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Evaluation of Evaluation of Parenteral Parenteral Nutrition Nutrition
Utilization in Utilization in Oncology PatientsOncology Patients
Sivakami Janahiraman, SM Yew, Che Ton Saari Pharmacy Division, Hospital Kuala Lumpur (HKL)
CPA-MPS Conference Malaysia 2007CPA-MPS Conference Malaysia 2007
INTRODUCTIONINTRODUCTION
● Parenteral Nutrition (PN) -therapeutic intravenous administration of nutrients
● Indicated in cases where oral or enteral feeding is:-
Insufficient Impossible Undesirable
(Messing B, 2000; Giovanni F et al, 1999)
INTRODUCTIONINTRODUCTION
Malnutrition is a common manifestation of cancer which is often present with loss of appetite and ineffective utilization of nutrients.
Impact of malnutrition: Higher risk of infection Poorer tolerance and response to treatment Lower quality of life Shorter survival
(Grant et al, 1994; Ottery, 1996; Nitenberg & Raynard, 2000)
INTRODUCTIONINTRODUCTION
The use of nutritional therapy in cancer
patients is tailored to complement the
primary treatment
1) PN support in surgery
2) PN support during chemotherapy
3) PN in radiation therapy
GENERAL OBJECTIVEGENERAL OBJECTIVE
To elucidate the appropriateness of PN support in cancer patients using the criteria of nutritional status and ultimate
outcome
SPECIFIC OBJECTIVESSPECIFIC OBJECTIVES
To identify the demographic characteristics of cancer patients
To obtain the diagnosis or related medical problem of patients
To identify the method of PN delivery To analyze the quantity of PN preparations
and duration of nutritional support provided To evaluate type of regimen administered to
patients
METHODOLOGYMETHODOLOGY
Setting: Hospital Kuala Lumpur Design: Retrospective study Subjects: Cancer patients Study location:
Record Units - Wisma Kayu (K2)
Surgical Out-Patient Dept
Oncology and Radiotherapy Dept
Urology and Nephrology Dept Study period: January 2005 – December 2005
SELECTION CRITERIASELECTION CRITERIA
INCLUSION CRITERIA EXCLUSION CRITERIA
Adult (>18 years) patients Paediatric (<18years) patients
Received Total Parenteral Nutrition Preterm neonates
Patients with complete medical record
STUDY FLOW CHARTSTUDY FLOW CHARTSCREENING OF PATIENTS’ RECORD IN TPN
PHARMACY (n=159)
PATIENTS FIT INCLUSION / EXCLUSION CRITERIA
SELECTED AS SUBJECTS (n=69)
DATA COLLECTION
RECORD UNIT
K 2, SOPD, RT & UN
STUDY FLOW CHARTSTUDY FLOW CHART
DATA COMPLETION(filling up incomplete details)
COMPLETE DATA (n=56) INSUFFICIENT DATA
DATA ANALYSIS REJECTED (n=13)
CONCLUSION
METHODOLOGYMETHODOLOGYNutritional status was determined by:
Serum albumin level < 35 g/L(Jeliffe 1966; Bishop et al 1981, Ireton J & Hasse J 1992)
Total protein < 60g/L(Jeliffe 1966, Bishop et al 1981, Kotler DP 2000 )
Total lymphocyte count < 1.5 x 10-9/L(Jeliffe 1966; Bishop et al 1981)
Ultimate outcome were one of the following: Improved Declined Death
RESULTS RESULTS & &
DISCUSSIONDISCUSSION
DEMOGRAPHICDEMOGRAPHIC
4313N =
Gender
malefemale
Ag
e(y
ea
rs)
100
80
60
40
20
0
37
Distribution of patients by age and gender
• Mean age : female (23.2%) - 59.5 + 16.7years male (76.8%) - 55.5 + 15.4 years
•There was no significant association between age and gender (p = 0.424).• Majority of subjects were Malays(28) followed by Chinese(17) and Indians(11).
Patients Receiving PN According to Diagnosis
8
3
6
12
6
24
34
2 2 2 2
02468
101214
Patie
nts
central48%
peripheral52%
Route of PN administration
Peripheral – 1 to 15 days (mean 5 + 7days)
Central – 1 to 25 days (mean 10 + 9days)
25
15
6
2
8
0 5 10 15 20 25 30
5-10 bags
11-15 bags
16-20 bags
21-25 bags
> 25 bags
PN p
repa
ratio
ns
Patients
Total PN preparations provided to patients
Type of Ready-Mix Preparation Prescribed Upon Initiation of PN
16%
14%
21%5%
28%
16% Reg 1
Reg 2
Reg 3
Reg 4
Reg 5
Reg 6
• 23% of the patients received compounded PN upon initiation (n=13).
0 20 40 60
Patients
TLC
TotalProtein
Albumin
Comparison of Nutritional Status Before Initiation of PN Supplementation
Malnourished
Well nourished
93% malnourished
70% malnourished
73% malnourished
Nutritional status correlated positively with albumin, total protein and total lymphocyte count (r=0.312, p<0.01).
0 20 40 60
Patients
TLC
Total Protein
Albumin
Comparison of Nutritional Status After PN Supplementation
Malnourished
Well nourished
55% malnourished
48% malnourished
37% malnourished
No significant difference in nutritional status among cancer patients withregard to duration of PN provided {F(1,54) = 0.238, p>0.05}.
0 5 10 15 20 25
Patients
1-7 days
8-14 days
15-21 days
> 21 days
Duration of PN Supplementation According to Nutritional Status
Well nourished
Malnourished
Ultimate Outcome in Patients Received PN
50%
27%
23%improved
declined
deceased
No significant difference in outcome and duration of PN supplementation {F(1,54) = 0.238, p>0.05}.
DISCUSSIONDISCUSSION
Prevalence of malnutrition in this study as identified by using serum albumin, total protein and TLC as indicator was comparable to that found in other studies
• Bauer et al 2002 – prevalence of malnutrition in oncology inpatients ~ 76%
Results of nutritional status and outcomes differ from other similar studies
• Neither adjunctive therapy nor supportive PN improved quality of life and ultimate outcome in terminally ill cancer patients
(Giovanni et al 1999)
CONCLUSIONCONCLUSION
Most oncology patients are malnourished before nutritional intervention
Early identification of patients at risk of malnutrition is necessary
Carefully targeted parenteral nutrition may benefit patients and improve outcome
Thank You….Thank You….