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 3
Arends J, et al. Clin Nutr. 2017; 36:11-48 4
Old Misunderstanding EN VS. PN Cotogni P. Ann Palliat Med. 2016;5(1):42-9. 5
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.
Arends J, et al. Clin Nutr. 2017; 36:11-48 8
Arends J, et al. Clin Nutr. 2017; 36:11-48 HCT = Hematopoietic cell transplantation. 9
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). 10
Prevalence of Malnutrition and Current Use of Nutrition Nutrition Support 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 Volume 38 Number 2 Original Communication % 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
Is There a Benefit? PN may contribute to the maintenance or improvement of quality of life (QoL) in advanced cancer patients Bozzetti F, et al. Clin Nutr. 2009;28:445-54 (ESPEN Guidelines). 12
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Cotogni P, et al., Cancer Medicine; 2017, in press.
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 Infectious Complications Medium-term VADs Long-term VADs 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. 0 a 9 5 4 b,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 Total CRBSI=catheter-related bloodstream infection; HPN=home parenteral nutrition; NS=not significant; PICC=peripherally inserted central catheter; VAD=venous access device; = not applicable. a P<.01 vs Hohn catheter and tunneled Groshong catheter; b P<.01 vs Hohn catheter; c P<.05 vs tunneled Groshong catheter. Cotogni P, et al. JPEN J Parenter Enteral Nutr. 2013;37:375-383. 15
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 Noninfectious Complications Medium-term VADs Long-term VADs 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 Risk Factors for Thrombosis, P-value Risk Factors for Dislocation, P-value 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 Use During HPN <.01 <.01 <.01 <.01 No Ultrasound Guidance <.001 Left Side Insertion <.001 Use During HPN <.01 <.01 <.01 <.01 Suture <.001 NS Cuff <2 cm from Exit Site <.01 Total PICC=peripherally inserted central catheter; VAD=venous access device; = not applicable. Cotogni P, et al. JPEN J Parenter Enteral Nutr. 2013;37:375-383. 16
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 12 Cotogni P, et al. JPEN J Parenter Enteral Nutr. 2013;37:375-83. 17
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 Bozzetti F, et al. Clin Nutr. 2009;28:445-54 (ESPEN Guidelines). 18
Should This Patient Continue PN or Start PN at Home? 19
How to Intervene? Kumpf VJ, Tillman EM. Nutr Clin Pract. 2012;27(6):749-57. 20
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.
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?
Is There the Indication for HPN in Patients With No Further Treatments? Yes It is not a contraindication for HPN that oncologic treatment has been stopped. Bozzetti F, et al. Clin Nutr. 2009;28:445-54 (ESPEN Guidelines). 25
of death due to malnutrition Arends J, et al. Clin Nutr. 2017; 36:11-48 26
Daanish Hoda Oncology, Mayo Clinic Rochester Cancer 2005;103:863-8. 2005 American Cancer Society Hoda D. Cancer 2005;103:863-8. 27
Arends J, et al. Clin Nutr. 2017; 36:11-48 28
HPN Is Not Recommended in Patients With: How to predict survival? Cotogni P. Ann Palliat Med. 2016;5(1):42-9.
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. 30
LA NUTRIZIONE ARTIFICIALE DOMICILIARE: più LUCI che OMBRE