1
|
Pironi L, Cuerda C, Jeppesen PB, Joly F, Jonkers C, Krznarić Ž, Lal S, Lamprecht G, Lichota M, Mundi MS, Schneider SM, Szczepanek K, Van Gossum A, Wanten G, Wheatley C, Weimann A. ESPEN guideline on chronic intestinal failure in adults - Update 2023. Clin Nutr 2023; 42:1940-2021. [PMID: 37639741 DOI: 10.1016/j.clnu.2023.07.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 07/21/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND & AIMS In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines. METHODS The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly. RESULTS The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%). CONCLUSIONS It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.
Collapse
Affiliation(s)
- Loris Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Center for Chronic Intestinal Failure, IRCCS AOUBO, Bologna, Italy.
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Francisca Joly
- Center for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Cora Jonkers
- Nutrition Support Team, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands
| | - Željko Krznarić
- Center of Clinical Nutrition, Department of Medicine, University Hospital Center, Zagreb, Croatia
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, United Kingdom
| | | | - Marek Lichota
- Intestinal Failure Patients Association "Appetite for Life", Cracow, Poland
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | | | - Geert Wanten
- Intestinal Failure Unit, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Carolyn Wheatley
- Support and Advocacy Group for People on Home Artificial Nutrition (PINNT), United Kingdom
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany
| |
Collapse
|
2
|
Nutritrauma: A Key Concept for Minimising the Harmful Effects of the Administration of Medical Nutrition Therapy. Nutrients 2019; 11:nu11081775. [PMID: 31374909 PMCID: PMC6723989 DOI: 10.3390/nu11081775] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 07/29/2019] [Accepted: 07/30/2019] [Indexed: 12/25/2022] Open
Abstract
Critically ill patients often require life support measures such as mechanical ventilation or haemodialysis. Despite the essential role of nutrition in patients’ recovery, the inappropriate use of medical nutrition therapy can have deleterious effects, as is the case with the use of respiratory, circulatory, or renal support. To increase awareness and to monitor the effects of inappropriate medical nutrition therapy, we propose to introduce the concept of nutritrauma in clinical practice, defined as metabolic adverse events related to the inappropriate administration of medical nutrition therapy or inadequate nutritional monitoring.
Collapse
|
3
|
Abstract
PURPOSE OF REVIEW This review discusses the monitoring aimed at achieving good long-term outcomes in people dependent on home parenteral nutrition (HPN). RECENT FINDINGS There have been recent studies highlighting the importance of treating low bone mineral density in HPN-dependent patients, methods of screening for liver disease, assessment of quality of life (QoL) and the need for early assessment for intestinal transplantation and growth factor therapy. SUMMARY High-quality HPN services require expert multidisciplinary teams with a focus on strict aseptic catheter care protocols alongside regular monitoring and management of clinical, laboratory and patient-related factors. Areas that should be considered in the routine monitoring of HPN include regular laboratory measurements, QoL, assessment for intestinal failure-associated liver disease, treatment of metabolic bone disease and consideration of evolving treatments, alongside management of any underlying condition leading to intestinal failure.
Collapse
Affiliation(s)
- Martyn Dibb
- Royal Liverpool University Hospital, Liverpool
| | - Simon Lal
- Salford Royal Hospital, Salford, England, UK
| |
Collapse
|
4
|
Davila J, Konrad D. Metabolic Complications of Home Parenteral Nutrition. Nutr Clin Pract 2017; 32:753-768. [DOI: 10.1177/0884533617735089] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Jamie Davila
- Center for Gut Rehabilitation and Transplantation Clinician, Cleveland Clinic, Cleveland, Ohio, USA
| | - Denise Konrad
- Home Nutrition Support Clinician, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
5
|
Pironi L, Arends J, Bozzetti F, Cuerda C, Gillanders L, Jeppesen PB, Joly F, Kelly D, Lal S, Staun M, Szczepanek K, Van Gossum A, Wanten G, Schneider SM. ESPEN guidelines on chronic intestinal failure in adults. Clin Nutr 2016; 35:247-307. [PMID: 26944585 DOI: 10.1016/j.clnu.2016.01.020] [Citation(s) in RCA: 445] [Impact Index Per Article: 55.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 01/27/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Chronic Intestinal Failure (CIF) is the long-lasting reduction of gut function, below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth. CIF is the rarest organ failure. Home parenteral nutrition (HPN) is the primary treatment for CIF. No guidelines (GLs) have been developed that address the global management of CIF. These GLs have been devised to generate comprehensive recommendations for safe and effective management of adult patients with CIF. METHODS The GLs were developed by the Home Artificial Nutrition & Chronic Intestinal Failure Special Interest Group of ESPEN. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds, and accepted in an online survey of ESPEN members. RESULTS The following topics were addressed: management of HPN; parenteral nutrition formulation; intestinal rehabilitation, medical therapies, and non-transplant surgery, for short bowel syndrome, chronic intestinal pseudo-obstruction, and radiation enteritis; intestinal transplantation; prevention/treatment of CVC-related infection, CVC-related occlusion/thrombosis; intestinal failure-associated liver disease, gallbladder sludge and stones, renal failure and metabolic bone disease. Literature search provided 623 full papers. Only 12% were controlled studies or meta-analyses. A total of 112 recommendations are given: grade of evidence, very low for 51%, low for 39%, moderate for 8%, and high for 2%; strength of recommendation: strong for 63%, weak for 37%. CONCLUSIONS CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for both the underlying gastrointestinal disease and to provide HPN support. The rarity of the condition impairs the development of RCTs. As a consequence, most of the recommendations have a low or very low grade of evidence. However, two-thirds of the recommendations are considered strong. Specialized management and organization underpin these recommendations.
Collapse
Affiliation(s)
- Loris Pironi
- Center for Chronic Intestinal Failure, Department of Digestive System, St. Orsola-Malpighi University Hospital, Bologna, Italy.
| | - Jann Arends
- Department of Medicine, Oncology and Hematology, University of Freiburg, Germany
| | | | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Lyn Gillanders
- Nutrition Support Team, Auckland City Hospital, (AuSPEN) Auckland, New Zealand
| | | | - Francisca Joly
- Centre for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Darlene Kelly
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA; Oley Foundation for Home Parenteral and Enteral Nutrition, Albany, NY, USA
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - Michael Staun
- Rigshospitalet, Department of Gastroenterology, Copenhagen, Denmark
| | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - André Van Gossum
- Medico-Surgical Department of Gastroenterology, Hôpital Erasme, Free University of Brussels, Belgium
| | - Geert Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Stéphane Michel Schneider
- Gastroenterology and Clinical Nutrition, CHU of Nice, University of Nice Sophia Antipolis, Nice, France
| | | |
Collapse
|
6
|
|
7
|
Adabala M, Jhaveri KD, Gitman M. Severe hyperkalaemia resulting from octreotide use in a haemodialysis patient. Nephrol Dial Transplant 2010; 25:3439-42. [DOI: 10.1093/ndt/gfq381] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
8
|
Antonelli D, Fares L, Anene C. Enoxaparin Associated with Huge Abdominal Wall Hematomas: A Report of Two Cases. Am Surg 2000. [DOI: 10.1177/000313480006600823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Enoxaparin is a low-molecular-weight heparin used for prophylaxis against deep venous thrombosis. Indications include hip and knee replacement surgery, risk of deep venous thrombosis during abdominal surgery, and prevention of ischemic complications of unstable angina and non-Q-wave myocardial infarction. Its efficacy in the prevention of the above complications has been previously studied; however, the liberal use of enoxaparin is not without incident. Complications of enoxaparin include hemorrhage, thrombocytopenia, and local reactions. Since 1993 there have been more than 40 reports of epidural or spinal hematoma formation with the concurrent use of enoxaparin and spinal/epidural anesthesia or spinal puncture. Herein reported are two cases of abdominal wall hematomas in patients receiving prophylaxis with enoxaparin. Both patients sustained an unexplained fall in the hematocrit and abdominal pain. A CT scan confirmed the diagnosis. One patient recovered uneventfully; however, the other patient, on chronic hemodialysis, became hemodynamically unstable and hyperkalemic and sustained a fatal cardiac arrhythmia. An extensive review of the literature revealed no similar cases of abdominal wall hematomas associated with enoxaparin although other complications, including spinal and epidural hematomas, psoas hematomas, and skin necrosis have been reported. The extended use of enoxaparin as an anticoagulant requires the physician to be vigilant of these rare complications. Bleeding can occur at any site during therapy with enoxaparin. An unexplained fall in the hematocrit or blood pressure should lead to a search for a bleeding site.
Collapse
Affiliation(s)
| | - Louis Fares
- St. Francis Medical Center, Trenton, New Jersey
| | | |
Collapse
|
9
|
Abstract
After 25 years, there is enough clinical outcome experience to determine appropriate use of home parenteral nutrition in different disease states and age groups. Information regarding how to avoid complications and how patients and families can find necessary psychosocial support is provided in this article. Currently, small bowel transplantation is not a safer choice, unless there is severe liver disease caused by home parenteral nutrition or lack of central intervenous access.
Collapse
Affiliation(s)
- L Howard
- Department of Medicine, Albany Medical College, New York, USA
| | | |
Collapse
|