HPN in Advanced Cancer Flashcards
How might multmodal treatment look?
Multiple Care Providers and a journey spanning months
* Chemotherapy
* Radiation therapy
* Surgery
* Multimodal therapy: CT/RT; Surgery/CRT; CRT/Surgery/Palliation
What is typically the adequacy of energy and protein via oral route?
- energy: 77%
- protein: 69%
What are strong reccomendations from the ESPEN guidelines?
- Screening
- Assessment: to include objective markers, nutrition impact symptoms, function, body comp
- Nutrient Provision: Energy: 25-30kcal/kg, Protein: 1-1.5 gm/kg, Vitamins: RDA (not Excess esp. vit E)
- Refeeding Syndrome
Efficacy of nutrition intervention from ESPEN
- Use Supplements if needed
- avoid harmful diets
- EN or PN if oral intake is insufficient
- Pursue ERAS strategies which are specific approach to surgery to to avoid fasting and initiate feeding soon after
ESPEN nutrition in advanced cancer
- Assessment indicated
- Consider EN or PN if therapy has the potential to impact survival and Quality of Life
ESPEN definition of intestinal failure
the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth.
intestinal insufficiency
reduction of gut absorptive function that doesn’t require intravenous supplementation to maintain health and/or growth
ESPEN classification of intestinal failure in adults
Intestinal failure can be classified into five major pathophysiological conditions, which may originate from various gastrointestinal or systemic diseases:
1. short bowel
2. intestinal fistula
3. intestinal dysmotility (snipped vagus nerve)
4. mechanical obstruction
5. extensive small bowel mucosal disease
What is indicated by this graph?
HPN has gotten a lot safer
Survival and PN Dependence in Adults With SBS/IF
After 2 yrs probability of permanent intestinal failure is 94%
* Survival (2, 5 yrs): 86%, 75%
* PN Dependence (2, 5 yrs): 49%, 45%
* Basically dont really get off of PN
Mortality of intestinal failure
Death is related to:
* underlying disease
* TPN related liver disease (15% long term TPN)
* Sepsis (catheter related), related to residual bowel length
* malnutrition
Use of HPN in advanced cancer care
Addresses the malnutrition associated with IF
* reduction in food intake
* Metabolic Derangement: Insulin resistance, lipolysis
* Systemic Inflammation driving catabolism
* Muscle Protein Depletion – results in reduction in quality of life, treatment intolerance, reduction in physical function
Ethical considerations in feeding patients with advanced cancer
- Respect for the religious, cultural and ethnic background of patients
- Consideration of social, emotional and existential aspects
- The risks and detriments as well as the possible futility of artificial nutrition must be weighed against possible physiologic and or psychological benefits, for a given patient and family.
- As a general rule, the risks of PN are regarded to outweigh its benefits for patients with a prognosis of less than 2 months. However, in some cultures, active feeding in any form is regarded as essential.
- Withdrawal of artificial feeding or deciding not to initiate artificial feeding in a patient who is unable to consume food is usually considered only in an end-of-life setting.
- Potential Benefits: Survival, QOL
What outcomes does HPN impact?
- mortality
- survival
- QoL
Prognosis of incurable cachectic cancer patients on HPN
Karnofsky performance scores
Daily life with HPN for intestinal failure
- PN duration can be up to 10-12 hrs per night
- Pump alarms activate on average 13-14 times per night
- Constant need to urinate due to the amount of PS volume
- Taking part in evening events is usually not possible or takes enormous changes in your PS routine
Impact of HPN on caregiver burden
Basal level of strain was relatively high but did not increase after 2 weeks of home care. Nourishment (HPN) has a cultural and symbolic value and is experienced by the family caregiver as an expression of love and care for the severely ill relative. Physicians tend to see nourishment as a medical treatment aimed at achieving physiological objectives.
* no difference in the nutritional status and quality of life of the patients.
* No increase in caregiver burden despite advancing Cancer
* salient positive features of HPN: a sense of relief and security - nutritional needs were met, both patients and family members reported the experience as having a direct and positive effect on QoL.
What needs to be considered with HPN?
- Parenteral nutrition formulation: amount, composition.
- Intestinal rehabilitation strategy-Medical Short Bowel Treatment
- Optimizing Catheter function: reduce CRBSI, prevent thrombosis
- Strategies to reduce PNALD
- Inform patients of the potential role of growth factor treatments; the GPL2-analog, teduglutide/revestive, is the first choice
- Intestinal transplantation: recommend HPN as the primary treatment and the early referral of patients to intestinal rehabilitation centers with expertise
Venous access for HPN
- Short term: PICC
- Long-term: Tunneled catheter (broviac, Hickman) catheter
- Avoid Femoral Lines
- Avoid portacaths (best for chemo meds, can get infected easily with nutrient rick fluid)
- Apply best care practices to reduce CRBSI, thrombosis
Northern Alberta approach to HPN
- Doc to Doc Consult – do not establish the expectation that HPN will be provided
- Identify the patient who will benefit
- Palliative Homecare consult required
- Risk of refeeding syndrome assessed and addressed
- Consider “premix” PN
- Rationale for and plan
Who might benefit from HPN?
- estimated survival > 2 months
- KPS >60
- supportive family or home environment
- reasonable symptom control
- reasonable narcotic use, minimal edema
- appropriate IV access
Northern Alberta HPN Program Goals in Advanced Cancer
- Improve quality and quantity of life for patients suffering with advanced cancer and intestinal failure as a consequence
- Do not add to burden of care
- Continuously reevaluate care
