Home Parenteral Nutrition for Metastatic Colorectal Cancer with Intestinal Obstruction

Indications and Guidelines

• The European Society for Clinical Nutrition and Metabolism recommends home parenteral nutrition (HPN) for incurable cancer patients who are unable to meet nutritional requirements by oral or enteral route and are at risk of death due to malnutrition 1, 2.
• HPN is specifically recommended for patients with malignant obstruction or partial obstruction of the gastrointestinal tract, provided they do not suffer from severe organ dysfunction 1, 2, 3.
• The American Society for Parenteral and Enteral Nutrition and the European Society for Clinical Nutrition and Metabolism suggest that HPN can be considered for patients with chronic intestinal failure due to malignant disease 6.

Standard of Care and Medical Necessity

• Home parenteral nutrition is the established standard of care for patients who cannot meet nutritional requirements enterally and can receive therapy outside acute care settings 5, 6.
• The request for HPN meets medical necessity and represents standard of care for patients with metastatic colorectal cancer, complete intestinal obstruction requiring gastrojejunostomy bypass, and inability to tolerate enteral feeding 1, 2, 3.

Patient Selection and Prognosis

• HPN should not be commenced if the patient will likely succumb from underlying disease rather than poor nutritional status 1, 2, 3.
• The clinical problem of under-nutrition/starvation rather than direct tumor progression supports HPN initiation 2, 3.
• Discharged home patients with reasonable functional status, who underwent surgical intervention, and have no mention of severe uncontrolled symptoms or multi-organ failure are favorable candidates for HPN 1, 2, 6.

Administration and Monitoring

• Daily parenteral nutrition is medically necessary when the enteral route is not functional 4, 5.
• Cyclic administration of parenteral nutrition is recommended, typically overnight infusion, to allow patient mobility during daytime hours and improve quality of life 5, 6.
• Formal teaching programs and ongoing nursing support are essential components of HPN programs, including monthly nursing visits for catheter site assessment, prevention of line sepsis, metabolic monitoring, and patient/caregiver education reinforcement 5, 6.

Complications and Precautions

• Patients are at high risk for refeeding syndrome, and initial TPN should start at no more than 25% of calculated energy requirements with prophylactic phosphate supplementation 8, 7.
• Tunneled central catheters are the standard for long-term HPN, and line sepsis prevention protocols must be rigorously followed 5, 6.
• The indication for HPN should be regularly reviewed during the course of therapy, and HPN should be discontinued if the patient's cancer progresses to the point where death is imminent from tumor burden rather than malnutrition 1, 2, 3.