Home parenteral nutrition--a 3-year analysis of clinical and laboratory monitoring.

We report a 3-year analysis (1986 to 1989) of the management of 63 home parenteral nutrition patients, 40 with short-bowel syndrome and 23 with chronic intestinal obstruction with or without intestinal resection. Intravenous fluid requirements varied from 0.9 to 6 L/day, and the content of glucose varied between 46 and 531 g/day, protein varied from .0 to 85 g/day, fat from .0 to 100 g/day, sodium from 37 to 695 mEq/day, potassium from 30 to 220 mEq/day, chloride from 60 to 760 mEq/day, and acetate from 0 to 200 mEq/day. Body weight was normalized and well maintained in the majority of patients, but using the strict definition of deficiency as the presence of one abnormal value during 3 years, more than half had abnormal plasma chloride, glucose, alkaline phosphatase, serum glutamic oxaloacetic transaminase, total protein, albumin, selenium, and iron concentrations, and more than a third had low calcium, magnesium, vitamin D, and vitamin C levels. Normochromic anemia was seen in 73% and high blood creatinine associated with low urine volumes in 42%. Most (78%) returned to relatively normal lifestyles, but employability was occasionally impaired by loss of third-party insurance coverage resulting from a therapy that may cost $100,000 per year. Overall mortality was low (5% per year), but 73% needed readmission to hospital, mainly for suspected catheter sepsis. The results indicate that home parenteral nutrition has allowed many patients to survive gut failure and return to work but problems with chronic fluid, electrolyte and micronutrient deficiencies, catheter sepsis, and insurance coverage often restrict optimal rehabilitation.

Organization and operation of a home parenteral nutrition program with emphasis on the pharmacist's role.

A home parenteral nutrition program was organized at Mayo Clinic-Rochester Methodist Hospital in 1975. To date, 26 patients with chronic malnutrition usually due to either severe short bowel syndrome or extensive Crohn's disease have been trained in home parenteral nutrition for a total treatment period of 430 patient-months. Home parenteral nutrition is an attractive alternative for these patients in that it dramatically improves nutrition, promotes rehabilitation at home, and probably decreases long-term expenses. The numerous medical, psychosocial, and financial problems confronting patients on home parenteral nutrition are managed through a multispecialty team consisting of physicians, pharmacists, nurse, social worker, dietitian, physiatrist, psychiatrist, and business manager. The pharmacist is the person with whom the patient has the most contact during a 2-week training period. In addition to patient education, the pharmacist coordinates the transition to home care, offers in-service education on home parenteral nutrition to nurses and house officers, tests and evaluates the equipment, coauthors a training manual, and edits a quarterly newsletter to patients who are on home parenteral nutrition.

Patient compliance with a home parenteral nutrition program.

A systematic study of patient compliance to home parenteral nutrition (HPN) was done by an independent nurse who visited 10 patients and families at varying periods after HPN had been started. A compliance scale was based on assessment of aseptic technique, sequence of steps followed, safety precautions, proper use of equipment, and knowledge of complications. Compliance percentiles ranged from 73 to 97, with a median of 95. Seven of the 10 patients scored 90% or more in overall compliance. The only category that clearly showed a deficiency was patient knowledge of potential complications of HPN. Factors that correlated positively with a high compliance score were male sex, absence of children in the home, and wives who were enthusiastic about HPN and who offered the most moral support. This study shows that patients with chronic disabling diseases of the small bowel and severe malnutrition can be managed safely at home with HPN if they are properly trained and supervised.

Home parenteral nutrition as primary therapy in patients with extensive Crohn's disease of the small bowel and malnutrition.

UNLABELLED: Seven patients with extensive Crohn's disease have received nightly supplementary home parenteral nutrition (HPN) for a total of 120 patient months. Indications for HPN were short bowel in 5, growth failure in 1, and gastric outlet obstruction in 1. Before HPN, body weight averaged 72% of ideal body weight in 5 patients; 1 adolescent was less than the third percentile in weight. Anthropometry in 6 patients confirmed decrease in fat and lean body mass in all. All patients were anemic and serum albumin was low in 6 of 7 (1.8 to 3.0 g per dl). During HPN average weight gain was 11 kg in the 6 patients treated for 6 months or longer. Hemoglobin increased an average of 1.5 g per dl and serum albumin increased an average of 1.0 g per dl. There were 50% fewer hospitalizations after HPN was begun compared with similar time periods before HPN. HPN did not prevent or reverse complications of Crohn's disease other than malnutrition. Major complications were displacement of the catheter on two occasions in 1 patient and metabolic acidosis in 2 patients. Sepsis did not occur. CONCLUSION: HPN is justified in selected patients with extensive Crohn's disease and malnutrition in that patients gain weight, nutritional parameters improve, and patients' activities increase as number of hospitalizations decrease.