An audit of parenteral nutrition standard bag usage in a large teaching hospital

Abstract

Patients with systemic sclerosis (SSc) may develop significant gastrointestinal involvement (GI). When severe, this can lead to intestinal failure (IF) requiring home parenteral nutrition (HPN). However, few outcome data are reported for these patients (1,2,3). Records were reviewed of all patients with SSc who required HPN, at a national IF centre, between 1990 and 2012. Disease characteristics and survival/outcome data were evaluated. 25 patients (5 male, median age: 55 (range 24-76)) with SSc received HPN (37,200 catheter days). Median time from SSc onset to HPN was 113 months (range 14-389). All had small intestinal involvement. 80% had proven bacterial overgrowth. 44% had experienced at least one episode of pseudo-obstruction. 16% had undergone a small intestinal resection. 1 patient, with severe colonic and pharyngeal dysmotility, failed to tolerate enteral feeding. Prior to HPN initiation, 6 patients failed a naso-enteric feeding trial. 10 patients had a gastrostomy or jejunostomy inserted; 7 of whom received enteral feeding for less than 1 year. The remaining 9 patients commenced HPN directly, without enteral tube feeding, because of the severity of their dysmotility/associated co-morbidity. Only 2 patients were weaned off HPN (after 8 and 29 months) following successful medical optimisation. After 1 year, median body mass index rose from 18.7 to 21.2. 3 patients received HPN for more than 10 years. The cumulative percentage of patients on HPN after 1, 5 and 10 years were 75%, 37% and 23% respectively. No patients died from HPN-related complications. 16 died from causes related to their SSc. 1 died from malignancy. 8 patients survive, 7 of whom remain on HPN (median duration: 40 months, range 9-178). 9 patients were trained to manage their central venous catheters and selfadminister HPN. 16 patients relied on others for their HPN administration. Reported catheter complications included non-thrombotic occlusion (0.70/1,000 catheter days), sepsis (0.19/1,000 catheter days) and central venous thrombosis (0.11/1,000 catheter days). The sepsis rate for all HPN patients, at the same IF centre, is 0.39/1,000 catheter days. No one developed IF-associated liver disease. This is the largest reported series of patients with SSc requiring HPN. Our data shows that HPN offers a safe means of nutritional support for patients with severe SSc-related GI involvement, but that SSc-related mortality remains high. Patients with SSc had a low catheter-related sepsis rate. Additionally, the majority relied on others for their catheter care. 1. Ng SC, Clements PJ, Berquist WE, Furst DE, Paulus HE. Home central venous hyperalimentation in fifteen patients with severe scleroderma bowel disease. Arthritis Rheum. 1989; 32: 212e6. 2. Jawa H, Fernandes G, Saqui O, Allard JP. Home parenteral nutrition in patients with systemic sclerosis: a retrospective review of 12 cases. J Rheumatol. 2012; 39(5):1004e7. 3. Brown M, Teubner A, Shaffer J, Herrick AL. Home parenteral nutrition-an effective and safe long-term therapy for systemic scleros...