ESPEN Guidelines on Parenteral Nutrition: Home Parenteral Nutrition (HPN) in adult patients
Section snippets
Home parenteral nutrition support should be used in patients who cannot meet their nutritional requirement by enteral intake, and who are able to receive therapy outside an acute care setting
Long-term PN is indicated for patients with prolonged gastrointestinal tract failure that prevents the absorption of adequate nutrients to sustain life. As it is a life-saving therapy for patients with irreversible intestinal failure, it does not require evaluation of efficacy by randomized controlled trial. Its ability to maintain quality of life and promote rehabilitation supports the use of home treatment.
Comments: Intestinal failure is defined as a condition with reduced intestinal
Nutritional support team for HPN
The expertise of a nutrition support team (NST) is recommended for HPN.
The core NST consists of a physician, nutrition nurse specialist, senior dietician and senior clinical pharmacist. The NST will prepare management protocols to facilitate patient education, help to minimize complications, assist cost-containment, and audit the practice.
For long-term treatment, patients and/or carers are trained to manage parenteral nutrition at home. All patients requiring this complex treatment should have
The nutritional requirements in patients on HPN?
Comments: The levels of specific nutrients provided for the adult receiving home parenteral nutrition should be based on a formal nutritional assessment. Nutritional requirements should include disease specific needs and factors to be considered include medical condition, nutritional status, activity level, and fluid restrictions and organ function. Absorption from the GI tract, usually improves with time due to intestinal adaptation.
The prescription is decided prior to the discharge of the
Tunneled central catheters are used, as permanent access is required for long-term parenteral nutrition
Implanted ports are an acceptable alternative.
PICC-lines are intended for shorter-term use and cannot be recommended for HPN patients.
Multi-lumen catheters are not recommended in order to minimize the risk of infection. The routes most commonly used are the subclavian vein or internal jugular vein.
Comments: HPN requires a well functioning central venous line. When considering which is the best type of central venous device a number of issues must be taken into consideration; these include the
How should teaching of patients (benign disease) for HPN be carried out?
There should be a formal teaching program for the patient and/or carer. The teaching program should include catheter care, pump use, and preventing, recognizing and managing complications. Experienced nurses are usually best placed to take responsibility for the teaching program.
Comments: HPN is a complex therapy and selecting patients suitable for this treatment option is a demanding task. It is important to evaluate the patient's cognitive and physical abilities before starting a HPN training
How to monitor HPN treatment
Biochemistry (electrolytes, kidney function, liver function, glucose, hemoglobin, iron, albumin and C-reactive protein), and anthropometry should be measured at all visits; measurement of trace elements and vitamins are recommended at intervals of 6 months. Bone mineral density assessment by DEXA scanning is recommended at yearly intervals. Monitoring should usually take place at the supervising hospital by the nutrition support team. Monitoring can also be carried out by a home care agency with
Liver disease in HPN
HPN-associated liver disease is related to the composition of the HPN and to the underlying disease or coexisting liver disease. The fat/glucose energy ratio should not exceed 40:60 and lipids should comprise no more than 1 g/kg per day.
All forms of over-feeding should be avoided.
Glucose administration in excess of 7 mg/kg per min, and continuous HPN are also considered risk factors.
Aluminum contamination of HPN should be less than 25 μg/l
The amount of sodium should be no more than required, to avoid sodium induced hypercalciuria.
The calcium, magnesium and phosphate content of the HPN should maintain normal serum concentrations and 24-h urinary excretion.
The recommended ratio is 1 mmol of calcium to 1 mmol of phosphate.
The amount of amino acids prescribed should not be greater than losses, in order to limit hypercalciuria.
The recommended intravenous dose of vitamin D is 200 IU/day
Consider vitamin D withdrawal in patients with low bone mineral density (BMD), low serum parathyroid hormone,
Quality of life in HPN
HPN will have an impact on quality of life (QoL) either positively or negatively depending on the patient and underlying disease. Patients with a chronic disease will have had time to cope with the condition and can usually accept the need for HPN. In contrast, those with previously good health who have to adjust to HPN and the impact of sudden illness will encounter a loss of quality of life. HPN treatment aims to rehabilitate the patient and restore quality of life.
Generic tools for measuring
Catheter related complications
All of these issues are addressed in detail in the ESPEN guidelines on central venous catheters. This section will therefore address only those aspects particular to HPN.
Infection:
Comments: Efforts should be made to ensure that the longevity of lines is as high as possible in HPN since the risk of cumulative complications and loss of vascular access have directly life-threatening consequences in dependent patients.
In a study to investigate the difference in bacteriology between colonized
The indication for intestinal transplantation is irreversible, benign, chronic intestinal failure associated with life-threatening complications of HPN
Present data do not support direct referral for intestinal transplantation of patients with high risk of death due to underlying disease, chronic dehydration or significantly impaired quality of life. In all patients an individual case-by-case decision is required.
Comments: Intestinal transplantation is a relatively new therapeutic option for irreversible chronic intestinal failure associated with life-threatening complications due to long-term home parenteral nutrition (HPN). By 2003 more than
Conflict of interest
Conflict of interest on file at ESPEN ([email protected]).
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