etc.).

After transplant, patients require intestinal rehabilitation and a lifetime of immunosuppression and monitoring. Successful intestinal transplant patients develop a management plan incorporating healthy medical and psychosocial lifestyle choices.

Common ICD-9 Codes and V Codes
Specific to Intestinal Failure and Intestinal Transplant

Below is a list of certain ICD-9 codes and V codes for Intestinal Failure and Intestinal Transplant. Please note that this list is not all-inclusive.

Bug of the Month: Catheter-related Infections

Staphylococcus aureus bacteria. Image courtesy of the CDC/Matthew J. Arduino, DRPH; Janice Carr.

Intravenous catheters are a mainstay of high-tech infusion services. They are the access to often life-saving therapy for multiple patients and diagnoses, and the key to successful therapy in the typically more comfortable home environment (not to mention the decreased risk of nosocomial infection as patients spend fewer required days in the hospital). At the same time, catheter-related risks include complications such as local and systemic infections, septic thrombophlebitis and endocarditis.

Increasingly, catheter-related infections (CRIs) are due to methicillin-resistant Staphylococcus aureus (MRSA). Recognizing both the clinical and economic impact of CRIs, The Centers for Disease Control and Prevention (CDC) has listed bloodstream infections and other catheter-related adverse events as one of its seven healthcare safety challenges. Its goal is to decrease the rate of CRIs by half within five years. Home infusion has a significant opportunity/responsibility to support the prevention of CRIs.

Risk
The fundamental risk factor for CRIs is exposure to and contamination from pathogens, typically bacteria, in and/or around the catheter insertion site. Resulting colonization of the intravenous line places patients at risk for the spread of infections. Central venous catheter-related infections are a common cause of bacteremia and sepsis.

Causes
When organisms touch the catheter surface, they produce adhesive materials that attach them to the catheter wall. The organisms then grow and multiply to form clusters. These clusters produce a self-protecting slime (an exopolymer substance) called biofilm that helps protect the organisms from exposure to intravenous antimicrobial therapy.

Catheters that have been used for a few days typically have more biofilm on the external wall. Catheters in place longer-term have more biofilm on the internal wall. Glucose, including that in total parenteral nutrition, and heparin also contribute to the growth of biofilm.

Common causative organisms for CRIs and catheter-related bloodstream infections (CRBSI) include:

• Coagulase-negative Staphylococcus spp.
• Staphylococcus aureus
• Enterococcus spp.
• Corynebacterium spp.
• Gram-negative organisms e.g., Escherichia coli and Pseudomonas aeruginosa
• Yeasts e.g., Candida albicans
  

Signs and Symptoms
Signs and symptoms of CRIs may be localized, occurring at or around the insertion site or the track of a tunneled line, or systemic, even to the point of bacteremia and sepsis.

Treatment
Factors affecting the therapy decisions for a CRI or CRBSI include the type of catheter, severity of symptoms, any underlying disease or co-morbidities, the actual or potential pathogens involved and the patient’s history of and response to antibiotic usage. Catheter removal is certainly the most reliable means of eradicating the infection, but there are risks and benefits to that treatment option. Some considerations include how to manage the patient without a central line, the need to replace the line and with which type of catheter. The risks of leaving an infected or colonized line in are significant as well and include persistent illness, a venous thrombosis or hematogenous spread leading to metastatic infections such as sepsis, endocarditis or pneumonia.

Antibiotics or antifungals will likely be prescribed to treat the suspected or actual causative organisms. Empiric therapy may be necessary prior to culture results, switched to the narrowest spectrum antimicrobial as soon as possible. After stabilization, a switch to effective oral anti-infective agents may be possible. While intravenous antibiotics are useful for treatment of the infection, they are poor at eliminating the colonization of the line itself.

Prevention
It is well recognized that prevention of health-care related infections is a high priority. The CDC has developed recommendations specific to CRI strategies. Attention to sterile technique on insertion helps minimize the invasion of skin pathogens. Minimization of routine changes of the central venous catheters and reduction of hub manipulation are key preventative measures. Since CRIs in home infusion typically appear after the first 30 days of catheter insertion, it is essential that clinicians, patients and caregivers maintain ever-vigilent aseptic technique when accessing or in any way caring for their central catheter site and line. It is critical that the patient and/or caregiver learn to access and maintain line patency by following professional standards.

Antibiotic lock (ABL) is a technique that involves filling the CVC lumen(s) with pharmacological concentrations of an anti-infective agent. The anti-infective solution is left in place for a prescribed period of time and then either aspirated or flushed as ordered. Similarly, ethanol lock therapy (ELT) involves the use of concentrated medical-grade ethanol in the catheter lumen for a specific dwell time. Ethanol is bactericidal, and ELT sterilizes the intraluminal space of the intravascular catheter and may effectively prevent sepsis if biofilm is present.

CRBSI rates can be successfully minimized in the home setting, assuming appropriate line maintenance, flushing and patency. In one of the largest studies of CRI in home infusion, the combined infectious complication rate, both systemic and local, was 0.45 per 1,000 catheter days (2.5%). This was considerably lower than the mean hospital infection rate range of 2.2–10.8 per 1,000 days. The cumulative risk of acquiring a catheter-related BSI has ranged between 1% and 10% for CVCs in general, and 6% for total parenteral nutrition catheters. The lower home infusion rate may be related to the decreased exposure of home care patients to virulent pathogens, a generally healthier study population, and less frequent intervention/manipulation of the catheter than in inpatients. Regardless, the home infusion numbers set standards by which outcomes must be measured.

Do You Know?

How many people in the United States are estimated to have short bowel syndrome?

1. a) 5,000 to 10,000
2. b) 10,000 to 20,000
3. c) 20,000 to 30,000

Answer – b) 10,000 to 20,000
In the United States, it is estimated that between 10,000 to 20,000 people have short bowel syndrome, or 3.3 patients per million.

Resource Center

Oley Foundation
The Oley Foundation is a national, independent, non-profit organization that provides information and psycho-social support to consumers of home parenteral and enteral nutrition, helping them live fuller, richer lives. The Oley Foundation also serves as a resource for consumer’s families, clinicians, industry representatives and other interested parties. Programs are directed by the staff and guidance is provided by a board of dedicated home parenteral and enteral nutrition professionals and patients. For more information, visit www.oley.org.

American Society for Parenteral and Enteral Nutrition
The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) is dedicated to improving patient care by advancing the science and practice of nutrition support therapy. Founded in 1976, A.S.P.E.N. is an interdisciplinary organization whose members are involved in the provision of clinical nutrition therapies, including parenteral and enteral nutrition. With more than 5,500 members from around the world, A.S.P.E.N. is a community of dietitians, nurses, pharmacists, physicians, scientists, students and other health professionals from every facet of nutrition support clinical practice, research and education. A.S.P.E.N. also works closely with other healthcare organizations to advance a patient-centered approach to nutrition care and with government agencies about the optimal use of nutrition therapies. For more information, visit www.nutritioncare.org.

ADA
The American Dietetic Association (ADA) is one of the world’s largest organizations of food and nutrition professionals. ADA is committed to improving the nation’s health and advancing the profession of dietetics through research, education and advocacy. More than 68,000 ADA members have rapid access to a vast array of professional resources. For more information, visit www.eatright.org

Coram
Visit coramhc.com/services to learn more about the benefits of home parenteral nutrition management, anti-infective services and pre- and post-transplant services.

Bibliography

• Ryder M. Catheter-related infections: It’s all about biofilm. Topics Adv Pract Nurs eJournal [serial on the Internet]. 2005 [cited 2006 Sept 11];5(3). Available from: http://www.medscape.com/viewarticle/508109.
• O’Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep. 2002;51(RR-10):1-29.
• Cain, D, Gorski, L, Monk-Tutor, M, Powers, T. Home continuum: Approaches in care management for home infusion professionals. Continuing Education for Nurses and Pharmacists. Vol.1, No.2.
• Moureau, N, Poole, S, Murdock, MA, Gray, SM, Semba, CP. Central venous catheters in home infusion care: outcomes analysis in 50,470 patients. J Vasc Interv Radiol 2002; 13:1009–1016.
• Barclay, L (October 2007). Chlorhexidine-based solutions may be preferred to prevent catheter-related infection. Arch Intern Med. 2007;167:2066-2072.
• Celebrate Life Newsletter, April 2008 by Ezra Steiger, MD, FACS, CNSP, Cleveland Clinic, Cleveland, Ohio.
• http://www.optn.org/policiesAndBylaws/policies.asp [3.11 Intestinal Transplant]
• http://www.optn.org/AR2007/Chapter_V_AR_CD.htm?cp=6 [2007 OPTN/SRTR Annual Report: CHAPTER V - Liver and Intestine Transplantation in the United States, 1997-2006]
• http://www.unos.org