Journal Review:

Home Parenteral and

Enteral Nutrition
Daniel Lokic 2023 March 28th
What is Enteral Nutrition?

Patients unable to meet individual nutrition needs

through conventional oral intake.

Alternate route for patients to receive adequate

nutrients into their bodies.

Done through NGT, Orogastric, Nasoenteric,

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Gastrostomy, jejunostomy, and trangastric tubes.

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What is Enteral Nutrition Cont.

Fewer complications, fewer costs, and improved

outcomes

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Increased nutrient utilization

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Maintenance of normal gut pH and flora

Inhibiting opportunistic bacterial overgrowth and

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support of gut mucosa's immunological barrier.

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What is Parenteral Nutrition?

Method of nutrition support in which nutrients and

the option for various other medications to be
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infused directly into the bloodstream

More costly, more invasive

Should only be done if the benefits of PN outweigh

the risks.

Done through central venous access or peripheral

venous access. 1

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When to use Enteral Nutrition
Dysphagia
Neurologic disorders such as ALS,
systemic sclerosis, Parkinson’s disease,
cerebrovascular accident
Malignancy and/or ongoing treatments
such as radiation
Burns
Chronic obstructive pulmonary disease
Chronic infection
Preoperative or postoperative
malnutrition
Upper gastrointestinal obstruction
Malabsorptive or maldigestive states
Inflammatory bowel disease
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When to use Parenteral Nutrition
Chronic intestinal obstruction or pseudoobstruction

Short bowel syndrome

Preoperative or postoperative malnutrition

Intestinal injury/trauma

High-output stoma or enterocutaneous fistula

Inability to supply or maintain nutrition via enteral access

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Central Venous Access for HPN
Type of 1 1
Duration Pro Con
Catheter

Peripherally
Ease of insertion and removal
inserted May have an increased risk of
Short-term Cost-effective
central thrombosis and displacement
Accessibility
catheter (PICC)

Requires surgical placement and

Low risk of infection removal
Subcutaneous
Long-term Easier site care Requires a needle to access the
port
Patient comfort port limited use in patients who
requiring daily line access

Tunneled Low risk of infection compared to

Long-term Requires surgical insertion
catheter non-tunneled

Non-tunneled Ease of insertion, can be done at High rate of infection

Short-term
catheter bedside Patient discomfort 7
Enteral Access for HEN

Best route is determined by duration of use, adequacy of intestinal function, and

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risk of aspiration

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Patients who require <30 days of enteral, nasoenteric tube is preferred
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Patients who require >30 days of enteral, percutaneous route is preferred

For aiding in the activation of normal neural and hormonal pathways involved in
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digestion and absorption of nutrients, Intragastric feeding is preferred

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Nutritional Formulation and Administration

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Indirect calorimetry the best way to assess a patients nutrient needs

Harris-Benedict equation has become standard in clinical practice due indirect

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calorimetry's limited availability.

Starting EN/PN should be started slowly to prevent refeeding syndrome

Starting EN/PN in a hospital before transitioning to at home feeding is preferred

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Nutritional Formulation and Administration Cont.

Typically HPN is cycled/infused overnight

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EN can be administered through bolus feeding, preferred for intragastric feeding

Infusion pump is used to provide patients a controlled rate of feeds mainly used
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for jejunal and gastric feeds.

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Patient and Caregiver Training
General education topics for HPN Starting and stopping PN infusion
administration
Programming the infusion pump
Hand hygiene
How and where to obtain supplies
Aseptic technique to access and
maintain catheter and catheter site How to manage supply or PN
contamination
PN administration including
multivitamin and insulin additives Who to contact with questions or
concerns
How to use tubing, caps, and other
supplies
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 HPN Monitoring

Laboratory timing 1 Laboratory studies 1

Complete blood count, Comprehensive metabolic panel, Prothrombin time/INR,

Magnesium, Phosphorus, Zinc, Selenium, Copper, Manganese, Vitamin A, Vitamin
Baseline
E25 hydroxy, vitamin D, Vitamin B12/methylmalonic acid, FolateIron studies,
Ferritin, Parathyroid hormone, Essential fatty acids, Triglyceride

Weekly/Biweekly/M Basic metabolic panel

onthly Magnesium
until stabilization Phosphorus

Quarterly after Complete blood count

stabilization Comprehensive metabolic panel

Triglyceride

Annually Same as baseline

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HEN Monitoring
Body weight

Hydration status

Routine laboratory monitoring at least annually

Routine micronutrient level monitoring at least annually

More frequent monitoring and supplementation if deficiencies are identifies

Bone density screening should also be monitored

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HPN Complications
Most common are infections, thrombosis, malfunction, breakage, and dislodgment
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of the catheter.

Infection of the catheter tunnel and exit site, deep venous thrombosis (DVT), and
metabolic complications such as electrolyte abnormalities and liver disease. 1

Large reason for hospitalization in patients on HPN is catheter-related

bloodstream infection (CRBSI). 1

Important to have awareness of these complications and close monitoring to

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prevent and identify these problems.

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HEN Complications
Complications that may occur during or after percutaneous placement include
injury to surrounding organs, wound infection, hemorrhage, leakage at the tube
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site, and buried bumper syndrome.

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Infection and bleeding are the most common complications.

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Infection can occur at any time after placement.

Bleeding can require external pressure or temporary tightening of the external

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bolster against the skin, endoscopic, radiologic, or surgical intervention.

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Re-feeding Syndrome
At risk for re-feeding syndrome
BMI < 18.5

Unintentional weight loss > 10% of total body weight

Little or no nutritional intake

Low levels of potassium, magnesium, or phosphate prior to feeding

Comorbidities that predispose to malnutrition including anorexia nervosa,

malignancy, advanced age, alcohol/substance misuse or abuse

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HPEN Cost
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Can be covered by insurance incuding Medicare

Medical documentation must clearly address the indication for nutrition support,
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anticipated length of need, and why the type of feeding is necessary

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EN can be compared to the cost of a monthly grocery bill

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PN is often too expensive for those without insurance.

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HPEN Quality of Life and Survival
Formula infusion time

Duration of nutritional support therapies

Sleep disturbance related to nutrition infusion and equipment

Family and social life disturbance

Recreational activity limitations from implanted medical devices

Involvement in support group

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Prevalence
of HPN and
HPEN

Prevalence of home parenteral

and Enteral Volume 32 number 6.

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(n.d.). Retrieved May 7, 2023, from
https://cdn.ymaws.com/oley.org/r
esource/resmgr/docs/Prevalence_
of_Home_Parentera.pdf
Prevalence of HPN and HPEN cont.
HEN HPN
Data from U.S. population
showed 463 per million
citizens in 1995 using home
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enteral nutrition.
Increased to 1,385 per
million in 2017 3

Folwarski, M., Kłęk, S., Szlagatys-Sidorkiewicz, A., Wyszomirski, A., Brzeziński, M., &
Skotnicka, M. (2021). Trend Observations in Home Parenteral Nutrition. Prevalence,
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Hospitalizations and Costs: Results from a Nationwide Analysis of Health Care
Provider Data. Nutrients, 13(10), 3465. https://doi.org/10.3390/nu13103465
Conclusion

Increase in Home
Parenteral/Enteral
Nutrition every year

Greater insurance
access for HPEN

More assistance and

information to prevent
complications

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Any Questions?
 References
Bering, J., & DiBaise, J. K. (2022). Home Parenteral and Enteral Nutrition. Nutrients, 14(13), 2558.
https://doi.org/10.3390/nu14132558
Prevalence of home parenteral and Enteral Volume 32 number 6. (n.d.). Retrieved May 7, 2023,
from
https://cdn.ymaws.com/oley.org/resource/resmgr/docs/Prevalence_of_Home_Parentera.pdf
Folwarski, M., Kłęk, S., Zoubek-Wójcik, A., Szafrański, W., Bartoszewska, L., Figuła, K., Jakubczyk,
M., Jurczuk, A., Kamocki, Z., Kaźmierczak-Siedlecka, K., Kowalczyk, T., Kwella, B., Matras, P.,
Skonieczna-Żydecka, K., Sonsala-Wołczyk, J., Szopiński, J., Urbanowicz, K., & Zmarzły, A. (2020).
Home Enteral Nutrition in Adults-Nationwide Multicenter Survey. Nutrients, 12(7), 2087.
https://doi.org/10.3390/nu12072087
Folwarski, M., Kłęk, S., Szlagatys-Sidorkiewicz, A., Wyszomirski, A., Brzeziński, M., & Skotnicka, M.
(2021). Trend Observations in Home Parenteral Nutrition. Prevalence, Hospitalizations and Costs:
Results from a Nationwide Analysis of Health Care Provider Data. Nutrients, 13(10), 3465.
https://doi.org/10.3390/nu13103465