Gastroenterology

Gastroenterology

Volume 124, Issue 6, May 2003, Pages 1651-1661
Gastroenterology

Management of complications in patients receiving home parenteral nutrition

https://doi.org/10.1016/S0016-5085(03)00326-3Get rights and content

Abstract

Patients receiving long-term home parenteral nutrition tend to fall under the care of adult and pediatric gastroenterologists. This article reviews the management of potential infectious, mechanical and metabolic complications and describes common psychosocial issues related to the therapy. The point at which to refer the patient to an intestinal failure program offering autologous bowel reconstruction and small bowel transplantation is discussed.

Section snippets

Management of home parenteral nutrition complications

Because HPN patients are living at home, management of acute complications is initiated by the patient and their caregiver. This underscores the need for good initial training. To enhance this training, a patient-oriented HPN complication chart is available free to all HPN consumers and their clinicians from the Oley Foundation,19 supporting patients and their families on home parenteral and enteral nutrition (www.c4isr.com/oley/newHPN.pdf.). The frequency of the different HPN complications is

Infectious complications

HPN patients can have fever from many causes, but if no symptoms or signs point to other causes, the chief concern becomes catheter-related sepsis. As shown in Table 3, adults have an episode of catheter sepsis on average once every 2 to 3 years. In children, the frequency is 50% higher. Catheter sepsis rates are decreased in very long-term HPN survivors.26

Although septic events are rarely fatal, they are the most common type of catheter-related infection (>80%) and the most frequent reason for

Mechanical complications

Catheter occlusion occurs at a rate of 0.071 episodes per year (Table 3). It often starts as a fibrin sheath that grows around the intravascular portion of the catheter, sometimes acting as a one-way valve preventing withdrawal of blood but permitting infusion of the nutrient solution. Eventually the sheath or a blood clot causes complete catheter occlusion. Occasionally infused fluid, unable to reach the vein lumen, flows back between the sheath and the catheter to the exit site. This

Fluid and electrolytes

This is a critical issue for short-bowel patients. Many patients after a period of adaptation can absorb enough oral calories and protein to maintain their weight, often by eating 4000–6000 calories/day. But this through-put can induce large enteric losses, especially in the individual with a high jejunostomy. Such a patient may lose 4 L/day compared with a stool loss of 100 mL/day in a healthy person. Large enteric fluid losses can be exacerbated by a number of factors (Table 4) and sipping

Introducing home parenteral nutrition therapy

It is helpful to get immediate input from professionals with HPN experience. HPN implies an enormous commitment from the patient and their family and although it may offer the only possibility of long-term survival, experience has taught this must be an unpressured patient and family decision. Some home situations cannot provide safe HPN. Long-term daily professional nursing is rarely available and few nursing homes accept parenteral nutrition patients. If the patient and family opt to go ahead

Referral to an intestinal failure program

Many short-bowel patients who cannot graduate off parenteral nutrition and are developing serious HPN metabolic complications, may benefit from evaluation at an intestinal failure center that has expertise in HPN, autologous bowel reconstruction, and small-bowel transplantation. Some short-bowel patients can reach better nutritional compensation and recover from cholestasis induced by bacterial overgrowth in dysmotile segments with the intestinal lengthening and tapering surgery introduced by

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