Adult home parenteral nutrition: a clinical evaluation after a 3-year experience in a Southern European centre

Cardiac Changes in Patients on Long-Term Parenteral Nutrition

Patients with short bowel syndrome (SBS) on long-term home parenteral nutrition (HPN) chronically receive high fluid volumes directly into the right atrium (RA) through the superior vena cava. We retrospectively evaluated cardiac function measured by routine transthoracic echocardiography (TTE) in a population of 26 SBS patients on long-term HPN and compared their data on echocardiograph-derived right heart structure and function, with those of a control group of 26 patients also bearing a central venous catheter (CVC) for other reasons. Results showed that body weight and BMI were significantly higher in the control group. The echocardiographic estimate of RA pressure was higher in HPN patients than in controls (p = 0.01). An increased estimate of RA pressure indicates the need to consider TTE in the follow-up of long-term HPN patients to detect functional impairment early.

Is home parenteral nutrition safe for cancer patients? Positive effects and potential catheter-related complications: A systematic review

PURPOSE

Total Parenteral Nutrition began to be applied frequently in the houses of patients starting from the 1990s and is stated in literature as Home Parenteral Nutrition (HPN). The purpose of this review is to answer the question of whether or not HPN is safe for cancer patients.

METHODS

Searches were conducted in Cochrane, CINAHL, PubMed, Springer, Google Scholar, and the Web of Science databases.

RESULTS

The 1,949 articles were accessed in the total, and 20 articles have been included in the review. In the studies being evaluated, it can be determined that HPN has influenced the quality of life, performance status, and the nutrition level of cancer patients positively. Most frequently seen complications were infections relating to the catheter, the mechanical obstruction in the catheter and venous thrombosis. For each 1,000 days with HPN or a catheter, infections in the interval of 0.05 and 3.08, mechanical problems in the interval of 0.07 and 2.13, and thrombosis in the interval of 0.05 and 0.20 were determined.

CONCLUSIONS

While HPN influenced quality of life, nutrition, and the personal performance of cancer patients positively, the rate of complications is at a level that can be managed at home.

ESPEN guideline on clinical nutrition and hydration in geriatrics

BACKGROUND

Malnutrition and dehydration are widespread in older people, and obesity is an increasing problem. In clinical practice, it is often unclear which strategies are suitable and effective in counteracting these key health threats.

AIM

To provide evidence-based recommendations for clinical nutrition and hydration in older persons in order to prevent and/or treat malnutrition and dehydration. Further, to address whether weight-reducing interventions are appropriate for overweight or obese older persons.

METHODS

This guideline was developed according to the standard operating procedure for ESPEN guidelines and consensus papers. A systematic literature search for systematic reviews and primary studies was performed based on 33 clinical questions in PICO format. Existing evidence was graded according to the SIGN grading system. Recommendations were developed and agreed in a multistage consensus process.

RESULTS

We provide eighty-two evidence-based recommendations for nutritional care in older persons, covering four main topics: Basic questions and general principles, recommendations for older persons with malnutrition or at risk of malnutrition, recommendations for older patients with specific diseases, and recommendations to prevent, identify and treat dehydration. Overall, we recommend that all older persons shall routinely be screened for malnutrition in order to identify an existing risk early. Oral nutrition can be supported by nursing interventions, education, nutritional counseling, food modification and oral nutritional supplements. Enteral nutrition should be initiated if oral, and parenteral if enteral nutrition is insufficient or impossible and the general prognosis is altogether favorable. Dietary restrictions should generally be avoided, and weight-reducing diets shall only be considered in obese older persons with weight-related health problems and combined with physical exercise. All older persons should be considered to be at risk of low-intake dehydration and encouraged to consume adequate amounts of drinks. Generally, interventions shall be individualized, comprehensive and part of a multimodal and multidisciplinary team approach.

CONCLUSION

A range of effective interventions is available to support adequate nutrition and hydration in older persons in order to maintain or improve nutritional status and improve clinical course and quality of life. These interventions should be implemented in clinical practice and routinely used.

Home Parenteral Nutrition Support in Adults: Experience of a Medical Center in Asia

BACKGROUND

Parenteral nutrition (PN) support is mandatory in patients with gut failure. Short bowel syndrome is a term used for symptoms and pathophysiological disorders brought about by the removal or malfunction of a large portion of the small bowel. Inflammatory bowel disease, vascular disease, and malignancy are the most common causes of short bowel syndrome in adults. There are many complications associated with chronic use of PN. Cholestasis, nutrient deficiency, small bowel bacterial overgrowth, and catheter-related infections were noted in these patients. Due to the various etiologies, we tried to find the optimal method to manage these patients.

METHODS

We reviewed all patients over 16 years old, from 1989 to 2002, who required home PN support for at least 30 days. Charts were reviewed to obtain information regarding demographics, nutrition management, outcome, and complications related to PN. Survival was estimated by using the Kaplan-Meier method. The association of survival with primary disease, length of small bowel, age, and gender was assessed by proportional hazard regression analysis.

RESULTS

There were 31 patients who needed home PN support during this period, 14 male and 17 female. The average age was 55 (median age, 53; range, 28-88); the average period of PN administration was 19 months (median, 7; range, 1-115 months). The most common indications for home PN were alimentary tract obstruction and short bowel syndrome. Most deaths were related to their original diseases and catheter-related sepsis. Malignant diseases were a major indication for home PN (HPN). However, 20% of these patients with incurable diseases lived longer than 1 year. The disease patterns were different from those in western societies. Most patients had malignancies and vascular insults in our series. There was much less inflammatory bowel disease in our patients than in western countries; catheter-related infections were frequent and caused 25% of mortality.

CONCLUSIONS

HPN is very important to patients with intestinal failure or who are waiting for recovery from temporal intestine insufficiency. Even in malignant diseases, a significant number of patients survived for >1 year with treatment of HPN. Most complications related to their underlying diseases and associated infections. Improving patient education and treatment might improve the prognosis of these patients and expand the application of this technique to help more patients with small intestine failure.

Management of intestinal failure in inflammatory bowel disease: small intestinal transplantation or home parenteral nutrition?

Inflammatory bowel disease and Crohn's disease in particular, is a common cause of intestinal failure. Current therapeutic options include home parenteral nutrition and intestinal transplantation. For most patients, home intravenous therapy including parenteral nutrition, with a good probability of long-term survival, is the favoured choice. However, in selected patients, with specific features that may shorten survival or complicate home parenteral nutrition, intestinal transplantation presents a viable alternative. We present survival, complications, quality of life and economic considerations that currently influence individualised decision-making between home parenteral nutrition and intestinal transplantation.

Home artificial nutrition: an update seven years after the regional regulation

BACKGROUND & AIMS

Home Artificial Nutrition (HAN) is a well established extra-hospital therapy, contributing to decreased health care costs, by reducing the number and length of hospitalizations. The knowledge of the epidemiology of HAN helps plan health-care funding and in analyze the factors that can improve HAN service.

SUBJECTS AND METHODS

An update on the prevalence of Home Artificial Nutrition (HAN) in the Campania region (Southern Italy) and patients clinical characteristics has been regularly carried out in the past seven years after a specific regional regulation issued in 2005.

RESULTS

Total number of patients on HAN has increased from 355 in April 2005 to 1165 in April 2012 (+228.2%); in particular, patients on Home Parenteral Nutrition (HPN) increased from 156 in April 2005 to 306 in April 2012 (+96.2%) and patients on Home Enteral Nutrition (HEN) from 199 to 838 (+321.1%) respectively. HEN/HPN ratio in adults has changed from 1.3/1 in April 2005 to 2.7/1 in April 2012, gradually nearing the expected national mean ratio of 5/1 as observed in the 2005 national survey.

CONCLUSIONS

The specific regional regulation in Campania has contributed to increase the prescription of HAN and to ameliorate its indications; in particular, through the years, HEN is gradually nearing national standards.

Epidemiology of catheter-related infections in adult patients receiving home parenteral nutrition: a systematic review

BACKGROUND AND AIMS

Catheter-related infection (CRI) is the most common and serious complication for adult patients receiving home parenteral nutrition (HPN). Our aim is to provide epidemiological data on infection incidence, infecting pathogens and contributing risk factors.

METHODS

Four electronic databases (Embase, Medline, IPA, CINAHL) were screened for eligible studies published between 1970 and March 2012. Methodological quality was evaluated and terminology/definitions were re-categorized.

RESULTS

Thirty-nine studies were included. Extensive variability was observed in terminology/definitions as well as in expression of CRI rate. After correct interpretation of definitions, overall catheter-related bloodstream infection rate (CRBSI) ranged between 0.38 and 4.58 episodes/1000 catheter days (median 1.31). Gram-positive bacteria of human skin flora caused more than half of infections. An analysis of the reported risk factors showed that the origin of a CRBSI is often multifactorial. The risk factors were related to the patient, the venous access device, the education, HPN therapy and follow-up.

CONCLUSIONS

This review on CRI in adult HPN patients revealed that included studies are of low quality and used poorly described risk factors and different definitions. The human skin flora caused most of infections; therefore, hand hygiene and training remain essential.

Characterization of post-hospital infections in adults requiring home parenteral nutrition

OBJECTIVE

Limited data are available on the incidence and risk factors for infection in patients requiring home parenteral nutrition (HPN).

METHODS

A retrospective study was conducted in 101 consecutive adults (63 female, 38 male) discharged on HPN from the Emory University Hospital, Atlanta, GA. New bloodstream infections (BSIs) requiring rehospitalization and other infections were evaluated.

RESULTS

Most infections (75%) developed during the initial 6 mo after hospital discharge; rates of BSI were particularly high during the first 4 mo. Fifty-six patients (55.4%) developed 102 BSIs (11.5 BSIs/1000 catheter-days). Most BSIs were attributed to gram-positive organisms (46%), including coagulase-negative Staphylococcus, Staphylococcus aureus, Enterococcus species, and others, followed by Candida species (20%) and gram-negative organisms (13%). Twenty-one percent of BSIs were polymicrobial. The BSI incidence rate ratio was significantly increased for patients with mean prehospital discharge blood glucose concentrations in the highest quartile versus the lowest quartile (incidence rate ratio 2.4, P = 0.017). Patients with a peripherally inserted central catheter versus non-peripherally inserted central catheter central venous catheters had significantly higher rates of BSI (P = 0.018). Thirty-nine patients (38.6%) developed 81 non-BSIs, including pneumonia, urinary tract infections, and surgical site infections. Postdischarge PN dextrose, lipid, and total calorie doses were unrelated to BSI but were variably related to the rate of non-BSIs.

CONCLUSIONS

Adult patients on HPN exhibit a very high incidence of post-hospital infections. Higher mean blood glucose levels during predischarge hospitalization and the use of peripherally inserted central catheters at discharge are associated with an increased risk of BSI in the postdischarge home setting.

Nutritional screening and early treatment of malnutrition in cancer patients

BACKGROUND: Malnutrition is a frequent complication in patients with cancer and can negatively affect the outcome of treatments. On the other hand, side effects of anticancer therapies can also lead to inadequate nutrient intake and subsequent malnutrition. The nutritional screening aims to identify patients at risk of malnutrition for prompt treatment and/or careful follow-up. METHODS AND RESULTS: This manuscript highlights the need of an interdisciplinary approach (oncologist, nutritionist, dietitian, psychologist, etc.) to empower patients who are experiencing loss of physiological and biological function, fatigue, malnutrition, psychological distress, etc., as a result of cancer disease or its treatment, and maintain an acceptable quality of life. CONCLUSIONS: It is necessary to make all healthcare professionals aware of the opportunity to identify cancer patients at risk of malnutrition early in order to plan the best possible intervention and follow-up during cancer treatment and progression.

Central venous catheter infections and antibiotic therapy during long-term home parenteral nutrition: an 11-year follow-up study

BACKGROUND

Catheter-related bloodstream infections are a serious and common complication in patients receiving home parenteral nutrition (HPN).

METHODS

Prevalence of infections, type of agents, and effectiveness of antibiotic therapy were evaluated in 296 patients (133 males, 163 females; mean age 58.2 +/- 13.5 years) receiving HPN for at least 3 months, from January 1995 to December 2006. Patients underwent 99,969 (331 +/- 552; minimum 91, maximum 4353) days of catheterization, corresponding to 93,236 (311 +/- 489; minimum 52, maximum 4353) days of HPN.

RESULTS

Fifty-two patients (24 males and 28 females; 35 oncological and 17 nononcological) were diagnosed with 169 infections. The overall corresponding infection rate was 2.0 per 1000 days of catheterization, with a progressive, regular decrease with time. In 30 cases, immediate central venous catheter removal was necessary. Infections were eradicated in 103 of 139 (74%) cases. As to the most common causative agent, 86 (51%) infections were due to Staphylococcus epidermidis. Of these, 64 were treated from 1995 to 2004, 57 of them (89%) successfully; 22 were treated from 2005 onward, only 7 of them (32%) successfully.

CONCLUSIONS

Although the global infection rate has progressively decreased over the years, S epidermidis has shown an alarming increase in resistance to antibiotic treatment in the last 2 years, suggesting the need for strategies to prevent central venous catheter infection.

ESPEN Guidelines on Parenteral Nutrition: central venous catheters (access, care, diagnosis and therapy of complications)

When planning parenteral nutrition (PN), the proper choice, insertion, and nursing of the venous access are of paramount importance. In hospitalized patients, PN can be delivered through short-term, non-tunneled central venous catheters, through peripherally inserted central catheters (PICC), or - for limited period of time and with limitation in the osmolarity and composition of the solution - through peripheral venous access devices (short cannulas and midline catheters). Home PN usually requires PICCs or - if planned for an extended or unlimited time - long-term venous access devices (tunneled catheters and totally implantable ports). The most appropriate site for central venous access will take into account many factors, including the patient's conditions and the relative risk of infective and non-infective complications associated with each site. Ultrasound-guided venepuncture is strongly recommended for access to all central veins. For parenteral nutrition, the ideal position of the catheter tip is between the lower third of the superior cava vein and the upper third of the right atrium; this should preferably be checked during the procedure. Catheter-related bloodstream infection is an important and still too common complication of parenteral nutrition. The risk of infection can be reduced by adopting cost-effective, evidence-based interventions such as proper education and specific training of the staff, an adequate hand washing policy, proper choices of the type of device and the site of insertion, use of maximal barrier protection during insertion, use of chlorhexidine as antiseptic prior to insertion and for disinfecting the exit site thereafter, appropriate policies for the dressing of the exit site, routine changes of administration sets, and removal of central lines as soon as they are no longer necessary. Most non-infective complications of central venous access devices can also be prevented by appropriate, standardized protocols for line insertion and maintenance. These too depend on appropriate choice of device, skilled implantation and correct positioning of the catheter, adequate stabilization of the device (preferably avoiding stitches), and the use of infusion pumps, as well as adequate policies for flushing and locking lines which are not in use.

Home parenteral nutrition in advanced cancer: where are we?

Patients with advanced and incurable cancer are a compelling group. Questions and comments that these individuals and their families have may include: “My daughter is expecting our first grandchild in 3 months — can I hope to see our new family member?”; “I can’t keep any food down — is there anything I can do?”; “I am worried about losing so much weight, and feeling tired and weak — is there anything that may help?”; “Will I suffer a lot?”. Indeed, the most pressing concerns of the patient relate to predictions about survival and control of symptoms. The clinician taking care of the patient may wonder what is the utility or futility of home parenteral nutrition (HPN) in both the individual with advanced cancer and in this population of patients at large, whether there is potential for harm such as increasing the burden of care or prolonging suffering, and how to optimize care and communication with the patient and their families. The nutrition scientist may want to know what the implications of advanced cancer are on nutrient requirements and utilization, whether there are markers that would differentiate between cachexia and simple starvation, and whether it is possible to use specific nutrients to modify the disease process. This review will provide insights into the understanding of the role of HPN in advanced cancer and opportunities for further investigation.

Canadian home total parenteral nutrition registry: preliminary data on the patient population

BACKGROUND

Long-term administration of home total parenteral nutrition (HTPN) has permitted patients with chronic intestinal failure to survive for prolonged periods of time. However, HTPN is associated with numerous complications, all of which increase morbidity and mortality. In Canada, a comprehensive review of the HTPN population has never been performed.

OBJECTIVES

To report on the demographics, current HTPN practice and related complications in the Canadian HTPN population.

METHODS

This was a cross-sectional study. Five HTPN programs in Canada participated. Patients' data were entered by the programs' TPN team into a Web site-based registry. A unique confidential record was created for each patient. Data were then downloaded into a Microsoft Excel (Microsoft Corp, USA) spreadsheet and imported into SPSS (SPSS Inc, USA) for statistical analysis.

RESULTS

One hundred fifty patients were entered into the registry (37.9% men and 62.1% women). The mean (+/- SD) age was 53.0+/-14 years and the duration requiring HTPN was 70.1+/-78.1 months. The mean body mass index before the onset of HTPN was 19.8+/-5.0 kg/m(2). The primary indication for HTPN was short bowel syndrome (60%) secondary to Crohn's disease (51.1%), followed by mesenteric ischemia (23.9%).

COMPLICATIONS

over one year, 62.7% of patients were hospitalized at least once, with 44% of hospitalizations related to TPN. In addition, 28.6% of patients had at least one catheter sepsis (double-lumen more than single-lumen; P=0.025) and 50% had at least one catheter change. Abnormal liver enzymes were documented in 27.4% of patients and metabolic bone disease in 60% of patients, and the mean Karnofsky score was 63.

CONCLUSIONS

In the present population sample, the data suggest that HTPN is associated with significant complications and health care utilization. These results support the use of a Canadian HTPN registry to better define the HTPN population, and to monitor complications for quality assurance and future research.

Clinical outcome of long-term home parenteral nutrition in non-oncological patients: a report from two specialised centres

OBJECTIVE AND METHODS

Forty-one (20 m, 21 f) non-oncological home parenteral nutrition (HPN) patients (52.0+/-16.6 years, BMI 20.2+/-4.0 kg/m(2)), enrolled from 1995 to 2005, underwent a clinical and biochemical follow-up at 3 months, 1 and 3 years.

RESULTS

At admittance the Karnofsky Index ranged between 40 and 50 in 13 (31.7%) and 60 and 80 in 28 (68.3%) patients; the most frequent underlying disease was mesenteric infarction (11 patients, 27%). All had a central venous access. Mean catheterization days were 864+/-992, while mean HPN days were 630+/-668. At the 3-month follow-up, all patients were on HPN, at 1 year 24 (58.5%) and at 3 years 11 (27%). At 3 months, 1 and 3 years there was a significant increase in BMI (p=0.001), body weight (p=0.001) and Karnofsky Index (p=0.001), as well as an improvement of several biochemical parameters. Survival rate of HPN patients was 90.2% at 1 year, 87.8% at 3 years and 82.9% at 5 years. As to HPN-related complications, there was a central venous catheter (CVC) obstruction in 8 patients (19.5%) and 47 CVC infections in 24 (58.5%) patients. The infection rate was 1.32/(00) days of catheterization (1.8/(00) from 1995 to 1998 and 1.0/(00) from 1999 to 2005). Hospitalisation was necessary in over 50% of patients, and death occurred in 8, always as a consequence of the primary disease.

CONCLUSIONS

The experience of the nutritional team and careful patient and caregiver training reduce CVC infection rate and the overall risk of complications possibly due to HPN.

Determinants of quality of life in home parenteral nutrition

PURPOSE OF REVIEW

To highlight the most important and salient articles regarding home parenteral nutrition and quality of life published within the last 3 years.

RECENT FINDINGS

In recent years, quality of life research in home parenteral nutrition has highlighted the need for a therapy-specific validated questionnaire. Several papers suggest a greater psychological input is required to better understand and evaluate this patient population. Issues surrounding the use of home parenteral nutrition in malignancy have arisen, prompting discussion on ideal timing and candidacy for home parenteral nutrition. Intestinal transplantation is evolving and improving, making it a possible alternative to home parenteral nutrition. Earlier referral is suggested as late referral can result in poorer outcome.

SUMMARY

Home parenteral nutrition is a life-sustaining therapy for individuals with intestinal failure. There is now a relatively large amount of research into the quality of life in this population, but more focused measurements (in the form of validated therapy-specific questionnaires) are required to answer questions relating to cancer and intestinal transplantation.