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Home Artificial Nutrition (HPN) in adult patients

Home Artificial Nutrition (HPN) in adult patients. F. Bozzetti (Milano) B. Messing (Paris) M. Staun (Copenhague) A. Van Gossum (Brussels). HPN in adult Content. Indications and Epidemiology Venous access care Metabolic complications: prevention and treatment

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Home Artificial Nutrition (HPN) in adult patients

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  1. Home Artificial Nutrition (HPN)in adult patients F. Bozzetti (Milano) B. Messing (Paris) M. Staun (Copenhague) A. Van Gossum (Brussels)

  2. HPN in adultContent • Indications and Epidemiology • Venous access care • Metabolic complications: prevention and treatment • How to adapt nutritional support? • HPN in cancer patients • Training and monitoring

  3. Home Artificial Nutrition (HPN)in adult patientsIndications and Epidemiology A. Van Gossum (Brussels)

  4. HPN in adultHistory (1) 1. HPN was initiated in North America (Shils et al) and in Western Europe (Solassol et al) in the early seventies 2. HPN programs started in specialized centres that rapidly developped a growing experience 3. At the beginning, HPN was exclusively reserved for patients with life-threatening intestinal failure related to benign diseases

  5. HPN in adultHistory (2) 4. In the meantime, the number of HPN centres increased with a high variable number of patients from one to another centre 5. HPN has been progressively used in patients with intestinal failure related to advanced cancer (carcinomatosis) 6. HPN is now worldwide used in industrialized countries. However, legislations and funding are still lacking in many European countries

  6. Intestinal failureDefinition A condition in which the intestine is unable to process sufficient food to maintain an adequate nutritional state ( parenteral nutrition)

  7. The central IV line was considered to be the "artificial gut"

  8. HPNUnderlying diseases • Benign: • Crohn's disease • mesenteric vascular disease • post-surgical, trauma • intestinal pseudo-obstruction • radiation enteritis • miscellaneous: chronic pancreatitis, mucosal atrophy, anorexia nervosa,… • Malignant • AIDS

  9. HPNCauses • Short bowel syndrome • Digestive fistula • Alteration of GI motility • Chronic intestinal (pseudo-) obstruction (carcinomatosis) • Intractable diarrhea (AIDS) • Severe malnutrition

  10. Short bowel syndrome Major resection of the small bowel Nutritional and metabolic consequences Diarrhea, fluid and electrolyte abnormalities, malabsorption, weight loss

  11. Short bowel syndromeParenteral nutrition-dependency Cut-off values of SB lengths • End-enterostomy (I) 100 cm • Jejunocolonic (II) 65 cm • Jejunoileocolonic (III) 30 cm Messing B, Transplant Proceedings, 1998

  12. Jejuno-sigmoid anastomosis

  13. Duodenostomy (Foley sonde)

  14. Incidence of HPN from 1 January 97 to 31 December 97 ESPEN-HAN, Clin Nutr 1999, 18, 135

  15. HPN in adultIncidence / Prevalence • The point prevalence of HPN is estimated to be 6 to 10 times higher in US than in Europe • Late available data: • Incidence: • 3/106 inhabitants/y France (2001-2004) • 1.65/106 inhabitants/y Spain (2001) • Point prevalence: • 12/106 inhabitants/y Scotland (2001) • 9/106 inhabitants/y UK (2001)

  16. Point prevalence and new registrations of adults receiving HPN (UK) BANS Registry, 2003

  17. Distribution of underlying diseases for HPN patients in Europe (1997; n = 479) ESPEN-HAN, Clin Nutr 1999, 18, 135

  18. Indications for HPN in 7 different European countries where reporting was assumed to be more than 80% of patients (1997) ESPEN-HAN, Clin Nutr 1999, 18, 135

  19. Outcome at 1 January 1998 for HPN patients enrolled between 1 January 97 and 31 June 97 ESPEN-HAN, Clin Nutr 1999, 18, 135

  20. HPNComplications 1. Catheter-related– sepsis – venous thrombosis – occlusion – migration 2. Metabolic• liver abnormalities • biliary stones • metabolic bone disease • trace element and/or vitamins deficiencies • manganese toxicity • renal function impairment 3. Psychological 4. Quality of life 5. Rehabilitation

  21. Long-term HPNComplications (n = 228) • Hospitalization stays (within 12 previous months): 23 days (0 to 270 d) • Reasons for hospitalizations: • underlying diseases (37%) • HPN related (30%) (majority: catheter sepsis) • other (33%) ESPEN-HAN, Clin Nutr 2001, 30, 205

  22. Long-term HPNClinical features • n = 228 patients • Depression: 17% • Opiates use: 8% • Analgesics use: 35% • Interest for intestinal transplantation: 8% ESPEN-HAN, Clin Nutr 2001, 30, 205

  23. Long-term HPN (n = 228)Rehabilitation status Before At HPN evaluation I Able to work full time 50% 35% or looking after home and family unaided II Able to work part time 14% 33% or looking after home and family with help III Unable to work but able 12% 23% to cope with HPN unaided and able to go out occasionally IV Housebound: needs major 24% 9% assistance ESPEN-HAN, Clin Nutr 2001, 30, 205

  24. HPN – Indications and EpidemiologyConclusions (1) 1. HPN is worldwide used in industrialized countries 2. In many European countries as well as in US, cancer has become the main indication for HPN 3. For patients with benign diseases, the main indications are short bowel and chronic intestinal motility disorders

  25. HPN – Indications and EpidemiologyConclusions (2) 4. The number of HPN centres increased with a variable degree of expertise 5. The prevalence in US is expected to be 10 times higher than in Europe (from 2 to 12/106 inhabitants) 6. HPN related complications are quite rare and rehabilitation status is good in the majority of the patients

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