Home Parenteral Nutrition Patients Research Articles

Repair of Central Venous Catheters in Home Parenteral Nutrition patients: Results of a large regional UK Centre

Repair of Central Venous Catheters in Home Parenteral Nutrition patients: Results of a large regional UK Centre

P128 INCIDENCE AND OUTCOMES OF HOME PARENTERAL NUTRITION IN PATIENTS WITH CROHN’S DISEASE IN OMLSTED COUNTY, MINNESOTA, USA

Patients (pts) with Crohn’s disease (CD) undergoing multiple surgeries are at risk of extensive bowel resections, short bowel syndrome (SBS) and malnutrition and may need home parenteral nutrition (HPN). The aim of our study was to estimate the incidence of HPN use in pts with CD in a population-based cohort, and to assess clinical outcomes and complications associated with nutritional intervention.

Palliative home parenteral nutrition in patients with ovarian cancer and malignant bowel obstruction: experiences of women and family caregivers

BackgroundMalnutrition is a problem in advanced cancer, particularly ovarian cancer where malignant bowel obstruction (MBO) is a frequent complication. Parenteral nutrition is the only way these patients can received adequate nutrition and is a principal indication for palliative home parenteral nutrition (HPN). Giving HPN is contentious as it may increase the burden on patients. This study investigates patients’ and family caregivers’ experiences of HPN, alongside nutritional status and survival in patients with ovarian cancer and MBO.MethodsThis mixed methods study collected data on participant characteristics, clinical details and body composition using computed tomography (CT) combined with longitudinal in-depth interviews underpinned by phenomenological principles. The cohort comprised 38 women with ovarian cancer and inoperable MBO admitted (10/2016 to 12/ 2017) to a tertiary referral hospital. Longitudinal interviews (n = 57) were carried out with 20 women considered for HPN and 13 of their family caregivers.ResultsOf the 38 women, 32 received parenteral nutrition (PN) in hospital and 17 were discharged on HPN. Nutritional status was poor with 31 of 33 women who had a CT scan having low muscle mass, although 10 were obese. Median overall survival from admission with MBO for all 38 women was 70 days (range 8–506) and for those 17 on HPN was 156 days (range 46–506).Women experienced HPN as one facet of their illness, but viewed it as a “lifeline” that allowed them to live outside hospital. Nevertheless, HPN treatment came with losses including erosion of normality through an impact on activities of daily living and dealing with the bureaucracy surrounding the process. Family caregivers coped but were often left in an emotionally vulnerable state.ConclusionsWomen and family caregivers reported that the inconvenience and disruption caused by HPN was worth the extended time they had at home.

A framework to support quality of care for patients with chronic intestinal failure requiring home parenteral nutrition

Chronic intestinal failure requiring home parenteral nutrition (HPN) is a disabling condition that is best facilitated by a multidisciplinary approach to care. Variation in care has been identified as a key barrier to achieving quality of care for patients on HPN and requires appropriate strategies to help standardize management. The Australasian Society for Parenteral and Enteral Nutrition (AuSPEN) assembled a multidisciplinary working group of 15 clinicians to develop a quality framework to assist with the standardization of HPN care in Australia. Obstacles to quality care specific to Australia were identified by consensus. Drafts of the framework documents were based on the available literature and refined by two Delphi rounds with the clinician work group, followed by a further two involving HPN consumers. The Oxford Centre for Evidence-Based Medicine Levels of Evidence was used to assess the strength of evidence underpinning each concept within the framework documents. Quality indicators, standards of care, and position statements have been developed to progress the delivery of quality care to HPN patients. The quality framework proposed by AuSPEN is intended to provide a practical structure for clinical and organizational aspects of HPN service delivery to reduce variation in care and improve quality of care and represents the initial step towards development of a national model of care for HPN patients in Australia. While developed for implementation in Australia, the evidence-based framework also has relevance to the international HPN community.

Fish oil supplementation with various lipid emulsions suppresses in vitro cytokine release in home parenteral nutrition patients: a crossover study

Long-chain n-3 polyunsaturated fatty acids modulate immune cell functions. The primary objective of this study was to evaluate the impact of different lipid emulsions (LEs) with supplemented doses of fish oil (FO) on serum cytokine concentration and in vitro cytokine production in patients with intestinal failure on home parenteral nutrition (HPNPs). We hypothesized that FO supplementation would diminish lipopolysaccharide (LPS)-stimulated cytokine production. Twelve HPNPs receiving Smoflipid for at least 3 months were given FO (Omegaven) for a further 4 weeks. After this cycle, the patients were randomized to subsequently receive 1 cycle with Lipoplus and 1 cycle with ClinOleic for 6 weeks or vice versa plus 4 weeks of added Omegaven after each cycle in a crossover design. Comparison of the baseline LE regimens showed lower LPS-stimulated production of IL-1β in the HPNPs on Lipoplus than on the Smoflipid and ClinOleic regimens, as well as lower IL-8 compared to the Smoflipid regimen. Omegaven reduced IL-8 concentration in serum under the Lipoplus regimen and diminished LPS-stimulated production of IL-1β under the Smoflipid and ClinOleic. IL-6 and TNF-α production was depressed only in those on Smoflipid. Irrespective of the LE used, the HPNPs compared to the healthy controls showed higher IL-6, IL-8, and TNF-α concentrations in serum and LPS-stimulated production of IL-6 as well as lower n-6/n-3 long-chain polyunsaturated fatty acids in the erythrocyte phospholipids. LPS-stimulated production of IL-6 correlated negatively with the parenteral dose of eicosapentaenoic acid + docosahexaenoic acid. In conclusion, FO-supplemented parenteral nutrition suppresses in vitro cytokine production.

Elevated Whole-Blood Manganese Levels in Adult Patients Prescribed "Manganese-Free" Home Parenteral Nutrition.

Manganese toxicity can occur as a complication of home parenteral nutrition (HPN). Patients can present with Parkinson disease-like symptoms. Preparations of trace elements (TEs) in parenteral nutrition (PN) generally provide amounts in excess of requirements. Our previous review observed 60% of adult HPN patients had high whole-blood manganese levels. Multi-TE (MTE) solutions were subsequently removed from all HPN formulations in January 2015. The aim of this evaluation was to determine whole-blood concentrations of manganese in adult patients receiving HPN to establish whether levels are now maintained within the normal reference range. A retrospective review of whole-blood manganese levels in all patients receiving HPN between January 2018 and January 2019 from 1 hospital site was carried out. 100 patients were included in the review (59 female and 41 male). Normal whole-blood manganese levels (73-219 nmol/L) were observed in 70% of patients and elevated levels (>219 nmol/L) in 30% of patients. In the patients with elevated levels, 57% had not received manganese supplementation for at least 1 year prior to manganese being measured. Markers of cholestasis were similar between the 2 groups. Incidence of elevated whole-blood manganese concentrations in patients receiving HPN decreased from 60% to 30% upon discontinued use of an MTE solution. Elevated levels remain a concern despite patients being prescribed "manganese-free" PN. Patients receive this TE in amounts adequate to meet requirements through contamination and dietary intake alone, suggesting additional parenteral supplementation of manganese is not required.

Ethanol Lock Therapy Markedly Reduces Catheter‐Related Blood Stream Infections in Adults Requiring Home Parenteral Nutrition: A Retrospective Study From a Tertiary Medical Center

The use of central venous catheter (CVC) access for home parenteral nutrition (HPN) is associated with catheter-related bloodstream infections (CRBSIs). There are limited data on the use of ethanol lock therapy (ELT) to prevent CRBSI in adult HPN patients. Our aim was to determine whether the routine institution of ELT decreased the incidence of CRBSI compared with historic controls at Emory University Hospital (EUH) in Atlanta, Georgia, USA. EUH medical records of adult HPN patients discharged with a tunneled, silicone CVC on ELT were retrospectively studied during a pre-hoc determined 14-month observation period (n = 87; 13,386 catheter days) and compared with clinically similar HPN patients from the same institution before institution of the ELT protocol for all appropriate patients. The ELT protocol involved instilling 2mL of 70% ethanol into each catheter lumen daily after the HPN cycle, following initial flushing with normal saline. Only 5 of 87 patients (5.7%) who received ELT were diagnosed with a CRBSI (0.45/1000 catheter days) during observation. We compared these data with our previously published clinically matched patient population from EUH (n = 22) receiving HPN via a silicone CVC without ELT. Of these historical controls, 45.5% were diagnosed with 1 or more CRBSIs (8.7/1000 catheter days) during observation (P <.001 vs the current ELT cohort). In this retrospective study with historical controls from the same academic center, institution of ELT in adults requiring HPN via a silicone CVC was associated with a marked (19-fold) reduction in CRBSI.

Challenges of Monitoring Essential Fatty Acid Deficiency in Home Parenteral Nutrition Patients Intolerant to Intravenous Lipid Emulsions: A Comprehensive Case Study

Challenges of Monitoring Essential Fatty Acid Deficiency in Home Parenteral Nutrition Patients Intolerant to Intravenous Lipid Emulsions: A Comprehensive Case Study

SUN-PO125: Home Parenteral Nutrition in Patients with Type III Intestinal Failure. Patagonian Experience

SUN-PO125: Home Parenteral Nutrition in Patients with Type III Intestinal Failure. Patagonian Experience

MON-PO433: Examine the Role of Health Perception, Self-Efficacy and Use of Social Media on QOL of Home Parenteral Nutrition (HPN) Patients in Poland and Israel

MON-PO433: Examine the Role of Health Perception, Self-Efficacy and Use of Social Media on QOL of Home Parenteral Nutrition (HPN) Patients in Poland and Israel

SUN-PO133: Assessment of Renal Function in Home Parenteral Nutrition Patients for Intestinal Failure

SUN-PO133: Assessment of Renal Function in Home Parenteral Nutrition Patients for Intestinal Failure

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.

P1.53: Are Femoral Tunnelled Central Venous Catheters safe to use for HPN?

Background: Patients with Intestinal Failure (IF) require reliable intravenous access for provision of Parenteral Nutrition. Venous access for Home Parenteral Nutrition (HPN) patients with Type 3 IF can be compromised due to thrombosis of deep veins. Preferred choice of veins for central venous catheter are the supra cardiac veins. Femoral tunnelled CVC are avoided due to concerns of catheter related blood stream infection (CRBSI) and are considered as a last resort when all other thoracic CVC access is exhausted. We assess the outcomes of tunnelled femoral catheters in our cohort of HPN patients. Methods: We did a retrospective analysis of a prospectively collected data of all HPN patients and venous access from January 2013 to December 2018 managed at a National HPN Unit. The details of venous access, complications of CVC, sex and details of stoma extracted from database. Results: In a cohort of 9 HPN patients with tunnelled femoral CVC, 6 were females and 3 were males leading to a total of 8418 days. A total 3 episodes of CRBSI were recorded in 1 patient. All of the 3 episodes (methicillin – sensitive Staphylococcus aureus (MSSA), Escherichia Coli and CNS) were successfully salvaged. The average no of days for femoral CVC was 935 days. The rate of CRBSI was 0.35 per 1000 catheter days. 8 patients had stoma or open abdominal wound. There were no episodes of ipsilateral femoral DVT. The CVC was replaced for 2 patients due to fracture of CVC. Conclusion: Tunnelled femoral CVC CRBSI rate (0.35)is comparable to thoracic veins CVC CRBSI rate(0.31) in our unit. Furthermore femoral access could be considered as a reliable access to provide HPN. It may be considered as an option if more than 2 thoracic deep veins are occluded to prevent complete occlusion of SVC. We feel tunnelled femoral CVC is a safe option to consider for HPN

Long-Term Use of Mixed-Oil Lipid Emulsion in Soybean Oil-Intolerant Home Parenteral Nutrition Patients.

Although home parenteral nutrition (HPN) is lifesaving for patients with chronic intestinal failure (IF), long-term use can be associated with complications such as infections, metabolic abnormalities, and IF-associated liver disease (IFALD). The key to treatment of many of these complications is prevention. Guidelines recommend avoidance of overfeeding, use of oral/enteral nutrition if possible, cyclic PN, and maintaining dose of soybean oil (SO) intravenous lipid emulsion (ILE) <1 g/kg/day as preventive strategies for IFALD. Additionally, with development of IFALD, ω-6/ω-3 polyunsaturated fatty acid ratio should be decreased in ILE. The newly available mixed-oil (MO) ILE offers such an opportunity; however, there is a paucity of long-term data available. The current study reports our long-term experience with MO ILE use in HPN patients. Seventeen patients (8 female and 9 male) with an average age of 47 ± 12 years and median HPN duration of 4.6 years (1.1-32.1 years) have utilized MO ILE for >12 months after being transitioned from SO ILE because of intolerance. Use of MO ILE allowed an increase in ILE energy from 8% ± 8% to 22% ± 8% while reducing dextrose energy from 66% ± 8% to 54% ± 5%, maintaining stability in alkaline phosphatase and triglyceride levels, and achieving improvement in aspartate aminotransferase, alanine aminotransferase, total bilirubin, and α-tocopherol levels. In this HPN cohort with SO ILE intolerance, MO ILE was well tolerated and allowed an improvement in macronutrient composition while improving some liver parameters over a 12-month period.

Home Parenteral Nutrition in Patients with Intestinal Failure: Possible Undetected Complications.

Background: Septic pulmonary embolism (SPE) may be a frequently undetected complication of central venous catheter (CVC)-related bloodstream infections (CRBSIs). Materials and Methods: The incidence of SPE was evaluated in a cohort of non-oncological patients on home parenteral nutrition (HPN) who were hospitalized for a CRBSI from January 2013 to December 2017. The main clinical, microbiological, and radiological features and the therapeutic approach were also described. Results: Twenty-three infections over 51,563 days of HPN therapy were observed, corresponding to an infection rate of 0.45/1000. In 10 out of the 23 cases (43.5%), pulmonary lesions compatible with SPE were identified. Conclusion: Our results demonstrated that a CRBSI can produce asymptomatic SPE with lung infiltrates in 43.5% of the cases, suggesting the need to check for secondary lung infections to choose the most appropriate antimicrobial therapy.

Non-interventional, retrospective data of long-term home parenteral nutrition in patients with benign diseases: Analysis of a nurse register (SERECARE).

The aim of this study was to evaluate the safety and efficacy of home parenteral nutrition (HPN) service in patients with benign chronic intestinal failure (CIF). This was a 10-y retrospective, non-interventional, multicenter study conducted with adult and pediatric patients with CIF who received HPN service. We analyzed data prospectively collected from a dedicated register by HPN nurses. From January 2002 to December 2011 a total of 794 patients (49.7% male, median age 1 y for children and 57 y for adults) were included in the analysis. Over the 10-y period, 723 central venous catheter (CVC) complications occurred, of which 394 were infectious (54.5%), 297 were mechanical (41.1%), and 32 (3.3%) were defined as CVC-related thrombosis. The complication rate was higher in children (1.11 per patient) than in adults (0.70 per patient). During the observation period, the rates of both infectious and mechanical complications showed a global declining trend and ∼75% of patients had neither infectious nor mechanical CVC complications. HPN efficacy was evaluated in 301 patients with a minimum follow-up of 36 mo. Body mass index and Karnofsky score showed that the median growth significantly increased (P < 0.001) over baseline for adults and pediatric patients in the 0 to 2 age range. The use of a structured register has proved to be a key strategy for monitoring the outcomes of long-term treatment, improving time efficiency, and preventing potential malpractice. To our knowledge, this is the largest survey ever documented; the results were consistent despite the heterogeneity of the centers because of duly applied standard rules and protocols.

Repair of Central Venous Catheters in Home Parenteral Nutrition Patients.

For patients receiving home parenteral nutrition (HPN), vascular access with a central venous catheter (CVC) is essential to safely administer parenteral nutrition (PN) to meet their nutrition and hydration needs. Unfortunately, despite rigorous training and prevention strategies, CVCs are susceptible to complications such as infection, occlusion, thrombosis, and mechanical failure. Much of the published research on CVC complications focuses on infections; however, catheter occlusions and mechanical failures also contribute significantly to catheter dysfunction and loss. Frequent CVC exchanges put HPN patients at risk of loss of vascular access, making it essential that any strategies that can salvage the CVC be implemented prior to removal. CVC repair is 1 technique that can be utilized to avoid CVC exchanges in certain situations. CVC repairs can be performed in the office or on the ward and are cost effective when compared with CVC replacement. When performed by trained clinical staff, the procedures are highly successful and associated with low risk.

Essential Amino Acid Profile in Parenteral Nutrition Mixtures: Does It Meet Needs?

Background and Aims: The study compares the essential amino acid (EAA) composition of different parenteral nutrition (PN) mixtures with whey protein EAA profile and the theoretical daily EAA requirements (set by WHO/FAO/UNU or IAAO method). According to the individual EAA profile, the potential effect of several PN mixtures was evaluated on the skeletal muscle mass (SMM) of patients on home PN. Methods: Eight AA solutions and fifteen complete PN mixtures were considered. Twenty-nine clinically stable patients with short bowel syndrome on home total PN were retrospectively evaluated. SMM was estimated by bioelectrical impedance analysis. Results: The prescribed doses of EAA that showed a significant increase in home PN patients muscle mass were considerably greater than the theoretical ones, showing an EAA profile similar to whey protein. At the daily dose of 1 g of total AA s/kg body weight (BW), the considered PN mixtures mostly failed to improve SMM. Only prescribed doses which included more than 0.25 g/kg BW of total BCAA with at least 0.10 g/kg BW leucine, 0.08 g/kg BW isoleucine, and 0.06 g/kg BW methionine showed a significant increase in SMM. Conclusions: The theoretical daily requirement for each EAA was met by all considered PN solutions when the prescribed daily dose of total AAs was set at 1 g/kg BW. Nevertheless, our data suggest that only an increase in total BCAA, also richer in single AA leucine, isoleucine, and methionine, is associated with the maintenance and/or increase of SMM. According to these preliminary observations, we support the prescription of an EAA composition of PN mixtures close to that of whey protein for the preservation of SMM in patients on long-term total PN.

Catheter-related bloodstream infections in home parenteral nutrition patients and catheter salvage

Catheter-related bloodstream infections in home parenteral nutrition patients and catheter salvage

A systematic review of home parenteral nutrition in patients with advanced cancer

The use of Home Parenteral Nutrition (HPN) in patients (pts) with advanced cancer, who cannot meet their nutritional requirements by oral or enteral routes, remains controversial with significant variation worldwide. Our aim was to review data from literature and identify the potential benefit of HPN in pts with advanced cancer. Articles on HPN in advanced cancer from 2002 to 2016 were searched in Pubmed. The primary end point was survival, secondary end points were quality of life (QoL) and nutritional/performance (Karnofsky score, KPS) status.