Comment
HOME PARENTERAL NUTRITION: AN APPRAISAL THE INTRODUCTION of techniques for artificial nutritional support has ensured that patients with severely impaired or absent intestinal function may not only survive but enjoy a reasonable quality of life. Inspite of developments in methods of enteral nutrition and steady progress towards a solution of the major technical and immunological problems which accompany intestinal transplantation, significant numbers of these patients will need long-term parenteral nutrition for the forseeable future. Such patients are best treated by home parenteral nutrition (HPN). Home parenteral nutrition has been available in theUK since the late nineteen seventies.' The inevitable rationing of health care resources requires a critical appraisal of all clinical activity, this particularly applies to expensive treatment such as HPN which may cost from £20,000-30,000rer year for each patient. Recent experience from the USA, the UK,3 and Europe" sheds light on the value and implementation of this expensive therapeutic modality. Effective HPN involves careful patient selection, management, and monitoring. The UK study is an audit of 400 patients.' the first 200 of which were the subject of an earlier report.' it includes the majority of patients who have received treatment in the UK. The American OASIS study'reports the outcome in 1594 HPN patients in the seven major disease categories, representing approximately 8% of HPN patients at the time of the investigation, and including a bias towards the major centres. The European report describes the outcome in 200 patients from selected European centres," Important differences in the selection of patients are apparent between the USA and British practice. Most obvious is the treatment of 80 patients per million of the US population compared to 2-4 per million in Britain. In part this may be explained by use of HPN for patients with malignancy-" and AIDS 2,7 in America, such patients are rarely treated with HPN in this country? Furthermore some healthcare insurers will cover the cost of parenteral nutrition but not cover the cost of electrolyte solutions. However, although these factors may serve to increase the numbers of patients receiving HPN in the USA, they are unlikely to offer a complete explanation for the difference in the numbers of patients undergoing treatment. On the contrary it seems probable that many patients are deprived of the benefit of HPN in the UK. There are two per million currently on treatment overall, but this figure covers large regional variations. For example there are 14 per million receiving HPN in Tayside, and treatment centres are patchily distributed throughout the UK where an increased awareness of the benefits of treatment is needed. The potential indications for HPN can be considered in three groups: patients who suffer from intestinal failure, electrolyte depletion, and a miscellaneous group of disorders. Intestinal failure may be caused by inflammatory disease such as Crohn's disease or radiation enteritis, motility disorders such as idiopathic intestinal pseudo-obstruction or scleroderma, or short bowel syndrome following surgery for vascular occlusion or Crohn's disease. There are some patients who
principally require fluid and electrolytes on account of enterocutanous fistulae or the high jejunostomy syndrome. A mixed and controverial group includes patients with neoplastic disease, AIDS, or growth failure. Information from the three studies is useful in determining the value of treatment in these patient groups. Treatment outcome can be assessed in terms of survival, quality of life including the ability to work, complications and the proportion of time spent in hospital. In the American study of 1594 patients the four year survival was 70-80% in all groups except patients with AIDS and malignancy? There were 601 deaths, 545 were caused by the underlying disease only 12 were caused by complications of HPN. The one year survival in the AIDS patients was 7%, and 25% in patients with malignant disease. The assumption that these patients do not merit treatment presupposes that survival is the only useful end-point. Two studies have addressed the quality of life on HPN of patients with AIDS7 and inoperable malignant intestinal obstruction." Both were retrospective surveys using patient records and questionnaires. Twenty-two patients with AIDS with a weight loss in excess of 10%, and in whom enteral feeding was not tolerated received HPN for 56 patient months; 15 gained weight and nine returned to their previous activity. HPN was considered to be beneficial or highly beneficial by an independant nutrition panel in 11 of 17 patients with inoperable malignant intestinal obstruction who survived a mean of 53 days. In the OASIS study 49% of all patients completely adapted to their disease and treatment, the majority of the remainder partially adapted? The UK patients were categorised in groups 1-4, patients in group 1 and 2 could respectively undertake full time and part time employment. Patients in group 3 could go out of the house whereas the group 4 patients were housebound.V' Groups 1 and 2 accounted for 63% of patients? Similar results were reported from the European series," but in both studies the degree of adaptation was influenced by the underlying disease. For example in the UK series groups 1 and 2 accounted for over 75% of patients with Crohn's disease and volvulus, 50-75% of patients with mesenteric vascular disease radiation enteritis and pseudo-obstruction, and less than 50% with systemic sclerosis and neoplasia. Age is another variable which influences adaptation, 75% of the patients over the age of 65 in the European study were in groups 3 and 4.4 The Tayside experience of 36 patient years of treatment, 35 courses in 26 patients from six weeks to nine years duration, is that 76% of patients fell into groups 1 and 2, and 95% of the time on treatment was spent at home. Of the 5% of time spent in hospital half was related to the underlying disease and half to treatment complications. The view that HPN is commonly associated with serious complications is no longer tenable. Fifteen of the 69 deaths in the 400 UK patients were caused by complications of treatment (3.75%); catheter sepsis, superior vena caval thrombosis, and hepatic failure were the main causes. 8 Twelve of the 608 deaths in the American study were due to such complications (0.75%).2 In the UK study there was one catheter complication every 0.98 patient years on treatment,
69
Comment
this included an annual incidence for catheter sepsis of 0.473, catheter occlusion of 0.442, and central vein thrombosis of 0.063.3 The corresponding figures for catheter complications in the Tayside patients is: 0.24, 0.18 and 0.24. The risk of catheter sepsis can be contained by the use of a careful catheter protocol," The provision of all the energy requirements in the form of dextrose is more likely to lead to caval thrombosis than occurs with the use of a three-in-one mix,lO particularly with the catheter tip in the superior vena cava rather than the right atrium. 11 Conversely the lipid mix is more likely to occlude the catheter, 12 this may be prevented by using an ethanol rather than saline flush before the application of the heparin 10ck. 13 Hepato-biliary disease is clearly 14 multifactoral: it may be associated with the underlying disease for example sclerosing cholangitis and Crohn's disease, arise because of the overprovision of some nutrients such as dextrose and amino-acids, or reflect bacterial overgrowth, bile acid metabolism and microbial translocation that follow the failure to take an oral diet. The importance of eating merits emphasis. The problem of bone disease, such as osteoporosis, awaits adequate explanation. 15 ,16 Finally micronutrient deficiencies may continue to occur. Inspite of the reformulation of trace element solutions selenium deficiency is still a problem particularly in previously depleted patients who do not receive a nutrition bag every dayP Trace element solutions currently contain the minimum daily requirement of selenium. Until better methods of palliation become available many patients with intestinal failure will continue to need artificial nutritional support. With careful supervision such patients may lead satisfactory independent lives and continue their employment with minimal time spent in hospital. These results are only likely to be achieved in a medical or surgical gastroenterology unit with wide experience of nutritional support and a nutrition team which includes dedicated nursing staff to supervise catheter techniques. This treatment should not be undertaken in hospitals without such a facility. The HPN register serves a useful role for education and audit. The UK study reports that 51 consultants from 38 centres have registered patients, over 80% of these patients have come from 10 centres. The largest referral centres in descending order have been Hope Hospital Salford, St Marks Hospital London, Ninewells Hospital Dundee, and Newcastle Upon Tyne. The need for continuing development
70
and the cost and potential hazards of treatment are reasons for obligatory registration and concentrating treatment in established centres with a good track record. Not only will this ensure good standards of care, it will provide the opportunity to evaluate HPN in patients in whom the role of this treatment is at present unclear, for example the acquired immunodeficiency syndrome. Christopher R Pennington Gastrointestinal Unit Department of Clinical Pharmacology Ninewells Hospital Dundee REFERENCES
2
3 4 5 6 7 8 9 10
11 12 13 14 15 16 17
Anonymous. Home parenteral nutrition in England and Wales. Br Med J 1980; 281:1407-1409. Howard L, Heaphy L, Fleming RC, Liniger L, Steiger E. Four years of North American registry home parenteral nutrition outcome data and their implications for patient management. Journal of Parenteral and Enteral Nutrition 1991; 15: 384-393. O'Hanrahan T, Irving MH. The role of home parenteral nutrition in the management of intestinal fairure - report of 400 cases. (Personal communication). Messing B, Landais P, Goldfarb B, Irving M. Home parenteral nutrition in adults: a multicentre survey in Europe. Clinical Nutrition. 1989; 8: 3-9. Maughall MM, Irving MH. Home parenteral nutrition in the United Kingdom and Ireland. Lancet 1986; 2: 383-387. August D, Thorn D, Fisher RL, Welchek CM. Home parenteral nutrition for patients with inoperable malignant bowel obstruction. Journal of Parenteral and Enteral Nutrition 1991; 15: 232-327. Singer P, Rothkopf MM, Kvetan V, Kirvela 0, Gaare H, Askanazi J. Risks and benefits of home parenteral nutrition in the acquired immunodeficiency syndrome. Journal of Parenteral and Enteral Nutrition 1991; 15: 75-79. Stokes MA, Irving MH. Mortality in patients on home parenteral nutrition. Journal of Parenteral and Enteral Nutrition 1989; 13: 172-175. Keohane PP, Jones BMJ, Attril H, et al. Effect of catheter tunnelling and a nutrition nurse on catheter sepsis during parenteral nutrition. A controlled trial. Lancet 1983; 2: 1388-1390. Pithie AD, Pennington CR. The incidence aetiology and management of central vein thrombosis during parenteral nutrition. Clinical Nutrition 1987; 6: 151-153. Pithie AD, Soutar JS, Pennington CR. Catheter tip position in central vein thrombosis. Journal of Parenteral and Enteral Nutrition. 1988; 12: 613-614. Messing B, Beiiah M, Giarard-Papau F et al. Technical hazards of using nutritive mixes in bags for cyclical parenteral nutrition in 48 gastroenterological patients. Gut 1982; 23: 297-303. Johnston D, Walker K, Richards J, Pennington CR. An ethanol flush for the prevention of catheter occlusion. Clinical Nutrition 1992 (in press) Fisher RL. Hepatobiliary abnormalities associated with total parenteral nutrition. Gastroenterology Clinics of North America 1989; 18: 645-667. Shike M, Hillis ME, Ellar A et a1. Bone disease in prolonged parenteral nutrition: osteopenia without mineralisation defect. American Journal of Clinical Nutrition 1986; 44: 89-98. Foldes J, Rimon B, Miggia-Sullam Metal. Progressive bone loss during long term home parenteral nutrition. Journal of Parenteral and Enteral Nutrition 1990; 14: 139-142. Malone M, Shenkin A, Fell GS, Irving MH. Evaluation of a trace element preparation in patients receiving home parenteral nutrition. Clinical Nutrition. 1989; 8: 307-312.
HOME PARENTERAL NUTRITION: AN APPRAISAL THE INTRODUCTION of techniques for artificial nutritional support has ensured that patients with severely impaired or absent intestinal function may not only survive but enjoy a reasonable quality of life. Inspite of developments in methods of enteral nutrition and steady progress towards a solution of the major technical and immunological problems which accompany intestinal transplantation, significant numbers of these patients will need long-term parenteral nutrition for the forseeable future. Such patients are best treated by home parenteral nutrition (HPN). Home parenteral nutrition has been available in theUK since the late nineteen seventies.' The inevitable rationing of health care resources requires a critical appraisal of all clinical activity, this particularly applies to expensive treatment such as HPN which may cost from £20,000-30,000rer year for each patient. Recent experience from the USA, the UK,3 and Europe" sheds light on the value and implementation of this expensive therapeutic modality. Effective HPN involves careful patient selection, management, and monitoring. The UK study is an audit of 400 patients.' the first 200 of which were the subject of an earlier report.' it includes the majority of patients who have received treatment in the UK. The American OASIS study'reports the outcome in 1594 HPN patients in the seven major disease categories, representing approximately 8% of HPN patients at the time of the investigation, and including a bias towards the major centres. The European report describes the outcome in 200 patients from selected European centres," Important differences in the selection of patients are apparent between the USA and British practice. Most obvious is the treatment of 80 patients per million of the US population compared to 2-4 per million in Britain. In part this may be explained by use of HPN for patients with malignancy-" and AIDS 2,7 in America, such patients are rarely treated with HPN in this country? Furthermore some healthcare insurers will cover the cost of parenteral nutrition but not cover the cost of electrolyte solutions. However, although these factors may serve to increase the numbers of patients receiving HPN in the USA, they are unlikely to offer a complete explanation for the difference in the numbers of patients undergoing treatment. On the contrary it seems probable that many patients are deprived of the benefit of HPN in the UK. There are two per million currently on treatment overall, but this figure covers large regional variations. For example there are 14 per million receiving HPN in Tayside, and treatment centres are patchily distributed throughout the UK where an increased awareness of the benefits of treatment is needed. The potential indications for HPN can be considered in three groups: patients who suffer from intestinal failure, electrolyte depletion, and a miscellaneous group of disorders. Intestinal failure may be caused by inflammatory disease such as Crohn's disease or radiation enteritis, motility disorders such as idiopathic intestinal pseudo-obstruction or scleroderma, or short bowel syndrome following surgery for vascular occlusion or Crohn's disease. There are some patients who
principally require fluid and electrolytes on account of enterocutanous fistulae or the high jejunostomy syndrome. A mixed and controverial group includes patients with neoplastic disease, AIDS, or growth failure. Information from the three studies is useful in determining the value of treatment in these patient groups. Treatment outcome can be assessed in terms of survival, quality of life including the ability to work, complications and the proportion of time spent in hospital. In the American study of 1594 patients the four year survival was 70-80% in all groups except patients with AIDS and malignancy? There were 601 deaths, 545 were caused by the underlying disease only 12 were caused by complications of HPN. The one year survival in the AIDS patients was 7%, and 25% in patients with malignant disease. The assumption that these patients do not merit treatment presupposes that survival is the only useful end-point. Two studies have addressed the quality of life on HPN of patients with AIDS7 and inoperable malignant intestinal obstruction." Both were retrospective surveys using patient records and questionnaires. Twenty-two patients with AIDS with a weight loss in excess of 10%, and in whom enteral feeding was not tolerated received HPN for 56 patient months; 15 gained weight and nine returned to their previous activity. HPN was considered to be beneficial or highly beneficial by an independant nutrition panel in 11 of 17 patients with inoperable malignant intestinal obstruction who survived a mean of 53 days. In the OASIS study 49% of all patients completely adapted to their disease and treatment, the majority of the remainder partially adapted? The UK patients were categorised in groups 1-4, patients in group 1 and 2 could respectively undertake full time and part time employment. Patients in group 3 could go out of the house whereas the group 4 patients were housebound.V' Groups 1 and 2 accounted for 63% of patients? Similar results were reported from the European series," but in both studies the degree of adaptation was influenced by the underlying disease. For example in the UK series groups 1 and 2 accounted for over 75% of patients with Crohn's disease and volvulus, 50-75% of patients with mesenteric vascular disease radiation enteritis and pseudo-obstruction, and less than 50% with systemic sclerosis and neoplasia. Age is another variable which influences adaptation, 75% of the patients over the age of 65 in the European study were in groups 3 and 4.4 The Tayside experience of 36 patient years of treatment, 35 courses in 26 patients from six weeks to nine years duration, is that 76% of patients fell into groups 1 and 2, and 95% of the time on treatment was spent at home. Of the 5% of time spent in hospital half was related to the underlying disease and half to treatment complications. The view that HPN is commonly associated with serious complications is no longer tenable. Fifteen of the 69 deaths in the 400 UK patients were caused by complications of treatment (3.75%); catheter sepsis, superior vena caval thrombosis, and hepatic failure were the main causes. 8 Twelve of the 608 deaths in the American study were due to such complications (0.75%).2 In the UK study there was one catheter complication every 0.98 patient years on treatment,
69
Comment
this included an annual incidence for catheter sepsis of 0.473, catheter occlusion of 0.442, and central vein thrombosis of 0.063.3 The corresponding figures for catheter complications in the Tayside patients is: 0.24, 0.18 and 0.24. The risk of catheter sepsis can be contained by the use of a careful catheter protocol," The provision of all the energy requirements in the form of dextrose is more likely to lead to caval thrombosis than occurs with the use of a three-in-one mix,lO particularly with the catheter tip in the superior vena cava rather than the right atrium. 11 Conversely the lipid mix is more likely to occlude the catheter, 12 this may be prevented by using an ethanol rather than saline flush before the application of the heparin 10ck. 13 Hepato-biliary disease is clearly 14 multifactoral: it may be associated with the underlying disease for example sclerosing cholangitis and Crohn's disease, arise because of the overprovision of some nutrients such as dextrose and amino-acids, or reflect bacterial overgrowth, bile acid metabolism and microbial translocation that follow the failure to take an oral diet. The importance of eating merits emphasis. The problem of bone disease, such as osteoporosis, awaits adequate explanation. 15 ,16 Finally micronutrient deficiencies may continue to occur. Inspite of the reformulation of trace element solutions selenium deficiency is still a problem particularly in previously depleted patients who do not receive a nutrition bag every dayP Trace element solutions currently contain the minimum daily requirement of selenium. Until better methods of palliation become available many patients with intestinal failure will continue to need artificial nutritional support. With careful supervision such patients may lead satisfactory independent lives and continue their employment with minimal time spent in hospital. These results are only likely to be achieved in a medical or surgical gastroenterology unit with wide experience of nutritional support and a nutrition team which includes dedicated nursing staff to supervise catheter techniques. This treatment should not be undertaken in hospitals without such a facility. The HPN register serves a useful role for education and audit. The UK study reports that 51 consultants from 38 centres have registered patients, over 80% of these patients have come from 10 centres. The largest referral centres in descending order have been Hope Hospital Salford, St Marks Hospital London, Ninewells Hospital Dundee, and Newcastle Upon Tyne. The need for continuing development
70
and the cost and potential hazards of treatment are reasons for obligatory registration and concentrating treatment in established centres with a good track record. Not only will this ensure good standards of care, it will provide the opportunity to evaluate HPN in patients in whom the role of this treatment is at present unclear, for example the acquired immunodeficiency syndrome. Christopher R Pennington Gastrointestinal Unit Department of Clinical Pharmacology Ninewells Hospital Dundee REFERENCES
2
3 4 5 6 7 8 9 10
11 12 13 14 15 16 17
Anonymous. Home parenteral nutrition in England and Wales. Br Med J 1980; 281:1407-1409. Howard L, Heaphy L, Fleming RC, Liniger L, Steiger E. Four years of North American registry home parenteral nutrition outcome data and their implications for patient management. Journal of Parenteral and Enteral Nutrition 1991; 15: 384-393. O'Hanrahan T, Irving MH. The role of home parenteral nutrition in the management of intestinal fairure - report of 400 cases. (Personal communication). Messing B, Landais P, Goldfarb B, Irving M. Home parenteral nutrition in adults: a multicentre survey in Europe. Clinical Nutrition. 1989; 8: 3-9. Maughall MM, Irving MH. Home parenteral nutrition in the United Kingdom and Ireland. Lancet 1986; 2: 383-387. August D, Thorn D, Fisher RL, Welchek CM. Home parenteral nutrition for patients with inoperable malignant bowel obstruction. Journal of Parenteral and Enteral Nutrition 1991; 15: 232-327. Singer P, Rothkopf MM, Kvetan V, Kirvela 0, Gaare H, Askanazi J. Risks and benefits of home parenteral nutrition in the acquired immunodeficiency syndrome. Journal of Parenteral and Enteral Nutrition 1991; 15: 75-79. Stokes MA, Irving MH. Mortality in patients on home parenteral nutrition. Journal of Parenteral and Enteral Nutrition 1989; 13: 172-175. Keohane PP, Jones BMJ, Attril H, et al. Effect of catheter tunnelling and a nutrition nurse on catheter sepsis during parenteral nutrition. A controlled trial. Lancet 1983; 2: 1388-1390. Pithie AD, Pennington CR. The incidence aetiology and management of central vein thrombosis during parenteral nutrition. Clinical Nutrition 1987; 6: 151-153. Pithie AD, Soutar JS, Pennington CR. Catheter tip position in central vein thrombosis. Journal of Parenteral and Enteral Nutrition. 1988; 12: 613-614. Messing B, Beiiah M, Giarard-Papau F et al. Technical hazards of using nutritive mixes in bags for cyclical parenteral nutrition in 48 gastroenterological patients. Gut 1982; 23: 297-303. Johnston D, Walker K, Richards J, Pennington CR. An ethanol flush for the prevention of catheter occlusion. Clinical Nutrition 1992 (in press) Fisher RL. Hepatobiliary abnormalities associated with total parenteral nutrition. Gastroenterology Clinics of North America 1989; 18: 645-667. Shike M, Hillis ME, Ellar A et a1. Bone disease in prolonged parenteral nutrition: osteopenia without mineralisation defect. American Journal of Clinical Nutrition 1986; 44: 89-98. Foldes J, Rimon B, Miggia-Sullam Metal. Progressive bone loss during long term home parenteral nutrition. Journal of Parenteral and Enteral Nutrition 1990; 14: 139-142. Malone M, Shenkin A, Fell GS, Irving MH. Evaluation of a trace element preparation in patients receiving home parenteral nutrition. Clinical Nutrition. 1989; 8: 307-312.
