LA NUTRIZIONE ARTIFICIALE DOMICILIARE:
LUCI E OMBRE
PAOLO COTOGNI
SC Terapia del Dolore e Cure Palliative Dipartimento di Anestesia e Rianimazione
AOU Città della Salute e della Scienza
Università di Torino
3 Arends J, et al. Clin Nutr. 2017; 36:11-48
Arends J, et al. Clin Nutr. 2017; 36:11-48
VS.
5
Old Misunderstanding
EN PN
Cotogni P. Ann Palliat Med. 2016;5(1):42-9.
EN Feasibility
When EN is not sufficient or feasible?
EN patients may be unable to achieve the target nutritional intake due to:
complications of long-term nasoenteric tube placement or PEG tube placement
clinical problems:
Diarrhea
Nausea
Vomiting
Constipation
Aspiration
McClave SA, Chang WK. Gastrointest Endosc. 2003;58:739-5 Orrevall Y, et al. Nutrients. 2013;5:267e82.Arends J, et al. Clin Nutr. 2017; 36:11-48
HCT = Hematopoietic cell transplantation.
9 Arends J, et al. Clin Nutr. 2017; 36:11-48
Nutrition Support during Chemotherapy
• “If patients develop GI toxicity from chemotherapy or radiation therapy, short-term PN is usually better tolerated (and more efficient) than EN to restore the intestinal
function and prevent nutritional deterioration.”
Bozzetti F, et al. Clin Nutr. 2009;28:445-54 (ESPEN Guidelines).
Disease State (n)
% of Patients with
Nutrition Support
% of Malnourished
Patients with Nutrition
Support
% of Non- Malnourished
Patients with Nutrition
Support
% Receiving Oral Supplements
% Receiving Enteral Nutrition
% Receiving Parenteral
Nutrition
Blood (377) 34.5 44.5 29.3 20.3 9.5 16.2
Head and Neck (366) 63.7 76.5 51.3 36.4 40.4 6.1
Lung (247) 42.9 55.4 32.6 38.8 11.1 8.1
Breast (229) 14.8 34.0 9.89 12.3 5.2 4.1
Colon/Rectum (191) 30.4 41.3 23.3 21.5 5.8 10.9
Esophagus/Stomach (103) 65.0 77.4 46.3 47.8 25.8 19.6
Uterus/Ovaries (87) 32.2 41.0 25.0 14.7 6.8 21.3
Prostate (72) 13.9 40.0 9.7 13.0 1.5 4.5
Pancreas (42) 66.7 78.6 42.9 55.0 6.3 24.3
Kidney/Bladder (29) 41.4 66.7 14.3 28.6 15.4 7.7
Others (160) 31.9 52.2 23.7 19.1 10.6 10.2
TOTAL (1903) 39.8 57.6 28.4 24.2
13.8 9.6
Adapted from Hébuterne X, et al. JPEN J Parenter Enteral Nutr 2014;38:196-204 11
Prevalence of Malnutrition and Current Use of Nutrition
Nutrition Support
Volume 38 Number 2 Original Communication
Is There a Benefit?
PN may contribute to the maintenance or
improvement of quality of life (QoL) in advanced
cancer patients
13
15
Volume 37 Number 3 Original Communication
Medium-term VADs Long-term VADs
Total
PICC Hohn Tunneled Port
No of VADs 65 107 45 72 289
Local Infection, No. 2 2 2 3 9
No./1000 Catheter-Days 0.17 9.19 0.26 0.14 0.17
No./1000 HPN-Days 0.24 0.26 0.39 0.34 0.30
CRBSI, No. 0a 9 5 4b,c 18
No./1000 Catheter-Days 0 0.87 0.64 0.19 0.35
No./1000 HPN-Days 0 1.17 0.97 0.45 0.60
Risk Factors for CRBSI,
P-value
Use During HPN ― <.001 <.001 <.001
Previous VAD ― NS <.05 <.05
No Ultrasound-Guidance ― <.04 NS NS
Securement by Suture ― <.05 NS ―
Infraclavicular Exit Site ― <.01 ― ―
Cuff <2 cm from Exit Site ― ― <.05 ―
Infectious Complications
CRBSI=catheter-related bloodstream infection; HPN=home parenteral nutrition; NS=not significant;
PICC=peripherally inserted central catheter; VAD=venous access device; — = not applicable.
aP<.01 vs Hohn catheter and tunneled Groshong catheter; bP<.01 vs Hohn catheter;
cP<.05 vs tunneled Groshong catheter.
Cotogni P, et al. JPEN J Parenter Enteral Nutr. 2013;37:375-383.
Catheter-Related Complications in Cancer Patients on Home Parenteral Nutrition: A Prospective Study
of Over 51,000 Catheter Days
Medium-term VADs Long-term VADs
Total
PICC Hohn Tunneled Port
No of VADs 65 107 45 72 289
Venous Thrombosis, No. (%) 0 3 (2.8) 0 0 3 (1)
Mechanical Complications
Catheter Dislocation, No. (%) 5 (7.7) 15 (15) 4 (8.9) ― 25 (8.6)
Rupture of External Tract, No. (%) 2 (3.1) 0 2 (4.4) ― 4 (1.4)
Lumen Occlusion, No. (%) 2 (3.1) 3 (2.8) 0 7 (9.7) 12 (4.1)
TOTAL 9 (13.9) 19 (17.8) 6 (13.3) 7 (9.7) 41 (14.1)
No./1000 Catheter-Days 0.78 1.83 0.77 0.32 0.80
No./1000 HPN-Days 1.07 2.46 1.16 0.79 1.36
Risk Factors for Thrombosis,
P-value
Use During HPN <.01 <.01 <.01 <.01
No Ultrasound Guidance ― <.001 ― ―
Left Side Insertion ― <.001 ― ―
Risk Factors for Dislocation,
P-value
Use During HPN <.01 <.01 <.01 <.01
Suture ― <.001 NS ―
Cuff <2 cm from Exit Site ― ― <.01 ―
Noninfectious Complications
Volume 37 Number 3 Original Communication
PICC=peripherally inserted central catheter; VAD=venous access device; — = not applicable.
Catheter-Related Complications in Cancer Patients on Home Parenteral Nutrition: A Prospective Study
of Over 51,000 Catheter Days
12
Cotogni P, et al. JPEN J Parenter Enteral Nutr. 2013;37:375-83. 17
Catheter-Related Complications in Cancer Patients on Home Parenteral Nutrition: A Prospective Study
of Over 51,000 Catheter Days
Volume 37 Number 3 Original Communication
CONCLUSIONS
• If accurately managed, HPN can be safely provided
for most cancer patients, even in an advanced stage, without expecting a relevant incidence of catheter-related
complications
• Therefore, concerns about the risks should not still have
influence on the decision to feed or not a cancer patient
when HPN is clinically indicated
Is There an EBM?
• It would have been ethically unacceptable to have a non-PN control arm
• So, any prospectively controlled evidence of potential benefit
is denied
RCT EBM
19
Should This Patient Continue PN or
Start PN at Home?
How to Intervene?
Dreesen M, et al. Support Care Cancer. 2013;21:1373-81. 21
How to Intervene?
“… HAN should be prescribed and regularly
monitored using defined protocols shared between oncologists and clinical nutrition specialists.”
How to Intervene?
Worthington P. et al. JPEN J Parenter Enteral Nutr. 2017.
How to Intervene?
How to Intervene?
25
Is There the Indication for HPN in
Patients With No Further Treatments?
Bozzetti F, et al. Clin Nutr. 2009;28:445-54 (ESPEN Guidelines).
Yes “It is not a contraindication for HPN that oncologic
treatment has been stopped.”
of death due to malnutrition
Arends J, et al. Clin Nutr. 2017; 36:11-48
Hoda D. Cancer 2005;103:863-8. 27
Daanish Hoda Oncology, Mayo Clinic Rochester
Cancer 2005;103:863-8.
©2005 American Cancer Society
Arends J, et al. Clin Nutr. 2017; 36:11-48
Cotogni P. Ann Palliat Med. 2016;5(1):42-9.
