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Parenteral Nutrition in Cancer Patients

Parenteral Nutrition in Cancer Patients. Dr. Osman Abbasoğlu Professor of Surgery , Hacettepe University Department of Surgery , Ankara December 8, 2018, İstanbul. Outline. 1. Essentials of parenteral nutrition (PN) 2. Parenteral nutrition in cancer

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Parenteral Nutrition in Cancer Patients

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  1. ParenteralNutrition in CancerPatients Dr. Osman Abbasoğlu Professor of Surgery, Hacettepe UniversityDepartment of Surgery, Ankara December 8, 2018, İstanbul

  2. Outline 1. Essentials of parenteral nutrition (PN) 2. Parenteral nutrition in cancer 3. Personal experience, conclusion

  3. Outline 1. Essentials of parenteral nutrition (PN) 2. Parenteral nutrition in cancer 3. Personal experience, conclusion

  4. 2000; 59:457‒466 Parenteral Nutrition in the Critically-Ill Patient: More Harm than Good?

  5. 2001; 74:160‒3

  6. Is EN Really Safer Than PN? 0.57§ 0.72 “No significant difference in 30-day mortality associated with the route of delivery of early nutritional support in critically ill adults” No significant differences in the numberof treated infectious complications Harvey S.N Engl J Med. 2014;371:1673-1684.

  7. PN Is as Safe as EN “Early nutritional support through the parenteral route, as it is typically administered, is neither more harmful nor more beneficial than such support through the enteral route” Harvey S. N Engl J Med. 2014;371:1673.

  8. When Is ParenteralNutritionUsed? Patient Nutrition Assessment Functional GI Tract Parenteral Nutrition No Yes Short Term or No Central Access Long Term Enteral Nutrition Peripheral PN Central PN GIS Function Returns Yes No 8

  9. Outline 1. Essentials of parenteral nutrition (PN) 2. Parenteral nutrition in cancer 4. Personal experience, conclusion

  10. FrequentProblems in OncologyPatients • Intestinalfailure, peritonealcarcinomatosis • Severe mucositis • Severe diarrhea • Intractablevomiting • ……. Expectedsurvival >2 month

  11. If the GIS is not functional, nutrition support can be given only by parenteral nutrition Intestinalobstruction Peritoneal carcinomatosis Intra-abdominal infections Ukleja A, et al. NutrClinPract 2010;25:403–14 Nehra V et al. J Nutr Biochem 1999;10:2-7

  12. Ways of DeliveringParenteralNutrition Central PN • Right subclavian vein can be used as an access of choice • Tunneled catheters and implanted ports for long-term use Peripheral PN • Avoids morbidity related to central venous catheterization • Short-term (<2 weeks) therapy with low osmolar solutions

  13. Role of PN: GastrointestinalDysmotility in CancerPatients GI dysmotility in surgicalpatients is common - Peritonealcarcinomatosis - Adverseeffect of medications - Intra-abdominalinfections - …. Nutritionalgoals can not be achieved Tube feeding with trophic EN Weimann A,Curr Opinion Crit Care.2016;19:353

  14. Role of PN: GastrointestinalDysmotility in SurgicalPatients TrophicEN is veryimportant but allnutritionalrequirements can not be suppliedbytrophicnutrition Pharmacologicaloptionstostimulatebowelmotilityarelimited SupplementalParenteralNutrition Weimann A,Curr Opinion Crit Care.2016;19:353

  15. Requirementsfor PN in Cancer • Glucose: 60%-70% • Lipids: 30%-40% Energy: 25-30 Kcal/kg/day • Usually 1.5 g/kg/day • Inceased demands in severe illness, injury, etc. Protein: At least 1 g/kg/day Vitamins, Trace Elements Water and Electrolytes Volkert D. ClinNutr, 2018

  16. Most of thecomplications of PN are preventable! • Catheter insertion and catheter care standards • Avoidoverfeeding (increasesinfectionsandmortality) • Close monitoring of thepatients (avoidhyperglycemia) Pittiruti M . ClinNutr 2009;28:365 Cotogni P. JPEN 2013;37:375

  17. Pathogenesis of Catheter Associated BSIs Contaminationof the Catheter or Catheter Hub (>10 Days) 2. Contamination of the IV Fluid (Rarely) 4. Migration of Skin Organisms (<7 Days) 1. SKIN FIBRIN SHEATH, THROMBUS VEIN 3. Hematogenous Spread (Less Commonly) Crnich CJ, Maki DG. Clin Infect Dis. 2002;34:1232

  18. Pathogenesis of Catheter Associated BSIs Contaminationof the Catheter or Catheter Hub (>10 Days) 2. Contamination of the IV Fluid (Rarely) 4. Vastmajorityof central-line associated BSIs are preventable with the implementation of evidence-based interventions Migration of Skin Organisms (<7 Days) 1. SKIN FIBRIN SHEATH, THROMBUS VEIN 3. Hematogenous Spread (Less Commonly) Crnich CJ, Maki DG. Clin Infect Dis. 2002;34:1232

  19. Supporting PN Safety PN prescribing, compounding, and dispensing and administration is a multidisciplinary process involving healthcare professionals representing the disciplines of: • Medicine • Dietetics • Nursing • Pharmacy in a Nutrition Support Team Trujillo EB. JPEN. 1999;23:109 2. Newton R. Nutrition. 2001;17:347 3. Saalwachter AR.Am Surg. 2004;70:1107

  20. End of Life Care • Both EN and PN should be regarded as a medical treatment rather than a basic care • When the patient is close to the end of life, artificial nutrition is futile and unnecessary Orrevall Y. Nutrition 2015;31:610

  21. Home PN

  22. Outline 1. Essentials of parenteral nutrition (PN) 2. Parenteral nutrition in cancer 3. Personal experience, conclusion

  23. Hacettepe UniversityNutritionSupport Team

  24. Experience at Hacettepe University BetweenJanuary 2015-December 2017 n Peripheral PN 811 Central PN 512 Total 1323

  25. Complications of EN and PN are similar, 2017 data *p<0.05 Nutritionalgoals can be achievedwith SPN Kelleci B et al. 2018 40th ESPEN Congress Poster Presentation

  26. Conclusions • Incancerpatients, if GI tract is not functional PN is thetreatment of choicefornutritionalsupport • If enteral nutrition alone is not able to provide the necessary nutrients, combination of EN with PN should be considered • PN is ususallysafeandmost of thecomplications can be preventedwithclosemonitoring

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