25. Clinical Guidelines for Home Start Parenteral Nutrition Still Needed for Patient Safety and Prevention of Refeeding Syndrome

Background: Initiating parenteral nutrition (PN) at home (home start) can benefit patients requiring PN therapy with no alternate reason for hospitalization. Home start PN requires the expertise of experienced clinicians equipped to assess appropriateness and to implement a safe plan of care, ensuring patient safety and prevention of refeeding syndrome (RS).

In 2007, “Home Initiation of Parenteral Nutrition” was published. In 2020, ASPEN published “Consensus Recommendations for Refeeding Syndrome,” which provides guidance on categorizing risk and preventing RS, but not specific to home start PN. In 2021, Infusion Magazine published “ASPEN 2020 Consensus Recommendations for Refeeding Syndrome: Adapting screening tools for the home infusion setting,” which adapts the ASPEN Consensus Recommendations for the home setting. However, current published guidelines are still lacking for safe home start PN, particularly in patients at significant RS risk. Often, prescribers rely on the infusion team to provide PN recommendations, reinforcing the need for clinicians proficient with home start PN and RS prevention.

Purpose: This abstract spotlights case presentations of safe home start PN when significant risk for RS is present and emphasizes the need for current and comprehensive home start PN guidelines specific to significant RS risk.

Methods: It is not uncommon for home start PN patients to be at risk for RS. Case reports highlight how an experienced home infusion team can navigate and initiate home start PN successfully and safely when certain clinical parameters fall outside of optimal home start standards.

Results: Case report #1: Safe home start in patient with significant weight loss, minimal oral intake, mildly low serum K+, significant RS risk; with the need for PN to start over 12 hours (much less than the standard 18- to 20-hour starting cycle) to accommodate full-time work schedule. (Figure 1)

Case report #2: Safe home start in patient with hypomagnesemia, significant RS risk, with correction of serum Mg+2 level via IV replacement with hydration prior to PN start. (Figure 2)

In both cases, the prescriber requested PN recommendations be provided by the home infusion team.

Discussion: At the time patients are referred for home start PN, diminished oral intake, significant weight loss experienced, electrolyte imbalance evidenced, and dehydration may be present.

These case reports and author experience demonstrate that many home start PN patients have significant RS risk, where previous published guidelines advised against home start PN. However, recent publications such as the “ASPEN Consensus Recommendations for Refeeding Syndrome” and Infusion Magazine’s “Adapting ASPEN Consensus Recommendations for home” can guide clinicians for safe home start PN.

Conclusions: In situations where home start is contraindicated such as allergy to PN ingredients or severe electrolyte abnormalities refractory to normalization in the home setting, hospitalization for PN initiation should be recommended. Once PN tolerance is established, patient can safely transition home with PN. Further research on home start PN when RS risk is significant, and the development of published clinical practice guidelines is still needed.