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Do you know what has been recognized by medicine as one of the most important discoveries after antibiotics, the use of antiseptics and anesthesia? Hardly anyone can guess, because it is about parenteral nutrition – something that today seems simple, not interesting and somehow…. everyday.
The sight of the patient connected to the drip is common thanks to movies and series – in almost every sensational story, at least one of the heroes goes to the hospital, where doctors stick a vein in his wrist and thus administer various substances. Fortunately, for most patients, this way of administering essential substances ends with their hospital stay. However, there are people who are attached to drips for life.
Catheter for parenteral nutrition
Several hundred people in our country owe their lives to parenteral nutrition. Due to accidents, injuries or diseases, their digestive system does not work, so all the substances necessary for life must be administered to them bypassing the stomach and intestines. Glucose, proteins, vitamins, minerals, fats and electrolytes travel through the intravenous line. The mixture of nutrients for each patient is prepared separately or specially modified, because the need for specific components of the life-giving mixture depends on the state of health, activity or lifestyle. Sometimes you need more glucose, other times you need electrolytes and another time you need water.
How does it look technically? Fortunately, patients don’t have to get tired of punctures every time they need nutrition. The needles do not stick into the wrists or the back of the hand, as it is sometimes seen in movies.
– This way you can give your medicine for a short time, but it doesn’t work in the long run. In addition, parenteral nutrition requires the administration of more dense fluids – this is the case when the mixture contains protein and fat – and the small blood vessels would not bear this burden. In addition, even when nourishing the patient through larger vessels, the administration of the mixture must be spread over time, too quick administration of the preparation could lead to blockages or serious metabolic disorders, even threatening the patient’s death – says Dr. n. med. Stanisław Kłęk, president of the Polish Society of Parenteral and Enteral Nutrition.
The solution turned out to be a special catheter, which is implanted in patients every few months – although with proper care it can work for several years. It is placed under general anesthesia on the chest, so that its “outlet” goes to the atrium of the heart. This is where the nutrients go along with the preparation administered by the drip, and from there they travel throughout the body.
Parenteral nutrition at home
The first steps in parenteral nutrition are of course taken by the patient in the hospital. In the long run, however, it cannot stay that way, because that would mean that it will be locked in hospital walls for the rest of its life. That is why patients undergo specialist training, during which they are prepared to handle the catheter themselves and taught to feed themselves independently – and they go home (in Poland, parenteral nutrition at home has been possible for over 30 years). Of course, the lives of patients undergo radical changes: they will have to spend several hours a day connected to drips. Over time, however, they learn, for example, to “eat” during the night and to function normally during the day. But their health requires further changes: parenteral nutrition requires almost sterile cleanliness, so sick homes must be tidy – no less sterile than hospitals. Fortunately, this is achieved: sick people can be extremely disciplined – after all, their lives are at stake. Statistics show that there are even fewer infections at home than in hospitals.
There are many things that the sick have to learn. One of the most important things is proper catheter care – as it goes straight to the heart, any infection is life-threatening. Therefore, it must be handled with sterile clean hands, and must be hidden under a sterile dressing throughout the day. It is also the patient’s responsibility to prepare the mixture for himself that he will give himself. Although in some centers, hospital pharmacies prepare a ready-made mixture especially for the patient’s needs, which improves the entire procedure, but most patients still have to compose it on their own
– Experience shows that patients are able to take care of their own health perfectly – says Dr. Stanisław Kłęk. – Often better than pharmacists or hospital staff, as evidenced by the fact that infections are less common in homes than in hospitals. Let us add that Poland has reasons to be proud: we are one of the leading countries where people who are fed parenterally can really live a dignified and long life.
And although a ready-made mixture, available at a pharmacy, is still a rarity, it paradoxically works to the benefit of patients. Why? Because when aging on pharmacy shelves, it loses some of its value, because the ingredients are oxidized. Only the mixture prepared just before serving is wholesome.
– Thanks to the advances in science and medicine, parenteral nutrition is becoming safer and better suited to the needs of the body – says Prof. dr hab. Mikołaj Spodaryk, head of the Nutritional Treatment Department of the University Children’s Hospital in Krakow – Prokocim. – Over the years, catheters with which food is administered have been improved: today they can stay in the vessels for years without having to be replaced. They are provided with a special cuff to prevent infection; and they are closed with plugs, covered with antibacterial silver nanoparticles. The composition of the feeding mixture itself is of much better quality. Better matching of nutritional solutions to the needs of a specific organism reduces the number of complications. Food contains better amino acids, better fats and better vitamins than in the past. Modern pumps that allow you to better plan the number of administrations, food flow rate and feeding time.
Bowel disease
Who is the most common recipient of parenteral nutrition? Many diseases lead to this necessity. First of all, these are all serious intestinal diseases, ranging from advanced Crohn’s disease, through enteritis, to intestinal necrosis, which occurs as a result of mesenteric vessel embolism.
– Parenteral nutrition is also often used in cancer patients – says Stanisław Kłęk. – And not only intestinal cancer. In general, patients devastated by neoplastic disease often have problems with digestion, often complications after chemotherapy and related disorders of the digestive system are an indication for parenteral food administration. It also happens that patients are fed this way only for some time, e.g. after car accidents.
However, over 90 percent. fed parenterally are patients with the so-called short bowel syndrome. This condition usually occurs after the removal of a significant part or all of the intestine. Some people who suffer are left with a piece of it, called the border intestine. These people have a chance that the intestine will start working so efficiently that after a few years they will be able to (at least partially) give up drips.
Administration of the mixture in parenteral feeding
As for the timing of the mix, the children are at the worst. In their case, parenteral feeding is often a long-term procedure, lasting up to 20 hours a day. Fortunately, this period becomes shorter and shorter with time and after a few years, “night feedings” are often enough.
– Parenteral nutrition is exceptionally well tolerated by children – says Prof. dr hab. Mikołaj Spodaryk. – It’s worth remembering that Stanley Dudrick, the founder of the idea of parenteral nutrition, was a pediatrician. Originally, this method was developed precisely to help children – especially those born too early to eat normally. Even today, for many newborns and premature babies, parenteral nutrition is a prerequisite for survival. It also saves the lives of children who suffer from digestive system dysfunctions or who, due to various diseases, had to fall asleep a significant part of it, e.g. their intestines. Fortunately, modern parenteral nutrition is so safe and effective that all our babies look healthy and have no developmental problems when fed this way.
– Currently, children are fed mainly at night, thanks to which they can function normally during the day, go to kindergarten or school – adds Prof. dr hab. Mikołaj Spodaryk. “They just need to get used to the catheter and learn not to tamper with it. Only very young babies are fed around the clock – but such babies need to be fed very slowly and all the time. Fortunately, your meals get shorter over time and the gaps between them become longer. The digestive tract of a small child has great adaptability – much greater than in the case of an adult. What damaged the disease or that had to be removed has a chance to partially regenerate and increase its surface area. Thanks to the rehabilitation of the gastrointestinal tract, consisting in the skilful introduction of special diets, the intestinal surface can be increased up to 10 times. And it may turn out to be a sufficient surface for normal nutrition – although it may also be that parenteral nutrition will remain the only method of nutrition for the rest of your life.
Association of Appetite for Life
Marek Lichota was one of the patients sentenced to parenteral nutrition due to Leśniewski-Crohn’s disease. Struggling with disease, regulations and difficulties caused by the special way of serving food, he decided to start an association that would help others. In this way, the Association Appetite for Life was established. One of its tasks is to provide patients with information about the disease and the centers treating it. Fortunately, the number of the latter is growing.
In the past, only two hospitals cared for patients who were fed parenterally at home: the Independent Public Clinical Hospital. prof. Witold Orłowski in Warsaw and the Children’s Health Center, also in Warsaw – the first one looked after only adults, the second only children. In recent years, new centers have emerged: in Łódź, Olsztyn, Kraków and Gdańsk. This year, the Stanley Dudrick Specialist Hospital in Skawina was also opened. It is a highly specialized center with the ambition to become the largest home parenteral and enteral nutrition center in Poland. It is worth knowing that prof. Stanley Dudrick, an American surgeon, is the originator of the idea of parenteral nutrition.
– Unfortunately, there is still a lot to be done – says Dr. Stanisław Kłęk. – Parenteral nutrition is still not considered a life-saving procedure. And it should be an integral part of treatment, as in most European Union countries. The effect of this state of affairs is the fact that sometimes our patients wait even several weeks for parenteral nutrition.
Text: Hanna Mądra