Parenteral Nutrition in Cancer Patients Dr Osman Abbasolu

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 3. Personal experience, conclusion

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

2001; 74: 160‒ 3

Is EN Really Safer Than PN? Outcome Primary Outcom Death within 30 days — no. /total no. (%) e Free of advanced respiratory No. of days support alive and Free of advanced free of specified cardiovascular support Free of renal support organ support Free of neurologic support up to 30 days¶ Free of gastrointestinal support No. of treated infectious complications per patient‖ Episodes of hypoglycemia Seconda ry Noninfecti Elevated liver enzymes Outcom ous Nausea requiring treatment es Complicati ons no. per Abdominal distention total no. Vomiting (%) New or substantially worsened pressure ulcers Median no. of days in the ICU (IQR)‡‡ Median no. of days in acute care hospital (IQR)§§ Death In the ICU no. per In acute care hospital total no. ¶¶ By 90 days (%) Absolute Parenteral Enteral Group Difference Group (N = 1197) Between Groups (N = 1191) (95% CI) Relative Risk (95% CI) 393/1188 (33. 1) 409/1195 (34. 2) 1. 15 (− 2. 65 to 4. 94) † 0. 97 (0. 86 to 1. 08) ‡ 14. 3± 12. 1 14. 3± 12. 2 0. 04 (− 0. 94 to 1. 01) 0. 94 18. 9± 13. 5 18. 5± 13. 6 0. 41 (− 0. 63 to 1. 53) 0. 44 19. 1± 13. 9 18. 8± 14. 0 0. 26 (− 0. 85 to 1. 47) 19. 2± 13. 8 18. 9± 14. 0 0. 34 (− 0. 81 to 1. 36) 0. 66 0. 72 13. 0± 11. 7 13. 2± 11. 8 − 0. 12 (− 1. 05 to 0. 80) 0. 81 0. 22± 0. 60 0. 21± 0. 56 0. 01 (− 0. 04 to 0. 06) 0. 72 44/1191 (3. 7)** 74/1197 (6. 2)†† 2. 49 (0. 75 to 4. 22) † 0. 006§ 212/1191 (17. 8) 179/1197 (15. 0) − 2. 85 (− 5. 81 to 0. 12) † 0. 07§ 44/1191 (3. 7) 53/1197 (4. 4) 0. 73 (− 0. 85 to 2. 32) † 0. 41§ 78/1191 (6. 5) 99/1197 (8. 3) 1. 72 (− 0. 38 to 3. 82) † 0. 12§ 100/1191 (8. 4) 194/1197 (16. 2) 7. 81 (5. 20 to 10. 43) † <0. 001§ 181/1190 (15. 2) 179/1195 (15. 0) − 0. 23 (− 3. 10 to 2. 64) † 0. 91§ 8. 1 (4. 0– 15. 8) 7. 3 (3. 9– 14. 3) 0. 15 17 (8– 34) 16 (8– 33) 0. 32 P Value 0. 57§ “No significant difference in 30 -day mortality associated with the route of delivery of early nutritional support in critically ill adults” 0. 57§ 0. 57 317/1190 (26. 6) 352/1197 0. 91 (0. 80 to 1. 03) 0. 13 No significant differences in the number of(29. 4) treated infectious complications § 431/1185 (36. 4) 450/1186 (37. 9) 0. 96 (0. 86 to 1. 06) 0. 44§ 442/1184 (37. 3) 464/1188 (39. 1) 0. 96 (0. 86 to 1. 06) 0. 40§ Harvey S. N Engl J Med. 2014; 371: 1673 -1684.

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.

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

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

Frequent Problems in Oncology Patients • Intestinal failure, peritoneal carcinomatosis • Severe mucositis • Severe diarrhea • Intractable vomiting • ……. Expected survival >2 month

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

Ways of Delivering Parenteral Nutrition 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

Role of PN: Gastrointestinal Dysmotility in Cancer Patients GI dysmotility in surgical patients is common - Peritoneal carcinomatosis - Adverse effect of medications - Intra-abdominal infections - …. Nutritional goals can not be achieved Tube feeding with trophic EN Weimann A, Curr Opinion Crit Care. 2016; 19: 353

Role of PN: Gastrointestinal Dysmotility in Surgical Patients Trophic EN is very important but all nutritional requirements can not be supplied by trophic nutrition Pharmacological options to stimulate bowel motility are limited Supplemental Parenteral Nutrition Weimann A, Curr Opinion Crit Care. 2016; 19: 353

Requirements for PN in Cancer Energy: 25 -30 Kcal/kg/day Protein: At least 1 g/kg/day • Glucose: 60%-70% • Lipids: 30%-40% • Usually 1. 5 g/kg/day • Inceased demands in severe illness, injury, etc. Vitamins, Trace Elements Water and Electrolytes Volkert D. Clin Nutr, 2018

Most of the complications of PN are preventable! • Catheter insertion and catheter care standards • Avoid overfeeding (increases infections and mortality) • Close monitoring of the patients (avoid hyperglycemia) Pittiruti M. Clin Nutr 2009; 28: 365 Cotogni P. JPEN 2013; 37: 375

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

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

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 1. Trujillo EB. JPEN. 1999; 23: 109 2. Newton R. Nutrition. 2001; 17: 347 3. Saalwachter AR. Am Surg. 2004; 70: 1107

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

Home PN

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

Hacettepe University Nutrition Support Team

Experience at Hacettepe University Between January 2015 -December 2017 Peripheral PN Central PN Total n 811 512 1323

Complications of EN and PN are similar, 2017 data Enteral nutrition Parenteral nutrition EN + PN (Suppl. PN) 98 382 32 Complications (%) 15. 3 12. 8 14. 8 Patients who achieved nutritional goals (%) 63. 3 57. 7 93. 7* Number of patients *p<0. 05 Nutritional goals can be achieved with SPN Kelleci B et al. 2018 40 th ESPEN Congress Poster Presentation

Conclusions • In cancer patients, if GI tract is not functional PN is the treatment of choice for nutritional support • If enteral nutrition alone is not able to provide the necessary nutrients, combination of EN with PN should be considered • PN is ususally safe and most of the complications can be prevented with close monitoring