Home Parenteral Nutrition Patients Research Articles

A snapshot of vitamin D deficiency in home parenteral nutrition patients in Northern England

A snapshot of vitamin D deficiency in home parenteral nutrition patients in Northern England

Causes and complications of tunnelled central venous catheter repairs in patients on home parenteral nutrition

Reliable vascular access devices are essential for the administration of home parenteral nutrition, therefore the ability to be able to repair damaged devices is of clinical benefit as it can mitigate the need to change the catheter. While there is published data to support the benefit of undertaking repairs with Pollack et al1 demonstrating that repair avoided the removal of 7% damaged catheters, details on the causes of catheter fracture and any subsequent catheter related complications post repair is lacking. This descriptive study aimed to outline the causes of catheter fracture and any subsequent catheter related complications in our cohort of home parenteral nutrition patients.

An evaluation of vitamin and mineral status of home parenteral nutrition patients at a home parenteral centre

The number of patients requiring home parenteral feeding (HPN) in the UK has increased significantly over the past 5 years, with a 200% increase in new home parenteral patients1. Patients requiring long-term HPN are at risk of developing micronutrient deficiencies, due to an increase in requirements, increased losses, or inadequate or inappropriate administration2. However there are limited studies looking at the correction and frequency of vitamin and trace element deficiencies in this population. The first aim of our study was establish if HPN patients were meeting recommended daily doses from parenteral feeding and daily multivitamin supplementation. The second aim of the study was to review the frequency of vitamin and mineral deficiencies and addition corrections in these patients over the course of one year.

Clinical outcomes of home parenteral nutrition patients using taurolidine as catheter lock: A long-term cohort study

Central venous access device (CVAD)-related complications, such as central-line associated bloodstream infections (CLABSIs), CVAD-related venous thromboses (CRVTs) and -occlusions frequently occur in home parenteral nutrition (HPN) patients. A preventive strategy to decrease the incidence of CLABSIs is the use of CVAD lock solutions, such as 2% taurolidine. The aim of this study was to evaluate long-term clinical outcomes of our HPN cohort while using taurolidine as lock solution. In addition, we explored risk factors associated with CVAD-related complications. We conducted a retrospective analysis of complications (CLABSIs, CRVTs and CVAD occlusions) and adverse events in adult HPN patients while using taurolidine as lock solution. Patients with a benign underlying disease leading to intestinal failure were included between 2006 and 2017at our tertiary referral centre for intestinal failure. Primary outcome was the effectiveness of taurolidine, as described by complication incidence rates. Secondary objectives were to assess adverse events of taurolidine, complication rates of patients who subsequently discontinued taurolidine and started using 0.9% saline alternatively, and risk factors associated with complications. In total, 270 HPN patients used taurolidine during 338521 catheter days. CLABSIs, CRVTs and CVAD occlusions occurred at a rate of 0.60 (CI95% 0.52-0.69), 0.28 (CI95% 0.23-0.34), and 0.12 (CI95% 0.08-0.16) events per 1000 catheter days, respectively. In 24 (9%) patients, mild to moderate adverse events resulted in discontinuation of 2% taurolidine. A subsequent switch to 0.9% saline resulted in an increased CLABSI rate (adjusted rate ratio 4.01 (95%CI 1.23-13.04), P=0.02). Several risk factors were identified for CLABSIs (a lower age, nontunneled catheters, infusion frequency), CRVTs (site of vein insertion), and CVAD occlusions (type of CVAD). Complication rates remained low in the long-term, and use of taurolidine was generally safe. The identified risk factors may help to create new strategies to further prevent CVAD-related complications and improve HPN care in the future.

Non-Antibiotic Antimicrobial Catheter Lock Solutions in Patients on Home Parenteral Nutrition.

Patients on home parenteral nutrition (HPN) are dependent on central venous access for long-term sustenance, and catheter-related bloodstream infections (CRBSIs) are a major cause of morbidity and mortality in this patient population. As such, there is much interest in finding new methods for preventing CRBSIs in patients on HPN. As it is thought that these infections are preceded by microbial colonization of the catheter, one approach is to use antimicrobial catheter lock solutions. Although antibiotic catheter lock solutions have been present for decades, their use has been mostly limited to the treatment of CRBSIs due to concern for promoting microbial resistance. Recently, however, with the advent of non-antibiotic antimicrobial catheter lock solutions, this approach is gaining popularity as a promising method to decrease rates of CRBSI in HPN patients.

Growth trajectory in paediatric home parenteral nutrition (HPN) patients- a single centre experience

Rationale: HPN patients have their PN tailored with the aim to achieve normal growth velocity. The aim of this study was to assess adequacy of weight and height trajectories in children on home parenteral nutrition (HPN) in a single centre.

A long term prospective study with peripherally inserted central catheters, tunneled catheters and ports in home parenteral nutrition

Rationale: Home parenteral nutrition (HPN) has become a common therapy, with tunneled central venous catheters (CVC) being preferred for its administration. Peripherally inserted central catheters (PICC) have been increasingly used but whether they should be preferred over other types of CVC is still controversial. We aimed to evaluate the catheter related complications of CVC in HPN patients.

No evidence for increased risk for candidaemia in the presence of polymorphisms in the CD58, LCE4A-CLORF68 and TAGAP loci in home parenteral nutrition patients

No evidence for increased risk for candidaemia in the presence of polymorphisms in the CD58, LCE4A-CLORF68 and TAGAP loci in home parenteral nutrition patients

Selected risk factors for atherosclerosis in home parenteral nutrition patients

Rationale: Inappropriate diet and eating habits as well as metabolic abnormalities could induce atherosclerosis development. Those are restrictively controlled in parenteral nutrition patients, but not in the healthy subjects. Common carotid artery intima-media thickness (CCA IMT) is now used as a marker of subclinical atherosclerosis. The aim of the present study is to clarify the relationship between parenteral nutrition and selected risk factors for atherosclerosis.

Small intestinal bacterial overgrowth, sepsis and diet affect liver function tests (LFTS) in home parenteral nutrition (HPN) patients: A Uk single-centre analysis

Small intestinal bacterial overgrowth, sepsis and diet affect liver function tests (LFTS) in home parenteral nutrition (HPN) patients: A Uk single-centre analysis

Rapid diagnosis of bloodstream infections in patients on home parenteral nutrition

Rationale: Home parenteral nutrition (HPN) patients have an increased risk of catheter-related bloodstream infections. Early identification of causative microorganism(s) is critical to optimize patient care and antimicrobial use. The droplet digital polymerase chain reaction (ddPCR) is a novel culture-independent molecular technique to rapidly identify pathogens in whole blood. The aim of this study was to measure the diagnostic accuracy of the ddPCR in the HPN-setting in comparison with the current gold standard blood cultures.

Swisshpn-Ii study: Intermediate results after one year focused on catheter and related complications

Rationale: Incidence of home parenteral nutrition (HPN) in Switzerland is about 4/a per 1 million inhabitants [1]. Although necessary, no representative national registry exists up to now to compare and evaluate treatments with other countries and healthcare systems. This SwissHPN-II study in adults implements a first, smaller, prospective study from 2013/2014 (SwissHPN-I) [1] to get a robust national registry. This study aims to characterize adult Swiss HPN patients, their underlying diseases, HPN indications and complications, and living conditions. This intermediate analysis focusses on PN catheters and related complications, including regimen after half of the study period.

Prevalence of splenomegaly and thrombocytopenia in paediatric home parenteral nutrition patients

Prevalence of splenomegaly and thrombocytopenia in paediatric home parenteral nutrition patients

Patient Experience in the Transition of Home Parenteral Nutrition Services Between Centers: Evaluation of a Transition Model.

Background:In 2014, Dudley Group of Hospitals (DGH) underwent an organizational change that necessitated closure of their Home Parenteral Nutrition (HPN) service. University Hospitals Birmingham NHS Foundation Trust (UHBFT) transitioned 50 patients from DGH into their HPN service. The transition model included communication with patients, communication between centers (development of an HPN Patient Passport), and rapid follow-up on transition ensuring clinical care continued uninterrupted.Aim:Evaluate patient experience and their level of satisfaction with our HPN transition model.Method:A 19-point, mixed mode paper-based questionnaire was developed. Questionnaires were posted to 42 surviving patients still receiving HPN.Results:Response rate: 67%. Communication with patients: The transition was discussed with them, and they had appropriate contact details during the process—94%. Patients informed of patient transition meetings—97%. Attendance at meetings: DGH 89%, UHBFT 55%. Ongoing care at UHBFT: 86% very satisfied and 11% satisfied. Overall rating of the transition process: 79% very satisfied and 14% satisfied. Friends and Family Test: 82% “extremely likely” and 18% “likely” to recommend our services.Conclusion:The transition model used was successful, with the majority of patients “very satisfied” with how the transition was managed and their ongoing care. Effective communication with patients and between the 2 centers was the key to success. To our knowledge, this is the first report of transition of care for HPN patients. It is proposed that this model may be used by other centers to plan for future HPN service transitions where necessary.

Indications and outcomes of home parenteral nutrition in patients with an ileoanal pouch.

Restorative proctocolectomy is a surgical treatment for patients with medically refractory ulcerative colitis and some cases of familial adenomatous polyposis. Intestinal failure, defined as an inability to maintain adequate hydration and micronutrient balances when on a conventionally accepted normal diet, is a rare complication of restorative proctocolectomy. We describe our experience of patients with restorative proctocolectomy who have developed intestinal failure requiring parenteral support. This was a retrospective analysis using a database of patients referred to our intestinal failure unit from January 1998 to January 2016. We analysed the records of all those patients who had restorative proctocolectomy who developed intestinal failure. 807 patient records analysed, 35 patients were found to have had a restorative proctocolectomy (13 male and 22 female). Ninety-one percent (n = 32) of patients developed IF as a consequence of unpredictable complications which occurred after RPC formation. Potentially predictable complications were noted in 9% (n = 3) of patients. Most cases of intestinal failure in restorative proctocolectomy were unpredictable. In a small number of patients, accurate assessment and measurement of the small intestine may have better predicted the adverse outcome of intestinal failure allowing improved pre-operative counseling of patients.

Repair of damaged central venous catheters is safe and doubles catheter survival: a home parenteral nutrition patient cohort study

Repeated central venous catheter loss due to complications, including material breakage, compromises the options to obtain adequate vascular access in home parenteral nutrition (HPN) patients. It remains unclear whether repair of damaged catheters is an effective strategy to extend catheter survival, avoid surgical replacement and maintain venous access. The aim of this study was to evaluate the effectiveness and safety of catheter repair in our cohort of intestinal failure patients. We conducted a retrospective analysis of all catheter repairs that were performed between 2006 and 2017at our tertiary referral centre for intestinal failure. Primary outcome was the additional median catheter survival after catheter repair, as calculated with Kaplan-Meier analyses. Secondary outcomes included risk for central line-associated bloodstream infections (CLABSIs) and risk factors for catheter damage, as calculated with Poisson regression analyses. CLABSI rates in post-repair periods were compared with pre-repair periods. Pre- and post-repair periods were either short-term (30 days), or long-term (whole catheter period). A total of 58 repairs in 41 catheters of 35 HPN patients were included in the analysis. The median time to first repair was 452 days (interquartile range (IQR) 206-1134). After first repair, catheter survival additionally increased by 510 days (IQR 147-1195). Repairs did not increase the short-term risk for CLABSIs: incidence rates were 1.23 and 1.26 CLABSIs/1000 catheter days for the 30 days pre- and post-repair periods, respectively (rate ratio, 1.05; 95%CI, 0.15-7.44; P=0.96). For the whole pre- and post-repair catheter period, incidence rates were 0.12 and 0.59 CLABSIs/1000 catheter days, respectively (rate ratio, 3.55; 95%CI, 1.10-11.45; P=0.03). The overall CLABSI incidence rates in undamaged versus repaired catheters were 0.84 and 0.31 CLABSIs/1000 catheter days, respectively (rate ratio, 0.47; 95%CI, 0.23-0.94; P=0.03). A lower age at catheter start and femoral catheterization were associated with a higher risk for catheter damage. Repair of damaged catheters is often successful and an effective strategy to prolong and maintain venous access in HPN patients. On the short-term, no increase in CLABSI incidence was observed. Despite a possible increase in CLABSI incidence on the long-term, overall CLABSI rates of repaired catheters remained well below the overall CLABSI incidence of undamaged catheters. Theidentification of two risk factors for catheter damage may help to prevent future catheter damage.

Randomised clinical trial: 2% taurolidine versus 0.9% saline locking in patients on home parenteral nutrition.

SummaryBackgroundThe catheter lock solutions 2% taurolidine and 0.9% saline are both used to prevent catheter‐related bloodstream infections (CRBSIs) in home parenteral nutrition patients.AimsTo compare the effectiveness and safety of taurolidine and saline.MethodsThis multicentre double‐blinded trial randomly assigned home parenteral nutrition patients to use either 2% taurolidine or 0.9% saline for 1 year. Patients were stratified in a new catheter group and a pre‐existing catheter group. Primary outcome was the rate of CRBSIs/1000 catheter days in the new catheter group and pre‐existing catheter group, separately.ResultsWe randomised 105 patients, of which 102 were analysed as modified intention‐to‐treat population. In the new catheter group, rates of CRBSIs/1000 catheter days were 0.29 and 1.49 in the taurolidine and saline arm respectively (relative risk, 0.20; 95% CI, 0.04‐0.71; P = 0.009). In the pre‐existing catheter group, rates of CRBSIs/1000 catheter days were 0.39 and 1.32 in the taurolidine and saline arm respectively (relative risk, 0.30; 95% CI, 0.03‐1.82; P = 0.25). Excluding one outlier patient in the taurolidine arm, mean costs per patient were $1865 for taurolidine and $4454 for saline (P = 0.03). Drug‐related adverse events were rare and generally mild.ConclusionsIn the new catheter group, taurolidine showed a clear decrease in CRBSI rate. In the pre‐existing catheter group, no superiority of taurolidine could be demonstrated, most likely due to underpowering. Overall, taurolidine reduced the risk for CRBSIs by more than four times. Given its favourable safety and cost profile, taurolidine locking should be considered as an additional strategy to prevent CRBSIs. Trial registration: Clinicaltrials.gov, identifier: NCT01826526.

Long-term Staphylococcus aureus decolonization in patients on home parenteral nutrition: study protocol for a randomized multicenter trial

BackgroundPatients with long-term intestinal failure are usually treated by means of home parenteral nutrition (HPN) where they administer their nutritional formulation intravenously via a central venous access device (mostly a catheter). This implies that such patients are exposed to a lifelong risk of developing Staphylococcus aureus bacteremia (SAB). SAB poses a threat to both catheter and patient survival and may lead to frequent hospitalization and a permanent loss of vascular access. In other clinical settings, S. aureus carriage eradication has been proven effective in the prevention of S. aureus infections. Unfortunately, there is a complete lack of evidence in HPN support on the most effective and safe S. aureus decolonization strategy in S. aureus carriers. We hypothesized that long-term S. aureus decolonization in HPN patients can only be effective if it is aimed at the whole body (nasal and extra-nasal) and is given chronically or repeatedly on indication. Besides this, we believe that S. aureus carriage among caregivers, who are in close contact with the patient, are of great importance in the S. aureus transmission routes.Methods/designThe CARRIER trial is a randomized, open-label, multicenter clinical trial in Dutch and Danish hospitals that treat patients on HPN. A total of 138 adult HPN patients carrying S. aureus will be randomly assigned to a search and destroy (SD) strategy, a quick and short, systemic antibiotic treatment, or a continuous suppression (CS) strategy, a repeated chronic topical antibiotic treatment. The primary outcome measure is the proportion of patients in whom S. aureus is totally eradicated during a 1-year period. Secondary outcomes are time to successful eradication, long-term antimicrobial resistance, adverse events, patient compliance, incidence of (S. aureus) infections, catheter removals, mortality rates, S. aureus transmission routes, quality of life, and health care costs.DiscussionThe CARRIER trial is designed to identify the most safe and effective long-term S. aureus carriage decolonization strategy in HPN patients. This will eventually lead to a better understanding of long-term S. aureus decolonization treatments in general. The results of this study will have a great impact on our daily clinical practice, which eventually may result in less S. aureus-related infections.Trial registrationClinicalTrials.gov; NCT03173053. Registered on 1 June 2017.

Effect of changing the lipid component of home parenteral nutrition in adults

The effect of different lipid emulsions (LEs) within the parenteral nutrition (PN) regimen of adult home PN (HPN) patients is not clear. This study investigated the effect of changing adult HPN patients from a soybean oil based LE (Intralipid) to either a fish oil containing LE (providing n-3 fatty acids) (SMOFLipid) or an olive oil based LE (ClinOleic). Thirty two adults receiving long-term HPN with Intralipid as the LE were transferred to receive either SMOFLipid (n=13) or ClinOleic (n=19) for 60 days. Liver function markers, cholesterol, triglycerides, a full profile of fatty acids, and several cytokines were measured at study entry and after 60 days. SMOFLipid did not affect liver function markers, blood lipids or plasma cytokines. ClinOleic lowered both gamma-glutamyltranspeptidase (P=0.044) and interleukin-8 (P=0.030) concentrations. Both LEs induced marked changes in the fatty acid profile of plasma. SMOFLipid resulted in significant decreases in the proportions of linoleic acid, several other n-6 fatty acids and the essential fatty acid (EFA) deficiency indicator mead acid and significant increases in the proportions of the n-3 fatty acids eicosapentaenoic acid and docosahexaenoic acid. ClinOleic resulted in significant decreases in the proportions of some saturated fatty acids, linoleic acid, several n-6 fatty acids, all n-3 fatty acids and mead acid and a significant increase in the proportion of oleic acid. The ratio of mead to arachidonic acid in plasma was not altered by either SMOFLipid or ClinOleic. No patient had a mead acid to arachidonic acid ratio of >0.2, the cut-off used to indicate EFA deficiency. Both SMOFLipid and ClinOleic significantly alter the fatty acid profile of plasma in adult HPN patients previously using Intralipid. Neither LE induces EFA deficiency in these patients. SMOFLipid did not alter liver function markers or inflammation. In contrast, ClinOleic decreased some, though not all, markers of liver function and inflammation. SMOFLipid and ClinOleic may both be considered for use in adult HPN patients.

Virtual Telemedicine Visits in Pediatric Home Parenteral Nutrition Patients: A Quality Improvement Initiative.

Despite being less costly than prolonged hospitalization, home parenteral nutrition (HPN) is associated with high rates of post-discharge complications, including frequent readmissions and central line-associated bloodstream infections (CLABSIs). Telemedicine has been associated with improved outcomes and reduced healthcare utilization in other high-risk populations, but no studies to date have supported effectiveness of telemedicine in pediatric HPN. We prospectively collected data on pediatric patients managed at a single HPN program who participated in postdischarge telemedicine visits from March 1, 2014 to March 30, 2016. We excluded patients with a history of HPN and strictly palliative care goals. Univariate analysis was performed for primary outcomes: Community-acquired CLABSI and 30-day readmission rate. Twenty-six families participated in the pilot initiative with median (interquartile range) patient age 1.5 (5.7) years old, diagnosis of short bowel syndrome in 16 (62%), and in-state residence in 17 (55%). Ishikawa (fishbone) diagram identified causes of post-discharge HPN complications. Areas of focus during telemedicine visit included central venous catheter care methods, materials, clinical concerns, and equipment. Compared to historical comparison group, the telemedicine group experienced CLABSI rates of 1.0 versus 2.7 per 1,000 line days and readmission rates of 38% versus 17% (p = 0.03, 0.02, respectively). Telemedicine visits identified opportunities for improvement for families newly discharged on HPN. In a small cohort of patients who experienced telemedicine visits, we found lower CLABSI rates alongside higher readmission rates compared with a historical comparison group. Further studies are needed to optimize telemedicine in delivering care to this high-risk population.