Home artificial nutrition in advanced cancer.

Attitudes to home artificial nutrition (HAN) in cancer vary greatly from country to country. A 6-year prospective survey of the practice of HAN in advanced cancer patients applied by a hospital-at-home programme in an Italian health district was performed to estimate the utilization rate, to evaluate efficacy in preventing death from cachexia, maintaining patients at home without burdens and distress and improving patients' performance status, and to obtain information about costs. Patients were eligible for HAN when all the following were present: hypophagia; life expectancy 6 weeks or more, suitable patient and family circumstances; and verbal informed consent. From July 1990 to June 1996, 587 patients were evaluated; 164 were selected for HAN (135 enteral and 29 parenteral) and were followed until 31 December 1996. The incidence of HAN per million inhabitants was 18.4 in the first year of activity and 33.2-36.9 in subsequent years, being 4-10 times greater than rates reported by the Italian HAN registers. On 31 December 1996, 158 patients had died because of the disease and 6 were on treatment. Mean survival was 17.2 weeks for those on enteral nutrition and 12.2 weeks for those on parenteral nutrition. Prediction of survival was 72% accurate. 95 patients had undergone 155 readmissions to hospital, where they spent 15-23% of their survival time. Burdens due to HAN were well accepted by 124 patients, an annoyance or scarcely tolerable in the remainder. The frequency of major complications of parenteral nutrition was 0.67 per year for catheter sepsis and 0.16 per year for deep vein thrombosis. Karnofsky performance score increased in only 13 patients and body weight increased in 43. The fixed direct costs per patient-day (in European Currency Units) were 14.2 for the nutrition team, 18.2 for enteral nutrition and 61 for parenteral nutrition. The results indicate that definite entry criteria and local surveys are required for the correct use of HAN in advanced cancer patients, that HAN can be applied without causing additional burdens and distress, and that its costs are not higher than hospital costs.     

Home parenteral nutrition using shunts

Most workers have found use of shunts unworkable as a means of access for home parenteral nutrition. Our experience using arteriovenous loop vein grafts for this purpose is described including any problems encountered. One shunt could not be established. In four other patients arteriovenous loop vein grafts have been used successfully. They are in our opinion superior to indwelling catheters as a means of access in long-term patients.     

Home parenteral nutrition and AIDS

The evolution of AIDS in 25 patients enrolled in a home parenteral nutrition(HPN) programme was analysed retrospectively. All patients were grade 4C or 4D (CDC criteria). All suffered from major gastrointestinal symptoms, 13 had anorexia (< 700 kcal/day) and the overall mean weight loss was 21%. HPN involved administration of an all-in-one nutritional formula (caloric intake = 148% of MREE) which was infused at night through a Broviac type silastic catheter or a subcutaneous infusion port. It was continued until the patient's death or temporary recovery. 19 patients died during PN, 4 showed a temporary stabilisation. The average duration of PN was 180 days (54-358). Because of rehospitalizations for opportunistic infections or PN complications, the mean time spent at home was only 101 days (13-296), or 58.5% of the total duration of PN. 21 patients experienced weight gain and the Karnofsky activity index increased in half the patients. A temporary return to work was possible in only 3 patients. 15 PN related septicaemias were diagnosed for 4400 days of PN (0.34 for 100 days). On the whole, HPN seems to have been beneficial in 13 out of 25 patients, but the criteria for identifying patients who are likely to respond are not clearly established.     

Comparative analysis in artificial nutrition

INTRODUCTION: It is well known to Hungarian experts in the field of nutrition that hospital inpatients in this country do not have the required nutrition. AIM: To compare data of intensive care national costing analysis from England and intensive care unit in County Hospital, Eger, Hungary in order to advise a cost effective nutrition protocol. METHOD: English data were extracted from the report of Intensive Care National Cost Block Programme, year 1999. The Hungarian data were obtained by top down method from annual costing report of the same year. The authors used Purchasing Power Parity to make international cost comparison between these countries. RESULTS: In proportion to Purchasing Power Parity, the hospital budget per patient for nutrition is more than double in England than in the studied intensive care unit in Hungary. Intensive care units in England spend 1% on nutrition, 13% on drugs and 10% on disposables. There is only 0.2% spent on nutrition, 29.8% on drugs and 8% on disposables in the studied intensive care unit in Hungary. Cost of nutrition per patient day is HUF 117 in Hungary, which is even lower than the hospital budget per patient day for nutrition. CONCLUSION: On the basis of the above findings and literature review as well, the authors set up a cost effective nutrition guideline: 1. Identify malnourished patient. 2. Nutrition can be delayed for 4-5 days in not malnourished patient. 3. Enteral nutrition should always be the first choice. 4. Total parenteral nutrition is beneficial only if given over at least 7 days. 5) It is cost effective to prevent nosocomial infections even at higher cost.     

Home initiation of parenteral nutrition.

Parenteral nutrition (PN) has been successfully initiated in the home since the early 1990s. The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Standards for Specialized Nutrition Support: Home Care Patients, Safe Practices for Parenteral Nutrition, and Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients do not contain specific information on the initiation of home PN (HPN). Peer-reviewed, published guidelines are necessary to provide safe and appropriate initiation of HPN. Certain patients should not have PN initiated in the home, such as those with organ failure, uncontrolled diabetes, or uncorrectable electrolyte abnormalities. Excellent candidates for initiation of HPN include patients who have failed enteral feedings, have gastrointestinal (GI) diseases without excessive GI losses, or those with an oncology diagnosis and inability to tube feed. One concern of initiation of HPN is the potential for refeeding syndrome. Refeeding syndrome can be prevented when patients are properly evaluated and managed before initiation of PN. Refeeding syndrome can be avoided by rehydration with fluid and electrolytes before initiation of HPN to normalize blood chemistry when necessary and by starting with a moderate-volume, low-carbohydrate HPN solution compounded with optimal potassium, phosphorus, and magnesium content, and slowly advanced to goal. The "start low and go slow" motto of nutrition support should continue to be followed, but more specific guidelines are needed to assist nutrition support clinicians with safe and appropriate initiation of HPN.     

Home parenteral nutrition via arteriovenous fistulae

Vascular access for home parenteral nutrition was achieved with arteriovenous fistulae during an average 14.3 months in seven patients. Two Cimino fistulae and six bovine grafts were used. The only complication was bovine graft thrombosis which occurred in six instances despite anticoagulant therapy. Thrombectomy could successfully be performed in three graft thrombosis. Considering complication rates arteriovenous fistulae are valuable alternatives for central venous catheters in long-term parenteral nutrition at home.     

Home enteral nutrition in paediatric practice

Nasogastric feeding at home is increasingly being used to provide nutritional support for children with chronic conditions associated with poor growth. The development of specialized feeding products together with accurate and portable enteral feeding pumps has facilitated this process. Parents manage home nasogastric feeding well but require education and continued support. This is probably best offered by a specialized multidisciplinary nutritional care team.     

Home artificial nutritional support in gastrointestinal disease

Recent studies in the area of home artificial nutrition have shown that the prevalence of home enteral and parenteral nutrition programmes is rising rapidly all over the world. Other features of the past few years are the shift from non-malignant towards malignant indications and the increasing number of geriatric patients.     

Home parenteral nutrition: effect of patients' lifestyle

The effect of home parenteral nutrition (HPN) on the lifestyle and employment of 30 patients was assessed by a standard questionnaire. Details of the parenteral nutrition and infusion routines, general health, involvement in treatment and the role of the HPN clinic were also investigated. HPN was found to have a major effect on employment prospects and leisure activities. All patients wanted to know more about their nutritional requirements, their assessment and their needs.     

Home parenteral nutrition with full-time home care nurses

A group of patients exists who cannot manage home parenteral nutrition (HPN) due to debilitating conditions and/or lack of family resources. They are limited to either nursing home placement or extended hospitalization unless home nursing care is provided. A 58-year-old single female with malabsorption secondary to scleroderma was sent home on cyclic HPN under the supervision of full-time home care nurses. A comprehensive patient-centered nurse training program was designed to teach nursing personnel from a private nursing service the theory and practice of HPN. Each nurse must achieve at least 80% in the theory posttest and demonstrate the competent performance of central venous catheter care, mixing of parenteral nutrition solutions, use of infusion pump, and application of the heparin lock. The results of the pre- and posttests have shown that the home care nurses have been able to learn the theory necessary for implementing HPN. The mean pretest value was 46% while the mean posttest value was 90% (n = 12, p = 0.01). The patient has been doing very well at home for 5 months in this psychologically, medically, and financially effective program covered by third party payers. To the best of our knowledge, this program has never before been accomplished.