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

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Arends J, et al. Clin Nutr. 2017; 36:11-48

Arends J, et al. Clin Nutr. 2017; 36:11-48

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VS.

5

Old Misunderstanding

EN PN

Cotogni P. Ann Palliat Med. 2016;5(1):42-9.

Worthington P. et al. JPEN J Parenter Enteral Nutr. 2017.

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.

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Arends J, et al. Clin Nutr. 2017; 36:11-48

HCT = Hematopoietic cell transplantation.

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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).

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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

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Is There a Benefit?

Bozzetti F, et al. Clin Nutr. 2009;28:445-54 (ESPEN Guidelines).

PN may contribute to the maintenance or improvement of quality of life (QoL) in advanced cancer patients

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Cotogni P, et al., Cancer Medicine; 2017, in press.

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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 ―

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Noninfectious Complications

Volume 37 Number 3

Original Communication

PICC=peripherally inserted central catheter; VAD=venous access device; — = not applicable.

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

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

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Is There an EBM?

Bozzetti F, et al. Clin Nutr. 2009;28:445-54 (ESPEN Guidelines).

• 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

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Should This Patient Continue PN or

Start PN at Home?

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How to Intervene?

Kumpf VJ, Tillman EM. Nutr Clin Pract. 2012;27(6):749-57.

21 Dreesen M, et al. Support Care Cancer. 2013;21:1373-81.

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?

Worthington P. et al. JPEN J Parenter Enteral Nutr. 2017.

How to Intervene?

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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

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Arends J, et al. Clin Nutr. 2017; 36:11-48

27 Hoda D. Cancer 2005;103:863-8.

Daanish Hoda

Oncology, Mayo Clinic Rochester Cancer 2005;103:863-8.

©2005 American Cancer Society

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Arends J, et al. Clin Nutr. 2017; 36:11-48

Cotogni P. Ann Palliat Med. 2016;5(1):42-9.

HPN Is Not Recommended in

Patients With:

How to predict

survival?

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Development and Validation of a Nomogram

to Predict Survival in Incurable Cachectic

Cancer Patients on Home Parenteral Nutrition

Cox modeling based nomogram for predicting 3-, 6-month and median overall survival

Adapted from Bozzetti F, et al. Ann Oncol. 2015;26(11):2335-40.

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ARTIFICIALE

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