How Do You Implement the Diet?

There is great variability in how the ketogenic diet (KD) is implemented. Most of the differences are preference based. A consensus statement attempted to unify professional practices. The KD can be safely used in all ages, modified for specific dietary needs, and administered as food, formula, or intravenous alimentation. Effectiveness, compliance, and minimal side effects are achieved using a team-based, family-centered support structure. The KD is commonly initiated in an in-patient setting with a gradual advancement of the fat. Some centers still begin the KD with a brief fast. Out-patient initiation with slower advancement to a full diet can be challenging but safely executed. Time to determine response and duration of treatment in responders varies. Side effects are better understood and best managed proactively by monitoring, but cannot always be prevented and must be weighed with the benefit of continuing the therapy.

Effect of Shorter Term of Intravenous Infusion for Reduction of Catheter-Related Bloodstream Infection After Gastrectomy

After gastrectomy, a longer period of intravenous alimentation is required than for other digestive surgeries, portending a higher risk of catheter-related bloodstream infection (CRBSI). From assessment of CRBSI occurring between 2004 and 2007 (preintervention group), the duration of intravenous infusion between 2008 and 2010 (postintervention group) was changed to shorter-term (6-day) infusion. To verify the effect of changes in injection schedule on the incidence of CRBSI, the occurrence of CRBSI was studied comparatively among preintervention and postintervention cases, excluding cases requiring intravenous infusion preoperatively, and cases requiring long-term intravenous infusion postoperatively due to postoperative complications. The rate of CRBSI in the postintervention group (0%; 0 of 298) was significantly lower than that in the preintervention group (1.7%; 8 of 477; P = 0.026). There was no significant difference between preintervention and postintervention groups in postoperative complications. Six-day infusion decreased the incidence of CRBSI after gastrectomy significantly, without increasing postoperative complications.

Infant Botulism: A Review of 12 Years' Experience at The Children's Hospital of Philadelphia

Fifty-seven patients with infant botulism were cared for at The Children's Hospital of Philadelphia between 1976 and 1987. The ages of the children ranged from 18 days to slightly more than 7 months. The average duration of hospitalization was 44 ± 34 days, with the average intensive care unit stay lasting 29 ± 25 days (54 of 57 patients). The majority (77%) of the patients were ultimately intubated and mechanicaily ventilated (68%). The principal indication for intubation was loss of protective airway reflexes and not hypercarbia or hypoxemia. In those patients who required mechanical ventilation the average duration was 23 ± 22 days, with the 10 most severely affected patients (≥28 days of mechanical ventilation) averaging 53 ± 25 days. Excluding patients ventilated for more than a month, those who underwent tracheostomy were hospitalized nearly twice as long as those who were managed by nasotracheal intubation only (33.5 days vs 63.2 days). The use of continuous nasogastric feedings has supplied most infants with sufficient enteral feedings to avoid weight loss and the need for central intravenous alimentation.

In Reply: Heparinization of Alimentation Solutions

We thank Poland and Bedard for their interest in our findings and for pointing out an error of omission in our reporting of the data. The infants in the heparinized group did indeed receive intravenous alimentation for a longer (mean) duration. The difference is due to skewing ofthe data by a subgroup of infants who required intravenous treatment for prolonged periods. Bronchopulmonary dysplasia developed in three infants in the heparmnized group v one infant in the nonheparinized group.

Heparinization of Alimentation Solutions Administered Through Peripheral Veins in Premature Infants: A Controlled Study

A randomized controlled study was done to determine whether the addition of heparin (1 U/mL) to peripheral intravenous alimentation solutions would affect the incidence of phlebitis and duration of patency of intravenous catheters in premature infants. Twenty-two-gauge Teflon catheters were uniformly used. One hundred five catheters infused with heparin were placed in 13 infants, and 122 catheters were placed in the control group of 13 infants. The time, nature, and incidence of complications were noted for each infusion site. Infusion of heparin was found to double the duration of patency of intravenous catheters and to reduce significantly the incidence of phlebitis. No complications related to the administration of heparin were noted. Heparinization of intravenous alimentation solutions should therefore be considered in premature infants as a means of reducing the work load and incidence of complications associated with peripheral lines.