Parenteral nutrition is a life-saving treatment for many patients who
cannot be nourished adequately by other feeding routes. For some patients
home parenteral nutrition (HPN) is the only means by which occupational
and social rehabilitation can be achieved, for others it improves their
quality of life, and for all patients undue hospitalization is avoided.
With the financial pressures in the health care systems of many countries,
government policies have increasingly encouraged the transfer of health
care from hospital to home.
The first report of a patient being discharged home on parenteral nutrition
was by American physicians (Shils ,1970) in 1967. Since then, HPN has
developed progressively all over the world. However, the development has
not been uniform. There are major international differences in the prevalence
and growth rate of HPN, in the organization of nutritional support services,
and in financial arrangements (Elia, 1995).
The prevalence and incidence of HPN varies greatly due to the view on
which diseases are considered an indication for HPN. In the advent of
HPN the main indication was short bowel syndrom related to Crohn's and
mesenteric vascular disease, whereas cancer was playing a minor role (Messing,
1989). Today this may still hold true in certain countries, e.g. Denmark,
the UK, or Spain. In other countries, such as Italy and Belgium, cancer
is the main indication for HPN (Van Gossum et al., 1996).
Tab. 1: Indications for HPN in 8 European countries
where reporting was assumed to include more than 80% of patients (Van Gossum
et al., 1996)
This leads to the question which objectives for home
parenteral nutrition are considered to be of importance.
Objectives of Home Parenteral Nutrition can be:
Improvement or stabilization of the nutritional status
Temporary treatment modality
Prolongation of life
Social and/or occupational rehabilitation of the patient
Improvement of the quality of life
Additional benefits for the patient and all parties involved in health
care, are the reduction of costs. With HPN many patients are able to leave
the hospital, thereby reducing the costs of an expensive therapy environment
(Elia, 1995).
In achieving these goals HPN has made many contributions to the development
of medicine, standards of care and the development of new medical devices.
For optimal care (thereby achieving highest cost effectiveness) the management
of patient discharge and the quality of care given at the home care site
is most important. This issue of Clinical Nutrition in Practice will discuss
the many subjects involved.
Literature
Elia M:
An international perspective on artificial nutritional support in the
community.
The Lancet 1995; 345:1345-1349
Messing B et al.:
Home parenteral nutrition in adults: a multicentre survey in Europe.
Clin Nutr 1989; 8: 3-9
Shils ME et al.:
Long-term parenteral nutrition through arteriovenous shunt.
N Engl J Med 1970; 283: 341-344
Van Gossum A et al.:
Home parenteral nutrition in adults: a multicentre survA??ey in Europe
in 1993.
Clin Nutr 1996; 15: 53-59
New developments in the field of parenteral nutrition prepared the way
for such a highly specialized treatment in the home environment. Despite
medical and technical advances, unfortunately, HPN is still not possible
for all patients. Certain criteria must be met in order to ensure an adequate
and safe nutritional treatment.
Careful selection of the eligible patients is most important.
Basically, there are three ranges of criteria that must be checked before
HPN can be started:
Medical criteria
Nutritional criteria
Implementation criteria
Table 2 gives an overview of the eligibility criteria that are important
for home candidates.
Tab. 2: Criteria for patient selection
2.1. Medical criteria
HPN is a relatively new therapy. HPN programs were successfully initiated
in many European countries and North America, mostly between 1975 and
1985 (Van Gossum 1996). The trends in indications have changed within
this time span, and different trends are now apparent among various countries.
The first patients treated with HPN were patients with gut failure due
to extensive bowel resection (short bowel syndrome), inflammatory bowel
disease or motility disorders. Or, in other words, patients whose life
expectancy was directly correlated to adequate nutrition.
Since that time, other medical indications that encompassed intermediate
- or even a short-term - life expectancy were taken into account. Therefore,
the percentage of cancer patients has especially increased.
Table 3 gives a comparison of the change of trends within Europe.
Tab. 3: Comparison of HPN indications (in %)
(1 Messing 1989, 2 Van Gossum 1996)
This trend can also be seen in the United States, where
the average growth in PN therapy was chiefly from new cancer patients
(Howard 1992).
Today, other indications for HPN include patients with intractable diarrhea
due to HIV/AIDS, refractory sprue and patients with high-output fistulas.
In addition, cancer patients with aggressive treatment modalities such
as chemotherapy or radiation therapy and accompanying severe side effects
(diarrhea, radiation enteritis, strictures, severe nausea and emesis)
are increasingly provided with transient HPN.
For home parenteral nutrition the patient should be in a metabolically
stable condition.
In addition, the nutritional status of the
patient must be assessed:
weight, weight-loss, height, protein stores, fat stores
type and degree of malnutrition
special nutrient deficiencies
medications and possible drug-nutrient-interactions
nutritional requirements
For further information see Chapter 3 and Clinical
Nutrition in Practice Part 2: Assessment of nutritional status and energy
requirements (B. Braun Melsungen, 1996).
With medical criteria and nutritional status
in mind, one can check on the necessary time frame and the goal of nutrition
therapy.
Tab. 4: Time-frame and goal of HPN
Now, the degree of the nutritional therapy and the appropriate access
can be decided on and should be documented as a therapeutic plan. At that
time usually HPN occurs as a treatment modality/option for the patient.
But the final decision can only be made when this special therapy can
safely be implemented in the home environment.
Unfortunately, not all of the medical and technical possibilities can
always be implemented. In order to put such a highly specialized treatment
into practice criteria concerning the patient and his/her family and the
patient's environment must be considered.
Psycho-social criteria
The patient and his family (or significant others) must be willing to
deal with this highly specialized therapy. There are many changes in the
patient's and the family's life.
The inability to partake of a meal may alter social interaction normally
shared with family and friends. Many of our social interactions are centered
on a meal, e.g., dinner dates, family or holiday celebrations. Both patient
and family/friends have to find new ways for socializing.
Infusion of parenteral solutions takes more time than sitting down for
meals. Therefore changes in lifestyle are inevitable. Working and social
activities may have to be scheduled around the patient's feeding routine.
Many patients are overwhelmed by the amount of equipment, supplies, and
solutions delivered to their home. Therefore careful preparation by training
the patient and/or caregiver with artificial nutrition application is
most important to instill selfconfidence (Rohde et al. 1986).
Altogether, the patient and his family must thoroughly be informed about
the disease, the reason for artificial nutrition, the possibilities that
arise out of home parenteral nutrition, and the possible problems. The
patient and his family should demonstrate willingness to deal with all
of these facts.
Environment
The patient's home environment must also fulfill some preconditions to
ensure proper and safe application of HPN (ASPEN 1992).
There must be enough and proper storage space for solutions and the medical
devices. Further "musts" are hygienic conditions of the storage
and preparation areas, and the hygiene of the patient himself. This should
be checked before a patient is discharged.
Educational criteria
In order to perform a safe parenteral nutrition therapy the patient and/or
caregiver must demonstrate the ability to understand and conduct the proper
management entailed. Indepth training is therefore inevitable.
The training of the patients and/or caregiver should include:
Knowledge of the underlying disease, the parenteral solutions, proper
handling of the preparation that may be necessary (e.g., adding vitamins),
proper handling of the application sets, the cleaning and rinsing of the
catheter, proper and safe handling of the dressing change procedures.
In addition, the patient and/or caretaker must be informed about the various
possible complications, and how to identify and react to them quickly
(Skipper et al. 1990).
The result of the training should be checked. The patient and/or caregiver
should demonstrate before discharge knowledge, ability, and selfconfidence
in handling critical situations.
Financial criteria
Parenteral nutrition is a quite expensive therapy. From the moment when
HPN arises as a possible treatment for the patient, the financial situation
has to be checked. Depending on the structure of the different health
care systems, coverage by the National Health Insurance or private insurance
A should be checked and the application processes should be started.
Other criteria
In cases where a nursing service has to be involved, a proper nursing
service should be chosen.
The nursing service should be familiar with parenteral nutrition and IV
infusions, as well as standard procedures and a quality assurance system.
The financial coverage must be checked.
All of the above mentioned implementation criterias are part of the discharge
planing and implementation. Additonally, proper follow-up of the patient
must be ensured to provide HPN, successfully.
A more indepth information on the discharge process is given in the following
chapter.
Literature:
ASPEN:
Standards for home nutrition support.
Nutr Clin Pract 1992; 7: 65-69
B. Braun Melsungen AG:
Assessment of nutritional status and energy requirements.
Clinical Nutrition in Practice 1996; # 2
Elia M:
An international perspective on artificial nutrtional support in the community.
The Lancet 1995; 345: 1345-1349
Howard L et al.:
Four years of North American registry home parenteral nutrition outcome
data and their implications for patient management.
J Parenter Enter Nutr 1995; 15 (4): 384-393
Howard L:
Home parenteral nutrition in patients with a cancer diagnosis.
J Parenter Enter Nutr 1992; 16 (6): 93S-99S
Messing B et al.:
Home parenteral nutrition in adults: a multicentre survey in Europe.
Clin Nutr 1989; 8: 3-9
Rohde CL, Braun T:
Home Enteral/Parenteral Nutrition Therapy. A Practioner's Guide.
The American Dietetic Association, Chicago 1986
SENPE, Grupo NADYA:A
Manual de Nutrición Artificial Domiciliania y Ambulatonia - Procedimientos
Educativos y Terapéuticos.
SENPE, 1997
Skipper A, Rotman NA:
Survey of the role of the dietitian in preparing patients for home enteral
feeding.
J Am Diet Assoc 1990; 90: 934-944
Van Gossum A et al.:
Home parenteral nutrition in adults: a multicentre survey in Europe in
1993.
Clin Nutr 1996; 15: 53-59
Many cancer patients, AIDS patients as well as many geriatric patients
at home or in nursing homes ultimately die of malnutrition. Despite this
fact, malnourishment alone is often not considered as a reason to start
nutritional intervention.
In severely ill patients, the deterioration of physical functions e.g.,
immune functions, wound healing, and brain functions, are often caused
by the lack of nutrients. Instead of taking into account a possible depletion
of nutrients, physicians and caregivers may believe that these symptoms
are solely caused by the underlying disease. Knowing that the patient
is receiving an appropriate medical therapy, adequate nutrition is often
neglected or even not taken into consideration.
Dudrick was one of the first to report an increase of survival in nonmalignant
patients as a result of HPN (Dudrick et al., 1979). Many other more recent
studies have shown that the nutritional status of patients directly correlates
with the prognosis of life expectancy, not only in cancer and AIDS patients
but also in patients with Crohn's disease (Howard et al., 1991; Messing
et al., 1995). In AIDS patients, HPN can postpone wasting of body cell
mass, thus leading to a stabilization and clinical improvement (Boulétreau
et al., 1995).
Besides an increase in life expectancy, other benefits of HPN have been
reported. In cancer which is the single most frequent indication for HPN,
it has been shown, that HPN leads to more effective medication therapy,
such as pain therapy, chemotherapy and radiation therapy (Malone, 1994).
Achieving an improvement in quality of life criteria under HPN is an
important outcome goal. HPN may have an impact on the financial and psychosocial
status of patients (Malone, 1994). Many patients are able to work or manage
their home, as shown in a quality of life scale used in the UK HPN Register.
Tab. 5: Quality of life of patients on HPN (O´Hanrahan
and Irving, 1992)
Additionally, the UK register shows that the highest grades of life
quality could be achieved in patients with Crohn's disease, volvulus and
radiation enteritis, whereas pancreatic disease and malignancy correlated
with lower grades in the quality of life scale.
Tab. 6: Relationship between quality of life of patients
on HPN and primary disease (expressed as percentage of the total number
of patients in each disease category) (O´Hanrahan and Irving, 1992)
Many patients report that being able to stay out of hospital leads
to an increased life satisfaction and better overall mental status.
The following table summarizes the most common outcome goals in HPN:
Tab. 7: Outcome goals in HPN
In the United States and UK registers, HPN was shown to be relatively
safe. Patient mortality related to HPN ranged from 5-15%. In most of the
patients who died, deaths were ascribed to the primary diseases. The likelihood
of dying from an HPN complication correlates with the duration of the
treatment. In the US less than 1% of cancer patients on HPN for only a
few months died of a complication related to parenteral nutrition. In
contrast, 10% of Crohn's patients receiving HPN for many years ultimately
developed a fatal HPN complication. Generally, younger patients do better
than older patients and have the best prognosis (Howard et al., 1995).
Literature
Boulétreau P et al.:
Home parenteral Nutrition and AIDS.
Clin Nutr 1995; 14: 213-218
Dudrick SJ et al.:
New concepts of ambulatory home hyperalimentation.
J Parenter Enter Nutr 1979; 3: 72-76
Howard L et al.:
Four years of North American Registry home parenteral nutrition outcome
data and their implications for patient management.
J Parenter Enter Nutr 1991; 15 (4): 384-393
Howard L et al.:
Current use and clinical outcome of home parenteral and enteral nutrition
therapies in the United States.
Gastroenterology 1995; 109: 355-365
Malone M:
Quality of life of patients receiving home parenteral or enteral nutrition
support.
PharmacoEconomics 1994; 5(2): 101-108
Messing B et al.:
Prognosis of patients with nonmalignant chronic intestinal failure receiving
long-term home parenteral nutrition.
Gastroenterology 1995; 108: 1005-1010
O'Hanrahan T, Irving MH:
The role of home parenteral nutrition in the management of intestinal
failure - report of 400 cases.
Clin Nutr 1992; 11: 331-336
In nearly all patients receiving HPN, nutrition therapy is started during
a hospital stay. Nutritional needs as well as the application method are
usually defined in the hospital. Additionally, most hospitals have their
own standards as to how they define nutritional regimens.
There are various methods for nutritional assessment and calculation
of nutritional requirements, which are described in detail in Clinical
Nutrition in Practice # 2 (B. Braun Melsungen, 1996) and in Clinical Nutrition
in Practice # 3 (B. Braun Melsungen, 1996).
After hospital discharge, prior to initiating HPN, it is important for
physicians and caregivers to check the completeness of the regimen prescribed
by the hospital and to care for the appropriate application.
The following checklists may help to verify both completeness and correct
application.
Nutritional regimen checklist (adults)
total energy requirement
- approximately 30-40 kcal per kg body weight and day
energy requirement: non-protein calories
- carbohydrates (glucose)
- lipids (LCT/MCT, other fatty acids)
protein requirement
- amino acids
liquid requirement
- total volume
micronutrients
- electrolytes
- vitamins
- trace elements
limits
- not more than 6 g carbohydrates per kg body weight and day
- usually not more than 1.5 g protein per kg body weight and day
- usually not more than 2 g fat per kg body weight and day
Note: electrolytes are usually part of carbohydrate or amino acid solutions,
whereas trace
elements and vitamins must be added separately.
Application checklist
necessary medical device
- infusion stand
- pump
- infusion sets
application time
- see recommended infusion time in directions for use
- if several solutions are used, the time is based upon the solution
with the highest osmolality (usually glucose solution)
- try to allow some hours of infusion-free time during the daytime
application training
- documented instruction on pump use according to Medical Device Directive
technical service
- address, telephone number
- day/night service
Example
For a patient with 60 kg body weight the following
products have been prescribed:
1500 ml three-chamber bag with 72 g amino acids, 225 g glucose and
75 g lipids per day, plus electrolytes
infusion stand
infusion pump
infusion sets for infusion pump
lipid transfer set
Check of completeness and appropriate application:
total energy
1900 kcal
?ok
micronutrients:
none ? contact prescribing physician
limits:
72 g amino acids
= 1,2 g/kg
?ok
225 g glucose
= 3,75 g/kg
?ok
75 g lipids
= 1,25 g/kg
?ok
total volume
1875 ml
= 31 ml/kg
= basic needs
?ok
?
inform physician on necessity of monitoring hydration
state
?ok
application time: 15 hours according to recommendation
?ok
application device: complete
?ok
accessories:
products for disinfection and medical care have to
be provided
training: patient and caregives have been trained in hospital
?ok
technical service: delivery and service organized
?ok
Special nutrient requirements
Patients who are released from hospitals for HPN, typically do not suffer
from severe dysfunctions or metabolic disorders (see table below). In
these cases of severe disorders the patients would remain in the hospital
in order to receive the special care and monitoring they need.
Fig. 1: Underlying diseases in patients receiving HPN
and HEN (OASIS, 1987)
Therefore, nearly all HPN patients can receive a standard regimen,
preferably through an all-in-one system, which is safe and easy to handle.
Supplemental parenteral nutrition
Parenteral nutrition may also be used in combination with enteral or
oral nutrition, when the gastrointestinal tract is only partly working,
as in short bowel syndrome. In these cases the administered parenteral
solutions have to add up together with the enteral and/or oral nutrients
to meet 100% of the patient needs. Depending on the total amount of parenteral
nutrients a peripheral venous access may be sufficient to provide supplemental
HPN.
Literature
B. Braun Melsungen AG:
Assessment of nutritional status and energy requirements.
Clinical Nutrition in Practice 1996; # 2
B. Braun Melsungen AG:
Basic concepts of parenteral nutrition.
Clinical Nutrition in Practice 1996; # 3
OASIS:
Home nutrition support Patient Registry.
Annual Report 1987
The application of parenteral nutrition requires
vascular access.
In general there are two main routes of access:
peripheral veins
central veins
Access as defined here means access not at the puncture site of the vessel,
but where the proximal tip of the access catheter ends.
Solutions used in TPN which provide all nutrients, including carbohydrates,
protein, electrolytes, vitamins, and trace elements, are by nature very
hyperosmolaric/-tonic. Infusion of such solutions into small peripheral
vessels with low blood flow results in severe damage of the endothelial
lining and rapid development of thrombophlebitis. Total parenteral nutrition
warrants access to veins with high blood flow where rapid dilution of
the highly osmolaric solutions is guaranteed.
Therefore, the decision on the kind of vascular access should be made
in regard to the following aspects:
osmolarity of the solution needed
pH
volume
duration/time frame
condition of the vessels
additional necessary medication
All of the aforementioned factors plus cannula/catheter material, cannula/catheter
size, vein size, site of venipuncture, antiseptic skin preparation at
time of placement, and aseptic daily care (including appropriate dressings)
play a role in the development of venous thrombophlebitis (peripheral
or central) (Payne-James, 1993; Williams, 1996).
The decision which route to take has therefore to be made with special
attention.
Peripheral access for home peripheral (partial)
parenteral nutrition (PPN) can only be used
for a short time, when only partial nutrition is needed or
to bridge the time before a central access is available.
Peripheral parenteral nutrition is limited,
however, by the development of peripheral vein thrombophlebitis (Williams,
1996). Phlebitis is the principle complication of PPN, occuring within
the first 72 hours in 26 to 48% of patients (Bayer-Berger, 1989).
The development of peripheral venous thrombophlebitis (PVT) is sudden
and unpredictable. PVT progresses after removal of the cannula/catheter,
adding weight to the advice that cannulas or midline catheter should be
removed at the first sign of PVT changes.
With this in mind and meticulous attention
to hygienic aspects, it is possible to anticipate phlebitis-free periods
of perhaps 5 days or more (Payne-James, 1993). Reports on phlebitis-free
periods range from 2 to 30 days. The following recommendations may help
to prolong the peripheral access without complications.
Inclusion of lipid emulsions in PPN is recommended since lipid emulsions
have a low osmolality and reduce therefore the osmolality of other solutions
when mixed together. Also, they have a direct protective effect against
PVT (Pineault, 1989; Mattioli, 1989).
For long-term and/or total parenteral nutrition central venous access
is imperative.
One has the choice between CVCs and implantable catheters. In long-term home
TPN usually catheters of the Broviac or Hickman type are surgically implanted.
In addition, totally implanted port-catheters have been developed and are gaining
greater significance (Messing, 1989; Van Gossum, 1996).
Central venous access sites are usually the vena subclavia and the internal
or external vena jugularis. The catheter tip of all kinds of CVCs should
end within the superior vena cava or within the atrium of the right heart.
The short-term CVCs, where the sites of skin puncture and vessel puncture
are only about 5 centimeters (2 inches) apart, should solely be used in a hospital
environment. Since they are more prone to catheter related sepsis than surgically
placed tunneled catheters, they were routinely changed after 10-14 days in
most hospitals. This kind of CVCs should not be used in HPN patients.
A newly arising alternative may be the so-called PICC lines (peripherally
inserted central catheters). These catheters are inserted in a suitable
vein in the antecubital fossa, usually the vena basilica. The PICCs compare
favorably with centrally-placed venous access devices for short-term
to medium-term access in the hospital as well as for long-term access
in the home-care setting (Loughran, 1995). Considering complication and
costs, PICC lines could be a good alternative for patients in a terminal
stage where a surgical procedure of any kind would be far to great a
burden.
The major disadvantage is that they do limit the mobility of the arm.
Hence, implanted catheters should preferably be placed in more active
patients.
Hickman and Broviac type catheters are percutaneously placed,
subcutaneously tunnelled catheters ending immediately above or below
the nipple line. Both catheters include a Dacron cuff near the exit of
the skin that anchors the catheter in place. Additionally, the cuff slows
the growth of bacteria along the catheter external surface, thereby decreasing
the development of catheter-related septicemia. These catheters are composed
of silicone elastomers or polyurethane and end in an open Luer-Lock-connection
(Grant, 1993).
Ports. An alternative is the totally implanted port. This device
consists of a titanium port chamber embedded in a biocompatible plastic
cover or a fully titanium port chamber with a self sealing silicone membrane
and a polyurethane or silicone catheter. Ports with a plastic cover are
lower in weight than fully titanium ports, which makes them more comfortable
for malnourished, underweight patients with a small subcutaneous fat
layer.
The port-chamber is placed in a small subcutaneous pocket and the catheter
tunnelled through the subcutaneous fat tissue to the chosen site of venous
entrance.
The major advantage of a port compared with the Hickman-/Broviac-style
catheters is that they are totally implanted with an access only when
punctured with a special non-coring port needle. Without this needle
there is no connection to the blood system, which leads to a lower infection
rate (Näslund, 1992) . In addition, ports have a better cosmetic
appearance and allow bathing and showering freely (Magnay et al., 1995).
Percutaneously and subcutaneously placed catheters are available in
mono, dual or triple versions to allow the infusion of incompatible solutions
by separated lines, e.g., parenteral nutrition and medications.
Special attention has to be given to the site of the catheter exit or
the port when the patient cares for himself. To manage the punctures,
infusion-line changes, skin-care and dressings he must have the exit
site within sight and reach. Additionally, for mobile patients the external
portion of the catheter or the port should not be in the range of the
seat belt.
Reports to the FDA indicate that over half of complications are related
to the management of CVCs by health care professionals (Scott, 1988).
Meticulous adherence to strict aseptic techniques is necessary with every
aspect of central venous catheter management: placement, maintenance,
dressings and the handling of the parenteral solutions (Kruse, 1993).
Literature
ASPEN Board of directors:
Guidelines for the use of parenteral and enteral nutrition in adult and pediatric
patients.
J Parenter Enter Nutr 1993; 17 (4) supplement: 10SA-11SA
Bayer-Berger M et al.:
Incidence of phlebitis in peripheral parenteral nutrition: effect of different
nutrient solutions.
Clin Nutr 1989; 8: 181-186
Kruse JA, Shah NJ:
Detection and prevention of central venous catheter-related infections.
Nutr Clin Pract 1993; 8: 163-170
Loughran, Borzatta M:
Peripherally incerted central catheters: A report of 2506 catheter days.
J Parenter Enter Nutr 1995; 19 (2): 133-136
Magnay S et al.:
Comparison of implanted ports with Broviac/Hickman-style catheters for long-term
home parenteral nutrition: the patients view.
Proceedings of the Nutrition Society 1995; 54: 103A
Mattioli S et al.:
Peripheral venous nutrition in surgical patients: techniques, indications and
results.
It J Surg Sci 1989; 19(3): 225-231
Messing B et al.:
Home parenteral nutrition in adults: a multicentre survey in Europe.
Clin Nutr 1989; 8: 3-9
Näslund E et al.:
Long term home parenteral nutrition using a subcutaneous venous access.
Clin Nutr 1992; 11: 93-96
Payne-James JJ, Khawaya HT:
First choice for total parenteral nutrition: the peripheral route.
J Parenter Enter Nutr 1993; 17 (5): 468-478
Pineault M et al.:
Beneficial effect of coinfusing a lipid emulsion on venous patency.
J Parenter Enter Nutr 1989; 13: 637-640
Scott WL:
Complications associated with central venous catheters.
Chest 1988; 94: 1221-1224
Van Gossum A et al.:
Home parenteral nutrition in adults: a multicentre survey in Europe in 1993.
Clin Nutr 1996; 15: 53-59
Williams N et al.:
Prolonged peripheral parenteral nutrition with ultrafine cannula and low-osmolality
feed.
Br J Surg 1996; 83: 114-116
3.4.1 Preparation of parenteral
nutrition solution
For total parenteral nutrition solutions including
all nutrients there are several possibilities as to how solutions are
delivered to the patient:
ready-to-use all-in-one-solutions
partly premixed (convenience) solutions, that require some admixture
by the patient or caregiver.
Compounding by pharmacy/provider:
The preparation of a safe, contaminant-free, and sterile PN product requires
an adequately equipped compounding facility: clean room, laminar flow
hood, aseptic filtration apparatus, compounding machine, refrigerator
for storage, transfer sets, compounder set, filters, adapters, connectors,
stopcocks, tubing clamps and mixing bags.
Personnel who prepare PN solutions should be
adequately trained and supervized in the performance of aseptic technique
(Thompson, 1991).
In the case of completely mixed PN solutions
transportation has to be carried out under refrigerated conditions. The
patient must have a refrigerator for storage, too.
Admixture by patient or caregiver:
When the patient or caregiver carries out the last steps of admixing,
several devices are needed:
Solutions, transfer sets, hangers, syringes, needles, filters, stopcocks
as well as disinfection materials (one each for hands/skin and surfaces.)
The caregiver/patient must be trained in aseptic admixing.
3.4.2 Infusion and Infusion devices
Once the solution is ready to hang, PN requires a delivery system. The
infusion method for HPN ranges from simple gravity drip to special gravity
flow rate devices to electrical pumps (Van Gossum, 1996).
In order to decide on the system to be used, one must keep several
aspects in mind :
How stable is the metabolism of the patient ?
Which device can be handled by the patient or caregiver ?
What is the optimal infusion rate ?
How does it fit into the patient's daily life ?
Infusion rate
For optimal metabolisation of the nutrients the infusion rate is very
important. In earlier times overdosage of the nutrients, especially of
glucose, was common. Both the total daily amount of a nutrient and the
amount applied per hour have to be kept in mind. Since the first reports
on maximal glucose utilization by Wolfe et al. (1979) many studies have
dealt with this subject. Optimal utilization can only be achieved when
the application rate does not overcharge the metabolic pathways thereby
leading to immediate and long-term complications of parenteral nutrition,
e.g., hyperglycemia, hypertriglyceridemia and/or fatty liver. Hence, the
application rate has to be calculated for every patient according to his
body weight (metabolic mass).
According to the stability of a patient's metabolism one can decide which
infusion device is best suited in terms of accuracy.
Gravity infusion systems
Owing to physicochemical and patient factors, gravity systems are the
most inaccurate infusion systems. Even with the best possible material,
a gravity drip device with a roll-regulator achieves a deviation of ±30%
at best. For safety reasons a gravity system is not recommended for HPN.
Another gravity device with a special flow rate regulator does a somewhat
better job with a deviation of ±15%. For metabolic stable patients
this may be adequate.
Infusion pumps
Infusion pumps deliver measured quantities of fluid at a constant flow.
Depending upon the mechanical setup, an accuracy of ?5% deviation can
be achieved. Patients in an unstable condition or on long-term treatments
are in great danger of metabolic aberrations. Therefore the most accurate
device is desirable.
Infusion time
The best time for the infusion is one that causes the least disruption
to the patient's life. For mobile patients overnight infusions increase
the time when "free-living" is possible. When metabolic conditions
allow some infusion-free time one should fit them into the daily schedule
of the patient in the most convenient way.
Filters
Filters prevent air entry into the vascular system and remove particulate
matter, bacteria, and fungi. Parenteral nutrition solutions are an optimal
environment for the growth of bacteria and fungi (Fossum, 1988). Therefore,
adherance to aseptic techniques with every kind of manipulation is a must.
The use of an infusion filter is an additional safety device, but its
use is not a standard in every country. At least with patients in highly
septic or immunosuppressive states the use of a filter is advisable. Additionally,
the use of filters may decrease the incidence of phlebitis as reported
by Falchuck (1985).
There are filters with different pore sizes on the market. Since bacteria
are at least 0.22 µm in size, bacterial filters have a pore width
of 0.2 µm. For lipid-containing solutions a special lipid-filter
with a pore width of 1.2 µm must be used, since the lipid particles
are up to 1 µm in size. This filter diminishes the most problematic
fungus Candida albicans totally and up to 90% of bacteria.
An additional safety aspect of filters is the fact that they block infusions
when incompatible solutions lead to precipitates. Precipitate formation
in parenteral nutrition admixtures have the potential of life-threatening
events. This is not to be taken as a substitute for checking compatibility
of solutions/medications prior to infusion.
Because of both aspects FDA advices that a filter should be used when
infusing either central or peripheral parenteral nutrition admixtures.
The use of a 1.2 µm air-eliminating filter for lipid-containing
admixtures and a 0.22 µm air-eliminating filter for non-lipid-containing
admixtures is suggested (FDA, 1994).
Infusion stands
For secure handling and application an infusion stand is needed. It also
guarantees a somewhat more hygienic environment for the solutions. Patients
that still move around should also have an infusion stand or drip stand
that can be moved easily and securely even on carpets or over thresholds.
Depending on the kind of vascular access, several devices are needed
or may be of help.
Port needles
In case of a port, final access is achieved by a special port needle.
The use of a special non-coring port needle is a must. Needles used with
venipuncture or IM injection are coring, and would destroy the silicon
septum of the port.
The port needle is available in different diameters and lengths. To spare
the silicon sealing of the port, the smallest gauge size needed should
be used according to the viscosity of the solution. The length of the
needle should be adapted to the thickness of the skin layer that has to
be punctured. For long-term infusions like in HPN, needles with attached
tubing are preferable, since handling immediately at the needle may lead
to damage of the port septum.
Safety valves
Whenever an access to the central venous system is made at the thorax,
the access is influenced by breathing. An accidentially open access may
lead to air embolization. The use of safety valves increases security,
since they open only when connected with a male luer connection of an
infusion line or a syringe. They close automatically when disconnected.
Flushing/Rinsing
Appropriate catheter care includes maintaining catheter patency and prevention
of catheter occlusion. Every kind of central venous catheter should be
flushed before and after the infusion (Evans, 1993). Flushing is usually
done with isotonic saline solution. Syringes used for flushing should
never be smaller than 10 ml. The pressure that can develop with syringes
= 10 ml may damage the catheter.
The line should be flushed between the addition of any potential incompatible
components, e.g., medication (FDA, 1994).
To prevent occlusion caused by thrombus formation, additional flushing
with a heparinized solution (100 to 200 IU/ml) is widely in use. The timing
of the heparin flush varies with the infusion method and type of catheter.
A heparin flush should be given daily for Hickman and Broviac style catheters
and monthly for ports (Evans, 1993).
Even small doses of heparin with routine application may cause adverse
reactions, such as bleeding complications (Clemence, 1995). Therefore,
the volume of the heparin flush should be based on the catheter design.
The volume can range between 1 and 5 ml. Manufacturers provide the information
of the internal filling volume. The kind and frequency of flushing solutions
is still in debate and controlled studies are needed.
The decision on heparin use and the amount should carefully weigh the
risk of occlusion (e.g., predisposed patients with increased risk of clotting)
against the risk of adverse reactions (e.g., elongation of bleeding times).
In long-term patients there may also be an increased risk for metabolic
bone disease (Pennington, 1995).
Regular rinsing with an alcohol saline solution has been advised for
lipid-containing solutions (Johnston, 1992). Care must be taken to ensure
that this is not used with patients with a history of alcoholism.
Disinfection and hygiene
There are three areas where disinfection should be applied:
hands
surface
skin
Meticulous attention has to be placed on aseptic technique in every step
of PN handling.
The choice of an appropriate disinfection solution and the appropriate
time of action should be recognized. Additionally, the use of sterile
gloves is indispensable.
Strict compliance with hand washing and disinfection is important. Catheter
care standards and protocols may improve compliance with aseptic technique
and reduce the rate of catheter-related infections (Kruse, 1993).
Connections between CVC and infusion line or syringes should be made by
a no-touch technique using sterile gauze and a skin/surface disinfectant.
Skin disinfection at the site of port puncture or the catheter entry
site should be routine. First, the skin around the catheter or puncture
site should be cleaned. Second, an antiseptic solution should be applied.
The antiseptic solutions in use are usually alcohol solutions and/or povidine-iodine
solutions (Orr, 1993; Kruse, 1993; Clemence, 1995). Afterwards an appropriate
dressing should be set in place.
Dressing
Dressing materials that cover the catheter insertion site and surrounding
skin ideally provide a bacterial barrier or are a neutral material that
neither reduces nor enhances bacterial growth (Orr, 1993). Traditionally,
catheter dressing materials were composed of dry, sterile gauze and an
adhesive tape. This kind of dressing is opaque and not waterproof. The
other widely used dressing is a transparent semi-permeable polyurethane
film dressing. It allows a visual inspection and is waterproof.
Gauze dressings should be changed at least every 48 hours, and transparent
dressings should be changed every 2 to 5 days.
Comparisons of these two kinds of dressings in regard to catheter-related
colonization or catheter-related septicemia are contradictory (Orr, 1993).
Both dressings have their advantages and drawbacks. More controlled data
is needed to delineate the most effective dressing materials and frequency
of change.
Storage space and conditions
For all of the aforementioned materials enough storage space must be
available at the home of the patient. The storage space should be clean,
dry, and within a normal room temperature range.
The visiting nurse should inspect the place regularly. To maintain optimal
conditions, the amount and frequency of material delivery should be appropriate
in regard to the space available.
Completely premixed PN solutions need a refrigerator for storage. Adequate
space and cleanliness must be guaranteed.
Refrigerated solutions must be allowed to warm up to room temperature
adequately before the application, to avoid related complications. The
solutions should be infused within 24 hours after re-warming.
Waste
There is a lot of waste production when artificial nutrition is applied.
Secure disposal of sharps, cannulas, and breakable ampulles require special
containers. Also, a hugh amount of packaging, glass and plastic material
may be produced. There may even be recommendations or legal regulations
how the wastage has to be removed and destroyed (BAPEN, 1995). Adaquate
waste containers must be available.
Literature
BAPEN:
Home parenteral nutrition - Quality criteria for clinical services and
the supply of nutrient fluids and equipment.
BAPEN 1995, Maidenhead, UK
Clemence MA et al.:
Central venous catheter practices: Results of a survey.
Am J Infect Control 1995; 23: 5-12
Evans NJ et al.:
Care of central venous catheters.
In: Rombeau JL, Caldwell MD (eds). Parenteral Nutrition. Philadelphia:
WB Saunders Co. 1993: 353-366
Falchuck KH et al.:
Microparticulate-induced phlebitis: Its prevention by in-line filtration.
N Engl J Med 1985; 312: 78-82
Food and Drug Administration (FDA):
Safety alert: Hazards of precipitation associated with parenteral nutrition.
Am J Hosp Pharm 1994; 51: 1427-1428
Fossum K et al.:
Growth of micro-organisms in all-in-one TPN-admixtures containing lipids.
Clin Nutr 1988; 7: 73-79
All necessary nutrients (carbohydrates, lipids, amino acids, electrolytes,
vitamins, trace elements) must be provided for complete parenteral nutrition.
Commercial products are available in the form of single nutrient solutions
(glass bottles or plastic containers) or as all-in-one convenience-systems.
Carbohydrates and lipids are utilized as an energy source in parenteral
nutrition. The recommended ratio of glucose to lipids ranges from 65:35
up to 40:60 percent (Wolfram, 1994; Hendler, 1996).
Carbohydrates
The carbohydrate glucose is the most commonly used energy substrate for
parenteral nutrition. It is readily available, inexpensive, and efficiently
metabolised by most patients.
In order to avoid exceeding physiological limits resulting in acute and
long-term complications, the amount of glucose administered should range
from 3-6 g/kg body weight per day. A minimum of 100-150 g glucose per
day is necessary for tissues exclusively dependent on glucose as their
energy source (Müller, 1993; McMahon, 1995).
Carbohydrate/glucose solutions are available
in different concentrations (5-70%)
with or without electrolytes
with or without amino acids
Commonly used glucose concentrations in standard regimen range from 25-35%,
equivalent to an osmolarity of 1200 to 1700 mosm/l (Louie and Niemiec,
1986). Solutions for peripheral application should not exceed an osmolarity
of 900 mosm/l, corresponding to a glucose concentration of 10% (Daly JM
et al.,1985; Everitt et al., 1996; Ireton-Jones et al., 1996; Kane et
al., 1996).
Lipids
Lipid emulsions have a relatively low osmolarity while providing a high
amount of energy (9 kcal/g lipid), thus increasing the patient's tolerance
of peripheral administration when added to a glucose solution. Lipids
provide the necessary amounts of essential fatty acids. The daily adult
requirement for linoleic acid is estimated to be 7-10 g, which may rise
after severe injury.
Lipid emulsions have concentrations of 10 to 30%. Lipid sources either
consist exclusively of long-chain triglycerides (LCT), or of long and
medium-chain triglycerides (MCT) in a 1:1 ratio. The use of parenteral
solutions containing MCT has become more and more common. When compared
with LCT, intravenously administered MCT are more rapidly hydrolysed and
eliminated from the plasma and are preferentially oxidized (Wolfram, 1986).
Additionally, clinical studies with MCT/LCT-emulsions have revealed a
protein-saving effect, a preservation of liver function and an improvement
of immunological functions when compared with pure LCT emulsions (Dennison
et al., 1988; Carpentier et al., 1989; Gogos et al., 1990; Sedman et al.,
1991).
Recent research focuses on the development of lipid emulsions containing
a balanced ratio of ?-3/?-6-fatty acids, which may have positive
effects on immune functions.
If there is no contraindication against lipids 1-2 g/kg body weight a
day should be administered depending on the energy requirement.
Proteins/Amino acids
Proteins are macromolecular substances, made up of 20 different amino
acids. Eight of these amino acids have been classified as essential for
adults because the body is unable to synthesize them. The main purpose
of protein or amino acid intake is to maintain protein balance. For this
reason the protein intake is calculated separately from the non-protein
energy provided by carbohydrates and lipids.
The protein requirement depends on the type and severity of the illness,
the nutritional status and the age of the patient (Hendler, 1996).
Tab. 10: Requirements for amino acids and nitrogen
in adult parenteral nutrition
Amino acid solutions should contain all eight essential amino acids
and an approximately complete range of the non-essential amino acids.
A poor or imbalanced intake of amino acids may result in protein loss
associated with a decrease of functional capacity, a higher incidence
of complications, prolonged wound healing, decreased organ function and
ultimately in death, in relation to the nitrogen deficiency (Robin and
Greig, 1986; Stein, 1990).
Commercially available amino acid solutions provide a mixture of amino
acids. The products differ in their concentrations, individual amino acid
and electrolyte profiles. In addition, products containing carbohydrates
are also available.
Fluids and electrolytes
Disturbances of water and electrolyte balance result in dehydration or
hyperhydration and disturbances in the acid-base balance. Hence, water
and electrolytes must be given in balanced quantities. The normal requirements
for adults are shown in table 11.
Tab. 11: Recommended intake for water and electrolytes
in adult parenteral nutrition
Electrolyte requirements may differ widely between patients and at
different stages of the disease. This may be caused by fluid loss, such
as sweating, high output stomas, fever or hyperventilation.
Vitamins and trace elements
Vitamins and trace elements are enzyme cofactors as well as structural
elements. Many rate-limiting enzymes are involved in the biochemical conversion
of "nutrients" into "energy". Deficiencies may leed
to adverse clinical consequences , e.g. inefficient substrate utilization,
poor wound healing, sepsis, death. Therefore, vitamins and trace elements
are essential dietary components and must be included daily. The recommendations
for parenteral vitamin intake are shown in table 12 (AMA, Nutrition Advisory
Group, 1979).
water and lipid-soluble vitamin mixture without vitamin K
single vitamin solutions
The amounts of the vitamin mixtures added should
provide the recommended daily requirements. Since vitamin K may interfere
with anticoagulation therapy, it is better to use a vitamin K-free product
in these cases. Whenever a vitamin K-free product is used, the state of
coagulation should be monitored carefully. When required, vitamin K can
be administered as a single vitamin preparation IM or IV as short term
infusion.
The knowlegde concerning parenteral trace element
requirements is still very limited. There are some suggestions for daily
intravenous intake made by diverse working groups. The ranges of these
suggestions are compiled in table 13 (AMA, 1979; Hallberg, 1982; Jeejeebhoy
1983; DAKE, 1990; Baumgartner 1991):
Tab. 13: Suggestions on daily intake of trace elements
in parenteral nutrition
3.5.3 Compatibility of solutions
and stability of admixtures
TPN mixtures contain substrates with different physical and chemical
properties. Incompatibility of solutions can either cause chemical instability
of ingredients or physical instability, i.e. flocculation or coaggulation
of the emulsion (Manning and Washington, 1992).
Due to the potential for life-threatening situations caused by incompatible
IV solutions, the FDA has published specific recommendations for TPN preparations
(FDA, 1994).
Incompatibilities can occur because of a number of factors (Manning and
Washington, 1992):
the amount of phosphorus and calcium
the order of mixing
the mixing process
the concentration and the pH of the solutions
the ambient temperature
Admixture should only be carried out by specially trained personnel using
strict aseptic technique. TPN must be compounded by a pharmacist familiar
with the handling, storage, stability, and compatibility of solutions
and additives. Many pharmacies work according to the guidelines for compounding
parenteral nutrition solutions, thus ensuring improved quality assurance.
Home care personnel, who start and monitor infusions, should carefully
look for the presence of precipitates both before and during the infusion.
Patients and carers should be trained to notice the visible signs of precipitation.
They should also be advised to stop the infusion and seek medical assistance
if precipitates are present (Steiger at al., 1990).
Most HPN patients are provided with all-in-one
solutions. The administration of nutrients as an all-in-one mixture has
several advantages over a separate bottle system (Meguid, 1989):
the work load of the staff is reduced,
the handling is easier,
less time is required for patient training,
the risk of errors is reduced.
The patients are supplied with a prepared system
containing all nutrients either by their hospital or their pharmacy. Furthermore,
convenient all-in-one systems are produced by the pharmaceutical industry.
There are 2- and 3-chamber bags that are prefilled with amino acids, carbohydrates
and electrolytes, with or without lipids. Additives are added to the solution
immediately before the infusion. These convenient all-in-one systems are
advantageous because the shelf life is relatively long (2 years) and the
bags can be stored at room temperature.
Literature
American Medical Association (AMA), Nutrition Advisory Group:
Multivitamin preparations for parenteral use. A Statement by the Nutrition
Advisory Group.
J Parenter Enter Nutr 1979; 3: 258-262
American Medical Association (AMA):
Guidelines for Essential Trace Element Preparations for parenteral use.
A statement by an expert panel.
JAMA 1979; 241(19); 2051-2054
Baumgartner TG:
Clinical Guide to parenteral micronutrition.
Fujisawa (Lyphomed), USA 1984 & 1991
Carpentier YA et al.:
Long term TP??? ) N and liver dysfunction.
Clin Nutr 1989; 8 (Suppl): 31
Daly JM et al.:
Peripheral vein infusion of cextrose/amino acid solutions ( 20% fat emulsion.
J Parenter Enter 1985; 9; 296-299
Deutsche Arbeitsgemeinschaft für klinische Ernährung (DAKE):
Empfehlungen für die tägliche Vitaminzufuhr bei parenteraler
Ernährung Erwachsener.
Infusionstherapie 1990; 17; 60-61
Deutsche Arbeitsgemeinschaft für klinische Ernährung (DAKE):
Empfehlungen für die Zufuhr von Spurenelementen bei parenteraler
Ernährung Erwachsener.
Infusionstherapie 1990; 17; 283
Dennison AR et al.:
Total parenteral nutrition using conventional and medium-chain triglycerides:
Effect on liver function tests, complement, and nitrogen balance.
J Parenter Enter Nutr 1988; 12:15
Everitt NJ et al.:
Peripheral infusion as the route of choice for intravenous nutrition:
a prospective two year study.
Clin Nutr 1996; 15; 69-74
Food and Drug Administration:
Safety alert: Hazard of precipitation associated with parenteral nutrition.
Am J Hosp Pharm 1994; 51: 1427-1428
Gogos CA et al.:
Effects of different types of total parenteral nutrition on T-lymphocyte
subpopulations and NK cells.
Am J Clin Nutr 1990; 51: 119
Hallberg D et al.:
Parenteral Nutrition: Goals and Achievements, Part 1.
Nutr Supp Serv 1982; 2; 15-24
Hendler RS:
Nutrient requirements.
20th ASPEN Congress 1996: 19-28
Ireton-Jones CS et al.:
Peripheral parenteral nutrition: The other alternative for nutrition support.
Infusion 1996; 3; 44-48
Jeejeebhoy, KN:
Micronu??? ) trients - State of the Art.
New Aspects of Clinical Nutrition 1983; 1-24
Kane KF et al.:
High osmolality feedings do not increase the incidence of thrombophlebitis
during peripheral IV nutrition.
J Parenter Enter 1996; 20; 194-197
Health care systems differ widely from country to country, implicating
also different regulations in home care therapies, including the distribution
of products. As a result of an European questionnaire conducted by the
ESPEN home artificial nutrition work group, it was determined that in
most cases the prescribing hospitals supply the patients with the products
needed for HPN (see table 14). If this is the case, HPN is organized through
the hospital staff and continuing care is provided by the hospital, sometimes
in cooperation with local ambulatory caregivers.
Tab. 14: Origin of nutritional supplies delivery (Van
Gossum et al., 1996)
Things get more complicated when solutions are supplied through pharmacies,
application systems and accessories are delivered by medical retailers
and the family doctor is prescribing all necessary products. In any case
a good basic knowledge of the therapy is needed for all people involved
in the management of HPN.
As in most of the patients HPN is administered throughout the night time,
a 24-hour service has to be provided either by the hospital, or by any
other supplier, to ensure that the therapy can be continued in case of
application problems.
In HPN, nutrients are usually provided as all-in-one systems (Messing
et al., 1989), being ready-to-use pre-mixed TPN bags from industrial compounding,
hospital or outpatient pharmacies. Convenience systems like multi-chamber
bags can usually be stored for a longer time at room temperature, because
lipids and micronutrients are added just before using the products. Whereas,
pre-mixed ready-to-hang TPN bags containing all components have to be
stored in refrigerators, having an expiry date of two to five days.
In the two above mentioned European survey studies published by Messing
et al. (1989) and Van Gossum et al. (1996), pumps were reported to be
used in 58% to 86% of HPN patients. According to the European Medical
Directives, the supplier of the infusion pump has to instruct the user
how to handle the pump and has to fill in a documentation form of the
instruction.
Coordination of all the necessary steps in product delivery is a task
that may be covered by the nutritional team of the hospital or by the
caregivers, including family members or the patient himself.
Literature
Messing B et al.:
Home parenteral nutrition in adults: a multicentre survey in Europe.
Clin Nutr 1989, 8: 3-9
Van Gossum A et al.:
Home parenteral nutrition in adults: a multicentre survey in Europe in
1993.
Clin Nutr 1996; 15: 53-59
Up to 60% of the patients undergoing HPN take care of themselves. In
many other cases relatives do the caring (Messing, 1989; ESPEN, 1996).
Prior to discharge from the hospital patients on HPN as well as their
caregivers have to undergo a special training that ensures a sufficient
quality of care at home. In the US, standards for home nutrition support
exist. Several organizations are responsible for the realization of these
standards. In other countries standards for care have not yet been realized.
The training of the patient takes 2 to 3 weeks (Messing, 1989; ESPEN,
1996).
In the American Standards for Home Nutrition Support the learning goals
of educational training are listed in detail (Tab.15).
Tab.15: Learning goals of educational training. Standards
for Home Nutrition
Support (ASPEN, 1992)
Slides and handbooks are good materials for training. When teaching
patients/carers or developing effective patient nutrition education material
attention should be paid to several aspects:
The reading level of the materials should be at the level of the audience.
To improve the learnability of the material it is necessary to put the
information into small, manageable units (Evans, 1993).
To simplify learning the patient/carer has to be involved into the learning
process, being given the chance to ask questions and to bring own ideas
into the lessons. Both theoretical and practical lessons should be included
in the training procedure. Part of the practical training could be to
practice the HPN with a model (Halbach, 1995). Recording the lessons on
cassette may be helpful. The cassette makes the preparation of the HPN
easier because the patient/carer can act while listening.
The patient also should learn why he handles the HPN the way he does.
This is important to recognize problems and handle them correctly. It
also makes it easier to adapt to changes that take place in HPN, for example
product changes of the feeding solution or the application system.
Prior to discharge from hospital the following conditions must be
met (Wood, BAPEN):
no medical contraindications against HPN
the trainer of HPN has to be sure that the patient/carer is able to
manage HPN on his own
Aim of the training is that the patient/carer feels:
confident in his ability to self-care or in the ability of a carer
that expression of physical, emotional or social discomfort, when
shared with the hospital staff, will be treated with respect and an
appropriate intervention
trust in his general practitioner´s knowledge of HPN
that he is one of many patients receiving HPN
Literature
ASPEN:
Standards for Home Nutrition Support.
Nutr Clin Pract 1992; 7: 65-69
ESPEN - Home Artificial Nutrition Working Group:
Home parenteral nutrition in adults: a multicentre survey in Europe in
1993.
Clin Nutr 1996; 15: 53-59
Evans MA et al.:
Home nutrition support patient education materials.
Nutr Clin Pract 1993; 8: 43-47
Halbach B:
Enterale und parenterale Ernährung zu Hause (2. Teil).
Pflegen Ambulant 1995; 4: 26-32
Messing B et al.:
Home parenteral nutrition in adults: a multicentre survey in Europe.
Clin Nutr 1989; 8: 3-9
Wood S:
Protocol for teaching patients/carers prior discharge on home parenteral
nutrition (HPN).
BAPEN
In all countries health expenses are continously discussed and regulations
are being changed frequently. As costs are increasing every year, correspondingly,
public and private insurances are limiting their reimbursement more and
more and increasing patient co-payment. In the USA in 1992, 7-8 billion
dollars were spent for specialized nutritional support. Most of these
expenses were consumed in hospital settings with only approximately 10%
being accounted for by non-hospitalized patients, 80% of those receiving
enteral nutrition and 20% HPN (Malone, 1994).
Annual cost of HPN range from US $70,000 to US $185,000 depending on
the type of solutions being used, volumes, frequency of application and
the cost of home care services (Fleming, 1996). Potential savings of around
US $40,000 to US $50,000 have been estimated when comparing the costs
of HPN to hospital based parenteral nutrition (Carlson et al., 1995).
Patients or families may have to face severe financial problems depending
on the health insurance they have. In general, there are no standards
in reimbursement and coverage of therapy costs. For example as reported
by Malone, insurance in the US may only guarantee a maximum life time
coverage of US $1 million, which in case of continuing HPN may be reached
within 10 years. Many insurances in the US as well as in Europe reimburse
at a rate of 80% of the total costs of therapy, including HPN. In these
cases, patients would have to pay the balance of 20%, which ultimately
could account for expenses ranging from US $15,000 to US $35,000 per year,
unless a fixed maximum patient co-payment is set.
In a quality of life study in the US, results of a fiscal questionnaire
show that costs for professional assistance in HPN range from $4,000 (n=76)
to $30,000 (n=2) per year and total yearly expenditures related to HPN
ranged from $12,000 to $296,000 (n=1). The mean family incomes in this
study were $25,000 to $35,000. For nearly one third of the family caregivers,
their responsibilities for the patient required them to miss work days,
turn down a better job, decreased the number of hours worked, or quit
their job (Smith, 1993).
Many insurances are granting special conditions for people with low incomes
or for pediatric patients. In these cases up to 100% of the total cost
may be reimbursed. In Germany, family members can also apply for a home
care stipendium payed by the public care insurance (Pflegeversicherung),
if they care for the patient at home when a high level of care is necessary.
As a conclusion, patients and caregivers would be well advised to check
available financial resources and their individual family situation in
detail prior to initiating HPN to both prepare for managing therapy and
to avoid undue financial hardship.
Literature
Carlson, GL et al.:
Quality of life on home parenteral nutrition: a single centre study of
37 patients.
Clin Nutr 1995; 14: 219-228
Fleming, CR:
Home parenteral nutrition: a 20-year reflection and a look to the future.
ASPEN physician workshop 1996
Malone, M:
Quality of life of patients receiving home parenteral or enteral nutrition
support.
PharmacoEconomics 1994; 5 (2): 101-108
Smith, CE:
Quality of life in long-term parenteral nutrition patients and their family
caregivers.
J Parenter Enter Nutr 1993; 17 (6):501-505
The organization of discharge for a patient with HPN begins while he
still is in the hospital. Several persons and institutions have to be
informed about the forthcoming discharge: the patient himself, his relatives,
the caregiver or the nursing service, the family doctor, the health insurance
company, and the supplier of the infusions and other necessary materials.
Home care services are offered by several companies and organizations.
These services help to arrange the discharge and to manage the therapy.
They can be regarded as the connecting link between the patient and various
authorities.
Prior to hospital discharge the physician of the Nutrition Team has to
(Sailer, 1990):
inform the family doctor:
the family doctor should be involved in the therapy;
he should keep in touch with the hospital doctor after discharge
do or delegate the organization and administration
give psychological help to the patient, together with the nutrition
nurse
The responsibility of the nutrition nurse concerning the discharge is
(Sailer, 1990):
to motivate patient and caregiver
to help the physician with the psychological counselling
to contact:
the nursing service
the family doctor
the health insurance
the HPN/supply retailer (if applicable)
to educate and train the patient and caregiver
Not every patient is suitable for HPN. Therefore, several aspects have
to be checked prior to hospital discharge (ASPEN, 1992; SVK, 1994):
The patient's home environment has to be checked. The physician, in
consultation with the appropriate social worker or other health professionals,
should conclude whether home therapy is more appropriate than long-term
institutional care.
The treatment and care plan should be designed to achieve the HPN
objectives.
The patient's home environment should be appropriate for the safe
use of HPN support.
The patient/carer should be willing and able to perform HPN support
procedures.
The patient/carer should be knowledgeable about therapeutic expectations,
risks, benefits and responsibilities of HPN and should agree to participate.
The patient/carer should understand the rationale, risks, benefits,
and therapeutic options regarding nutrition support.
The patient and/or family should understand the cost of equally suitable
nutrition support approaches and alternatives, insurance coverage, and
financial responsibilities.
Every part of home parenteral services should be documented. Medical
records should be maintained for every patient receiving HPN and should
include at a minimum (ASPEN, 1992):
The designation of a physician with expertise in parenteral nutrition
having primary responsibility for patient's home nutrition care.
All pertinent patient diagnosis and prognoses, including long- and
short-term treatment objectives.
A nutrition assessment and medical evaluations, with follow-up as
appropriate.
Scope and results of initial and ongoing education of patient/carer.
A treatment plan which shall include orders established and signed
by referring physician for care of the patient (which include medical
orders for nutrients, medications, activity level, access-site care).
A care plan including consideration of functional limitations of
the patient, activities permitted, psychosocial needs, suitability of
home environment for provision of home nutrition services and name(s)
of other individual(s) who will assist in care of the patient if required.
A current medication profile including prescription and nonprescription
drugs, home remedies, and known allergies or sensitivities.
Signed and dated progress notes for each contact between the patient
and physician/nutritional support team or home nutrition therapy provider;
progress notes should report response to nutrition therapy including
results of serial monitoring, complications, and revisions in the therapeutic
regimen.
Signed and dated progress notes for each contact between the home
nutrition therapy provider and the physician/nutritional support team
including results of serial monitoring, complications, and revision
in the therapeutic regimen.
A summary statement at termination of nutrition therapy including
the reason for terminating treatment, complications, patient outcome,
and follow-up.
Literature
ASPEN:
Standards for Home Nutrition Support.
Nutr Clin Pract 1992; 7: 65-69
Sailer, D:
Organisation und Durchführung eines ambulanten Ernährungsprogrammes.
Ernährung 1990; 1: 82-86
Schweizerischer Verband für Gemeinschaftsaufgaben der Krankenkasse
(SVK):
Künstliche Ernährung zu Hause. 10.03.1994; 4/7
Home Parenteral Nutrition is a very efficient therapy and in fact has
helped a number of patients to recover from important illnesses. But HPN
is not free from complications which, in some cases, might be severe and
life-threatening.
Monitoring is the key to minimize HPN-associated complications. The patient
must be monitored for (ASPEN 1993):
therapeutic and adverse effects, and
clinical changes that may influence nutrition support.
This monitoring should be a combined effort of the nutrition support
team, local physician, home health nurse, and the home care vendor. Protocols
for periodic review of the patient's status should be established.
Routine monitoring should include (ASPEN 1992, ASPEN 1993, Schmid 1991,
Skipper 1989):
Clinical monitoring physical examination, vital signs (blood pressure), temperature,
medications, review of current medications for drug-nutrient-interactions,
signs of dehydration
Nutrition monitoring weight, anthropometric parameters, intake (especially in cases
were parenteral nutrition is combined with oral or enteral intake),
signs of nutrient deficiencies
hematologitests: Hemoglobin, hematocrit, WBC, RBC, PTT
organ function: Bilirubin, alkaline phosphatase, GOT, GPT
vitamin D
disease specific parameters
Catheter monitoring
visual inspection of the catheter entrance (redness, swelling,
pain, exudate)
catheter patency
Psychological monitoring
how patient and family are coping with life-style changes
4.2 Problem solving
Routine monitoring should prevent or minimize complications of HPN support.
Knowlegde of specific complications of HPN and their incidence may draw
and heighten one's attention for the first signs of their appearance.
In a multicenter survey performed in Europe (Messing, 1989) covering
the follow-up of 194 patients in nine different countries, a profile of
complications was reported according to technical and metabolic complications.
Later studies confirmed the findings by showing similar results.
Tab.16: Technical complications during HPN leading
to catheter change
(Messing et al., 1989)
The cumulated duration of the 200 HPN periods in the aforementioned
survey represented 207 patient years. In this report, complications related
to the technical aspects of HPN were present in 37% of patients. Metabolic
complications were reported in 30% of patients, and included bone and
joint problems and liver or gallbladder diseases as shown in table 17.
Tab. 17: Metabolic complications under HPN (Messing
et al., 1989)
This is one of the main complications related to HPN. The reasons for
these infections are basically the poor adhesion to aseptic application
techniques, contaminated tubing, contaminated parenteral solution, or
ingrowth of skin bacteria.
As mentioned in other chapters, handling of the lines and systems require
an aseptic technique which needs practice and surveillance until it is
well performed by the patient or caregiver. The use of sterile gloves,
disinfection solutions, masks, etc. are mandatory to minimize the incidence
of this complication. It has been shown that the correct use of these
techniques may significantly reduce the catheter-related bacteremias (Stotter,
1987).
Staphilococcus aureus (40%) and epidermidis (40%) seem to be the main
organisms responsible for this complication. Candida (15%) and other gram-negative
organisms (5%) are less frequent (Howard, 1989).
The main symptoms of catheter-related sepsis include redness,
pain, swelling or drainage at the insertion site, increases in body temperature
above 38°C, chills, sweating, and lethargy. Also, urine tests may
show glucose levels greater than 1 or 2%.
The immediate action, according to the Oley Foundation Guidelines,
that the patient should take when identifying these symptoms, is to immediately
inform the doctor responsible for the HPN treatment or seeking help at
the nearest hospital emergency.
It is important to stress again that the training of the patient is key
not only to detect this severe complication at once, but more importantly
to prevent it. Prevention by having detailed guidelines (Young, 1988)
or having skilled patients and personnel has been shown to be effective.
With these measures, a reduction of the complication rate was achieved
from
29-39% to levels as low as 8-10% (Stotter, 1987).
Blockage of catheter
The reasons for this complication is unclear and probably multifactorial.
Heparinization of the catheter has become an action, routinely performed
in order to avoid this complication. The usual prevention protocol asks
for regular rinsing of the central venous catheter with 3-5 ml of a 0.9%
sodium chloride solution containing 100 to 200 IU of heparine/ml.
The symptoms for the patient are that he/she is unable to infuse the
parenteral nutrition. In this cases the patient should clamp the catheter
and call the doctor for further direction.
In case of real catheter clotting, different actions may be performed,
and the Home Parenteral Nutrition team should have previously protocolized
them according to their criteria and severity:
Rinsing the CVC with sodium chloride 0,9%, being aware to adhere
to aseptic measures.
Applying 5.000 IU urokinase in 2ml saline, for 0.5 to a maximum of
2 hours inside the catheter (by medical doctor only).
Ethanol solution in water 70% inside catheter (Pennington, 1987).
Between 0.2 to 1 ml of chloride acid 0.1 N (Shulman, 1988).
When all the different techniques to destruct the clot have failed, removal
of the catheter is performed.
Migration of catheter
Quite a number of times a movement of the catheter from the original
position takes place. In those circumstances the Home Parenteral Nutrition
team, and especially the responsible physician should decide whether the
catheter has to be changed.
Venous thrombosis
The reasons for venous thrombosis are also multifactorial. The catheter
diameter, the number of lumens, catheter material, catheter placement,
and the correct positioning seem to influence the generation of venous
thrombosis. Di Constanzo states in his study from 1988, that rigid catheter
materials are more frequently responsible for venous thrombosis. Therefore,
polyurethane or silicone catheters are the first choice to avoid this
complication.
Patients with venous thrombosis appear to have edema, heat, encephalitis,
diplopia, papilloedema, neck swelling and distension, thrombophlebitis
and pulmonary thromboembolism (NADYA, 1997).
It is still unclear what the real origins of this complication are, which
comprises not only joint and/or bone pains, but also histological modifications,
with a clear decrease of bone density (Hurley, 1990). Shike et al. (Shike
et al., 1980) showed that patients receiving complete HPN including vitamins
developed osteomalacia, hypercalcemia and hypercalciuria, with a negative
calcium balance. Blood phosphate appeared to be normal and PTH was also
normal or slightly low. When vitamin D was removed from parenteral nutrition,
calciuria diminished and calcemia decreased to normal values. The conclusion
from this study suggested that giving normal doses of vitamin D, with
normal serum levels, would cause an histological osteomalacy related hypercalcemia
and hypercalciuria. Nontheless, bone fractures and bone losses may occur
in further stages (Harrison, 1982).
Although it is quite clear that high levels of vitamin D may lead to
osteomalacy and therefore to hypercalcemia and hypercalciuria, normal
levels of 25-hydroxy-vitamin D do not necessarily suggest vitamin D toxicity.
Harrison (Harrison, 1988) suggests that patients with hypercalcemia receiving
normal amounts of vitamin D, either show an excessive sensitivity towards
Vitamin D intake in normal amounts, or normal vitamin D serum levels may
somehow influence or trigger underlying factors.
As a conclusion, it is not yet clear which is the reason for this frequently
occuring complication and therefore a thorough follow-up of the patient
must be performed, monitoring vitamin D intake, calcemia evolution and
presence of pain in bones and joints.
Hepatic illness, jaundice and gallbladder lithiasis
In some patients receiving HPN, high levels of transaminases as well
as hepatic-function markers, hormones and bilirubin may be found. The
reason for this, again, is multifactorial. Some of these factors are rather
not directly related to the parenteral nutrition infusion but to factors
like previous presence of malnutrition, previous hepatic illness, sepsis,
length of the remaining gut, bacterial overgrowth, etc. Some changes could
be directly related to the quantity and quality of the parenteral nutrition
infused, e.g., excess of non-protein calories, especially glucose overdosage,
nutrient deficits, no oral or enteral intake, and the length of the parenteral
nutrition therapy.
A deficit in essential fatty acids can be responsible for steatosis (Jeejeebhoy,
1973). Today, it is a common practice to give total parenteral nutrition
including fat (lipids), thereby avoiding this effect. Giving fat as part
of the parenteral nutrition solution not only accomplishes this objective,
but also allows reducing the amount of glucose (non-protein calories).
Previously, glucose was given in quite exccessive amounts. When this ocurred,
acetyl-CoA and fatty acids were produced in excess. Insulin was also stimulated,
thus inhibiting fat reserve mobilisation (Howard, 1993).
On the other hand, excessive lipid infusion directly leads to a fatty
infiltration in hepatic lymphosomes. The intake of MCT/LCT has proved
to be an advantage, due to the fact that MCT is not accumulated in this
hepatic tissue. MCT are preferably being burnt, unlike LCT which clearly
tend to accumulate in the liver (Carpentier, 1990).
Other metabolic complications
Very often little to no attention is paid to the amount and profile of
vitamins and trace elements. The home parenteral team should gain consent
upon the correct amount of these micronutrients. There are various differing
recommendations of severeal medical and health associations. One should
bear in mind, that parenteral needs can differ from enteral needs (Howard,
1993).
Finally, patients under HPN may develop electrolyte imbalances. Usually,
electrolyte imbalances are the result of dehydration and/ or increased
losses due to vomiting, diarrhea, fistula or ostomy output. Sodium, magnesium
and potassium are the most sensitive electrolytes that require regular
follow-up. Rapid weight loss or weight gain, thirst, weakness, edema,
fine tremor, muscle cramping, numbness, skin changes, and tingling of
hands or around the mouth, are symtoms of electrolyte imbalances. Daily
ionograms and tailor-made PN-prescriptions can help to recover a good
balance of minerals. Regular attention to adequate fluid and electrolyte
intake, and immediate attention to occuring losses as well as to medication
influences should help to prevent these complications.
Literature
ASPEN
Standards for Home Nutrition Support
Nutr Clin Pract : 1992; 7, 65-69
ASPEN
Nutrition Support Dietetics. Core Curriculum, 2nd ed.,
ASPEN, Silver Spring 1993
Carpentier YA et al.:
New developments in fat emulsions.
Proc Nutr Soc 1990; 49: 375-380
Di Constanzo J et al.:
Mechanism of thrombogenesis during total parenteral nutrition: Effect
of catheter composition.
J Parenter Enter Nutr 1988; 12: 190-194
Harrison JE, Jeejeebhoy KN:
The bone and mineral metabolism unit. The effect of TPN on bone mass.
Presented at the symposium on "Metabolic bone disease in total parenteral
nutrition", Deerfield, IL, June 1982
Howard L et al.:
Five years of experience in patients receiving home nutrition support
with the external catheter.
J Parenter Enter Nutr 1989; 13: 478-483
Howard L et al.:
Home Parenteral Nutrition in Adults.
In: Rombeau JL, Caldwell MD (eds). Parenteral Nutrition. Philadelphia:
WB Saunders Co. 1993: 814-839
Hurley DL, McMahon M:
Long-term parenteral nutrition and metabolic bone disease.
Endocrinol Metab Clin North Am 1990; 19: 113-131
Jeejeebhoy KN et al.:
Total PN at home for 23 months without complication and with good rehabilitation:
a study of technical and metabolic features.
Gastroenterology 1973; 65: 811-820
Messing B et al.:
Home parenteral nutrition in adults - a multicentre survey in Europe.
Clin Nutr 1989; 8: 3-9
Pennigton CR, Pithis AD:
Ethanol lock in the management of catheter occlusion.
J Parenter Enter Nutr 1987; 11: 507-508
Schmid P.
Totale Parenterale Nutrition.
Bern 1991
SENPE, Grupo NADYA:
Manual de Nutrición Artificial Domiciliania y Ambulatonia - Procedimientos
Educativos y Terapéuticos.
SENPE, 1997
Shike M et al.:
Metabolic bone disease in patients receiving long-term parenteral nutrition.
Ann Intern Med 1980; 92: 343-350
Shulman RJ et al.:
Use of hydrochloric acid to clear obstructed central venous catheters.
J Parenter Enter Nutr 1988; 12: 509-510
Skipper A.
Dietician's Handbook of Enteral and Parenteral Nutrition
Aspen Publishers, Gaithersburg 1989
Stotter AT et al.:
Junctional care: the key to prevention of catheter sepsis in intravenous
feeding.
J Parenter Enter Nutr 1987; 11: 159-162
The Oley Foundation for Home Parenteral Nutrition.
HPN Complication Chart
Young G et al.:
Catheter sepsis during parenteral nutrition: The safety of long-term opsite
dressings.
J Parenter Enter Nutr 1988; 12: 265-370
Home Parenteral Nutrition is a relatively new treatment modality available
to patients. Since the first report in 1967, there have been continous
and rapid changes in nutrition support knowledge and the development of
new solutions and medical devices.
For optimal use of this treatment modality, particular attention should
be paid to patient selection.
The underlying disease and the metabolic state must be checked and
HPN must be clearly indicated.
A comprehensive nutritional assessment is indispensable. The goal
of the nutritional therapy should be clear and should be stated before
HPN is started.
Additionally, the patient and his family must be able to deal with
such a highly specialized therapy.
In order to avoid serious complications, the implementation criteria
must be carefully checked. The environment must allow proper and safe
application of the HPN solutions.
The patient and/or caregiver must be able to handle the application.
Financial reimbursement must be checked .
When these selection criteria indicate that HPN is possible, the discharge
of the patient has to be planed and implemented in an organized fashion.
Access route and devices have to be chosen and to set in place.
The nutritional regimen has to be calculated carefully. The HPN regime
should be complete and conveniently applicable.
The application devices have to be chosen and listed.
The delivery of solutions and devices must be secured.
The patient and/or caregiver/nursing services must be trained in
the application of HPN as well as the care of the venous access.
Information between hospital and all ambulant services must be continously
exchanged.
The discharge documents should be comprehensive and the ongoing monitoring
set between hospital and the local physician.
Complications of HPN should be known by all parties involved, as
well as the steps to deal with the various complications.
When all aspects of HPN are carefully looked upon and organized in an
orderly and timely manner, HPN can not only be a life-saving and cost-saving
treatment modality, but also vastly increase the patient's quality of
life.
AIDS
AMA
ASPEN
BAPEN
bw
Ctx
CVC
CVT
DAKE
e.g.
ESPEN
FDA
Fe
GOT
GPT
HEN
HIV
HPN
IM
IU
IV
LCT
MCT
NADYA
pH
PICC line
PN
PPN
PTH
PTT
PVT
RBC
Rtx
SENPE
SVK
TPN
UK
US
vs
WBC
Acquired Immuno-Deficiency Syndrome
American Medical Association
American Society of Enteral and Parenteral Nutrition
British Society of Enteral and Parenteral Nutrition
body weight
Chemotherapy
Central Venous Catheter
Central Vein Thrombophlebitis
Deutsche Arbeitsgemeinschaft für Klinische Ernährung
for example
European Society of Enteral and Parenteral Nutrition
Food And Drug Administration (USA)
Ferrum
Glutamat-oxalacetat-transaminase
Glutamat-pyruvat-transaminase
Home Enteral Nutrition
Human Immunodeficiency Virus
Home Parenteral Nutrition
Intramuscular
International Units
Intravenous
Long Chain Triglycerides
Medium Chain Triglycerides
Nutrición Artificial Domiciliania y Ambulatonia
pondus Hydrogenii
Peripheral Inserted Central Catheter
Parenteral Nutrition
Peripheral Parenteral Nutrition
Parathyroid hormone
Prothrombin Time
Peripheral Vein Thrombophlebitis
Red Blood Cell Count
Radiation therapy
Sociedad Española de Nutrición Parenteral y Enteral
Schweizerischer Verband für Gemeinschaftsaufgaben der Krankenkassen
Total Parenteral Nutrition
United Kingdom
United States
versus
White Blood Cell Count
