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.

Nutrición parenteral modular: ¿un nuevo concepto? / Modular parenteral nutrition: a new concept?

Introducción: Definimos Nutrición Parenteral Modular (NPM) como las mezclas de nutrición parenteral (NP) obtenidas a partir de la adición de diferentes macronutrientes a preparados estándar (NPE) tanto binarios (aminoácidos y glucosa) como ternarios (aminoácidos, lípidos y glucosa). Objetivos: El objetivo de este estudio es demostrar que utilizando la NPM se pueden ajustar las fórmulas de NP a las necesidades individuales de cada paciente y disminuir la carga de trabajo. Material y métodos: Estudio retrospectivo de casos y controles de las NP preparadas durante el primer semestre de los años 1995, 2000 y 2005. Las NP se subdividen en: estándar (NPE) —dispensadas sin manipular—, individualizadas (NPI) y modulares. Se comparan los protocolos en los diferentes periodos, y para evaluar la carga de trabajo se relaciona el volumen de fluido trasvasado con el volumen total preparado. Se aplican los tests de chi cuadrado y t de Student con significación para p < 0,05. Resultados: En 1995 prácticamente sólo se utilizaban fórmulas individualizadas. En el año 2000 se introdujeron NPE y NPM para las fórmulas de mantenimiento y las de estrés moderado. Finalmente, en el año 2005 se ha incluido el concepto modular para fórmulas de estrés severo y/o inmunomoduladoras. Como consecuencia de estos cambios, en el protocolo se observa una disminución de las NPI debido a la introducción progresiva de las NPM. En 1995 la NPM representaba un 2,6% del total de elaboraciones, aumentando a un 64,7% en el 2000 y a un 74,7% en el 2005. Este hecho se ha traducido en una disminución en el volumen trasvasado a través del sistema volumétrico de elaboración. En 1995 se trasvasó el 87,3% del volumen total, en el 2000 el 34,3% y finalmente en el 2005 pasó a ser sólo de un 20,6% (diferencias estadísticamente significativas entre los tres periodos; p < 0,05). En el año 2005 se elaboraron 543 NPI, de las cuales 169 (31,1%) fueron para pacientes con encafalopatía hepática o con insuficiencia renal aguda no dializados. A las NPM elaboradas durante este mismo periodo, se ha incorporado: glutamina, emulsiones lipídicas de aceite de pescado, lípidos estructurados, lípidos de patrón de oliva, soluciones poliiónicas y micronutrientes específicos. Discusión: La NPM permite adecuar las fórmulas de NP a un amplio abanico de situaciones clínicas, aunque en determinadas patologías siguen siendo imprescindibles las formulaciones individualizadas. La utilización de NPM se traduce en una disminución de fórmulas individualizadas que se refleja en una menor carga de trabajo

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 lipídicas, 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

[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.

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

Objetivos: Determinar la relación entre aditivar dipéptidos de glutamina a la nutrición parenteral (NP) y la morbi-mortalidad en paciente crítico. Material y métodos: Estudio retrospectivo de casos y controles. Como casos se recogieron pacientes a los que se administró NP suplementada con 2 g de nitrógeno (glutamina) durante el período 2001-2004. Los controles fueron pacientes con NP sin glutamina recogidos durante el 2000. Todos los pacientes incluidos presentaban infección definida como la presencia de un foco infeccioso más 2 de los siguientes criterios: leucocitos > 12.000 x 106/L, fiebre > 38 ºC, frecuencia cardíaca > 90 latidos/minuto o PCO2 100 mg/L o fístula. Se excluyeron los pacientes con insuficiencia renal, diálisis previa, encefalopatía hepática o dieta mixta. Las variables de morbi-mortalidad registradas fueron: hiperglucemia, fracaso renal, días con NP, días en UCI, días de hospitalización y mortalidad. Resultados: Se incluyeron 202 pacientes (75 casos y 127 controles). En el estudio univariante previo no aparecieron diferencias significativas para las variables independientes entre los 2 grupos. En el estudio multivariante, la aditivación de glutamina se asoció significativamente a menor incidencia de fracaso renal (OR:0,28; IC:0,08-1,00), menor hiperglucemia (OR:0,38; IC:0,19-0,75), menos días de hospitalización (OR:0,64; IC: 0,44-0,92) y menos días en UCI (OR:0,64; IC: 0,45-0,93). Para la variable exitus, la adición de glutamina mostró tendencia a la inclusión en el modelo (p = 0,097). En cuanto a los días con NP la variable glutamina no se incluyó en modelo Conclusiones: En pacientes críticos, la adición de glutamina a la NP conlleva una recuperación más rápida y menor incidencia de hiperglucemia y fracaso renal. Dados estos resultados, la adición de glutamina a las NP de determinados pacientes es un recurso efectivo para acelerar su recuperación y evitar determinadas complicaciones

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 106/L, fever > 38 ºC, heart rate > 90 bmp, or PCO2 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: 0.08- 1.00), 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

[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.