Home Total Parenteral Nutrition Patients Research Articles

A249 RETROSPECTIVE CHART REVIEW OF PATIENTS WITH MALNUTRITION REQUIRING ADVANCED NUTRITIONAL SUPPORT POST BARIATRIC SURGERY

BackgroundObesity is a global pandemic with a steady increase in global BMI since 1975. Bariatric surgery is an effective treatment for patients with severe obesity in order to sustain long-term weight loss and reduce comorbidity burden and mortality associated with obesity. However, post-bariatric surgery patients face nutritional complications ranging from micronutrient deficiencies to intestinal failure requiring total parenteral nutrition (TPN). From our institution of home TPN patients, 6.4% of patients had bariatric surgery. Intestinal failure is a burdensome diagnosis for patients, and there is a paucity of literature characterizing patients post-bariatric surgery who develop intestinal failure.AimsWe aim to identify the patient characteristics, surgical details, and nutritional traits that predisposed patients to developing intestinal failure requiring advanced nutritional support.MethodsThis is a retrospective chart review of 48 patient admitted to the Royal Alexandra Hospital post-bariatric surgery for nutritional support and followed by the TPN program dieticians and nurses.ResultsOur results show the mean BMI was 49.94 kg/m2 pre-bariatric surgery. Interestingly, the mean BMI at time of hospitalization for bariatric-surgery related complications was 33.210 kg/m2 which is classified as overweight but most of patients were severely malnourished with SGA C (43.8%), SGA B (29.17%), and 8.3% were SGA A. Patients requiring parenteral nutrition post-bariatric surgery are mostly female, developed barriers to oral intake, 15% engaged in medical tourism, 58.3% had an underlying mental health diagnosis, and only 18.8% were on a multivitamin even though it is standard of post-bariatric surgery care. The time between initial bariatric surgery to hospital admission was 11.2 years, and most required ≥1 revisional surgery. The mean age at bariatric surgery was 33.2-years old and the average age at initial hospitalization was 48.9-years old. Patients requiring ≥2 admissions had vertical band gastroplasty or sleeve gastrectomy (both 36.8%) while 21.1% had Roux-en-Y gastric bypass. Of these patients, 39.6% of patients required ≥2 hospital admissions and the mean total days spent in hospital was 57.15 days. While these complications are uncommon, these patients result in multiple prolonged hospitalizations and can be difficult to manage.ConclusionsOverall, the results of our study will allow the multidisciplinary teams that care for post-bariatric surgery patients to identify patients at risk of intestinal failure and potentially intervene with early enrollment into home nutrition program. With increasing awareness, patients at higher risk can be closely monitored in order to prevent micronutrient deficiencies before they progress to intestinal failure and require lifetime parenteral nutrition.Funding AgenciesNone

Evaluation of quality of life and caregiver burden in home parenteral nutrition patients: A cross sectional study

Home total parenteral nutrition (HPN) is indicated in long-term intestinal failure (IF) to maintain or improve the nutritional status, guarantee patient survival and improve quality of life (QoL). The patients "caregiver" is often an essential partner to help perform daily activities. The aim of this study was to compare QoL, experienced distress and (if present) caregiver burden for relatives in two distinct categories of IF patients, i.e. those with short bowel syndrome as compared to those suffering from intestinal dysmotility. All HPN patients and their caregivers of our HPN population were invited for this study. Qol and distress were assessed using the validated HPN-Qol and the "Lastmeter" (distress thermometer) questionnaire (for HPN patients) or the Caregiver Strain Index (CSI) (for caregivers) for the short bowel and dysmotility groups as well as for the combination. During the year 2016 a total of 193 patients and their caregivers were invited. Fifty-six patients (37%) reported not to have a caregiver. Overall, 147 patients (76%) and 91 caregivers (63%) completed the questionnaires. The most common underlying conditions leading to IF were short bowel syndrome (SBS, 48%) and intestinal dysmotility disorders (42%). Both the SBS and the dysmotility group had a reasonable Qol (SBS 6 vs. dysmotility 5.8) but the experienced distress was significantly higher in the latter group (SBS 5 vs. dysmotility 7). The distress of the dysmotility group was mainly determined by fatigue, abdominal pain, immobility, inability to work/go to school, limited contact with friends, nausea and vomiting, bloating, abdominal pain, troubles with sleeping, dizziness, inability to eat, being cold, fatigue and decreased taste. The Qol of patients with SBS was not significantly affected by aspects associated with HPN. The caregiver of dysmotility patients experienced a higher burden when compared with the caregiver in the SBS group (strain 0-13, ≥7 reflect high burden), due to increased demands on time and perceived strain. Our results suggest that QoL of IF patients differ depending on the underlying disease, with the dysmotility group experiencing a higher burden when compared to short bowel patients. Also, in particular the burden that dysmotility patients experience with regard to eating, the presence of fatigue and abdominal pain significantly impacts their Qol. This study provides the first evaluation of perceived caregiver burden for relatives of patients with HPN. Here also the caregiver of dysmotility patients experienced a higher burden compared to caregivers of patients with SBS. These findings suggest that more focused care with attention to specific items within various groups (SBS, dysmotility) of the IF population is needed.

Abnormal regulation of serum lipid fatty acid profiles in short gut rats fed parenteral nutrition with lipid

Despite absence of essential fatty acid deficiency (EFAD), increases in arachidonic acid to linoleic acid ratios occur in serum phospholipid of patients treated with chronic total parenteral nutrition (TPN). The parenteral lipid component of TPN contains abundant linoleate; thus low phospholipid linoleate may reflect increased conversion to arachidonate. Arachidonic acid excess has been associated with a proinflammatory milieu through increased eicosanoid production and might contribute to the increases in inflammatory markers seen in home TPN patients. We investigated fatty acid metabolism in a rodent model of malabsorption. We hypothesized that short gut rats would metabolize parenteral lipid differently from intact rats. We performed laparotomy and 80% small bowel resection (or sham surgery) in rats. Sixteen sham and 16 short gut rats were randomly assigned to TPN with lipid or fat-free TPN. After 5 days, weight loss was similar in all groups. Analysis of serum phospholipids demonstrated that 20:3ω9 (eicosatrienoic acid) was relatively increased in fat-free TPN groups, irrespective of surgery type, as were distal very long chain ω3 class fatty acids, as anticipated. Uniquely, both nutrition (TPN/lipid v fat-free TPN) and surgery type (sham v short gut) were significant in determining arachidonic acid levels. Relatively elevated arachidonate occurred in both groups of fat-free rats, suggesting increased Δ6 and/or Δ5 desaturase activity, as expected. In contrast, giving TPN/lipid lowered arachidonate (suggesting appropriately downregulated desaturases) in sham animals, but not in short gut animals. Ratios of arachidonic and di-homo-γ-linolenic to linoleic acids further suggested increased turnover of precursor ω6 to arachidonic acid in short gut rats given lipid compared with the other groups. These preliminary data show that intravenous (IV) lipid gave rise to serum lipid fatty acid profiles that differed in short gut and sham rats. The short gut rat may have a heightened hepatic desaturase activity, inappropriate for the quantity of linoleic acid provided parenterally. Therefore, the short gut rat is an appropriate model to study further arachidonic acid excess in home TPN patients.

Disturbances in essential fatty acid metabolism in patients receiving long-term home parenteral nutrition.

Patients receiving home total parenteral nutrition (HTPN) are at risk for the development of essential fatty acid deficiency (EFAD). This study examined the essential fatty acid status of patients on long-term HTPN for gut failure. Serum phospholipid and triglyceride fatty acids were measured in 11 patients and 10 healthy volunteers. Patients had similar levels of linoleic acid (18:2w6) in serum triglyceride fatty acids but significantly lower levels of 18:2w6 in serum phospholipids compared to controls. Although there was accumulation of Mead acid (20:3w9) in both fatty acid fractions, the ratio of 20:3w9 to arachidonic acid (20:4w6) remained less than 0.2, reflecting an adequate essential fatty acid status in these patients. There were, however, substantial increases in 20:4w6 content in both triglyceride and phospholipid fractions in serum despite the lower levels of 18:2w6 in serum phospholipids, suggesting that an accelerated hepatic conversion of 18:2w6 to 20:4w6 occurs in HTPN patients, as well as the 20-carbon members of w3 (20:3w3) and w9 (20:3w9) families. The determination of optimal parenteral fat intakes should be investigated further as important priority in patients receiving long term HTPN.

A comparative study of polyurethane and silicone cuffed-cathetersin long-term home total parenteral nutrition patients

Aim: The purpose of this study was to report our compared experience of long-termcomplications with polyurethane (LeaderCuff) and silicone (Lifevac) tunnelled, cuffed catheters in home adult TPN patients. Methods: All catheters were Inserted by a percutaneous technique under local anaesthesia. Results: Forty silicone catheters were Inserted In 31 patients and 13 polyurethane catheters were Inserted In 11 patients totaling a total experience of 480 months and 175 months respectively. Mean catheter life span was 12 months (range: 0.25–47) and 13 months (range: 3–44) for Lifevac and LeaderCuff catheters, respectively. Complication rates (expressed as patient-year of TPN) were no significantly different for Lifevac and LeaderCuff catheters: sepsis (U.15 vo 0.14), obstruc (0.05 vs 0), dislodgement (0.13 vs 0.07) and thrombosis (0 vs 0.14). The fracture rate was 20 times lower for Lifevac than for LeaderCuff ( P < 0.01): in all cases, this mechanical problem was due to the dysfunction of the detachable flow-control device. Conclusion: Both Lifevac and LeaderCuff catheters enable safe, long-term,venous access and prevent, in most casas, inadvertent catheter dislodgement. There Is little evidence, from our study, to support the hypothesis that polyurethane catheters offer more security than silicone catheters In home TPN adult patients.

Evaluation of outcomes for patients with AIDS receiving home total parenteral nutrition.

This study evaluated the outcomes of patients with acquired immunodeficiency syndrome (AIDS) provided home total parenteral nutrition (HTPN) when specific criteria were used to initiate HTPN. Fifteen males who received HTPN and seven males who consumed only an oral diet were studied. The HTPN patients received an average of 55 kcal.kg-1.d-1 and 2.0 g of protein.kg-1.d-1 from HTPN and oral diet. Non-HTPN patients consumed an average of 35 kcal.kg-1.d-1 and 1.2 g protein.kg-1.d-1. Body weight (BW), lean body mass (LBM), and serum albumin (SA) were measured when HTPN was initiated or initial nutrition counseling was provided to the non-HTPN patients and again at the end of the study period. Over the study period, the HTPN patients gained an average 5.5 kg of BW and 3.0 kg of LBM, whereas the non-HTPN lost an average of 5.0 kg of BW and 3.0 kg of LBM. BW and LBM may be used to assess the response to HTPN in AIDS patients.

Essential fatty acid deficiency and home total parenteral nutrition patients

Essential fatty acid deficiency and home total parenteral nutrition patients

Essential fatty acid deficiency and home total parenteral nutrition patients

The requirements for essential fatty acids in patients on home parenteral nutrition are not well described. We therefore studied the needs of 12 patients receiving parenteral nutrition for at least 4 mo (range: 4 mo-17.3 yr; mean 7.0 ± 5.2 yr). Prior to the study, each patient had been receiving intravenous lipids either weekly or biweekly and had a triene to tetraene ratio (TTR) on plasma phospholipids performed at least annually. A TTR ≥ 0.2 was considered diagnostic for essential fatty acid deficiency (EFAD). The purpose of this study was to determine the required intravenous lipid supplementation in patients on home total parenteral nutrition (HTPN). Patients with an initial TTR of <0.2 had their intravenous lipid stopped and changes in their serum phospholipid fatty acids were followed every 3–4 wk. Nine of 12 patients had TTRs > 0.2 at some point in the study. Phase I consisted of patients who at initiation of the study had normal TTRs and were taken off lipid supplementation until their TTR became abnormal. Phases II, III, IV, and V consisted of lipid delivered in total nutrient admixtures in biweekly doses of 0.6, 1.2, 1.8, and 2.4 g of fat/kg bodyweight, respectively. Eight patients normalized their TTRs on the biweekly lipid regimens; one patient expired before his ratio normalized; and three patients could not be made deficient in essential fatty acids after 26 or more wk of fat-free parenteral nutrition. Most patients required 1.2 to 2.4 g of lipid/kg bodyweight/biweekly to correct serologic EFAD. The clinical background, as well as the length of small bowel remaining, did not seem to identify those patients who required lipid supplementation nor the final dose of lipid needed to normalize their TTRs.

L-glutamine supplementation in home total parenteral nutrition patients: stability, safety, and effects on intestinal absorption.

A study was conducted to determine safety and efficacy of L-glutamine when added to total parenteral nutrition (TPN) solutions of patients receiving TPN in the home. Stability studies were first performed on various concentrations of L-glutamine in TPN solutions mixed by the Pharmix method. These showed that glutamine was stable in home TPN solutions for at least 22 days. The daily home TPN solutions of seven stable patients were then supplemented with glutamine at a dose of 0.285 g/kg of body weight for 4 weeks. The glutamine-TPN solutions were prepared weekly. Five patients received the full 4 weeks of glutamine-TPN. In two patients, administration of glutamine-TPN mixtures was stopped at the end of week 2 and week 3 because of elevations in liver enzymes. A third patient's liver enzymes rose at the end of week 4. These abnormalities subsided after discontinuation of the glutamine-TPN solution. Plasma levels of glutamine increased during the first 3 weeks of supplementation but these increases were not statistically significant. D-Xylose absorption studies performed before and after the administration of glutamine-TPN did not reveal any improvement in small-bowel absorptive capacity. In conclusion, stable glutamine-TPN solutions for use by home TPN patients can be formulated. However, supplementation of home TPN solutions at this dose was associated with apparent hepatic toxicity and did not demonstrate a beneficial effect on intestinal absorptive capacity as measured by D-xylose absorption. Therefore, on the basis of this study, routine supplementation of home TPN solution with glutamine cannot be recommended.

Home artificial nutritional support in Cambridge Health District—1988–1990

A 2-year prospective study was undertaken to assess the indications for, prevalence and outcome of home artificial nutritional support (HANS) in the Cambridge Health District (CHD), England. Thirty-nine patients were identified, 33 receiving home enteral-tube feeding (HETF) and six receiving home total-parenteral nutrition (HTPN). About half the patients received HETF to treat chronic anorexia and the remaining half received it because of swallowing difficulties. All HTPN patients had intestinal failure. Patients receiving HTPN were young to middle aged adults, whereas the majority (80%) of those receiving HETF were either children (<16 years) of elderly patients (>60 years). Patients in both the HETF and HTPN groups tended to be either short-term or long-term feeders. There was a high disease-related mortality rate among the HETF patients (45.5% over 2 years) but there were no deaths in the HTPN group. It is concluded that HANS is provided for a small number of severely disabled individuals, many of whom have a poor prognosis.

Selected ultratrace elements in total parenteral nutrition solutions

Ultratrace elements are potentially essential (eg. boron, molybdenum, nickel, and vanadium) or toxic (eg, aluminum and cadmium) in humans. Long-term total parenteral nutrition (TPN) patients can inadvertently receive significant amounts of ultratrace elements present as contaminants in TPN solutions. We determined the intake of selected ultratrace elements from a standard TPN solution and compared it with the amount reported to be absorbed from food in normal subjects. Contamination of TPN solutions with ultratrace elements was widespread and variable. The daily intakes of Mo, Ni, V. and Cd from this contamination were comparable to the amounts reported to be absorbed through the gastrointestinal tract in normal subjects. Al intake was high; B intake was low, approximately 10% of the amount absorbed by normal subjects. Thus, TPN solutions are contaminated with significant amounts of ultratrace elements. The biological significance of the intravenous infusion of these ultratrace elements is unclear and requires further investigation, particularly in home TPN patients.

Hunger and appetitive factors during total parenteral nutrition

A previous study of short-term (average of 31 days) Total Parenteral Nutrition (TPN) patients indicated that they experienced hunger even though they received adequate calories for energy balance. A prolonged suppression of hunger was noted when lipid was added to the total nutrient intake. Recent experiments with intravenous infusion of lipids in normal volunteers have failed to show appetite suppression beyond that expected from caloric regulation. The goal of our study was to collect information regarding hunger and appetitive experiences associated with intravenous alimentation of healthy, long-term, home TPN patients. Our results from questionnaire returns of 29 respondents showed hunger to be generally low during most of the day. Those patients taking small amounts of food orally typically reported moderate hunger before eating. There was no evidence of any significant difference between hunger reports given on days when lipid was infused vs. days when lipid was omitted. Aversive sensations were frequently associated with lipid infusion but not with nonlipid nutrient infusion. Hunger in TPN patients is discussed in terms of expectancy and hedonic factors as contrasted with physiological need.

Evaluation of a new catheter for total parenteral nutrition.

Central venous catheters play an important role in the management of children with a variety of disorders. Desirable characteristics of such catheters include ease and reliability of placement, secure fixation, low rates of complication, and ease of removal. We describe our experience with a new form of catheter that displays all of these characteristics. One hundred twenty-nine catheters were inserted in 111 patients over a 2-year period for a total of 5,729 treatment days. This catheter is made of silicone rubber and is positioned by using P-wave changes seen during intraoperative electrocardiography. x-Ray confirmation is not routinely necessary. The catheter is fixed in position by use of a grommet, which is sutured in the neck at the site of the venotomy. This form of fixation allows the catheter to be easily removed by nonsurgical means while keeping it securely in position for the duration of use. Our experience with this catheter has been associated with a low incidence of septic (1.1-4.2 septic episodes per 1,000 patient days) and mechanical (2.3 episodes per 1,000 patient days) complications in a setting that includes both in-hospital and home total parenteral nutrition patients. It is felt that this new form of catheter and catheter fixation offers several advantages over other types of central venous catheters currently in use.

Evaluation of a New Catheter for Total Parenteral Nutrition

SummaryCentral venous catheters play an important role in the management of children with a variety of disorders. Desirable characteristics of such catheters include case and reliability of placement, secure fixation, low rates of complication, and ease of removal. We describe our experience with a new form of catheter that displays all of these characteristics. One hundred twenty‐nine catheters were inserted in III paients over a 2‐year period for a total of 5.729 treatment days. This catheter is made of silicone rubber and is positioned by using P‐wave changes seen during intraoperative electrocardiography. x‐Ray confirmation is not routinely necessary. The catheter is fixed in position by use of a grommet, which is sutured in the neck at the site of the venotomy. This form of fixation allows the catheter to be casily in position for the duratio of use. Our experience with this catheter has been associated with a low incidence of septic (1.1–4.2 septic episodes per 1.000 patient days) and mechanical (2.3 episodes per 1,000 patient days) complications in a setting that includes both in‐hospital and home total parenteral nutrition patients. It is felt that this new form of eatheter and catheter fixation offers several advantages over other types of central venous catheters currently in use.

Serum lipoproteins in home total parenteral nutrition patients.

Patients maintained in our home total parenteral nutrition (HTPN) program receive very small amounts of cholesterol in their solutions. Because of the severe intestinal insufficiency which is characteristic of this group, they do not absorb significant amounts of cholesterol or bile salts from their intestines. We investigated the serum lipoproteins in nine patients maintained on HTPN for 36 +/- 4 (mean +/- SEM) months. Fat emulsions were given twice a week as a source of essential fatty acids. Mean serum cholesterol 110 +/- 6.5 mg/dl, LDL-cholesterol 75 +/- 6 mg/dl, and HDL-cholesterol 29 +/- 1 mg/dl, were at or below the 5th percentile compared with age- and sex-matched Lipid Research Clinic controls. HDL-cholesterol to serum cholesterol ratio was in the normal range (0.25 +/- 0.30). The mean serum cholesterol did not rise, but the mean serum triglyceride rose significantly from 72 +/- 4 to 104 +/- 16 mg/dl (p less than 0.05) immediately after completion of TPN infusions with fat emulsions. There was a negative correlation between the length of HTPN therapy and the total serum cholesterol (r = 0.43, p less than 0.05). Thus, HTPN patients have markedly depressed concentrations of total serum cholesterol, LDL-cholesterol, and HDL-cholesterol, but the ratio of HDL cholesterol to total serum cholesterol is in the normal range.

Bone disease in prolonged parenteral nutrition: osteopenia without mineralization defect

A metabolic bone disease characterized by a mineralization defect, low plasma 1,25(OH)2D, and hypercalciuria has been described in patients receiving prolonged total parenteral nutrition (TPN). Because the practice of TPN differs from center to center, we investigated 13 home TPN patients to determine whether they had similar or different bone abnormalities. They had received TPN for a mean period of 51 ±38 mo. Bone pain occurred in six patients and two had multiple vertebral and rib fractures (with trauma in one patient). Bone pain was mild to moderate and not incapacitating. Bone histomorphometry showed reduced bone volume, reduced osteoid with normal resorption and calcification rates. These abnormalities were associated with hypercalciuria, but the plasma levels of l,25(OH)2D were normal. Abnormalities in bone metabolism in this group of patients suggest a fundamental decrease in bone matrix-formation rather than a mineralization defect as the underlying mechanism.

Blood vitamin levels of long-term adult home total parenteral nutrition patients: the efficacy of the AMA-FDA parenteral multivitamin formulation.

Although the AMA-FDA parenteral adult multivitamin formula is now widely used, there are no published data on the efficacy of this formulation in maintaining adequate vitamin nutriture in patients on long-term parenteral nutrition. Blood levels of its constituent nutrients were determined in 16 clinically stable home total parenteral nutrition patients with severe gastrointestinal dysfunction, the majority of whom had been on home total parenteral nutrition for 1 to 9 yr and most of whom were ingesting some food orally. The daily formula (MVI-12) was added to the basic total parenteral nutrition formula in 2-day batches; the vitamins were thus infused approximately 3 hr after preparation on day 1 and after 27 hr on day 2. The duration of infusions was from 8 to 16 hr. Blood was drawn approximately 36 hr after completion of the last vitamin infusion. Plasma, trichloroacetic acid-treated plasma, and whole blood were frozen until analyzed for the vitamins by microbiologic or chemical methods. All vitamin levels, except for vitamin D metabolites, were measured four times in each patient between the 4th and 36th wk while receiving daily MVI-12. Single determinations of 25-OH and 1:25 (OH)2 vitamin D were made in eight of the 16 patients between the 61st and 84th wk while on MVI-12. Repeat values during this extended period were also made on five of the patients for vitamins A and E. These values were compared with serum vitamin levels obtained on an earlier formulation (MVI concentrate, Berocca C, and folate each given twice weekly and B12 given once weekly). The AMA-FDA formula given daily maintained blood levels above the lower normal limits for most of its constituent vitamins and vitamin D metabolites for the great majority of stable home total parenteral nutrition adults with unexplained occasional exceptions. However, almost half of the vitamin A levels and some of the pantothenate and biotin values were above the normal range; these tended to be associated with the presence of renal disease. Ascorbic acid and thiamin levels tended to be clustered in the lower normal range. Because of evidence for loss of ascorbic acid standing in total parenteral nutrition solutions for 24 hr prior to infusion, it is recommended that the vitamin formulation be added to the total parenteral nutrition solution just prior to infusion.

Pancreatitis in association with hypercalcemia in patients receiving total parenteral nutrition

Six patients receiving total parenteral nutrition (TPN) developed hypercalcemia and acute pancreatitis. Four were long-term home TPN patients, and two were short-term hospital TPN patients. Causes of pancreatitis other than hypercalcemia were not found. The etiology of the hypercalcemia remained unclear and in particular was not due to calcium infusion or hyperparathyroidism. In 4 patients in whom it was measured, the plasma parathyroid hormone was normal (in 2) or nondetectable (in 2). Hypercalcemia and pancreatitis subsided with discontinuation of TPN. Thus, some patients receiving TPN develop hypercalcemia, and in some of these pancreatitis ensues.