Catheter-related infection rates in patients receiving customized home parenteral nutrition compared with multichamber bags

Expert consensus statements and summary of proceedings from the International Safety and Quality of Parenteral Nutrition Summit

PURPOSE

The International Safety and Quality of Parenteral Nutrition (PN) Summit consisted of presentations, discussions, and formulation of consensus statements. The purpose here is to briefly summarize the summit and to present the consensus statements.

SUMMARY

There was a high degree of consensus, with all statements approved by all authors/summit experts. These consensus statements should be regarded not as formal guidelines but rather as best-practice guidance intended to complement national and international nutrition society evidence-based guidelines and position statements. This article also summarizes key discussion topics from the summit, encompassing up-to-date knowledge and practical guidance concerning PN safety and quality in various countries and clinical settings, focusing on adult patients. Clear geographical differences exist between practices in Europe and the United States, and different approaches to improve the safety, quality, and cost-effectiveness of PN vary, particularly with regard to the delivery systems used. Discussion between experts allowed for an exchange of practical experience in optimizing PN use processes, opportunities for standardization, use of electronic systems, potential improvements in PN formulations, better management during PN component shortages, and practical guidance to address patients' needs, particularly during long-term/home PN.

CONCLUSION

The consensus statements are the collective opinion of the panel members and form best-practice guidance. The authors intend that this guidance may help to improve the safety and quality of PN in a variety of settings by bridging the gap between published guideline recommendations and common practical issues.

Parenteral nutrition at home/long-term parenteral nutrition

PURPOSE

Some diseases require that patients receive parenteral nutrition (PN) over a prolonged time period. Long-term administration of PN can further complicate an already complex therapy, posing additional risk of potential complications. This article is based on presentations and discussions held at the International Safety and Quality of PN Summit, providing insights into aspects of home PN (HPN) and examples of good HPN practice.

SUMMARY

One critical step in the HPN process is when patients transition from a hospital to a home setting, and vice versa. Generally, electronic PN ordering is not feasible in an HPN setting, leading to potential difficulties in communication and coordination. HPN requires that patients (or their home caregivers) administer PN, and thus their education and competency are crucial. Likewise, the choice of PN formulation is of great importance. For example, using more modern intravenous lipid emulsions containing medium-chain triglycerides, olive oil, and/or fish oil can provide benefits in terms of liver function during long-term HPN. Internationally, there are wide variations in delivery of HPN, with compounded PN dominating in some countries while others make greater use of market-authorized multichamber bags (MCBs). Patient-related factors, institutional considerations, and the availability of different MCB formulations, are also contributing factors guiding formulation and delivery system preferences.

CONCLUSION

Education and communication remain key components of a successful HPN process. The information shared here may help to motivate efforts to improve HPN processes and to consider the often-differing perspectives of patients and their healthcare professionals.

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

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

A hybrid model of compounded and multi-chamber bag parenteral nutrition for adults with chronic intestinal failure

BACKGROUND

While international guidelines support the use of commercially available multi-chamber bags (MCBs), the majority of home parenteral nutrition (HPN) in the UK has been compounded PN, tailored to the patient. However, national capacity limitations in aseptic facilities have necessitated the increased use of MCBs. There are no studies evaluating the appropriateness or benefits of using a 'hybrid' regimen incorporating both MCBs and compounded PN in patients already established on compounded HPN.

METHODS

This was a cross sectional audit evaluation conducted on 1^st September 2021 at a national UK reference centre. All HPN-dependent adults prescribed HPN for Chronic Intestinal Failure were assessed by a multidisciplinary team for their potential of being switched to a 'hybrid' regimen of MCBs and compounded PN.

RESULTS

Of 180 patients currently receiving compounded HPN that included intravenous nitrogen with glucose ± lipid, 65 (36.1%) were deemed clinically suitable for a hybrid PN regimen, with minimal variance in PN constituents per week (volume 0%, non-N Kcals 0%, Nitrogen 0%, Fat -0.2% Glucose 0%, Sodium 0%, Potassium 0%, Calcium 0%, Magnesium 0%, Phosphate -0.1%) and requiring no additional central venous catheter manipulations. The potential reduction in compounded PN would reduce by 3627 bags per year, equating to a cost saving of £141,453 per year.

CONCLUSION

Wider use of hybrid MCB/compounded HPN regimens could lead to a reduction in the need for compounded PN to be produced by aseptic facilities. Further evaluation of acceptability and tolerance of hybrid regimens by patients already on compounded HPN is required.

CLINICAL RELEVANCY STATEMENT

This is the first study to demonstrate the feasibility and potential benefits of utilising multi-chamber parenteral nutrition (PN) bags for patients established on a compounded PN regimen. This article is protected by copyright. All rights reserved.