Review article: the management of long‐term parenteral nutrition

Abstract

SummaryBackgroundHome parenteral nutrition (HPN) is currently the management of choice for patients with chronic intestinal failure.AimTo summarise the major issues in delivering long‐term parenteral nutrition (>3 months) and assess outcome as per complications, mortality and quality of life. To assess the evidence for the therapeutic use of trophic factors such as teduglutide and to review evolving therapeutic options in the treatment of chronic intestinal failure.MethodsA literature search using PubMed and MEDLINE databases was performed.ResultsSafe delivery of HPN relies upon individualised formulations of parenteral nutrition administered via carefully maintained central venous catheters by trained patients or carers, supported by a skilled multidisciplinary team. Early diagnosis and treatment of complications including catheter‐associated blood stream infection (reported incidence 0.14–0.83 episodes/patient‐year on HPN) and central venous thrombosis (reported incidence 0.03 episodes/patient‐year) is important to minimise mortality and morbidity. There is a significant variation in the reported incidence of both hepatobiliary complications (19–75%) and advanced liver disease (0–50%). Five‐year survival rates in large centres are reported between 60% and 78% with survival primarily related to underlying diagnosis. Long‐term survival remains higher on HPN than with intestinal transplantation. The role of intestinal lengthening procedures is yet to be validated in adults.ConclusionsHome parenteral nutrition delivered by skilled nutrition teams has low incidences of catheter‐related complications. Most deaths relate to the underlying disease. Therapies such as teduglutide and small bowel transplantation appear promising, but home parenteral nutrition appears likely to remain the bedrock of management in the near term.

Parenteral nutrition in intestinal failure

“…23,25,26 PN formulations can be compounded as a three-in-one total nutrient admixture, containing amino acids, dextrose, and lipid, or as a two-in-one solution with only amino acids and dextrose. 27 Both types of formulations may be used in the immediate postoperative period, but a total nutrient admixture is more convenient for the stable home patient. The lipid emulsion is provided separately in this instance.…”

“…27,30 In the postoperative period, fluid, electrolytes, and acid-base balance should be corrected before initiating PN. Repletion doses of magnesium, phosphorus, and potassium may be required in the first few days.…”

Managing Successful Pregnancies in Patients with Chronic Intestinal Failure on Home Parenteral Nutrition: Experience from a UK National Intestinal Failure Unit

“…Chronic intestinal failure is associated with well documented clinical risks which include Intestinal Failure (IF) associated liver disease (IFALD), chronic kidney disease, biliary stones, osteoporosis and recurrent venous access complications, including thrombosis and infections [2,3]. However, with careful multidisciplinary management, these complications can be minimised and patients can maintain a good quality of life [2][3][4].…”

Long-Term Outcome of Home Parenteral Nutrition in Patients with Short Bowel Syndrome: A Case Report

“…Vitamin products are added to all patients receiving TPN. Trace elements include chromium, copper, iodine, iron, manganese and zinc, added to the TPN solution (4,5).…”

“…Other complications include hyperglycemia, hypophosphatemia, hypokalemia, hypomagnesaemia, hypercapnia, mucosal atrophy, cholecystitis, and increased liver enzymes (1,4,7).…”