Use of Subjective Global Assessment, Patient-Generated Subjective Global Assessment and Nutritional Risk Screening 2002 to evaluate the nutritional status of non-critically ill patients on parenteral nutrition.

OBJECTIVE: To evaluate the nutritional status of non-critically ill digestive surgery patients at the moment of parenteral nutrition initiation using three different nutritional test tools and to study their correlation. To study the association between the tests and the clinical and laboratory parameters used in the follow-up of PN treatment. METHODS: Prospective study over 4 months. Anthropometric and clinical variables were recorded. Results of Subjective Global Assessment; Patient-Generated Subjective Global Assessment; and Nutritional Risk Screening 2002 were compared applying kappa test. Relationship between the clinical and laboratory parameters with Subjective Global Assessment was studied by multinominal regression and with the other two tests by multiple linear regression models. Age and sex were included as adjustment variables. RESULTS: Malnutrition in 45 studied patients varied from 51% to 57%. Subjective Global Assessment correlated well with Patient-Generated Subjective Global Assessment and Nutritional Risk Screening 2002 (κ = 0531 p = 0.000). The test with the greatest correlation with the clinical and analytical variables was the Nutritional Risk Screening 2002. Worse nutritional state in this test was associated with worse results in albumin (B = -0.087; CI = -0.169/-0.005], prealbumin (B = -0.005; CI = [-0.011/-0.001]), C-reactive protein (B = 0.006;CI = [0.001/ 0.011]) and leukocytes (B = 0.134; CI = [0.031/0.237]) at the en of parenteral nutrition treatment. CONCLUSIONS: Half of the digestive surgery patients were at malnutritional risk at the moment of initiating parenteral nutrition. Nutritional Risk Screening 2002 was the test with best association with the parameters used in the clinical follow-up of parenteral nutrition treated patients.

Objetivo: Evaluar el estado nutricional de pacientes no críticos de cirugía digestiva, en el momento de iniciar la nutrición parenteral, utilizando tres tests de evaluación nutricional. Estudiar la correlación entre los tests y su asociación con los parámetros clínicos y de laboratorio utilizados para el seguimiento de estos pacientes. Métodos: Estudio prospectivo de 4 meses. Se recogen variables antropométricas y clínicas. Los resultados de Subjective Global Assessment, Patient-Generated Subjective Global Assessment y Nutritional Risk Screening 2002 se comparan mediante test kappa. La relación entre las variables clínicas y de laboratorio con Subjective Global Assessment se estudian con regresión multinominal; y con Patient-Generated Subjective Global Assessment y Nutritional Risk Screening mediante regresión lineal múltiple. Edad y sexo se introdujeron como variables de ajuste. Resultados: La desnutrición en 45 pacientes estudiados variaba entre el 51% y el 57%. Subjective Global Assessment correlacionaba bien con Patient-Generated Subjective Global Assessment y el Nutritional Risk Screening (= 0,531 p = 0,000). Nutritional Risk Screening 2002 mostró mejor asociación con variables clínicas y analíticas: peor estado nutricional en este test se asoció con peor comportamiento de albúmina (B = -0,087; CI = -0,169/-0,005]); prealbumina (B = -0,005; CI = [-0,011/ 0,001]), proteína C reactiva (B = 0,006;CI = [0,001/0,011]) y leucocitos (B = 0,134; CI = [0,031/0,237]) al final de la nutrición parenteral. Discusión: La mitad de los pacientes de cirugía digestiva presentan algún grado de desnutrición en el momento de iniciar la nutrición parenteral. El Nutritional Risk Screening 2002 se mostró como el test con mayor relación con las variables utilizadas en el seguimiento clínico de los pacientes con nutrición parenteral.

Liver function test alterations associated with parenteral nutrition in hospitalized adult patients: incidence and risk factors.

BACKGROUND: Parenteral nutrition-associated liver dysfunction can be progressive and irreversible, particularly in children and patients with long-term treatment. This study has assessed the incidence of abnormal liver function tests in hospitalized adults during short term parenteral nutrition (PN) and has investigated risk factors for developing alterations of each parameter. METHODS: A prospective cohort study of parenteral nutrition treated patients with preserved liver function at baseline. Variables examined included nutritional and clinical data and laboratory parameters. Determinations were performed before starting PN and weekly until liver function test alteration was observed. Risk factors were investigated by four stepwise forward logistical regressions. RESULTS: Eighty patients were included, 57.5% had liver function test alterations. PN mean duration was 15.9 (8-54) days. Mean days with PN and additional enteral/ oral nutrition were 1.5 (0-20). The following associations were found: gamma-glutamyl-transferase increased with soybean lipid intake and absolute diet; alkaline phosphatase increased with septic shock; alanine transaminase increased with septic shock, hyperglycemia and elevated creatinine; total bilirubin increased with septic shock, absolute diet, low prealbumin and glucose, and high creatinine. CONCLUSIONS: The incidence of altered liver function tests is high in adult hospitalized patients treated with short-term PN. However, the effect of nutritional factors in this alteration is low. Oral/enteral nutrition and reduction of soybean lipid supply can reduce increases in some liver function tests such as gamma-glutamyl-transferase and total bilirubin. The high association between all liver function tests and clinical systemic-hypermetabolic variables suggest the importance of specific nutritional strategies for this condition.

Pharmaceutical interventions in metabolic and nutritional follow-up of surgical patients receiving parenteral nutrition.

PURPOSE: To assess a control protocol concerning alterations in metabolic follow-up parameters in the context of a pharmaceutical care program designed for surgical patients receiving parenteral nutrition, through determination of the impact of pharmaceutical interventions on associated metabolic complications. METHODS: Prospective interventional study of two-months' duration performed in surgical patients receiving parenteral nutrition. The study variables included predefined biochemical parameters within the metabolic-nutritional profile. Four categories were established to classify the degree to which each parameter was altered: a) no alteration (within normal range); b) alteration with no associated complication; c) moderate complication, and d) severe complication. The type of pharmaceutical intervention carried out included a direct intervention on their part or a recommendation. Statistical differences between the mean analytical values before and after the intervention were assessed by parametric and non-parametric tests (P< .05). RESULTS: A total of 1055 analytical determinations corresponding to 44 patients were evaluated. Among them, 239 determinations (22.6%) presented some degree of alteration which corresponded to 162 complications. Complication is often defined whit more than one parameter. Ninety-three (57.4%) corrective interventions were carried out by direct intervention and 16 (9.9%) by recommendation. The results showed statistically significant differences or significant trend when the purpose of the pharmaceutical direct intervention was to increase albumin, prealbumin, potassium or phosphate levels or to decrease C-reactive protein, glucose or triglycerides. Significant differences or significant trend were not seen when no intervention was performed. CONCLUSION: Despite the fact that the parameters assessed may have been influenced by factors other than the parenteral nutrition treatment received, our findings show that systematic monitoring of specific analytic parameters can be effective for attaining success in nutritional therapy, in terms of improvement in nutritional status and prevention and control of associated complications.

[Modular parenteral nutrition: a new concept?]. / Nutrición parenteral modular: un nuevo concepto?

INTRODUCTION: We may define Modular Parenteral Nutrition (MPN) as parenteral nutrition (PN) mixtures obtained from adding different macronutrients to standard formulations (SPN) both binary (amino acids and glucose) and ternary (amino acids, lipids, and glucose). OBJECTIVES: The aim of this study is to demonstrate that PN formulations may be adapted to individual needs of each patient and workload may be reduced by using MPN. MATERIAL AND METHODS: Case-control retrospective study of PN prepared during the first semester of the years 1995, 2000, and 2005. PN are categorized in: standard (SPN) -given without manipulation-, individualized (IPN), and modular parenteral nutrition (MPN). The protocols are compared at the different periods, and the volume of transferred fluid is related with total prepared volume in order to calculate the workload. The Chi squared and student's t tests with a significance level of p < 0.05 are used. RESULTS: In 1995, virtually only individualized formulations were used. In the year 2000, SPN and MPN were introduced as maintenance formulas as well as those for moderate stress. Finally, in the year 2005, the modular concept has been introduced for severe stress and/or immunomodulatory formulas. As a result of these changes, we observe in the protocol a decrease in IPN due to progressive introduction of MPN. In 1995, MPN represented 2.6% of all elaborations, increasing up to 64.7% in 2000, and to 74.7% in 2005. This fact has resulted in a decrease in transferred volume through the volumetric elaboration system. In 1995, 87.3% of the total volume was transferred, in the year 2000 34.3%, and finally in 2005 only 20.6% (the differences between the three periods are statistically significant; p < 0.05). In the year 2005, 543 IPN were elaborated, of which 169 (31.1%) were for patients with liver encephalopathy or non-dialyzed acute renal failure. The following ingredients have been added to MPN during that same period: glutamine, fish oil lipid emulsions lipidicas, structured lipids, olive-pattern lipids, polyionic solutions, and specific micronutrients. DISCUSSION: MPN allows for adapting PN formulas to a wide range of clinical situations, although individualized formulations still are irreplaceable for some pathologies. The use of MPN is associated with a decrease in individualized formulas that reflects in lower workload.

[Optimising the quality of the unit dose dispensing process through the implementation of the semi-automated Kardex system]. / Optimización de la calidad del proceso de dispensación de medicamentos en dosis unitaria mediante la implantación del sistema semiautomático Kardex.

OBJECTIVE: To evaluate the effect of the incorporation of the semi-automated Kardex medication storage and dispensing system on the quality of the filling process of medicine trolleys in unit doses. METHOD: The speed of filling medicine trolleys in unit doses using the Kardex system was analysed retrospectively (n = 33,946 dispensings) and compared with the manual filling system (n = 5,284 dispensings); different filling procedures were used and compared. For each filling system and procedure, we obtained information for the number of dispensings and the time spent carrying this out. The speed of the process was calculated as the number of dispensings per hour. In addition, the drugs contained in the Kardex system were checked and the correspondence between both the actual and the theoretical content was assessed. RESULTS: The speed of the trolley filling process, expressed as the number of dispensings per hour, increased from 394 with the manual system (filling trolleys individually, n = 5,284 dispensings) to 417, 540 and 592 with the Kardex system when trolleys were filled individually (n = 16,530 dispensings), or grouped in two (n = 10,369 dispensings) or in three (n = 7,047 dispensings) respectively, at the start of the filling process. The check of the contents in the Kardex system detected 36% of trays with differences in quantity, one tray with out of date medication and three trays which should in theory have been empty and contained medication. CONCLUSIONS: The Kardex system optimises the speed of trolley filling with regard to the manual system, provided that the trolleys are grouped at the time of starting the preparation. The check of the cabinet contents shows that possibilities of error exist, related to its handling, which can be minimised by incorporating bar codes into the system s replenishment process.

[Glutamine use for parenteral nutrition in the critically ill patient: effects on morbimortality]. / Utilización de glutamina en nutrición parenteral en paciente crítico: efectos sobre la morbi-mortalidad.

OBJECTIVE: To determine the relationship between adding glutamine dipeptides to parenteral nutrition (PN) and morbimortality in the critically ill patient. MATERIAL AND METHODS: Case-control retrospective study. The cases were patients to whom PN supplemented with 2 g of nitrogen (glutamine) was administered during the period 2001-2004. Controls were patients with PN without glutamine, collected during the year 2000. All included patients had infection defined as the presence of an infectious site plus more than two of the following criteria: leucocytes > 12.000 x 10(6)/L, fever > 38 degrees C, heart rate > 90 bmp, or PCO2 < 31 mmHg. Besides, they had to have prealbumin plasma levels < 15 g/L or albumin levels < 25 g/L, and CRP > 100 mg/L or a fistula. Patients with renal failure, previous dialysis, hepatic encephalopathy, or mixed diet were excluded from the study. Morbimortality variables collected were: hyperglycemia, renal failure, days on PN, days in the ICU, hospitalization days, and mortality. RESULTS: Two hundred and two patients (75 cases and 127 controls) were included. In the previous univariate analysis no significant differences appeared for independent variables between both groups. In the multivariate analysis, glutamine addition was significantly associated to lower renal failure incidence (OR: 0.28; CI: 0.081.00), lower hyperglycemia (OR: 0.38; CI: 0.19-0.75), less hospitalization days (OR: 0.64; CI: 0.44-0.92), and fewer days in the ICU (OR: 0.64; CI: 0.45-0.93). For the variable "exitus", glutamine addition showed a trend towards inclusion into the model (p = 0.097). About the days on PN, the variable glutamine was not included into the model. CONCLUSIONS: In critically ill patients, adding glutamine to PN leads to quicker recovery and lower incidence of hyperglycemia and renal failure. In view of these results, adding glutamine to PN of particular patients is an effective measure to speed up their recovery and avoid certain complications.

[Automation of parenteral nutrition elaboration: adaptation to in force legislation]. / Automatización de la elaboración de nutrición parenteral: adecuación a la legislación actual.

INTRODUCTION: Quality and efficiency criteria of allowances associated to technological procedures are developing in a setting that values quality, and from there the Real Decree RD175/2001 has been issued by which the rules of correct elaboration and quality control of formulations and pharmacy preparations. Parenteral nutrition (PN) is a formulation and, as such, its elaboration and control have to agree with the in force regulations. With this aim, at the Bellvitge University Hospital we have developed a project for automation of elaboration of PN mixtures with the MicroMacro Pump 23 Baxa Compounder. OBJECTIVES: To assess the impact of implementing an automated system of volumetric control in PN elaboration. MATERIAL AND METHODS: The project development may be divided into two differentiated aspects. The first one consisted in the implementation and optimization of the automated system of volumetric control (ASVC). The second aspect comprehends the comparative control performed between the new system and the previous one, and which consisted of a gravimetric system with visual control. For that, real weights were gathered and were compared to predicted weights, and the time of elaboration per bag before and at two times after the implementation of the automated system was registered; the first time just after implementation of the system, and the second time within one year. RESULTS: For the comparison study between both systems used, 141 preparations in total, corresponding to individualized PN, were analyzed: 47 elaborated by means of the gravimetric system (GS), 47 with the ASVC during the implementation period (PN ASVC period 1), 47 PN elaborated with the ASVC within one year of implementation (PN ASVC period 2). The average variation between real weight and predicted weight at the three periods (pre-ASVC, NP ASVC period 1, NP ASVC period 2) was 2.41%, 1.35% and 1.25% respectively (table I). This decrease was statistically significant (p = 0.014). When analyzing the percentage of preparations out of the 3% variation range, we observed a significant reduction (p = 0.00001) by comparing the three periods (Table II). The average elaboration time with the ASVC increased approximately in 4 minutes by bag (3 min 58 sec) during the first studied period, and 3 min 10 sec during the second period, as compared with the study period with the GS. CONCLUSIONS: The new bag-filling system by means of volumetric control represents an improvement in accuracy control and a decrease in the risk for surpassing the acceptable limits. The implementation of a new technological procedure is a difficult task that implies the change of many aspects of the daily practice and that requires a "cultural" change in the PN Unit with the aim of optimizing the process. However, these issues allow for an adaptation to legal requisites in force regarding the regulations of proper elaboration and quality control of formulations as well as an improvement in the integral quality of care.

[Financial assessment of device for the preparation of intravenous mixtures in hospital pharmacy]. / Evaluación económica de un dispositivo para preparación de mezclas intravenosas en farmacia hospitalaria.

OBJECTIVE: To financially assess a device for the preparation of intravenous mixtures (DPIVM) --Grifill system-- such as IV gammaglobulin, salbutamol, ondansetron/dexametasone, cisplatin rehydrating solution and mesna. MATERIAL AND METHODS: The most relevant resources used in the preparation and rebottling of each of the above-mentioned intravenous mixtures (for both the DPIVM and the commonly used alternative system) are assessed, as well as unitary costs (obtained from six Spanish hospitals enrolled), and an approach to the real cost by system used is obtained. A sensitivity analysis is performed considering most influencing variables. Results are calculated for one month of system operation. RESULTS: For IV gammaglobulin, mesna, salbutamol, ondansetron/dexametasone and polyionic solutions DPIVM resulted in financial benefit, but it did not in the preparation of cisplatin rehydrating solution. CONCLUSIONS: An individualized study in each center is needed to achieve reliable financial data on the system's profitability at hospital pharmacy departments. DPIVM may allow significant financial savings in centers and hospital departments using high-cost pharmaceuticals susceptible of customized dosing --e. g., IV gammaglobulin, other blood derivatives, monoclonal antibodies and/or antibiotics-- or intravenous mixtures requiring pharmaceuticals usually purchased directly from the manufacturer that may be prepared from low-cost raw materials (for instance, salbutamol and polyionic solution) requiring high-quality manipulation (e. g., sterility and precision).

[Perioperative management of chronic medications not related with surgical procedures]. / Manejo perioperatorio de la medicación crónica no relacionada con la cirugía.

The correct management of chronic medications not related with surgical procedures in the perioperative period has a relevant place because each year millions of patients around the world undergo surgical procedures. For this reason the assistencial team should be aware of the importance of continuate or discontinuate determinate drugs during perioperative period because some of them are considered an important risk factor in the development of complications. The key is to differentiate necessary from unnecessary medication. This is a complex aspect, little studied, which difficult clinical decisions and favours the coexistence of several trends of clinical practice. The purpose of this review is to describe the factors that determinate the continuity or suspension of chronic medications which are not related with surgery in the perioperative period and to provide practice recommendations in lights of available publications.

[Impact of an intravenous mixture preparation device in hospital Pharmacy Departments. Perceived healthcare quality and user satisfaction]. / Impacto de un dispositivo de preparación de mezclas intravenosas en farmacia hospitalaria. Percepción de calidad asistencial y satisfacción del usuario.

OBJECTIVE: To integrally assess an intravenous mixture preparation device (IMPD) from the point of view of perceived healthcare improvement in a center (operational and organizational changes of the hospitals pharmacy department, staff nurse satisfaction and end-user satisfaction). MATERIAL AND METHODS: An observational, multicenter and domestic healthcare technology assessment project (an analysis to estimate relative value and contribution of a specific healthcare technology to both individual and collective health) is under discussion. Data were obtained from 6 Spanish hospitals. RESULTS: In 3 out of 4 Pharmacy Departments surveyed, reports on the use of IMPD showed that this system contributed to time saving, as well as improved preparation quality and system safety. From a nursing standpoint, the use of IMPD was mostly considered satisfactory, whereas most patients (81%) reported increased satisfaction with care provided after IMPD was included in their medication process. CONCLUSIONS: IMPD demonstrated satisfactory characteristics that were deemed positive by hospital pharmacy departments, nursing departments and patients.

[Hypophosphatemia in parenteral nutrition: prevention and associated risks factors]. / Hipofosfatemia en nutrición parenteral: prevención y factores de riesgo asociados.

AIM: To determine the incidence of hypophosphatemia in parenterally fed patients, the phosphate amount necessary to prevent this complication and associated risks factors. SETTING: Observational study, not controlled, in a third level hospital. PATIENTS: In-patients with parenteral nutrition with at least a complete laboratory work-up. INTERVENTION: For a complete year, days on parenteral nutrition, administered phosphate and plasmatic ionised calcium levels, y-glutamiltranspeptidase, glucose, phosphate, pre-albumin, urea, and leukocytes were recorded. A multiple stepwise regression analysis and logistic regression are used for data analysis. RESULTS: Eight hundred and twenty seven determinations, corresponding to 401 patients, were included. Significant variables (p < 0.05) were: administered phosphate and ionised calcium serum levels, glucose, pre-albumin, and urea; regression coefficients were 0.004 (95%CI: 0.002 to 0.006), -0.156 (95%CI: -0.270 to 0.037), -0.014 (95%IC: -0.022 to 0.009), 0.005 (95%CI: 0.002 to 0.009) and 0.019 (95%CI: 0.016 to 0.022), respectively; the constant was 1.0735 (95%CI: 0.939 to 1.2079). The risk for developing hypophosphatemia decreased from 0.65 (95%CI: 0.33 to 1.26) to 0.16 (95%CI: 0.078 to 0.35) when administered phosphate varied from the span 7.5-17.5 mmol to values higher than 27.5 mmol. CONCLUSIONS: It is necessary to routinely supplement nutrition with phosphate since its content in commercially available lipidic emulsions is not sufficient to prevent hypophosphatemia in the majority of patients with parenteral nutrition. Phosphate intake must be sufficient to restore the intracellular phosphate deficit and to compensate for the plasmatic phosphate fall, with special attention to poorly nourished, hyperglycaemic or with renal failure patients. Phosphate intakes around 27-37 mmol dramatically decrease the incidence of hypophosphatemia in studied patients, with no recorded cases of severe hypophosphatemia.

[Caloric overload in critically ill patients treated with parenteral nutrition]. / Sobrecarga calórica en el paciente crítico tratado con nutrición parenteral.

OBJECTIVE: To assess the degree of hypernutrition of critically-ill patients under treatment with parenteral nutrition (PN) in a multi-purpose intensive care unit (ICU). SCOPE: Patients under treatment with parenteral nutrition in a multi-purpose intensive care unit. Prospective study lasting four months. INTERVENTION: The amounts of the daily dose of glucose, lipids and nitrogen were calculated in PN, enteral nutrition (EN), dextrose solution (DS) and propofol. The daily dose of glucose and lipid administered intravenously (i.v.) was assessed with respect to the recommended value (4-5 mg/kg/min and 1.5 g/kg/day, respectively) and with respect to the dose prescribed in the PN regime The total daily calorie intake (i.v. plus EN) was assessed with respect to the recommended value (25-35 kcal/kg/day). RESULTS: The study involved 30 patients totalling 488 days with PN. The total daily dose of i.v. lipids (PN plus propofol) exceeded the recommended value on 23.2% of the days with propofol (13 of 56) and on 3.7% of the days without propofol (16 of 432). The total daily dose of i.v. dextrose did not exceed any day the maximum metabolization threshold. On 28.2% of the days with EN and 39.6% of the days without EN, the total daily dose of i.v. dextrose exceeded the PN regimen. Similarly, on 41% of the days with propofol, the total daily dose of i.v. lipids exceeded the PN regimen. The total calorie intake (i.v. plus EN) exceeded the recommended value on 46.9% of the days with EN (51 of 109) and on 5% of the days without EN (19 of 379). CONCLUSION: The glucose of dextrose solution and the propofol lipid are not routinely discounted from the PN regime. A trend towards hypernutrition of the critically-ill patient is shown, especially on days with simultaneous treatment with PN and EN.

[Quality of the home parenteral nutrition program: 14 years of experience at a general university hospital]. / Calidad del programa de nutrición parenteral a domicilio: 14 años de experiencia en un hospital general universitario.

The quality of home parenteral nutrition (NPD in its Spanish acronym) depends on the frequency and type of complication associated with NPD treatment and the likelihood of survival. The present study assesses the quality of the NPD programme in place in our hospital in terms of survival, infections and mechanical complications. A retrospective study was carried out into the clinical follow-up data of all the patients (n = 24) included in our NPD programme since its start in 1985 until 1998 (14 years). An estimate is made for: a) the annual index of infectious complications (IAC in its Spanish acronym), b) the annual index of mechanical complications (MAC in its Spanish acronym) and c) the likelihood of survival by means of the Kaplan-Meier method. The quality specifications adopted are those of the literature reflecting the current provision of NPD programmes and the survival values of patients undergoing dialysis for chronic kidney failure. The most frequent pathology in our context is benign (70.8%), distributed as follows: small bowel syndrome of ischaemic origin (45.8%), small bowel syndrome of non-ischaemic origin (12.5%) and idiopathic intestinal pseudo-obstruction (12.5%). The patients with benign pathologies present a higher survival rate than patients with neoplastic disease (95% in the fifth year of treatment versus 45% at twenty months), with a statistically significant difference. The annual index of infectious complications is 0.6 (median value of the 14 years studied). Similarly, the annual indices of obstructions and thromboses are 0.11 and 0.0095, respectively. In our opinion, the quality of the NPD programme in place at our hospital is highly satisfactory because both the survival rate and the annual indices of mechanical and infectious complications are acceptable with regard to the programmes in place in the international sphere. In addition, in terms of survival, NPD seems slightly more effective than dialysis for chronic kidney disease.