Home Parenteral Nutrition Patients Research Articles

A retrospective examination of risk factors for central line-associated bloodstream infections in home parenteral nutrition patients from a Queensland tertiary hospital.

Central line-associated bloodstream infections (CLABSIs) are a potential complication for home parenteral nutrition (HPN) patients. We sought to analyse risk factors of developing HPN-related CLABSI and assess CLABSI management in the Australian context. A retrospective observational cohort study was conducted on 34 adult patients receiving HPN via a central venous catheter (CVC) at a Queensland tertiary referral centre between 2016 and 2023. Patient charts were reviewed, and Kaplan-Meier analysis was employed to determine associations between characteristics and time to CLABSI in the first CVC using Peto-Peto Prentice test. A total of 39 CLABSI episodes occurred in 19 patients. Patients with ≥1 CLABSI used regular opioids more than those without CLABSI (P = 0.016). Fourteen (41%, n = 14/34) patients developed a CLABSI in their first CVC. No patient or line characteristics were found to be predictive of CLABSI in their first CVC. The CLABSI rate was 1.02/1000 catheter days. Most CLABSIs were caused by Enterobacterales (22%, n = 12/55) and Candida sp. (22%, n = 12/55). Empiric antimicrobial therapy was adequate in only 25% (n = 7/28), and the median time to effective antibiotic therapy was 22.7 h (interquartile range 4.8-29.8). There were three successful CVC salvages (8%, n = 3/39). In this cohort of patients, regular opioid use was associated with increased risk of developing CLABSI. Based on our findings, an empiric antimicrobial regime of vancomycin, cefepime and caspofungin will provide adequate coverage for most HPN-related CLABSIs in Australian IF units with a similar antimicrobial distribution and resistance pattern.

Catheter Selection in Home Parenteral Nutrition Patients and Noteworthy Definitions in The Diagnosis of Catheter Infections

The rising number of patients in need of long-term parenteral nutrition has necessitated home parenteral nutrition. Extended usage of central venous catheters and parenteral nutrition has given rise to its own complications. Among them, catheter-related bloodstream infections (CRBSI) are linked to life-threatening complications, especially sepsis, septic shock, and metastatic infections. The principal objective of this review is to define diagnostic methods, notable clinical and laboratory findings, and catheter salvage strategies towards preventing CRBSI, which include defining and interpreting blood culture and its results, its confounding variables and common shortcomings in routine practice. We will discuss the types and relative advantages and disadvantages of differing methods of central venous access and compare the common diagnostic definitions used by existing guidelines. CRBSI remains a serious complication, and we aim to debate when timely intervention will be necessary in light of the existing literature.

Avoiding the use of long-term parenteral support in patients without intestinal failure: A position paper from the European Society of Clinical Nutrition & Metabolism, the European Society of Neurogastroenterology and Motility and the Rome Foundation for Disorders of Gut-Brain Interaction.

The role of long-term parenteral support in patients with underlying benign conditions who do not have intestinal failure (IF) is contentious, not least since there are clear benefits in utilising the oral or enteral route for nutritional support. Furthermore, the risks of long-term home parenteral nutrition (HPN) are significant, with significant impacts on morbidity and mortality. There has, however, been a recent upsurge of the use of HPN in patients with conditions such as gastro-intestinal neuromuscular disorders, opioid bowel dysfunction, disorders of gut-brain interaction and possibly eating disorders, who do not have IF. As a result, the European Society of Clinical Nutrition and Metabolism (ESPEN), the European Society of Neuro-gastroenterology and Motility (ESNM) and the Rome Foundation for Disorders of Gut Brain Interaction felt that a position statement is required to clarify - and hopefully reduce the potential for harm associated with - the use of long-term parenteral support in patients without IF. Consensus opinion is that HPN should not be prescribed for patients without IF, where the oral and/or enteral route can be utilised. On the rare occasions that PN commencement is required to treat life-threatening malnutrition in conditions such as those listed above, it should only be prescribed for a time-limited period to achieve nutritional safety, while the wider multi-disciplinary team focus on more appropriate biopsychosocial holistic and rehabilitative approaches to manage the patient's primary underlying condition.

Feasibility of home parenteral nutrition in patients with intestinal failure due to small bowel neuroendocrine tumours: a systematic review

Feasibility of home parenteral nutrition in patients with intestinal failure due to small bowel neuroendocrine tumours: a systematic review

Prevalence of probable sarcopenia in home parenteral nutrition (PN) patient attending to intestinal failure clinic in a national home parenteral nutrition center

Prevalence of probable sarcopenia in home parenteral nutrition (PN) patient attending to intestinal failure clinic in a national home parenteral nutrition center

Review of catheter-related blood stream infections for home parenteral nutrition patients who have district nurses to administer their parenteral nutrition; 10 year experience of an HPN centre in England

Review of catheter-related blood stream infections for home parenteral nutrition patients who have district nurses to administer their parenteral nutrition; 10 year experience of an HPN centre in England

The clinical impact of using commercially available multi-chamber bags compared to bespoke manufactured bags for home parenteral nutrition patients with chronic Intestinal Failure

The clinical impact of using commercially available multi-chamber bags compared to bespoke manufactured bags for home parenteral nutrition patients with chronic Intestinal Failure

Avoiding the use of long-term parenteral support in patients without intestinal failure: A position paper from the European Society of Clinical Nutrition & Metabolism, the European Society of Neurogastroenterology and Motility and the Rome Foundation for Disorders of Gut–Brain Interaction

The role of long-term parenteral support in patients with underlying benign conditions who do not have intestinal failure (IF) is contentious, not least since there are clear benefits in utilising the oral or enteral route for nutritional support. Furthermore, the risks of long-term home parenteral nutrition (HPN) are significant, with significant impacts on morbidity and mortality. There has, however, been a recent upsurge of the use of HPN in patients with conditions such as gastro-intestinal neuromuscular disorders, opioid bowel dysfunction, disorders of gut-brain interaction and possibly eating disorders, who do not have IF. As a result, the European Society of Clinical Nutrition and Metabolism (ESPEN), the European Society of Neuro-gastroenterology and Motility (ESNM) and the Rome Foundation for Disorders of Gut Brain Interaction felt that a position statement is required to clarify - and hopefully reduce the potential for harm associated with – the use of long-term parenteral support in patients without IF.Consensus opinion is that HPN should not be prescribed for patients without IF, where the oral and/or enteral route can be utilised. On the rare occasions that PN commencement is required to treat life-threatening malnutrition in conditions such as those listed above, it should only be prescribed for a time-limited period to achieve nutritional safety, while the wider multi-disciplinary team focus on more appropriate biopsychosocial holistic and rehabilitative approaches to manage the patient’s primary underlying condition.

The Czech Home Parenteral Nutrition Registry REDNUP: Comprehensive Analysis of Adult Patients’ Data

Introduction: Home parenteral nutrition (HPN) is the primary treatment modality for patients with chronic intestinal failure, one of the least common organ failures. This article provides a retrospective analysis of the data collected on HPN patients in the Czech Republic over the past 30 years. Methods: National registry data were collected using a standardised online form based on the OASIS registry (Oley – A.S.P.E.N. Information System) across all centres providing HPN in the Czech Republic. Data collected prospectively from adult patients in the HPN program were analysed in the following categories: epidemiology, demographics, underlying syndrome, diagnosis, complications, and teduglutide therapy prevalence. Results: The registry identified a total of 1,838 adult patient records, reflecting almost 1.5 million individual catheter days. The prevalence of HPN has risen considerably over the last few decades, currently reaching 5.5 per 100,000 population. The majority of patients have short bowel syndrome and GI obstruction, with cancer being the most prevalent underlying disease. Catheter-related bloodstream infections have been the most prevalent acute complication. However, the incidence in 2022 was only 0.15 per 1,000 catheter days. The study also observed an increase in the prevalence of patients on palliative HPN over the last decade. Conclusion: This study presents a thorough analysis of data from the Czech REgistr Domaci NUtricni Podpory (REDNUP) registry. It shows an increasing prevalence of HPN, namely, in the palliative patient group. The sharing of national data can improve understanding of this rare condition and facilitate the development of international guidelines.

A98 EFFECT OF A PROLONGED MULTIVITMAIN SHORTAGE ON HOME PARENTERAL NUTRITION PATIENTS: SINGLE CENTRE EXPERIENCE

Abstract Background Multivitamin shortages in home parenteral nutrition (HPN) are scarce but have a significant impact on patient morbidity. Recently, Ontario, Canada experienced a HPN intravenous multivitamin shortage that lasted over 3 months. As per the American Society of Parenteral and Enteral Nutrition (ASPEN) guidelines, patients were instructed to use an over-the-counter multivitamin supplement during the shortage. However, due to the nature of HPN patients, the risk for malnutrition related complications remains high, specifically thiamine deficiency. Aims This study aims to assess the relationship between the multivitamin shortage and thiamine deficiency. We conducted an analysis before and after the intravenous multivitamin shortage in HPN patients and compared anthropometric, biochemical and clinical outcomes in those who followed the oral multivitamin recommendation versus those who did not. Methods This retrospective descriptive study included HPN patients in a single-centre program in Toronto, Canada who required HPN ≥ 5 days/week. These patients were followed throughout the multivitamin shortage which lasted from February - June 2023. Patients were categorized into two groups: those who consumed an oral multivitamin and those who did not. Clinical and biochemical data were collected pre and post-multivitamin shortage. Data was collected on compliance with taking oral multivitamins. The primary outcome was the presence of any adverse clinical outcome related to a micronutrient deficiency. Results Twenty-five HPN patients were included. 56% (n=14) of patients were compliant with oral multivitamin usage and met the ASPEN recommendations for supplementation. Compliant patients were significantly older and were on significantly longer duration of HPN. Two patients were diagnosed with WE and had brief hospitalizations. Both patients experienced complete resolution of their symptoms after treatment with high-dose thiamine. Hence, compliance with oral multivitamins did not correlate to developing WE. The median time from the shortage to the development of WE was 2 months. Though not statistically significant, those who developed WE were more likely to be female, utilized a venting gastrostomy tube, and utilized HPN for longer. Conclusions Complications related to micronutrient deficiency are rare in the HPN population but shortages in intravenous multivitamins can increase the risk of conditions such as WE. In our study, compliance with oral multivitamins did not guarantee protection from developing adverse outcomes, likely due to limitations in absorption due to altered gastrointestinal anatomy. A regimented protocol for screening should be implemented in HPN patients, especially during long shortages of key HPN components like multivitamins. Funding Agencies None

Ready-to-Use Multichamber Bags in Home Parenteral Nutrition for Patients with Advanced Cancer: A Single-Center Prospective Study.

Home parenteral nutrition (HPN) is increasingly prescribed for patients with advanced cancer. This therapy improves free-fat mass, quality of life and survival, but it is not free from complications, especially catheter-related bloodstream infections (CRBSIs). The use of commercial multichamber bags in HPN has not been extensively explored in oncologic patients and their association with complications is not well known. In this prospective cohort study, we included 130 patients with advanced cancer and HPN. We compared the effects of individual compounded bags (n = 87) vs. commercial multichamber bags (n = 43) on complications. There were no differences in any complication, including thrombosis (p > 0.05). There were 0.28 episodes of CRBSI per 1000 catheter days in the individual compounded bag group and 0.21 in the multichamber bag group (p > 0.05). A total of 34 patients were weaned off HPN, 22 with individual bags and 12 with multichamber bags (p = 0.749). Regarding survival when on HPN, the group with individual bags showed a median of 98 days (95% CI of 49-147), whereas those with multichamber bags showed a median of 88 days (95% CI of 43-133 (p = 0.913)). In conclusion, commercial multichamber bags for HPN in patients with advanced cancer are non-inferior when compared to individual compounded bags in terms of complications.

Suspected case of vitamin C deficiency in a home parenteral nutrition patient

Suspected case of vitamin C deficiency in a home parenteral nutrition patient

Superior vena cava syndrome in chronic intestinal failure patients: When the going gets tough

Catheter-related venous thrombosis is a severe complication of home parenteral nutrition (HPN) with potentially devastating consequences such as superior vena cava syndrome (SVCS). Early recognition and awareness of factors leading to its development are of paramount importance. However, studies are lacking in HPN patients focusing on this topic. In this study, we aimed to determine the incidence of SVCS in HPN patients and describe SVCS-related outcomes. This retrospective cohort study comprised all adult HPN patients who developed SVCS between 2000 and 2022 at our national HPN referral center. Primary outcome was the incidence of SVCS. Secondary outcomes include SVCS-related symptoms, tip location of central venous access device (CVAD) post-insertion and at time of SVCS, diagnostics and treatment. SVCS was diagnosed in 38 of 616 patients (6%), with an annual cumulative incidence rate ranging between 0 and 4.2%. Most common presenting symptoms were facial edema (82%) and arm edema (50%). Post-insertion, 17% (6/36) of patients had a correct position of the CVAD tip and 11% (4/36) during SVCS diagnosis. Computed tomography was the most used diagnostic imaging technique (66%). Sixty-three percent of patients started, 11% switched, and 21% continued anticoagulant treatment. The incidence of SVCS is relatively high in our vulnerable HPN population. It is key to recognize whenever such patients present with vascular obstruction-related symptoms and treat them in an early stage by a multidisciplinary team.

Feasibility of home parenteral nutrition in patients with intestinal failure due to small intestinal neuroendocrine tumours: a systematic review

Feasibility of home parenteral nutrition in patients with intestinal failure due to small intestinal neuroendocrine tumours: a systematic review

Non-interventional, 5-year retrospective data of home parenteral nutrition in patients with benign chronic intestinal failure: Analysis of an Italian nurse registry (SERECARE II)

ObjectiveThis study is an assessment of home parenteral nutrition service performance and safety and efficacy outcomes in patients with benign chronic intestinal failure. MethodsThis is a retrospective, non-interventional, and multicenter study. Data were collected by trained nurses and recorded in a dedicated registry (SERECARE). ResultsFrom January 1, 2013 to June 30, 2018, data from a total of 683 patients with benign chronic intestinal failure were entered in the registry. Patients included 208 pediatric (53.8% male; median age = 4.0 y) and 475 adult (47.6% male; median age = 59.0 y) participants. On average, patients were visited 5.4 ± 4.5 times and received 1.4 ± 0.8 training sessions. Retraining was not common and mostly due to change of therapy or change of caregiver. Of 939 complications, 40.9% were related to the central venous catheter and were mostly infectious (n = 182) and mechanical (n = 187). The rate of infectious and mechanical complications per 1000 catheter days decreased over 5 y (0.30–0.15 and 0.33 –0.19, respectively). The rate of complications per 1000 catheter days and the mean complications per patient were higher in pediatric than in adult patients. The hospitalization rate was 1.01 per patient throughout the study period. These data were similar to those registered in a previous study period (2002–2011) (n = 1.53 per patient). Changes over time in the efficacy variables were mostly small and non-significant. ConclusionsThis study confirms the importance of setting up and maintaining structured registries to monitor and improve home parenteral nutrition care. Safety outcomes have improved over the years, most likely due to the underlying efficient nursing service.

Monitoring manganese levels in Home Parenteral Nutrition patients- Does it mean anything?

Monitoring manganese levels in Home Parenteral Nutrition patients- Does it mean anything?

Central venous catheter (CVC) salvage in case of central line-associated bloodstream infection (CLABSI): A monocentric prospective study in patients on long-term home parenteral nutrition (HPN)

CLABSI is a major complication in HPN and frequently leads to central venous catheter (CVC) removal. We developed a salvaging attitude in long term HPN patients due to the necessity of venous preservation. The main objective of this study is to determine the prognosis of CLABSI. We followed-up for three months, in an approved HPN centre, a cohort of 250 adult patients receiving HPN with CLABSI from 2018 to 2020. CLABSI was defined by a blood culture growth differential [peripheral blood] - [CVC blood]≥2h. A therapeutic approach to conserve CVC was established according to the department's protocol. The primary endpoint was conservation of CVC with negative CVC and peripheral blood cultures at 3 months without complications. Data from 30 CLABSIs were collected for 22 HPN patients. The incidence rate of CLABSIs was 0.28 infections/1000 catheter days. Sixteen CVCs were removed immediately, with causes due to the type of germ (staphylococcus aureus: n=6, candida parapsilosis: n=4, klebsiella: n=2), chronic colonization (n=4) or initial complications (n=4). Among the 14 non-removed CVC, 11 were maintained at 3 months with blood cultures on CVC and peripheral negative for 9 (80%) of them. 3 CVC were removed during the 3 months follow-up (non-CVC-related sepsis n=2, and resistant pseudomonas aeruginosa n=1). The incidence rate of CLABSIs in an expert HPN centre remains low. In case of CLABSIs, according to specific protocol, approximately 50% of CVC were removed immediately (essentially due to bacteriological characteristics). In case of CLABSIs and without initial complication, 80% of CVCs can be maintained at 3 months. These results justify a conservative attitude according to standardized protocol.

Feasibility of Home Parenteral Nutrition in Patients with Intestinal Failure Due to Neuroendocrine Tumours: A Systematic Review.

Maintaining adequate nutritional status can be a challenge for patients with small bowel neuroendocrine tumours (NETs). Surgical resection could result in short bowel syndrome (SBS), whilst without surgical resection there is a considerable risk of ischemia or developing an inoperable malignant bowel obstruction (IMBO). SBS or IMBO are forms of intestinal failure (IF) which might require treatment with home parenteral nutrition (HPN). Limited data exist regarding the use of HPN in patients with small bowel neuroendocrine tumours, and it is not frequently considered as a possible treatment. A systematic review was performed regarding patients with small bowel NETs and IF to report on overall survival and HPN-related complications and create awareness for this treatment. Five articles regarding patients with small bowel NETs or a subgroup of patients with NETs could be identified, mainly case series with major concerns regarding bias. The studies included 60 patients (range 1-41). The overall survival time varied between 0.5 and 154 months on HPN. However, 58% of patients were alive 1 year after commencing HPN. The reported catheter-related bloodstream infection rate was 0.64-2 per 1000 catheter days. This systematic review demonstrates the feasibility of the use of HPN in patients with NETs and IF in expert centres with a reasonable 1-year survival rate and low complication rate. Further research is necessary to compare patients with NETs and IF with and without HPN and the effect of HPN on their quality of life.

Challenges of Home Parenteral Nutrition for Patients with Advanced Cancer

Context: Advanced cancer is one of the most complicated conditions for both patients and their relatives. This study aimed at investigating the challenges of home parenteral nutrition (HPN) in patients with advanced cancer. Evidence Acquisition: In this study, all articles published in English from 2000 to 2022 on dietary support for HPN in patients with advanced cancer were collected from several databases, including Medline, Scopus, and Google Scholar, using related keywords such as “advanced cancer” and “home parenteral nutrition”. Results: The different issues of HPN were examined for different dimensions such as HPN during palliative care, deciding HPN, patients’ safety, supportive environment, and health literacy. Regarding ethical issues on HPN, 4 principles including charity, autonomy, harmlessness, and justice should be considered in patients with advanced cancer. Considering recent findings on the beneficial effects of nutrients in patients with advanced cancer, there may be a need to revise the guidelines related to parenteral nutrition support in these patients. Conclusions: Different challenges should be especially considered in adopting appropriate approaches in the field of HPN in patients with advanced cancer. More longitudinal studies in this field are needed.

A multi-national survey of experience and attitudes towards managing catheter related blood stream infections for home parenteral nutrition

Catheter-related bloodstream infection (CRBSI) is the most common complication of home parenteral nutrition (HPN) in patients with chronic intestinal failure (CIF). The aim of this study was to assess the broad range of practices of international multi-disciplinary teams involved in the care of this complication occurring in CIF patients. An online questionnaire was designed and distributed to members of the European Society for Clinical Nutrition and Metabolism (ESPEN) and distributed to colleagues involved in managing patients with CIF. A total of 47 responses were included from centers across 21 countries. The centers had been delivering HPN for a median 21 years (IQR 11-35) and were actively following a median 58 patients (27-120) per center for benign CIF in 80% of cases (67-95). Tunneled catheters were the most common type of central venous catheters (CVC), representing 70% (47-86) of all CVC in use. For the management of CRBSI, written procedures were provided in 87% of centers. First measures included simultaneous central and peripheral blood cultures (90%), stopping HPN infusion (74%), and administrating an antibiotic lock and systemic antibiotics (44%). Immediate removal of the CVC was more likely in case of fungal infection (78%), Staphylococcus aureus (53%), or in case of PICC catheter (52%) (all p<0.01). After the first CRBSI, 80% of centers used preventive CVC locks (taurolidine in 84% of cases, p<0.001). We observed a large heterogeneity in practices regarding preparation, duration, reaspiration, and volume of CVC locks, and monitoring of CRBSI (timing of blood cultures, radiological work-up). In this international survey of HPN expert centers, we observed a significant consensus regarding the initial management of CRBSI and the use of secondary preventive CVC locks, while areas of variation exist. Management of CRBSI may be improved with clearer recommendations based on the micro-organism and the type of CVC, including PICC lines which are increasingly used yet insufficiently studied in HPN patients.