Parenteral nutrition for patients with advanced ovarian malignancy

Abstract

Background: Parenteral nutrition (PN) in patients with disseminated ovarian cancer remains controversial. The role of PN in providing nutrition and improving quality of life is unclear. The present study aimed to determine the pattern of prescribing in a large teaching hospital, and to identify subgroups where the use of PN was justified. Methods: Sixty‐five patients with advanced ovarian carcinoma received PN between January 2002 and May 2008. A retrospective case note review was undertaken to retrieve data on PN prescribing and outcomes in terms of duration of PN provision, complications, and survival. Results: Three subgroups were identified. Group I consisted of 18 (28%) patients who received PN for a median [interquartile range (IQR)] of 5 (2–11) days. The majority of these 18 patients (n = 13, 72%) had disease‐related terminal bowel obstruction. Out of 18 of these patients, 17 (95%) had poor performance status. The median (IQR) survival was 12 (6–28) days. Group II consisted of 40 (61%) patients who were re‐established on enteral nutrition. The median (IQR) duration of PN administration was 10 (6–17) days. The most common indication of PN was protracted ileus (n = 25, 63%). Out of 40 of these patients, 35 (88%) patients had good performance status. The median (IQR) survival was 264 (96–564) days. The third group of patients required home PN (n = 7, 11%). Four (58%) patients had short bowel syndrome and three (42%) had terminal intestinal obstruction. All of the patients had good performance status. The median (IQR) duration of PN administration and survival was 241 (90–305) days. Conclusions: Administration of PN appears to be justified in those patients with a good performance status (i.e. patients capable of self‐care), which constituted three‐quarters of this cohort. In the remaining patients with poor performance status, and particularly those with terminal intestinal obstruction, PN administration was difficult to justify. PN should not be denied based purely on the pathology, although cautious judgment is required to select those who are most likely to benefit.

When Is Parenteral Nutrition Appropriate?

“…Prognostic models for estimating survival are often imprecise and error prone, but a recent study suggests that simple tools based on performance status may serve as reliable indicators of survival 33 . Most reports pertaining to PN administration in palliative care use a Karnofsky performance status index of 50 or higher as a guide for determining eligibility for PN therapy 2 , 15 , 23 , 34 , 35 Table 9.2. provides detail regarding the use of the Karnofsky Performance Scale, which is designed for use with patients aged 16 years and older 36 .…”

A late evening snack round improves the carbohydrate intake of patients with cirrhosis: A clinical audit

“…It has been found that organisations still repeatedly fail to provide people with the basic right to food, drink and support when they need it [1]. In acknowledgment that food service in hospitals must be given a higher priority and recognised as an integral part of the patient's treatment and care, Irish hospitals must now have a system to evaluate nutrition and hydration care for patients admitted to hospital [2,3]. The purpose of this audit was to examine the level of mealtime support available to patients during the main mealtime service.…”

“…This accelerates muscle protein loss and is one of the multifactorial causes of sarcopenia [2]. In a systematic review Tsien et al [3] recommended a 50g carbohydrate late evening snack to minimise gluconeogenesis and preserve muscle mass. This has been adopted into clinical guidelines [4].…”

“…Twelve-hour food diaries in conjunction with twelve-hour recall were used to record all food and drink consumed. The results of this audit and evidence from the systematic review [3] were used to secure funding from a charitable source to provide a late evening snack round on the ward between 1900 and 2100 hours. The total carbohydrate intake of cirrhotic Malignant bowel obstruction (MBO) is a common complication of advanced gynaecological cancer, representing the cause of death in 25e9% of patients [1].…”

“…This is a difficult group of patients to predict the appropriateness of the dietetic intervention at the time. However, the use of PN is increasing in the advanced gynaecological cancer population [3] and early PN should be considered in those appropriate by assessing various factors including stage of cancer pathway, prognosis and tolerance to oral intake.…”