What is Home Parenteral Nutrition?

Không có bài viết liên quan.

Did you know that over 40,000 people in the United States rely on home parenteral nutrition (HPN) to survive?^[1] For these individuals, getting proper nutrition through eating and drinking is not possible due to serious medical conditions affecting their digestive system. Instead, they receive the nutrients, fluids, and electrolytes their bodies need through an intravenous (IV) catheter while at home, allowing them to live more normal daily lives outside the hospital setting.

In this article, we’ll take an in-depth look at what HPN is, who can benefit from it, how it works, and important considerations for patients and caregivers. By the end, you’ll have a solid understanding of this life-sustaining nutritional support therapy.

What Is Home Parenteral Nutrition?

Home parenteral nutrition (HPN) is the intravenous administration of nutrition to patients in the home setting.^[2] The word “parenteral” means delivered in a manner other than through the digestive tract. With HPN, a special nutrient solution is infused directly into the bloodstream through a catheter placed in a vein, bypassing the normal digestive process of the stomach and intestines.

HPN provides a complete and balanced source of nutrition for patients who cannot get enough calories, protein, fat, vitamins, minerals, and fluids by mouth or tube feeding into the stomach or intestines (known as enteral nutrition).^[3] The HPN solution contains all the essential nutrients tailored to meet the individual patient’s needs.

The ability to administer parenteral nutrition at home is a major advancement in medical care. In the past, patients had to remain in the hospital to receive this therapy. But with improvements in IV catheter care, infusion pumps, and delivery services, many patients can now safely receive HPN in the comfort of their own home, avoiding prolonged hospitalizations.

Why Is Home Parenteral Nutrition Needed?

The main reason patients require HPN is intestinal failure – when the intestines cannot absorb enough nutrients and fluids from food and supplements to maintain health and growth.^[4] This can be due to conditions such as:

• Short bowel syndrome – when large portions of the small intestine are surgically removed or not functioning properly
• Inflammatory bowel diseases like Crohn’s disease
• Motility disorders that prevent normal movement of contents through the intestines
• Bowel obstructions from cancer, scar tissue, or other blockages
• Severe malabsorption from conditions like chronic pancreatitis or radiation enteritis

In these situations, no matter how much the patient eats by mouth, the body cannot extract the necessary nutrition from the food. This leads to malnutrition, unintended weight loss, vitamin and mineral deficiencies, and potentially life-threatening complications. HPN helps prevent or reverse these effects by delivering nutrition directly into the bloodstream.

HPN may be needed temporarily while the intestines heal and adapt after surgery or illness. In some cases, the intestinal failure is permanent and HPN is required indefinitely for survival. An estimated 75% of HPN patients require it for the long-term.^[5]

Who Can Benefit From Home Parenteral Nutrition?

HPN is appropriate for infants, children, and adults with intestinal failure who are medically stable, can safely manage the therapy at home with support, and have a reasonable quality of life.^[6] Patients who may benefit include those with:

• Short bowel syndrome due to massive surgical resection from Crohn’s disease, cancer, injury, vascular insufficiency, or necrotizing enterocolitis in infants
• High-output intestinal fistulas or stomas leading to excessive fluid and electrolyte losses
• Severe motility disorders like chronic intestinal pseudo-obstruction
• Congenital disorders like microvillus inclusion disease
• Mechanical obstructions that cannot be surgically corrected
• Extensive mucosal disease from conditions like radiation enteritis or graft-versus-host disease

The decision to start HPN involves careful consideration by the patient, family, and a multidisciplinary medical team. They weigh factors like the patient’s diagnosis, prognosis, response to other therapies, ability to care for the IV catheter, safety of the home environment, and the patient’s goals and quality of life. For many, HPN provides essential nutritional support and hydration that enables them to live at home and participate in daily activities that would otherwise not be possible.

What Are The Components Of Home Parenteral Nutrition?

The HPN solution contains the perfect balance of nutrients and fluids customized to each patient’s needs based on their age, weight, medical conditions, and laboratory results. A registered dietitian nutritionist (RDN) specializing in nutrition support assesses the patient’s individual requirements and works with the physician and pharmacist to develop the appropriate HPN prescription.

The key components of the HPN solution include:^[7]

1. Macronutrients

• Protein: Provided as amino acids, the building blocks of protein. Adequate protein is essential to maintain lean body mass, support immune function, and promote wound healing.
• Carbohydrates: Supplied as dextrose, a form of glucose. Carbohydrates are the body’s main source of energy.
• Fat: Given as lipid emulsions. Fat provides a concentrated source of calories and essential fatty acids.

The total amount of calories and the ratio of carbohydrate, protein, and fat in the HPN solution is tailored to the patient’s estimated needs and adjusted based on their response over time. Too much or too little of any macronutrient can lead to complications.

2. Micronutrients

• Vitamins: Water-soluble and fat-soluble vitamins must be provided in HPN to prevent deficiencies, as they are normally absorbed through the intestines. The RDN ensures the patient receives sufficient amounts of essential vitamins like vitamin C, thiamine, folate, and vitamins A, D, E, and K.
• Trace Elements: Minerals like zinc, copper, chromium, and selenium are added in small amounts to meet the body’s needs and prevent imbalances.

3. Electrolytes

Electrolytes like sodium, potassium, magnesium, calcium, phosphorus, and chloride are crucial for maintaining fluid balance, nerve and muscle function, and bone health. The amounts in the HPN solution are individualized based on the patient’s laboratory values and losses from the GI tract or other sources.

4. Fluids

Patients receive the calculated amount of fluids needed to maintain hydration and replace ongoing losses through urine, stool, fistulas, or ostomies. Dextrose solutions of varying concentrations are used to provide free water along with the nutrient additives.

The HPN solution is carefully compounded by a pharmacist using strict aseptic techniques to maintain sterility. The solution is typically delivered in large volumes, ranging from 1-3 liters per day administered cyclically over 10-16 hours, usually overnight.^[8] This “cyclic” infusion regimen, rather than continuously, allows freedom from the pump during the day for work, school, and other activities.

How Is Home Parenteral Nutrition Administered?

HPN is administered through a central venous catheter (CVC) or rarely a peripheral venous catheter (PVC). The choice depends on the anticipated duration of therapy, the patient’s vascular access, and the osmolarity of the HPN solution.

1. Central Venous Catheter

A CVC is a thin, flexible tube surgically inserted into a large vein, usually in the chest, with the tip positioned in the superior vena cava just above the heart.^[9] CVCs are the preferred route for HPN because:

• They allow infusion of highly concentrated, hyperosmolar solutions that would be irritating to smaller peripheral veins
• They can remain in place for months to years with proper care
• Blood can be easily drawn from them for lab monitoring
• Lower rates of complications compared to PVCs

The most common CVC for HPN is a tunneled catheter like a Hickman® or Broviac®. The catheter is tunneled under the skin of the chest wall before entering the vein, which helps stabilize it and lower infection risk. It has a Dacron cuff near the exit site that promotes tissue ingrowth to secure it in place.

Patients and caregivers are extensively trained on aseptic techniques for catheter care, including handwashing, sterile dressing changes, and how to safely connect and disconnect the HPN solution. Meticulous catheter care is essential to prevent potentially life-threatening bloodstream infections.

2. Peripheral Venous Catheter

In some cases, a PVC may be used for HPN if only needed short-term or if the solution is not highly concentrated. A PVC is typically inserted in a vein in the hand or forearm. However, PVCs have higher rates of infiltration, phlebitis, and infection compared to CVCs. They often need to be replaced every few days due to complications. Therefore, CVCs are preferred for HPN when appropriate.

What Are The Risks And Complications Of Home Parenteral Nutrition?

While HPN is a life-sustaining therapy, it does carry risks of potentially serious complications. The most common include:^[10]

1. Infection

Central line-associated bloodstream infections (CLABSIs) are a leading cause of hospitalization and mortality in HPN patients. Bacteria or fungi can enter the bloodstream through the CVC, leading to sepsis. Symptoms may include fever, chills, low blood pressure, and altered mental status.

Prevention focuses on meticulous catheter care techniques using strict aseptic procedures. Patients are taught to look for signs of infection, including redness, swelling, drainage, or pain at the catheter site and to notify their medical team immediately if they occur.

2. Blood Clots

Venous thrombosis, or blood clots, can form around the catheter or in the vein itself. This can lead to catheter malfunction, swelling of the arm or neck, or potentially life-threatening pulmonary embolism if the clot breaks off and travels to the lungs.

Patients are monitored for signs of clots and may require anticoagulant medications to prevent or treat them. Catheters may need to be removed if clots become problematic.

3. Electrolyte Imbalance

The HPN solution provides significant amounts of fluid and electrolytes that can disrupt the body’s delicate balance, especially in the setting of excessive GI losses. Abnormalities in potassium, magnesium, phosphorus, or glucose can have dangerous effects on the heart, muscles, and other organs.

Careful monitoring of electrolyte levels and adjustment of the HPN prescription is required to avoid complications. Patients are also educated on symptoms to watch for and report.

4. Liver Dysfunction

Long-term HPN carries a risk of liver injury, ranging from mildly elevated liver enzymes to potentially fatal liver failure. The exact mechanisms are not fully understood but may involve toxicity from the HPN components or underlying digestive diseases.

Strategies to prevent liver complications include cycling the HPN infusion, avoiding overfeeding, and using lipid formulations with lower amounts of soybean oil. Patients with signs of liver dysfunction require close follow-up and adjustments to their HPN regimen.

Other potential risks of HPN include nutrient deficiencies or toxicities, metabolic bone disease, and reduced quality of life. However, with careful management and monitoring, many of these complications can be prevented or treated.

How Is The Effectiveness Of Home Parenteral Nutrition Monitored?

HPN patients require close monitoring by a dedicated nutrition support team to ensure the safety and effectiveness of the therapy. This includes regular assessment of:^[11]

• Nutritional Status: Patients undergo periodic measurements of weight, body composition, and laboratory markers of nutrition such as albumin and prealbumin. Dietitians assess if calorie and protein goals are being met and adjust the HPN prescription as needed.
• Hydration Status: Fluid balance is assessed through weight trends, physical exam, and laboratory values like blood urea nitrogen and serum osmolality. The HPN volume is titrated to maintain euvolemia.
• Electrolyte Balance: Frequent monitoring of electrolyte levels is crucial to prevent dangerous imbalances. The HPN solution is compounded with personalized electrolyte additives guided by lab results.
• Micronutrient Levels: Fat and water-soluble vitamin levels are checked periodically to detect deficiencies or toxicities. Trace elements like zinc, copper, and selenium are also monitored.
• Catheter Function: The catheter exit site is carefully inspected for signs of infection, and the line is assessed for patency and proper positioning. Patients are instructed to report any pain, swelling, drainage, or difficulty flushing the catheter.
• Liver Function: Liver enzymes, bilirubin, and clotting factors are trended to screen for HPN-associated liver disease. Imaging may be performed if liver dysfunction is suspected.
• Bone Health: Long-term HPN can lead to metabolic bone disease with loss of bone density. Patients undergo bone density scans and measurement of vitamin D, calcium, and parathyroid hormone levels to guide interventions.
• Quality of Life: The psychosocial well-being and functional status of HPN patients are assessed through validated questionnaires and interviews. The goal is to maximize independence and participation in daily activities.

Patients are seen routinely in clinic by their nutrition support physician, dietitian, and nurse to review progress and address any barriers to therapy. They also have 24/7 access to the team for urgent issues that arise. With vigilant monitoring and adjustments, HPN can be a safe and effective long-term therapy.

What Are The Alternatives To Home Parenteral Nutrition?

While HPN is the treatment of choice for many patients with intestinal failure, it may not be appropriate or feasible for everyone. Alternative nutritional interventions include:

1. Enteral Nutrition

For patients with a functional GI tract, nutrition may be provided through a feeding tube inserted into the stomach or small intestine. Enteral nutrition is generally preferred over HPN when possible because:

• It helps maintain the structure and function of the intestines
• It has a lower risk of infection and other complications compared to HPN
• It is typically more convenient and less costly than HPN

However, some patients cannot tolerate enteral nutrition due to severe malabsorption, obstruction, or intractable diarrhea. In these cases, HPN may be the only option.

2. Oral Nutrition Supplements

For patients who can safely eat and drink but are unable to meet their nutritional needs through food alone, high-calorie, nutrient-dense oral supplements may be recommended. These include products like Ensure®, Boost®, and Scandishakes®.

Oral supplements can help fill calorie and protein gaps and provide additional micronutrients. They are often used in combination with HPN or enteral nutrition to maximize oral intake. However, they are not appropriate as a sole source of nutrition for patients with significant malabsorption or obstruction.

3. Total Parenteral Nutrition In The Hospital Setting

Some patients with intestinal failure may not be suitable candidates for HPN due to unstable medical conditions, unsafe home environments, or inability to manage the complex therapy. In these cases, they may need to remain hospitalized to receive total parenteral nutrition (TPN) under close medical supervision.

Hospital-based TPN allows for more frequent monitoring and adjustments to the nutritional prescription. It may be necessary for patients with severe electrolyte imbalances, uncontrolled diabetes, or active infections until these issues are stabilized. The goal is often to transition to HPN when medically appropriate to allow the patient to return home.

The decision between HPN and alternative nutritional therapies is highly individualized and depends on careful assessment of the patient’s medical conditions, nutritional status, and personal preferences. A multidisciplinary nutrition support team works closely with the patient and family to determine the most appropriate and feasible option to meet their nutritional needs and goals.

FAQs

What is the meaning of home parenteral nutrition?

Home parenteral nutrition (HPN) refers to the intravenous administration of nutrition to patients in the home setting. It involves infusing a specialized solution containing protein, carbohydrates, fats, vitamins, minerals, and fluids directly into the bloodstream through a central venous catheter. HPN is used for patients who cannot absorb enough nutrients through oral or enteral routes due to severe intestinal disorders.

Can you have parenteral nutrition at home?

Yes, many patients can safely receive parenteral nutrition at home with proper training and support. Advances in home infusion technology and catheter care have made it possible for patients to administer HPN in the comfort of their own homes, avoiding prolonged hospital stays. However, the decision to pursue HPN depends on individual patient factors and requires close monitoring by a nutrition support team.

What are the indications for home parenteral nutrition?

The main indication for HPN is intestinal failure, which occurs when the intestines cannot absorb enough nutrients and fluids to sustain life. This can be due to conditions such as:

• Short bowel syndrome following extensive intestinal resection
• Inflammatory bowel diseases like Crohn’s disease
• Motility disorders that impair intestinal transit
• Mechanical obstructions from cancer or adhesions
• Severe mucosal diseases that prevent absorption

HPN may also be used in patients with high-output intestinal fistulas, certain congenital disorders, or temporary nutritional needs while the gut heals from surgery or illness.

What is the meaning of HPN?

In the context of nutrition support, HPN stands for “home parenteral nutrition.” It refers to the practice of administering parenteral nutrition, or intravenous feeding, to patients in the home setting rather than the hospital. HPN provides a lifeline for individuals with intestinal failure who cannot maintain adequate nutrition through other means.

Is HPN means hypertension?

No, in this context, HPN does not mean hypertension. While the abbreviation “HTN” is commonly used for hypertension, or high blood pressure, “HPN” here refers specifically to “home parenteral nutrition.” It’s important not to confuse these two distinct medical terms.

What diagnosis is HPN?

HPN itself is not a diagnosis, but rather a treatment modality for various underlying conditions that result in intestinal failure. The most common diagnoses that may require HPN include:

• Short bowel syndrome
• Inflammatory bowel diseases (Crohn’s disease, ulcerative colitis)
• Motility disorders (chronic intestinal pseudo-obstruction, scleroderma)
• Mechanical obstructions (cancer, strictures, adhesions)
• Radiation enteritis
• Congenital disorders (microvillus inclusion disease)

The specific diagnosis guides the individualized management and prognosis for each HPN patient.

Takeaways

• Home parenteral nutrition (HPN) is a life-sustaining therapy that provides intravenous nutrition to patients with intestinal failure who cannot absorb adequate nutrients through oral or enteral routes.
• HPN involves infusing a customized solution of protein, carbohydrates, fats, vitamins, minerals, and fluids through a central venous catheter while the patient remains at home.
• Candidates for HPN include those with short bowel syndrome, inflammatory bowel diseases, motility disorders, obstructions, and other conditions that impair nutrient absorption.
• The HPN solution is carefully compounded to meet each patient’s calorie, macronutrient, micronutrient, and fluid requirements based on their individual needs.
• HPN is most commonly administered through a tunneled central venous catheter, which requires meticulous care and aseptic technique to prevent complications.
• Potential risks of HPN include central line-associated bloodstream infections, venous thrombosis, electrolyte imbalances, and liver dysfunction. Close monitoring and follow-up by a nutrition support team are essential.
• While HPN can greatly improve quality of life and survival for patients with intestinal failure, it requires significant commitment, training, and support from both patients and caregivers.
• Alternatives to HPN include enteral nutrition, oral supplements, and hospital-based TPN, depending on the patient’s specific medical conditions and needs.
• The decision to pursue HPN is highly individualized and involves careful consideration by the patient, family, and multidisciplinary medical team to ensure the safest and most effective nutritional management plan.

References

1. Pironi L, Arends J, Bozzetti F, Cuerda C, Gillanders L, Jeppesen PB, Joly F, Kelly D, Lal S, Staun M, Szczepanek K, Van Gossum A, Wanten G, Schneider SM; Home Artificial Nutrition & Chronic Intestinal Failure Special Interest Group of ESPEN. ESPEN guidelines on chronic intestinal failure in adults. Clin Nutr. 2016 Apr;35(2):247-307. doi: 10.1016/j.clnu.2016.01.020. Epub 2016 Feb 8. PMID: 26944585.
2. Staun M, Pironi L, Bozzetti F, Baxter J, Forbes A, Joly F, Jeppesen P, Moreno J, Hébuterne X, Pertkiewicz M, Mühlebach S, Shenkin A, Van Gossum A; ESPEN. ESPEN Guidelines on Parenteral Nutrition: home parenteral nutrition (HPN) in adult patients. Clin Nutr. 2009 Aug;28(4):467-79. doi: 10.1016/j.clnu.2009.04.001. Epub 2009 May 22. PMID: 19464089.
3. Bielawska B, Allard JP. Parenteral Nutrition and Intestinal Failure. Nutrients. 2017 May 6;9(5):466. doi: 10.3390/nu9050466. PMID: 28481229; PMCID: PMC5452168.
4. Pironi L, Arends J, Baxter J, Bozzetti F, Peláez RB, Cuerda C, Forbes A, Gabe S, Gillanders L, Holst M, Jeppesen PB, Joly F, Kelly D, Klek S, Irtun Ø, Olde Damink SW, Panisic M, Rasmussen HH, Staun M, Szczepanek K, Van Gossum A, Wanten G, Schneider SM, Shaffer J; Home Artificial Nutrition & Chronic Intestinal Failure; Acute Intestinal Failure Special Interest Groups of ESPEN. ESPEN endorsed recommendations. Definition and classification of intestinal failure in adults. Clin Nutr. 2015 Apr;34(2):171-80. doi: 10.1016/j.clnu.2014.08.017. Epub 2014 Sep 21. PMID: 25311444.
5. Winkler MF, Smith CE. Clinical, social, and economic impacts of home parenteral nutrition dependence in short bowel syndrome. JPEN J Parenter Enteral Nutr. 2014 May;38(1 Suppl):32S-37S. doi: 10.1177/0148607113517717. PMID: 24418898.
6. Dibb M, Soop M, Teubner A, Shaffer J, Abraham A, Carlson G, Lal S. Survival and nutritional dependence on home parenteral nutrition: Three decades of experience from a single referral centre. Clin Nutr. 2017 Apr;36(2):570-576. doi: 10.1016/j.clnu.2016.01.028. Epub 2016 Feb 17. PMID: 26948419.
7. Ayers P, Adams S, Boullata J, Gervasio J, Holcombe B, Kraft MD, Marshall N, Neal A, Sacks G, Seres DS, Worthington P; American Society for Parenteral and Enteral Nutrition. A.S.P.E.N. parenteral nutrition safety consensus recommendations. JPEN J Parenter Enteral Nutr. 2014 Mar-Apr;38(3):296-333. doi: 10.1177/0148607113511992. Epub 2013 Nov 26. PMID: 24280129.
8. Dreesen M, Foulon V, Spriet I, Goossens GA, Hiele M, De Pourcq L, Willems L. Epidemiology of catheter-related infections in adult patients receiving home parenteral nutrition: a systematic review. Clin Nutr. 2013 Feb;32(1):16-26. doi: 10.1016/j.clnu.2012.08.004. Epub 2012 Aug 29. PMID: 22959630.
9. Santarpia L, Buonomo A, Pagano MC, Alfonsi L, Foggia M, Mottola M, Marinosci GZ, Contaldo F, Pasanisi F. Central venous catheter related bloodstream infections in adult patients on home parenteral nutrition: Prevalence, predictive factors, therapeutic outcome. Clin Nutr. 2016 Dec;35(6):1394-1398. doi: 10.1016/j.clnu.2016.03.009. Epub 2016 Mar 19. PMID: 27026577.
10. Lal S, Pironi L, Wanten G, Arends J, Bozzetti F, Cuerda C, Joly F, Kelly D, Staun M, Szczepanek K, Van Gossum A, Schneider SM. Clinical approach to the management of Intestinal Failure Associated Liver Disease (IFALD) in adults: A position paper from the Home Artificial Nutrition and Chronic Intestinal Failure Special Interest Group of ESPEN. Clin Nutr. 2018 Oct;37(5):1794-1797. doi: 10.1016/j.clnu.2018.07.006. Epub 2018 Jul 18. PMID: 30055869.
11. Bischoff SC, Austin P, Boeykens K, Chourdakis M, Cuerda C, Jonkers-Schuitema C, Lichota M, Nyulasi I, Schneider SM, Stanga Z, Pironi L. ESPEN guideline on home enteral nutrition. Clin Nutr. 2020 Jan;39(1):5-22. doi: 10.1016/j.clnu.2019.04.022. Epub 2019 May 11. PMID: 31109484.