Long-Term Use of Mixed-Oil Lipid Emulsion in Adult Home Parenteral Nutrition Patients: A Case Series.

BACKGROUND: Despite providing significant benefits, home parenteral nutrition (HPN) can be associated with complications such as infections, intestinal failure-associated liver disease, and metabolic abnormalities. Soybean oil (SO)-based intravenous lipid emulsion (ILE) has been noted to contribute to some of these complications, leading to the development of alternative sources of ILE. Mixed-oil (MO) ILE has recently been approved for use in adults with short-term studies revealing a benefit over SO ILE. Currently there is a paucity of data regarding long-term use in the HPN population. METHODS: The current study reports our experience with MO ILE in 9 HPN patients. RESULTS: A total of 9 patients (3 women and 6 men) with average age of 48.1 ± 15.1 years and a median HPN use of 9.9 years (9.0 months-30.7 years) were transitioned from SO ILE to MO ILE as a result of intolerance. The 9 patients tolerated MO ILE well for 140.7 ± 29.7 days. The percentage of calories provided through ILE increased from 7.6 ± 6.5% to 18.4 ± 8.2% (P = .003), whereas the dextrose decreased from 66.9 ± 8.4% to 56.9 ± 5.5% (P = .0007). Although statistical significance was not reached, there was a trend toward improvement in alkaline phosphatase from 138.0 (52-884) to 106 (47-512; P = .09). CONCLUSION: MO ILE was well tolerated in this small cohort and led to improvement in the macronutrient composition of HPN while providing a trend toward improvement in liver studies. These results are promising; however, additional randomized control trials are needed to delineate the true benefit.

Parenteral and Enteral Nutrition-From Hospital to Home: Will It Be Covered?

With scientific advances allowing for the safe delivery of parenteral and enteral nutrition in the home setting, challenges have risen with determining how this will be financially feasible for patients. In the United States, the government is one of the major payers for home parenteral and enteral nutrition (HPEN). Thus, it is important for nutrition providers to have an understanding of the Medicare criteria that must be met in order for these services to be covered. It can be difficult for clinicians to sift through these requirements and decipher for whom and when HPEN is covered. As our nutrition science knowledge and delivery continue to grow and evolve, potential barriers to this coverage may arise. This article provides background on those currently on HPEN in the United States, the current Medicare HPEN coverage criteria, and challenges we may face in the future.

Prevalence of Home Parenteral and Enteral Nutrition in the United States.

BACKGROUND: Malnutrition is highly prevalent and associated with increased morbidity and mortality. Studies continue to reveal significant clinical benefits with nutrition support, including improved wound healing, reduction in complications and length of stay, and mortality. Due to these benefits, the prevalence of home parenteral and enteral nutrition (HPEN) continues to increase worldwide. In the United States, given our healthcare insurance landscape, it has been very difficult to ascertain the true prevalence of HPEN. METHODS: Medicare beneficiary data for 2013 were obtained from Centers for Medicare and Medicaid Services. Commonly used Healthcare Common Procedure Coding System codes were used for home enteral nutrition (HEN) and home parenteral nutrition (HPN). Data regarding number of patients and insurance providers were also obtained from 3 of the largest home infusion providers in the United States (Coram CVS, Option Care Enterprises, and BioScrip Inc). Based on the ratio of Medicare to non-Medicare billing, an estimate of HPEN prevalence was obtained. RESULTS: For 2013, there were 6778 Medicare beneficiaries for HPN and 114,287 for HEN. The ratio of Medicare to non-Medicare was 0.271 for HPN and 0.261 for HEN, leading to an estimated prevalence of 25,011 patients receiving HPN (79 per million U.S. inhabitants) and 437,882 patients receiving HEN (1385 per million U.S. inhabitants). There are an estimated 4129 pediatric patients and 20,883 adult patients receiving HPN; for HEN, 189,036 pediatric patients and 248,846 adult patients. CONCLUSION: Compared with results from 1992, the prevalence of HEN has increased dramatically, while the prevalence of HPN has declined.

Use of Home Parenteral Nutrition in Post-Bariatric Surgery-Related Malnutrition.

BACKGROUND: Bariatric surgery is one of the most effective techniques for achieving sustained weight loss but can be associated with surgical complications or malabsorption so significant that it leads to malnutrition. Parenteral nutrition (PN) may be necessary to help treat surgical complications or malnutrition from these procedures. There are limited data describing this patient population and role for home PN (HPN). METHODS: A retrospective review of our HPN database was conducted to identify patients who were initiated on HPN between January 1, 2003, and August 31, 2015, and had a history of bariatric surgery. RESULTS: A total of 54 HPN patients (6.3%) had a history of bariatric surgery. Average age was 52.1 ± 12.8 years, and 80% were female. The most common surgical procedure was Roux-en-Y gastric bypass (72%), with malnutrition or failure to thrive being the most common HPN indication (57%). Weight at the time of HPN initiation was 71.9 ± 20.4 kg and significantly increased to 78.9 ± 24.4 kg by the end of treatment ( P = .0001). Serum albumin levels rose from 2.8 ± 0.77 g/dL to 3.7 ± 0.58 g/dL by the end of HPN ( P < .0001). Forty-five of 54 patients (83.3%) went on to revision surgery. CONCLUSION: The results of this retrospective review support initiation of HPN in the malnourished post-bariatric surgery patient both nutritionally and as a bridge to revision surgery.

Accuracy of Intravenous Electrocardiography Confirmation of Peripherally Inserted Central Catheter for Parenteral Nutrition.

BACKGROUND: Parenteral nutrition (PN) is a life-saving therapy for patients with intestinal failure. Safe delivery of hyperosmotic solution requires a central venous catheter (CVC) with tip in the lower superior vena cava (SVC) or at the SVC-right atrium (RA) junction. To reduce cost and delay in use of CVC, new techniques such as intravascular electrocardiogram (ECG) are being used for tip confirmation in place of chest x-ray (CXR). The present study assessed for accuracy of ECG confirmation in home PN (HPN). METHODS: Records for all patients consulted for HPN from December 17, 2014, to June 16, 2015, were reviewed for patient demographics, diagnosis leading to HPN initiation, and ECG and CXR confirmation. CXRs were subsequently reviewed by a radiologist to reassess location of the CVC tip and identify those that should be adjusted. RESULTS: Seventy-three patients were eligible, and after assessment for research authorization and postplacement CXR, 17 patients (30% male) with an age of 54 ± 14 years were reviewed. In all patients, postplacement intravascular ECG reading stated tip in the SVC. However, based on CXR, the location of the catheter tip was satisfactory (low SVC or SVC-RA junction) in 10 of 17 patients (59%). CONCLUSION: Due to the high osmolality of PN, CVC tip location is of paramount importance. After radiology review of CXR, we noted that 7 of 17 (41%) peripherally inserted central catheter lines were in an unsatisfactory position despite ECG confirmation. With current data available, intravenous ECG confirmation should not be used as the sole source of tip confirmation in patients receiving HPN.