Elsevier

Nutrition

Volume 24, Issue 10, October 2008, Pages 998-1012
Nutrition

Clinical practice guideline
AuSPEN clinical practice guideline for home parenteral nutrition patients in Australia and New Zealand

https://doi.org/10.1016/j.nut.2008.06.004Get rights and content

Abstract

Objective

Evidence based guidelines for home parenteral nutrition (HPN) were commissioned by the Australasian Society of Parenteral and Enteral Nutrition (AuSPEN) and developed by a multidisciplinary group. The guidelines make recommendations in four domains: patient selection, patient training, formulation and monitoring regimens, and preventing and managing complications.

Methods

The Appraisal of Guidelines Research and Evaluation guideline process was used to focus questions and identify evidence by systematic literature reviews of meta-analyses and randomized control trials in the Cochrane Library, Medline, Embase, and Cinahl to mid-2007. Where no randomized control trial evidence was found, the search was broadened to observational studies and expert opinion from related national and international guidelines as assessed by a validated appraisal process.

Results

Selection of patients must assess individual risk/benefit and medical ethics. Patient training should be undertaken within a structured framework. Access devices should be selected for lowest risk of complications, including occlusion, sepsis, and breakage and be managed by early diagnosis and treatment. HPN should be formulated according to individual patient requirements by professionals with relevant skills and training. Pumps and ancillary products should conform to quality standards. Other intravenous medications may be prescribed provided these are reviewed for compatibility and effects on metabolic status.

Conclusion

Overall there is a lack of randomized control trials to provide high-quality evidence-based guidance but graded recommendations can be made. Multidisciplinary teams in centers with HPN management expertise are required for optimal care. This guideline should improve outcomes and quality of life for HPN patients in Australia and New Zealand.

Section snippets

Objective

The objective is to provide evidence-based clinical practice guidelines for feeding adults intravenously at home or in the community when they have intestinal failure (IF) and are unable to meet oral nutritional and fluid requirements. This is commonly known as home parenteral nutrition (HPN). These guidelines have been written to support all health care professionals involved with the care of patients referred for HPN.

Aims

  • 1

    The guidelines will be factually up-to-date and reflect current, evidence-based best-practice HPN.

  • 2

    The guidelines will aid nutritional support (NS) personnel in their use of evidence-based recommendations to improve clinical and professional practices for HPN in Australia and New Zealand.

  • 3

    The guidelines will serve as a tool to help policy makers, health care organizations, and NS professionals to allocate sufficient resources to deliver safe and appropriate HPN in Australia and New Zealand.

Methods

A multidisciplinary working party of Australia and New Zealand health professionals with extensive experience in the provision of HPN was convened in 2005. This working party consisted of doctors, dietitians, pharmacists, scientists, and nurses and was later formalized into the AuSPEN HPN Guideline Development Group (GDG).

The GDG held three formal meetings and communicated regularly by e-mail and telephone. A consensus approach was used to develop the guideline. A separate pediatric working

Search strategy

Seven existing guidelines identified from our literature search that contained material relating to PN were appraised using a validated instrument (AGREE) for evaluation of clinical practice guidelines.

  • The National Institute for Health & Clinical Excellence (NICE) Nutrition Support in Adults [11]

  • The American Society of Parenteral and Enteral Nutrition (ASPEN) Nutrition Support in Clinical Practice: review of published data and recommendations for future research directions [12]

  • ASPEN Guidelines

Clinical and practical questions for HPN

Ten clinical questions were identified for inclusion in the AuSPEN HPN guideline. Each question is answered by reviews of the evidence and summaries of the GDG discussion, and a final recommendation is made (summarized in Appendix).

  • 1

    What are the criteria for selection for an HPN program?

  • 2

    How should patients be trained for HPN?

  • 3

    Who should provide care for patients on HPN?

  • 4

    How should CVCs for HPN be selected and placed?

  • 5

    How should HPN prescriptions be formulated and provided?

  • 6

    How should infusion pumps

References (71)

  • M.D. Lee et al.

    Stability of Total nutrient admixtures in reference to ambient temperatures

    Nutrition

    (2003)
  • K. Bethune et al.

    Use of filters during the preparation and administration of parenteral nutrition: position paper and guidelines prepared by a British pharmaceutical nutrition group working party

    Nutrition

    (2001)
  • P.A. Ball et al.

    Particulate contamination in parenteral nutrition solutions: still a cause for concern

    Nutrition

    (2001)
  • P.A. Ball et al.

    Ethanol locking as a possible treatment for microbial contamination of long-term central venous catheters

    Nutrition

    (2003)
  • A. Wengler et al.

    Monitoring of patients on home parenteral nutrition (HPN) in Europe: a questionnaire based study on monitoring practice in 42 centres

    Clin Nutr

    (2006)
  • A.D. Pinna et al.

    Intestinal transplantation

  • D.A. August et al.

    Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients

    JPEN

    (2002)
  • B. Jones

    Annual BANS report, 2007—artificial nutrition support in the UK 2000–2006; 2007

  • L. Gillanders et al.

    AuSPEN HPN register; 2007

  • Wilkinson T. NZ pharmaceutical management agency. Personal communication;...
  • C.E. Smith

    Quality of life in long-term total parenteral nutrition patients and their family caregivers

    JPEN

    (1993)
  • Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project

    Qual Safety Health Care

    (2003)
  • Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition; 2006

  • Nutrition support in clinical practice: review of published data and recommendations for future research directions

    JPEN

    (1997)
  • D.K. Heyland et al.

    Nutrition support in mechanically ventilated, critically ill patients

    JPEN

    (2003)
  • J.P. Baxter et al.

    Organization of managed clinical networking for home parenteral nutrition

    Curr Opin Clin Nutr Metab Care

    (2006)
  • A guide to the development, implementation, and evaluation of clinical practice guidelines. NHMRC; 1998

  • P. Ball et al.

    Integrating laboratory science and clinical evidence in grading systems for evidence-based guidelines

    Clin Nutr

    (2004)
  • Nutrition for health and development; 2000

  • J. Cox et al.

    Home infusion therapy

    J Infus Nurs

    (2005)
  • V. Colomb et al.

    Long-term outcome of children receiving home parenteral nutrition: a 20-year single-center experience in 302 patients

    J Pediatr Gastroenterol Nutr

    (2007)
  • G. Violante et al.

    Adult home parenteral nutrition: a clinical evaluation after a 3-year experience in a Southern European centre

    Eur J Clin Nutr

    (2006)
  • Cited by (0)

    The Australasian Society of Parenteral and Enteral Nutrition provided travel assistance to Guideline Development Group (GDG) members to attend one GDG meeting. No member of the GDG received financial support from any commercial provider of home parenteral nutrition other than expenses for educational lectures. Industry representatives from Baxter Healthcare Pty Ltd., a provider company, gave travel assistance to some members of the GDG and provided a meeting room for the initial meeting but thereafter were not part of the GDG. All authors comprised the GDG.

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