Speaking of home parenteral nutrition, you have to realize that we are talking about completely different patients that hospitalized patients, these people, they don’t want only to survive; they want to be active; they want to be able to work; they want to learn; they want to travel; they want to have kids.
The goal of home parenteral nutrition
So, this is the goal of home parenteral nutrition; we are not talking about the survival, we’re talking about how to make life easy for them and how to let them live their lives to the fullest. So, this is the actual issue here.
You also have to realize that long term parenteral nutrition, which of course is mostly home parenteral nutrition is indicated for a prolonged gastrointestinal tract failure or in other words is dedicated for patient with chronic intestinal failure that prevents the absorption of adequate nutrients to sustain life.
What is intestinal failure?
Intestinal failure is defined as the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth.
| Type 1 Acute | Type 2 Prolonged Acute | Type 3 chronic | |
| Management | Ward team | Multi-professional specialist team | Multi-professional specialist team |
| Disease outcome | Self-limiting of type 2 | Full recovery ~40% Enteral Nutrition ~10% Type lll (Home PN) ~50% | Full recovery ~50% Life-long HPN ~48% Intestinal transplant ~2% |
| Patient outcome | Depending on the underlying condition | Reported in-hospital mortality ~10-15% | Survival: Benign: ~70% at 5 years Malignant: A few months |
| Frequency | 15% of PO surgery almost all critically ill | ~ 9 million inhabitant | Benign: 5-20 per million inhabitant Malignant: variable |
Is home parenteral nutrition the correct option?
And in terms of home parental patients, we are talking about the chronic ones. As mentioned here, there is a chance that this patient will recover like 50% are fully recovered from chronic intestinal failure. But for the rest of them, whole parenteral nutrition is the only option.
Of course, there is a slight chance that some of them will undergo successful intestinal transplant but the chances are relatively low. This therapy, home parenteral nutrition, does not require any randomized control trials, because we know that this is the only treatment that we can offer for these patients. So, this is just like the only life protecting solution for them.
What kind of pathophysiological conditions may lead to chronic intestinal failure? (Pathophysiologic classifications)
- Short bowel, it doesn’t really matter what the primary diseases such as cancer or not cancer, benign or not benign. But as for the pathophysiological conditions. So short bowel comes first.
- Intestinal fistula.
- Intestinal dysmotility.
- Mechanical obstruction due to adhesions, or cancer, for example.
- Extensive small bowel mucosal disease.
Survival probabilities of home parenteral nutrition
The survival probabilities are really relatively high. So, for most of these patients, the chance for long-term survival is higher than 60%. Of course, everything depends on the disease. The best clinical condition, if we use can use words like this, is the Crohn’s disease. The worst of course is malignancy, so cancer.
But for the benign conditions, the survival probability is always higher than 60%.
Alternatives to home parenteral nutrition
Maybe we can offer those patients anything else? Not really, all these surgical procedures like Bianchi or STEP operations failed in adults. In children’s step procedure is effective, but it also has to be combined with long term parenteral nutrition.
Intestinal transplantation and home parenteral nutrition
That’s an option but not really good regarding long-term results. So, this leaves us with the conclusion that we can use intestinal transplantation in intestinal failure patient but only if home parenteral nutrition is ineffective or dangerous or there is a clinical status, which for which we need another treatment.
What contributes to high-quality home parenteral nutrition?
to get the high quality HBN we have to think about perfect intravenous access, perfect formula and good logistics.
HPN access
That’s the perfect access. That’s tunneled cuffed catheter, this is absolutely access of choice.
HPN formula
What about the formula? Of course, in all cases, all-in-one admixture. So, all the macronutrients, micronutrients, water and electrolytes, and one of the key components for parenteral nutrition is lipid emulsion.
And when you think about nutrition, if somebody asked me a question what kind of nutrition to give to your patient as an oral diet, you’d always say, probably the Mediterranean diet is the best. And this is also the right way to think about parenteral nutrition.
So, to create the best composition of all-in-one admixture you can also create something like Mediterranean diet by using the lipid emulsion within lowest content of polyunsaturated fatty acids.
The lipid emulsion based on olive oil is considered the best. It was the only lipid emulsion to help reduce the complication rates.
This is how it works: the better lipid emulsion, the better clinical results.
HPN logistics (three chamber bags)
The last thing to think about is how to improve logistics.
So, to get the best HPN, of course, can use compounding unit, but you know how difficult it might be to find a compounding unit in your neighborhood. So, what you can do in practice is you can use three chamber bags, because you have all the micronutrients there. You just need to enhance this bag with vitamins and trace elements. And just start feeding because you have a stable admixture parenteral nutrition.
You can choose whatever you want, you just need to fit this bag to your patient. And another thing that you have to think about regarding nutrition and logistic is how often you will feed this patient at home.
HPN is absolutely an effective procedure.
It saves lives, maintains growth and it can also give your patient good quality of life.
