The association between home parenteral nutrition and patients with FAP-associated intra-abdominal desmoids: a retrospective study.

BACKGROUND: Intra-abdominal desmoid tumors (IADTs) are a common complication of familial adenomatous polyposis (FAP). Treatment is not standardized for advanced disease. Medical and surgical treatments may be ineffective in preventing complications, which can cause intestinal failure. Home parenteral nutrition (HPN) can be a life-saving treatment in these patients. The aim of this study was to investigate the association with HPN in FAP-IADTs. METHODS: A retrospective review of FAP patients with IADTs at the Cleveland Clinic (CC) between 1980 and 2009 was performed. Patients and tumor characteristics were retrieved from the CC Jagelman Registry for Inherited Neoplasms and CC HPN database. Inclusion criteria were FAP-IADTs and 6-month follow up at CC. Exclusion criteria were <6-month follow-up, lack of 3-dimensional lesion or sheet desmoid, and/or incomplete medical records. Kaplan-Meier curves were analyzed for HPN and non-HPN groups. RESULTS: One hundred fifty-four patients were included and divided into 2 groups: HPN (n = 41, 26.6%) and non-HPN (n = 113, 73.4%). The HPN group was more likely to have advanced-stage disease and significantly higher incidence of chronic abdominal pain, narcotic dependency, bowel obstruction, ureteral obstruction, deep vein thrombosis, pulmonary embolism, fistulae, and sepsis (P < .05). The need for HPN represented a strong predictor of mortality (5-year survival HPN = 72% vs non-HPN = 95%), but duration of HPN did not affect mortality. CONCLUSION: HPN, although a life-saving treatment, is an independent poor prognostic factor associated with high morbidity and mortality.

Home parenteral nutrition tutorial.

The nutrition support practitioner may be called upon to help coordinate care at home for a patient who requires prolonged intravenous nutrition after he or she becomes stable enough to leave the hospital. This tutorial reviews the many concepts that must be considered to manage this type of care successfully.

Type and prevalence of adverse events during the parenteral nutrition cycling process in patients being prepared for discharge.

BACKGROUND: The mechanism for cycling parenteral nutrition (PN) varies from institution to institution. However, the types and frequency of adverse events (AEs) involved with this process are not well understood. PURPOSE: To determine the type and prevalence of AE in patients during PN cycling and identify factors associated with the occurrence of AEs. METHODS: Patients without severe organ dysfunction or uncontrolled diabetes mellitus scheduled to be discharged on cyclic PN with a goal of 12 hours were eligible. Patients were cycled from 24 to 12 hours over 2 or 3 days based on previously established criteria. Demographic, nutrition, and monitoring data were collected. AEs were documented and graded as mild or serious. RESULTS: Mild AEs occurred in 35 of 38 patients (92.1%) consisting primarily of mild hyperglycemia (86.8%) and tachycardia (29.0%). Serious AEs occurred in 8 of 38 patients (21.1%), including 7 patients (18.4%) with capillary blood glucoses between 255 and 324 mg/dL and 1 (2.6%) with tachypnea/tachycardia requiring immediate medical attention. No significant associations were made between demographic, medical, nutrition, or laboratory factors and serious AEs. No significant differences in demographic information, nutrition information, comorbidities, diet, medications, or composition of PN were found except for lower body weight in unsuccessful cyclers compared with successful cyclers (P = .042). CONCLUSIONS: Most patients incur AEs during PN cycling, primarily mild hyperglycemia and tachycardia. These findings suggest patients need to be monitored closely and treated aggressively for complications during PN cycling.

Ethanol lock therapy in reducing catheter-related bloodstream infections in adult home parenteral nutrition patients: results of a retrospective study.

BACKGROUND: Equivocal data demonstrate the efficacy of ethanol lock therapy (ELT) in preventing catheter-related bloodstream infections (CRBSIs) in home parenteral nutrition (HPN) patients, but it is not currently a standard of practice. The objective of this study is to investigate the efficacy of ELT in reducing the incidence of CRBSIs in HPN patients. METHODS: Medical records from the Cleveland Clinic database of adult HPN patients with CRBSIs placed on prophylactic ELT were retrospectively studied from January 2006 to August 2009 (n = 31). Outcomes were compared pre- and post-ELT with the patients serving as their own controls. Medical-grade (70%) ethanol was instilled daily into each lumen of the central venous catheter (CVC) between PN infusion cycles. Comparative analysis was performed using McNemar's test and Wilcoxon ranked tests. RESULTS: Thirty-one patients had 273 CRBSI-related admissions prior to ELT in comparison to 47 CRBSI-related admissions post-ELT. Adjusted data for only tunneled CVC pre- and post-ELT showed a similar reduction of CRBSI-related admissions from 10.1 to 2.9 per 1000 catheter days (P < .001). There was also a statistically significant reduction in culture-positive CRBSIs and number of catheters changed pre- and post-ELT. There were no reported side effects or complications in any patient undergoing ELT. CONCLUSIONS: This study supports the efficacy and safety of ELT in reducing CRBSI-related admissions in HPN patients and potentially helps reduce the burden of CRBSI-related healthcare costs. This novel technique shows great promise as a standard prophylaxis for CRBSI in HPN patients and must be incorporated in routine practice.

Intestinal failure management at the Cleveland Clinic.

The Cleveland Clinic institutional guidelines for the management of intestinal failure, including long-term or home parenteral nutrition and related complications, intestinal rehabilitation, and small bowel transplantation, were reviewed. PubMed was searched for relevant articles. The search was performed in November 2008; keywords used were home parenteral nutrition, short bowel syndrome, intestinal rehabilitation, and small-bowel transplantation. Randomized, prospective, observational, retrospective reviews and case report articles that contained relevant data for long-term parenteral nutrition, intestinal rehabilitation, and intestinal transplantation were selected. Researchers reviewed 67 selected articles that met our inclusion criteria. Our institution data registries for intestinal rehabilitation and home parenteral nutrition were also reviewed for relevant data. The survival of tens of thousands of children and adults with complicated gastrointestinal problems has been possible because of parenteral nutrition. In selected patients, a program of intestinal rehabilitation may avoid the need for long-term parenteral nutrition.

Measured versus estimated aluminum content of parenteral nutrient solutions.

PURPOSE: A study was conducted to directly measure the aluminum concentration in a select number of parenteral nutrient (PN) solutions and to compare this value with the calculated dose using the concentrations reported by the manufacturer. METHODS: Fifty 2.5-mL samples were prepared for analysis and were obtained from PN solutions prepared for adult and pediatric/neonatal patients. Intravenous large-volume parenterals were used as controls. Samples were sent to two different reference laboratories. Batch 1 included 26 samples, 22 from PN solutions, 1 control, and 3 paired (duplicate) samples selected from the 22 PN bags. Because 8 of the samples were lost to analysis, a second batch of samples was included. Batch 2 consisted of 24 samples from 4 PN solutions and 2 controls. Batch 2 was composed of four aliquots from each solution that were divided equally and sent to the two laboratories. RESULTS: Twenty-three values were used in the statistical analysis. The results showed that only two of the adult PN solutions equaled or exceeded the threshold set by the Food and Drug Administration (FDA) for measured aluminum exposure. The measured concentration of aluminum for all six of the pediatric and neonatal solutions met or exceeded the FDA threshold; however, this value was much lower than what had been estimated using the labeled aluminum concentration at expiry. CONCLUSION: In PN solutions expected to have a moderately high concentration of aluminum, the measured amount of aluminum was far less than the amount that would be estimated by calculation using the labeled concentrations of aluminum in each of the ingredients.