An inflammation-based prognostic score, the C-reactive protein/albumin ratio predicts the morbidity and mortality of patients on parenteral nutrition.

BACKGROUND: There is no "gold standard" score for predicting poor-nutrition-related outcomes. The objective of this study was to identify the optimal predictive score, based on inflammatory parameters, for the clinical outcomes of parenteral nutrition (PN). MATERIAL AND METHODS: This was a 4-year retrospective observational study of 460 patients treated with PN. C-reactive protein (CRP), prealbumin, albumin, CRP/prealbumin and CRP/albumin were studied as potential prognostic scores at the beginning of PN for clinical outcomes during PN. Three different statistical approaches were developed: 1) A univariate analysis of each of the 5 prognostic scores and 5 multivariate models for CRP/albumin and CRP/prealbumin to study their association with exitus, infection, sepsis, liver failure, renal impairment, cancer, intensive care unit stay, mechanical ventilation; 2) Univariate and multivariate survival analysis of PN length, intensive care unit (ICU) length of saty and days of mechanical ventilation vs CRP/albumin and CRP/prealbumin; 3) A ROC analysis of the prognostic accuracy of CRP/albumin and CRP/prealbumin over morbidity/mortality. RESULTS: 1) CRP, albumin and CRP/albumin gave more information about morbidity/mortality than prealbumin and CRP/prealbumin. CRP/albumin was statistically significant for exitus (OR 1.85; CI 95%: 1.00-3.45), infection (OR 2.15; CI 95%: 1.22-3.80), sepsis (OR 2.82; CI 95%: 1.69-4.70) and liver failure (OR 2.66; CI 95%: 1.55-4.58). CRP/prealbumin for sepsis was (OR 2.21; CI 95%: 1.34-3.64) and for liver failure (OR 2.04; CI 95%: 1.17-3.53); 2) CRP/albumin and CRP/prealbumin significantly predict PN duration, days in ICU and days on mechanical ventilation; 3) and are related to exitus, infection, sepsis and liver failure. CONCLUSION: The CRP/albumin score at the beginning of PN treatment has more prognostic capability than CRP/prealbumin, albumin or prealbumin. The systematic use of this score could help to identify those patients with higher risk.

Parenteral fish oil and liver function tests in hospitalized adult patients receiving parenteral nutrition: A propensity score-matched analysis.

BACKGROUND & AIMS: Intravenous fat emulsions are associated with liver disease and there is some evidence that the administration of intravenous fish oil (FO) may be useful in reversing it. The aim of our study was to assess whether there are differences in the changes of liver function tests (LFTs) in hospitalized adult patients with parenteral nutrition (PN) with FO and vegetal lipids vs patients without FO. The secondary aim was to study the relationship between impaired LFT and FO. METHODS: This was a 4-year, propensity score-matched analysis including patients aged ≥18 years treated with PN for ≥10 days. The exclusion criteria were previous liver disease, biliary disorders or pancreatic cancer, and altered initial LFT values. Patients were classified into 2 groups: FO cohort (patients who received FO - in addition to vegetal oil - after the first week of PN) and the vegetal oil cohort (patients who received only vegetal oil). A propensity score matched cohort design was developed. Univariate analyses were used to study the changes in LFTs. To evaluate whether LFT alterations vary with FO administration, four stepwise multiple linear regression models were conducted. RESULTS: 52 patients were included, 52% men, median 66 (55-75) years and 69 kg (61.7-78.8), with 18.5 (14-31.8) days of PN treatment. Maximum FO supplementation was 23%. During the first week with PN (none of the groups receiving FO), gammaglutamyl transferase (GGT), alkaline phosphatase (AP) and total bilirubin (BIL) increased significantly. Comparing LFT values at seven days of PN with at the end of PN treatment, the univariate analysis showed a better response for the FO group. The group without FO showed a significant increase for GGT and AP. In multivariate models, the percentage of FO administered was associated with a decrease in GGT, B = -0.33 [CI 95% = -0.54/-0.12], in AP, B = -0.12 [CI 95% = -0.20/-0.03] and ALT, B = -0.12 [CI 95% = -0.21/-0.024]. CONCLUSIONS: Lipid composition plays a significant role in LFT alteration associated with PN, and FO intravenous lipid emulsions (ILEs) minimize disturbance of LFTs in hospitalized adult patients.

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.

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 / Utilización de Subjective Global Assessment, patient-generated subjective global assessment y nutritional risk screening 2002 para evaluar el estado nutricional de pacientes no críticos con nutrición parenteral

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 (AU)

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 (κ = 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 (AU)

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.

Liver function test alterations associated with parenteral nutrition in hospitalized adult patients; incidence and risk factors / Alteraciones de los parámetros hepáticos asociados con la administración de nutrición parenteral en pacientes adultos hospitalizados; incidencia y factores de riesgo

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 (AU)

Introducción: La alteración hepática asociada a la nutrición parenteral (NP) puede ser progresiva e irreversible particularmente en niños y en tratamientos de larga duración. El objetivo de este estudio es establecer la incidencia de las alteraciones de los parámetros hepáticos en pacientes adultos hospitalizados en tratamiento con NP y estudiar los factores de riesgo asociados al desarrollo de las alteraciones de cada uno de los parámetros hepáticos. Métodos: Estudio prospectivo de cohortes de los pacientes tratados con NP con función hepática normal al inicio del tratamiento. Se estudiaron parámetros clínicos, nutricionales y analíticos. Las determinaciones se hicieron antes de iniciar la nutrición y semanalmente hasta que se detectó la alteración de algún parámetro hepático. Los factores de riesgo asociados a la alteración hepática se estudiaron con 4 regresiones logísticas. Resultados: Se incluyeron 80 pacientes y 57,5% mostraron alteraciones hepáticas. La media de duración de la NP fue 15,9 días (8-54) y la media de días con nutrición enteral u oral concomitantes fue de 1,5 (0-20). Se encontraron las siguientes asociaciones: la gamma-glutamil-transferasa aumentaba con la cantidad de lípidos de soja administrados y los días en dieta absoluta; la fosfatasa alcalina con el shock séptico, la alanina-aminotransferasa con el shock séptico, la hiperglucemia y los valores elevados de creatinina; la bilirrubina total con el shock séptico, la dieta absoluta, valores bajos de prealbúmina y glucosa; y valores altos de creatinina. Conclusiones: La incidencia de alteraciones de los parámetros hepáticos es elevada en pacientes adultos hospitalizados tratados con NP, aunque el efecto de los factores nutricionales en esta alteración es bajo. La nutrición oral/enteral y la reducción de los lípidos en forma de soja pueden reducir el aumento de algunos parámetros hepáticos como la gamma-glutamiltransferasa y la bilirrubina total. La gran asociación entre todos los parámetros hepáticos y las variables sistémicas indicadoras de hiper-metabolismo apuntan a la importancia de las estrategias nutricionales específicas en esta situación (AU)

Effectiveness of perioperative glutamine in parenteral nutrition in patients at risk of moderate to severe malnutrition.

BACKGROUND & AIMS: To determine whether perioperative glutamine supplementation of parenteral nutrition (PN) has an impact on morbidity and mortality of patients with previous moderate to severe risk of malnutrition. METHODS: A quasi-experimental study was conducted comparing the following groups: Control group 1: without glutamine dipeptide supplementation of PN during the perioperative period. Control group 2: PN was supplemented with glutamine dipeptide (0.4 g/kg/day) after surgery only. Group 3 (follow-up group): PN was supplemented with glutamine dipeptide (0.4 g/kg/day) in the perioperative period. Postoperative morbidity and mortality was recorded. RESULTS: Sixty-seven patients matched for baseline and surgical characteristics were recruited into the study. Univariate analysis showed a lower incidence of hyperglycemia and ICU admission in group 3, and a trend to significance (P = 0.078) in terms of a lower incidence of infection. In the multivariate analysis, only group 3 met the models of ICU admission (OR = 0.28), hyperglycemia (OR = 0.11), and renal failure (OR = 0.19). CONCLUSIONS: The results show that perioperative use of glutamine dipeptide in patients at risk of moderate to severe malnutrition before surgery is an effective option for decreasing the morbidity associated with malnutrition, as it improves blood glucose modulation and reduces infection and ICU stay.

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 to44 patients were evaluated. Among them, 239 determinations(22.6%) presented some degree of alteration which corresponded to162 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(..) (AU)

Objetivo: Evaluar un protocolo de control de las alteraciones de los parámetros metabólicos en el contexto de un programa de atención farmacéutica dirigido a pacientes quirúrgicos con nutrición parenteral, a través del impacto de las intervenciones farmacéuticas en las complicaciones metabólicas asociadas. Metodo: Estudio prospectivo de intervención de 2 meses de duración. Se estudia a pacientes quirúrgicos con nutrición parenteral. Como variables de estudio se incluyen los parámetros bioquímicos predefinidos en el perfil metabólico-nutricional. Se establecen 4 categorías para clasificar el grado de alteración de cada parámetro: a) sin complicación; b) alteración no asociada con complicación; c) complicación moderada, y d) complicación grave. El tipo de intervención del farmacéutico se realiza mediante intervención directa o consejo. Las diferencias estadísticamente significativas entre los valores medios de los valores de los parámetros analíticos previos y posteriores a la intervención farmacéutica se establecen con pruebas paramétricas y no paramétrica (p < 0,05). Resultados: Se evaluaron 1055 parámetros correspondientes a 44 pacientes. En total, 239 (22,6%) presentaron alteración, lo que correspondió a 162 complicaciones (para definir algunas complicaciones se utiliza más de un parámetro), de las cuales 93 (57,4%) se intentaron corregir mediante intervención directa y 16 (9,9%), mediante consejo. Los resultados mostraron diferencias estadísticamente significativas o una tendencia hacia la significación cuando el objetivo de la (..)(AU)

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.

[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.

[Standard parenteral nutrition preparations in complex clinical situations]. / Preparados estándar de nutrición parenteral en situaciones clínicas complejas.

GOAL: Binary and ternary parenteral nutrition preparations may be of limited use in certain cases. The goal of this study is to establish difficult nutritional situations to handle and analyze the type of formula used in these situations. MATERIAL AND METHODS: The study included patients treated with parenteral nutrition over 9 months. Three clinically complex situations were defined: long duration, lasting more than 25 days; kidney failure, uraemia > 20 mmol/L or serum creatinine > 200 micromol/L; and liver failure, total bilirubin > 30 mmol/L or ALT > 2 microkat/L and alkaline phosphatase > 3 microkat/L or GGT > 3 microkat/L. Mortality and hypoalbuminaemia (< 35 g/L) were studied and compared by means of a chi squared test (p < 0.05) against the rest of the patients. The use of individualized formulas was studied using a multiple logarithmic regression model, the dependent variable being the administration or not of an individualized formula and the independent variables being the 3 groups of patients in clinical situations defined as complex. The Odds Ratio (OR) was studied as the measure of risk. RESULTS: A total of 511 patients receiving 8,015 feeds with parenteral nutrition were studied. Of these, 283 were included in one or more of the 3 complex clinical situations. All three groups presented higher levels of mortality and hypoalbuminaemia with statistically significant differences when compared to the group in a non-complex clinical situation. The use of individualized formulas was greater in the three groups defined, with statistically significant differences resulting: OR=6.7 (CI 95%; 3.78-11.91) with long duration; OR=3.66 (CI 95%; 2.68-5.68) in kidney failure; and OR=1.5 (CI 95%; 1.01-2.35) in liver failure. CONCLUSIONS: Patients in complex clinical situations present greater visceral malnutrition, a worse clinical evolution and, at our hospital, their nutritional treatment by parenteral means is based on a greater use of individualized formulas.

[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.

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

Objetivo: Evaluar el grado de hipernutrición del paciente crítico en tratamiento con nutrición parenteral (NP) en una unidad de cuidados intensivos (UCI) polivalente. Ámbito: Pacientes en tratamiento con NP en una UCI polivalente. Estudio prospectivo de cuatro meses de duración. Intervención: Se cuantificó la dosis diaria de glucosa, lípido y nitrógeno procedente de la NP, la nutrición enteral (NE), el suero glucosado (SG) y el propofol. Se valoró la dosis diaria de glucosa y lípido administrado por vía intravenosa (IV) respecto al valor recomendado (4-5 mg/kg/min y 1,5 g/kg/día, respectivamente) y respecto a la dosis prescrita en la pauta de NP. Se evalúo el aporte calórico total diario (IV más NE) respecto al valor recomendado (25-35 kcal/kg/día).Resultados: Se estudiaron 30 pacientes que totalizaron 488 días con NP. La dosis diaria total de lípido IV (NP más propofol) superó el valor recomendado el 23,2 por ciento de los días con propofol (13 de 56) y el 3,7 por ciento de los días sin propofol (16 de 432). La dosis diaria total de glucosa IV no superó ningún día el umbral máximo de metabolización. El 28,2 por ciento de los días con NE y el 39,6 por ciento de los días sin NE la dosis diaria total de glucosa IV superó la pauta de NP. Igualmente el 41 por ciento de los días con propofol la dosis diaria total de lípido IV superó la pauta de NP. El aporte calórico total (IV más NE) sobrepasó el valor recomendado el 46,9 por ciento de los días con NE (51 de 109) y el 5 por ciento de los días sin NE (19 de 379).Conclusión: La glucosa procedente del SG y el lípido del propofol no se descuentan de forma rutinaria de la pauta de NP. Se demuestra una tendencia a sobrenutrir al paciente crítico, especialmente los días en tratamiento simultáneo con NP y NE (AU)

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 (IV) 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 (IV 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 IV 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 IV 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 IV dextrose exceeded the PN regimen. Similarly, on 41% of the days with propofol, the total daily dose of IV lipids exceeded the PN regimen. The total calorie intake (IV 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 criticallyill patient is shown, especially on days with simultaneous treatment with PN and EN (AU)

[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.

Calidad del programa de nutrición parenteral a domicilio 14 años de experiencia en un hospital general universitario / Quality of home parenteral nutrition programme: 14 years's experience at a general teaching hospital

La calidad del tratamiento con nutrición parenteral a domicilio (NPD) depende de la frecuencia y tipo de complicaciones asociadas al mismo, así como de la probabilidad de supervivencia. En este trabajo se evalúa la calidad del programa de NPD existente en nuestro hospital en términos de supervivencia, complicaciones infecciosas y complicaciones mecánicas. Se realiza un estudio retrospectivo de los datos del seguimiento clínico de todos los pacientes (n = 24) incluidos en el programa de NPD de nuestro centro desde su inicio en 1985 hasta 1998 (14 años). Se estiman: a) el índice anual de complicaciones infecciosas (IAC), b) el índice anual de complicaciones mecánicas (MAC) y c) la probabilidad de supervivencia mediante el método de Kaplan-Meier. Se toman como especificaciones de calidad los datos bibliográficos que reflejan la prestación actual de los programas de NPD existentes y los valores de supervivencia de los pacientes en diálisis por fracaso renal crónico. La patología más frecuente en nuestro medio es la benigna (70,8 por ciento) distribuyéndose como sigue: síndrome de intestino corto de origen isquémico (45,8 por ciento), síndrome de intestino corto de causa no isquémica (12,5 por ciento) y seudoobstrucción intestinal idiopática (12,5 por ciento). Los pacientes con patología benigna presentan una supervivencia más alta que los pacientes con enfermedad neoplásica (95 por ciento al quinto año de tratamiento frente a 45 por ciento a los 20 meses), siendo la diferencia estadísticamente significativa. El índice anual de complicaciones infecciosas es 0,6 (valor mediano de los 14 años estudiados). De igual modo los índices anuales de obstrucciones y trombosis son 0,11 y 0,0095, respectivamente. En nuestra opinión la calidad del programa de NPD existente en nuestro hospital es muy satisfactoria porque tanto la proporción de supervivencia como los índices anuales de complicaciones infecciosas y mecánicas son aceptables respecto a la prestación de los programas existentes a nivel internacional. Además, en términos de supervivencia la NPD resulta ligeramente más efectiva que la diálisis por fracaso renal crónico (AU)

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 neoplasic 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 (AU)

[Incidence and risk factors of mechanical complications in parenteral nutrition]. / Incidencia y factores de riesgo en las complicaciones mecánicas en nutrición parenteral.

The objective of the present study is to determine the incidence of mechanical complications in patients with parenteral nutrition in our hospital, and to study which factors associated with catheterization in these patients are related to the appearance of different types of mechanical complications. All the central venous catheters registered during the time period between 1988-1994 were included. For the statistical treatment 5 logistic multiple regression models were designed in function of the different types of mechanical complications studied (dependent variable) and in relation to the defined risk factors (independent variables). The difference was considered to be statistically significant when, for each variable, this is not 1 for the confidence interval. The understanding of the different risk factors associated with the appearance of mechanical complications allows a better level of clinical action in the prevention of these types of complications.

[The epidemiology of central venous catheterization (CVC) in parenteral nutrition. The clinical implications and factors that determine the selection of germs]. / Epidemiología de la cateterización venosa central (CVC) en nutrición parenteral. Implicaciones clínicas y factores que determinan la selección de gérmenes.

The objective of the study is, on one hand, to determine the etiology and the clinical implications as a function of the isolated germ, of central venous catheterization in patients with parenteral nutrition in our hospital, and on the other hand, to determine which factors are associated with the selection of germs of central venous catheterization in parenteral nutrition. For this we included venous catheters, colonized for 5 years, and with a study of the different segments (connection, insertion point, and tip). As a function of the appearance of associated clinical symptoms, of the results of the blood culture, and of the clinical evolution of the patient, the variables which determine the level of pathogenicity of the different groups of germs in the central venous catheterization, are defined; for the study of the factors associated with the selection of the different groups of germs, 8 variables were chosen. The data obtained are statistically treated, and the results are considered to be significant if p < 0.05. The understanding of the different factors associated with the selection of germs, and the level of clinical pathogenesis of the different groups, allows a better level of the clinical action in the prevention of the infection associated with the catheter.