Home Parenteral and Enteral Nutrition

Quality of care of oncological patients with home parenteral nutrition

PURPOSE

Transferring adult cancer patients from the hospital to the home environment for home parenteral nutrition (HPN) can be challenging. There is limited real-world data on how those affected perceive this situation. Our aim was to assess the quality of life (QoL) on HPN and the benefits and burdens from the cancer patient's perspective.

METHODS

This observational study from Germany examined the QoL on HPN on the basis of the Functional Assessment of Cancer Therapy - G questionnaire (FACT-G). The benefits and burdens of HPN were assessed using predefined questions and answers tailored to the situation of this patient group.

RESULTS

139 adults with advanced solid tumors in a palliative setting at 10 hospitals in Germany were eligible for the study. The follow-up was 12 weeks. At week 4, the Least-square (LS) mean (95% CI) change from baseline in the total FACT-G score was 0.9 (-2.4; 4.2) points, indicating QoL stability. HPN was associated with few complications, with a low rate of hospital readmission due to catheter-related issues (3.8%; n = 5). In the patient assessment of the benefits of HPN, the LS mean values at Week 4 ranged between 7.6 and 8.5 on a 10-point Likert scale. The most commonly perceived burden was "restricted mobility".

CONCLUSION

With thorough preparation for home parenteral nutrition, the transition from hospital to home care environment works well. QoL is largely maintained through HPN, and cancer patients perceive this situation as not or minimally burdensome alongside their underlying disease, although many patients found the limited mobility to be a burden.

TRIAL REGISTRATION NUMBER

NCT03425435 / Date of registration: February 01, 2018.

Continuous glucose monitoring in adults with short bowel syndrome receiving overnight infusions of home parenteral nutrition

BACKGROUND/OBJECTIVES

Consumers of home parenteral nutrition (HPN) are susceptible to dysglycemia. The aim was to characterize 24-h glucose profiles of HPN consumers using continuous glucose monitors (CGM) and to identify factors that influence glucose.

SUBJECTS/METHODS

Glucose profiles of 20 adults with short bowel syndrome (SBS) without diabetes were assessed using the Freestyle Libre Pro CGM. Measures included mean 24-h glucose, coefficient of variation (%), % time in range (TIR 70-140 mg/dL), among others. HPN parameters and lifestyle behaviors were obtained from self-reports and validated surveys. Linear mixed-effects models were used to test associations with glycemic measures adjusted for age, sex, and BMI. Significance was considered at P < 0.05.

RESULTS

Participants (77% female, age = 52 years, BMI = 21.4 kg/m², 95% white) had a 24-h mean and CV for glucose of 94.69 (8.96) mg/dL and 20.27%, respectively, and a mean TIR of 87.73%. Among non-daily HPN-dependent patients, the mean glucose and TIR were higher on days receiving HPN. Tapering HPN was associated with -6.882 (95% confidence interval = -12.436, -1.329) % lower CV, and higher HPN dextrose content per gram was associated with 0.039 (95% confidence interval = 0.008, 0.07) % higher CV. Smoking, more depressive symptoms, and higher insomnia severity showed associations with glucose levels and variability.

CONCLUSIONS

Metabolically stable HPN adult consumers have 24-h glucose measures comparable to healthy adults yet are notable for more time spent below range. The glucose profiles are influenced by HPN parameters such as tapering and dextrose and behaviors including smoking, depressive symptoms, and insomnia.

Sleep and home parenteral nutrition in adults: A narrative review

Infusions of home parenteral nutrition (HPN) are often cycled at night coinciding with sleep episodes. Adult consumers of HPN are known to experience poor sleep attributed to frequent awakenings and long durations of wakefulness after falling asleep. Consequently, most consumers do not meet recommendations for sleep duration and quality or daytime napping. The primary underlying pathophysiology resulting in sleep problems is nocturia; however, other factors also exist, including disruptions caused by medical equipment (ie, pump alarms), comorbid conditions, dysglycemia, and medication use. Early guidance on sleep is imperative because of the central role of sleep in physical health and wellbeing, including mitigating complications, such as infection risk, gastrointestinal problems, pain sensitivity, and fatigue. Clinicians should routinely inquire about the sleep of their patients and address factors known to perturb sleep. Nonpharmacologic opportunities to mitigate sleep problems include education on healthy sleep practices (ie, sleep hygiene); changes in infusion schedules, volumes, rates, and equipment; and, possibly, behavioral interventions, which have yet to be examined in this population. Addressing comorbid conditions, such as mood disorders, and nutrition deficiencies may also help. Pharmacologic interventions and technological advancement in HPN delivery are also needed. Research on sleep in this population is considered a priority, yet it remains limited at this time.

Assessment of the risk of contamination of enteral nutrition bottles based on the simulation of home use conditions and hygiene procedures

BACKGROUND

Home-prepared enteral formulations are supplied to patients through enteral nutrition bottles, via a gravity bag or other container, which may be inadequately sanitized and reused more times than recommended by the manufacturer. Such procedures increase the risk of contamination and can compromise the patient's clinical outcome. In light of this, the present study aimed to assess the risk of contamination of enteral nutrition bottles by simulating home use conditions and hygiene procedures.

METHODS

A simulation of bottle usage was conducted across the three categories of enteral nutrition (homemade enteral preparations, blended enteral preparations, and commercial enteral formulas) for 3 days, using three hygiene procedures reported by caregivers: use of detergent (DET); use of detergent and boiling water (DET+BW); and use of detergent and bleach (DET+BL). The microbiological contamination was determined by the analysis of aerobic mesophilic microorganisms.

RESULTS

The bottles that were used for 3 days, regardless of the enteral nutrition category, were within the acceptable limit for aerobic mesophilic microorganisms (between <4 and 8.0 colony-forming units [CFU]/cm2) when sanitized using the DET+BW and DET+BL procedures. The enteral nutrition bottles, when cleaned using the DET procedure during the 3 days of usage, showed low microbial contamination (between <4 and 3.0 CFU/cm2) in blended preparation and commercial formula only.

CONCLUSION

Thus, regardless of the enteral nutrition category, we found that the bottles can be used for 3 days, as long as the DET+BW or DET+BL hygiene procedure is applied and safe food handling measures are adopted.

Healthy Sleep Practices for Consumers of Home Total Parenteral Nutrition: A Mixed-Methods Community-Based Participatory Study

Background

Consumers of overnight home parenteral nutrition (HPN) often experience sleep disruption; however, existing healthy sleep recommendations are widely inapplicable to consumers.

Objectives

The aim of this mixed-methods, community-based participatory research study was to develop tailored recommendations on healthy sleep practices for HPN consumers.

Methods

The multipart study involved the following: 1) an initial draft of sleep recommendations based on the evaluation of existing general sleep hygiene guidelines by an expert panel of clinicians and consumers with lived experience; 2) semi-structured focus groups with consumers and clinicians; 3) pre- and post-knowledge tests completed by consumers, and 4) final approval of the recommendations by the expert panel.

Results

The literature synthesis resulted in 51 recommendations evaluated for relevance for HPN consumers. Focus groups with 20 HPN consumers and clinicians contributed additional recommendations based on lived experience. Ultimately, the final resource included recommendations spanning 4 sections: getting ready for bed, preparing the bedroom for sleep, daytime behaviors, and overall strategies for better sleep. Of the 36 recommendations, 58% were derived from existing general sleep hygiene guidelines, and the remaining 42% addressed sleep challenges experienced uniquely by consumers, including nocturnal polyuria, noise/light from medical equipment, and infusion schedules. Knowledge tests completed by 10 additional consumers indicated a modest increase in sleep health knowledge.

Conclusions

The curated healthy sleep resource tailored for HPN consumers was facilitated by a multidisciplinary expert panel, a strategic collaboration with members of the HPN community and their clinicians, and in partnership with patient advocacy and support organizations. The wide distribution of these resources may improve the overall well-being of HPN consumers.

Metabolic and Nutritional Issues after Lower Digestive Tract Surgery: The Important Role of the Dietitian in a Multidisciplinary Setting

Many patients undergo small bowel and colon surgery for reasons related to malignancy, inflammatory bowel disease (IBD), mesenteric ischemia, and other benign conditions, including post-operative adhesions, hernias, trauma, volvulus, or diverticula. Some patients arrive in the operating theatre severely malnourished due to an underlying disease, while others develop complications (e.g., anastomotic leaks, abscesses, or strictures) that induce a systemic inflammatory response that can increase their energy and protein requirements. Finally, anatomical and functional changes resulting from surgery can affect either nutritional status due to malabsorption or nutritional support (NS) pathways. The dietitian providing NS to these patients needs to understand the pathophysiology underlying these sequelae and collaborate with other professionals, including surgeons, internists, nurses, and pharmacists. The aim of this review is to provide an overview of the nutritional and metabolic consequences of different types of lower gastrointestinal surgery and the role of the dietitian in providing comprehensive patient care. This article reviews the effects of small bowel resection on macronutrient and micronutrient absorption, the effects of colectomies (e.g., ileocolectomy, low anterior resection, abdominoperineal resection, and proctocolectomy) that require special dietary considerations, nutritional considerations specific to ostomized patients, and clinical practice guidelines for caregivers of patients who have undergone a surgery for local and systemic complications of IBD. Finally, we highlight the valuable contribution of the dietitian in the challenging management of short bowel syndrome and intestinal failure.

Early enteral nutrition is associated with improved outcomes in critically ill mechanically ventilated medical and surgical patients

BACKGROUND AND AIMS

Data suggest that guidelines for enteral nutrition (EN) initiation are not closely followed in clinical practice. In addition, critically ill mechanically ventilated (MV) patients have varying metabolic needs, which often increase and persist over time, requiring personalized nutrition intervention. While both over- and under-nutrition can impact patient outcomes, recent data suggest that targeted early EN delivery may reduce mortality and improve clinical outcomes. This study examined if early EN improves clinical outcomes and decreases costs in critically ill patients on MV.

METHODS

Data from a nationwide administrative-financial database between 2018 and 2020 was utilized to identify eligible adult critical care patients. Patients who received EN within 3 days after intubation (early EN) were compared to patients who started EN after 3 days of intubation (late EN). Outcomes of interest included hospital mortality, discharge disposition, hospital and intensive care unit (ICU) length of stay (LOS), MV days, and total cost. After inverse-probability-of-treatment weighting, outcomes were modeled using a nominal logistic regression model for hospital mortality and discharge disposition, a linear regression model for cost, and Cox proportional-hazards model for MV days, hospital and ICU LOS.

RESULTS

A total of 27,887 adult patients with early MV were identified, of which 16,772 (60.1%) received early EN. Regression analyses showed that the early EN group had lower hospital mortality (OR = 0.88, 95% CI, 0.82 to 0.94), were more likely to be discharged home (OR = 1.47, 95% CI 1.38 to 1.56), had fewer MV days (HR = 1.23, 95% CI, 1.11 to 1.37), shorter hospital LOS (HR = 1.43, 95% CI, 1.33 to 1.54) and ICU LOS (HR = 1.36, 95% CI, 1.27 to 1.46), and lower cost (-$21,226; 95% CI, -$23,605 to -$18,848) compared to the late EN group.

CONCLUSIONS

Early EN within 3 days of MV initiation in real-world practice demonstrated improved clinical and economic outcomes. These data suggest that early EN is associated with decreased hospital mortality, increased discharge to home, and decreased hospital and ICU LOS, time on MV, and cost compared to delayed initiation of EN; highlighting the importance of early EN to optimize utcomes ando support the recovery of critically ill patients on MV.

A quality control circle process to improve enteral nutrition feeding support in discharged patients with colorectal cancer

Correct usage and maintenance of the enteral nutrition feeding pump system is always a challenge in nutrition support for patients with colorectal cancer (CRC). However, there are few studies on the sustained accuracy improvement of the enteral nutrition feeding system in discharged CRC patients. Here, we established a seven-month quality control circle (QCC) activity with the theme of improving the performance of home enteral feeding pumps (EFP) and examined the effect of QCC activity on the nutritional state and quality of life in discharged CRC patients. We enrolled 100 discharged CRC patients treated with home enteral nutrition from Zhejiang Cancer Hospital between March 2020 and December 2021. The patients were randomly split into two research groups: one participated in the QCC activity (n = 50) and the other did not (n = 50). QCC analysis indicated that the top 3 causes of EFP inaccurate usage are the simple and boring contents of training, various types of pumps, no examination rules, and lack of management. Furthermore, both intra- and inter-group comparisons showed that QCC significantly improved the patients' pass rate of nutrition pump operation from 52 to 70% after 1-month of activity, which gradually improved and got the highest (90%) after 3 months (p < 0.05). Interestingly, the established QCC activity significantly increased the patient-generated subjective global assessment (PG-SGA) and Barthel index (BI) scores, body fat mass (BFM) and superior longitudinal muscle (SLM) by intra- and inter-group comparisons. In this study, we clarified the main causes of inaccurate EFP usage and established a QCC process to improve the pass rate of EFP usage. It finally leads to the improvement of nutritional state and quality of life in CRC patients.

Small bowel transplant - novel indications and recent progress

INTRODUCTION

Advances in the management of intestinal failure have led to a reduction in the number of intestinal transplants. The number of bowel transplants has been mainly stable even though a slight increase has been observed in the last 5 years.

AREAS COVERED

Standard indication includes patients with a reasonable life expectancy. Recent progress can be deduced by the increased number of intestine transplants in adults: this is due to the continuous improvement of 1-year graft survival worldwide (without differences in 3- and 5-year) associated with better abdominal wall closure techniques. This review aims to provide an update on new indications and changes in trends of pediatric and adult intestine transplantation. This analysis, which stretches through the past 5 years, is based on a collection of related manuscripts from PubMed.

EXPERT COMMENTARY

Intestinal transplants should be solely intended for a group of individuals for whom indications for transplantation are clear and both medical and surgical rehabilitations have failed. Nevertheless, many protocols developed over the years have not yet solved the key question represented by the over-immunosuppression. Novel indications and recent progress in the bowel transplant field, minimal yet consistent, represent a pathway to be followed.

Efficacy and Safety of a Parenteral Nutrition Program for Patients with RAS Wild-Type Metastatic Colorectal Cancer Administered First-Line Cetuximab Plus Chemotherapy: A Propensity Score Matching Study

Malnutrition is a common problem in patients with metastatic colorectal cancer (mCRC) receiving targeted therapy plus chemotherapy, resulting in severe toxicity and decreased survival rates. This retrospective study employing propensity score matching (PSM) examined the efficacy and safety of a supplemental home parenteral nutrition (HPN) program for patients with RAS wild-type mCRC receiving cetuximab plus chemotherapy. This retrospective nationwide registry study included data from 14 medical centers/hospitals across Taiwan, and the data period ranged from November 2016 to December 2020. Patients with RAS wild-type mCRC receiving cetuximab plus chemotherapy as their first-line therapy were included and divided into HPN and non-HPN program groups. HPN was initiated based on patient-specific factors, such as baseline nutritional status, treatment-related toxicities, and comorbidities. Clinical outcomes were evaluated using response to therapy, duration of response (DoR), progression-free survival (PFS), and overall survival (OS). This study recruited 758 patients, of whom 110 and 648 were included in the HPN and non-HPN program groups, respectively. After 1:3 PSM, the data of 109 and 327 patients from the HPN and non-HPN program groups were analyzed, respectively. The HPN program group had a higher metastasectomy rate (33.9% vs. 20.2%, p = 0.005), and longer duration of treatment and DoR than the non-HPN program group (13.6 vs. 10.3 and 13.6 vs. 9.9 months, p = 0.001 and < 0.001, respectively). The HPN program group tended to have a longer median PFS (18.2 vs. 13.9 months, p = 0.102). Moreover, we noted a significant improvement in the median OS in the same group (53.4 vs. 34.6 months, p = 0.002). Supplemental HPN programs may be recommended for select patients with mCRC receiving targeted therapy plus chemotherapy to improve oncological outcomes.

Short bowel syndrome: Complications and management

Short bowel syndrome (SBS) occurs when a patient loses bowel length or function significantly enough to cause malabsorption, oftentimes requiring lifelong parenteral support. In adults, this occurs most commonly in the setting of massive intestinal resection, whereas congenital anomalies and necrotizing enterocolitis predominate in children. Many patients with SBS develop long-term clinical complications over time related to their altered intestinal anatomy and physiology or to various treatment interventions such as parenteral nutrition and the central venous catheter through which it is administered. Identifying, preventing, and treating these complications can be challenging. This review will focus on the diagnosis, treatment, and prevention of several complications that can occur in this patient population, including diarrhea, fluid and electrolyte imbalance, vitamin and trace element derangements, metabolic bone disease, biliary disorders, small intestinal bacterial overgrowth, d-lactic acidosis, and complications of central venous catheters.

Peptide-based formula: Clinical applications and benefits

The use of enteral nutrition (EN) continues to increase given benefits. However, with this increase in use, it is also becoming evident that enteral feeding intolerance (EFI) is also quite prevalent, leading to the inability to meet nutrition needs in many patients. Given the wide variability in the EN population as well as the number of formulas available, there is not a clear consensus regarding the best approach to EFI management. One approach that is emerging to improve EN tolerance is the use of peptide-based formulas (PBFs). PBFs refer to enteral formulas containing proteins that have been enzymatically hydrolyzed to dipeptides and tripeptides. These hydrolyzed proteins are often combined with higher medium-chain triglyceride content to generate an enteral formula that is essentially easier to absorb and utilize. Emerging data demonstrate that the use of PBF in patients with EFI may improve clinical outcomes along with a corresponding reduction in healthcare utilization and potentially the cost of care. This review aims to navigate through key clinical applications and benefits of PBF and to discuss relevant data shared in the literature.

Energy Guidance Using Indirect Calorimetry for Intestinal Failure Patients with Home Parenteral Nutrition: The Right Bag Right at the Start

Intestinal failure is defined as the inability to absorb the minimum of macro and micronutrients, minerals and vitamins due to a reduction in gut function. In a subpopulation of patients with a dysfunctional gastrointestinal system, treatment with total or supplemental parenteral nutrition is required. The golden standard for the determination of energy expenditure is indirect calorimetry. This method enables an individualized nutritional treatment based on measurements instead of equations or body weight calculations. The possible use and advantages of this technology in a home PN setting need critical evaluation. For this narrative review, a bibliographic search is performed in PubMed and Web of Science using the following terms: 'indirect calorimetry', 'home parenteral nutrition', 'intestinal failure', 'parenteral nutrition', 'resting energy expenditure', 'energy expenditure' and 'science implementation'. The use of IC is widely embedded in the hospital setting but more research is necessary to investigate the role of IC in a home setting and especially in IF patients. It is important that scientific output is generated in order to improve patients' outcome and develop nutritional care paths.

The Impact of Blenderized Tube Feeding on Gastrointestinal Symptoms, a Scoping Review

Severe gastrointestinal symptoms are one of the main reasons for switching from conventional artificial tube feeding to blenderized tube feeding (BTF). This study aimed to describe and quantify the impact of BTF on gastrointestinal symptoms in children and adults. We analyzed four databases (PubMed, Scopus, Cochrane Library, and Google Scholar). The review was performed following the PRISMA extension for Scoping Reviews checklist. The methodological quality of articles was assessed following the NIH quality assessment tools. The initial search yielded 535 articles and, after removing duplicates and off-topic articles, 12 met the inclusion criteria. All included papers unanimously converged in defining an improvement of gastrointestinal symptoms during blenderized feeding: the eight studies involving pediatric cohorts report a decrease from 30 to over 50% in gagging and retching after commencing BTF. Similar rates are reported for constipation and diarrhea improvement in most critically ill adults. Experimental studies and particularly randomized controlled trials are needed to develop robust evidence on the effectiveness of BTF in gastrointestinal symptom improvement with prolonged follow-up and adequate medical monitoring.