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.

Intoxicaciones agudas en el servicio de urgencias de un hospital universitario de nivel III: cambios producidos en los últimos 10 años / Acute poisoning in the emergency department of a level III universitary hospital: changes produced in the last 10 years

El objetivo fue evaluar los cambios epidemiológicos enlas intoxicaciones agudas (IA) entre 1994 y 2004. Para ello seestudiaron todos los casos atendidos en Urgencias con el diagnósticode intoxicación aguda, mediante un estudio transversal descriptivoanalítico desarrollado en dos períodos de un mes separados por 10 años, y comparando los resultados. Se registraron los datosdemográficos, clínicos y toxicológicos.La prevalencia de IA en Urgencias entre los períodos estudiadosaumentó significativamente (0,83 vs 1,25%) mientras que lahospitalización por esta causa pasó del 30,5% al 6,34%. La edadmedia se mantuvo entre los 32-33 años, así como la relaciónhombre/mujer, que osciló alrededor de 1. No se registraronfallecimientos.Los medicamentos fueron el tóxico más frecuente (51,3% y 62,7%respectivamente) con un aumento debido principalmente a lasbenzodiazepinas (BDZ). Asimismo, el alcohol incrementó supresencia en intoxicaciones múltiples, disminuyendo como agenteúnico. Las admisiones por drogas de abuso experimentaron unretroceso, del 26 al 19%. Los pacientes que recibieron tratamiento dealgún tipo disminuyeron aunque no de forma significativa, del 52,8 al44,4% y, a pesar del aumento de las BDZ, la utilización deflumazenilo varió de un 7% a un 8,5% de los casos. La utilización denaloxona disminuyó a la mitad.Los intentos de suicidio aumentaron el 25%, lo que supuso el 65% deltotal de la IA en el segundo período estudiado. La hospitalización, porel contrario, pasó de un 45% a un 6% en estos pacientes. Losfármacos, y entre ellos los psicotropos, fueron el tóxico másfrecuente, implicados en el 62% y 78% de los intentos de suicidio. Laasociación fármaco y alcohol aumentó de manera significativa (10% vs 22%). El registro de pacientes con antecedentes psiquiátricos seincrementó del 29% al 75%. En el intervalo de 21 a 30 años, elporcentaje de mujeres implicadas es el doble que el de hombres enambos períodos.La prevalencia de la IA experimentó un incremento significativo,paralelamente a los intentos de autolisis; sin embargo los ingresos enunidades de hospitalización, disminuyeron considerablemente tanto en el global de la IA como en los intentos de suicidio. Losmedicamentos, y entre ellos las BDZ fueron el tóxico más frecuente(AU)

The aim was to evaluate the epidemiological changes in the acutepoisonings (AP) between 1994 and 2004. For this purpose, all thecases attended at the Emergency Service with the diagnosis of acutepoisoning were studied, by means of a transverse descriptiveanalytical study developed in two periods of one month separated for 10 years, and comparing the results. The demographic, clinical andtoxicological data were recorded.The acute poisoning's prevalence in the Emergency Service increasedsignificantly (0,83 vs. 1,25%) whereas the hospitalization for thisreason decreased from 30,5% to 6,34%. The average age of our serieswere unchanged, (between 32-33 years) as well as the relation man /woman,that it ranged about 1. No deaths were recorded.Drugs were the most frequent poisoning agent (51,3% and 62,7%respectively) with an increase due principally to the benzodiazepines.Likewise, the alcohol increased its presence in multiple poisonings, diminishing as the only agent. The admissions for drugs of abuseexperienced a setback, from 26 to 19%. The patients who receivedany type of treatment diminished but not in a significant form, from 52,8 to 44,4% and, in spite of the benzodiazepines increase, theutilization of flumazenil changed from 7% to 8,5% of the cases. Theutilization of naloxone diminished to the half.The attempts of suicide increased 25%, which supposed 65% of thewhole of the IA in the second studied period. The hospitalization, onthe contrary, descended from 45% to 6% in these patients. Drugs, andamong them the psychotropes, were the most frequent poisoningagent, implied in 62% and 78% of the suicide attempts. Theassociation drug and alcohol increased in a significant way (10% vs.22%). The patients' record with psychiatric precedents was increasedfrom 29% to 75%. In the age interval from 21 to 30, the percentage ofwomen is twice than that of men in both periods.The prevalencia of the IA experienced a significant increase, parallelto the attempts of autolisis; nevertheless the admission inhospitalization units, diminished both in the global of the IA and inthe suicide attempts. Drugs, and among them the benzodiacepineswere the toxic agent most frequently involved(AU)