CPA-MPS Conference Malaysia 2007

Evaluation of Parenteral Nutrition Utilization in Oncology Patients

Sivakami Janahiraman, SM Yew, Che Ton Saari

Pharmacy Division, Hospital Kuala Lumpur (HKL)

INTRODUCTION

● 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)

INTRODUCTION

 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)

INTRODUCTION

The use of nutritional therapy in cancer patients is tailored to complement the primary treatment 1) 2) 3) PN support in surgery PN support during chemotherapy PN in radiation therapy

GENERAL OBJECTIVE

To elucidate the appropriateness of PN support in cancer patients using the criteria of nutritional status and ultimate outcome

SPECIFIC 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

METHODOLOGY



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 CRITERIA

INCLUSION CRITERIA EXCLUSION CRITERIA Adult (>18 years) patients Paediatric (<18years) patients Received Total Parenteral Nutrition Patients with complete medical record Preterm neonates

STUDY FLOW CHART

SCREENING OF PATIENTS’ RECORD IN TPN PHARMACY (n=159) PATIENTS FIT INCLUSION / EXCLUSION CRITERIA SELECTED AS SUBJECTS (n=69) DATA COLLECTION RECORD UNIT

STUDY FLOW CHART

K 2, SOPD, RT & UN DATA COMPLETION (filling up incomplete details) COMPLETE DATA (n=56) INSUFFICIENT DATA DATA ANALYSIS CONCLUSION REJECTED (n=13)

METHODOLOGY

Nutritional 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 & DISCUSSION

DEMOGRAPHIC

100 80 60 40 20 0 N = Gender 37 13 female 43 male •

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

2 0 6 4 14 12 10 8 8 3 6 12 6 2 4 3 4 2 2 2 2 B la d d e r C a P ro st a te C a L ym p h o m a G a st ric C a O e so p h a g e a l C a P a n cr e a tic C a C o lo n C a H e p a tic C a L e u ke m ia C e rvi x C a T h yr o id C a B re a st C a T o n si l C a

Route of PN administration

peripheral 52%



Peripheral – 1 to 15 days (mean 5 + 7days)



Central – 1 to 25 days (mean 10 + 9days)

central 48%

Total PN preparations provided to patients

> 25 bags 21-25 bags 16-20 bags 11-15 bags 5-10 bags 2 6 8 15 0 5 10 15

Patients

20 25 25 30

Type of Ready-Mix Preparation Prescribed Upon Initiation of PN

16% 16% 14% 28% 5% 21% •

23% of the patients received compounded PN upon initiation (n=13).

Reg 1 Reg 2 Reg 3 Reg 4 Reg 5 Reg 6

Comparison of Nutritional Status Before Initiation of PN Supplementation

Albumin Total Protein TLC

0

93% malnourished 70% malnourished 73% malnourished

20

Patients

40 60 Malnourished Well nourished

Comparison of Nutritional Status After PN Supplementation Albumin 55% malnourished Total Protein 48% malnourished

Malnourished Well nourished

37% malnourished TLC

0 20

Patients

40 60

Nutritional status correlated positively with albumin, total protein and total lymphocyte count (r=0.312, p<0.01).

Duration of PN Supplementation According to Nutritional Status

> 21 days 15-21 days 8-14 days Well nourished Malnourished 1-7 days 0 5 10 15

Patients

20 25

No significant difference in nutritional status among cancer patients with regard to duration of PN provided {F(1,54) = 0.238, p>0.05}.

Ultimate Outcome in Patients Received PN

23% 50%

improved declined deceased

27% No significant difference in outcome and duration of PN supplementation {F(1,54) = 0.238, p>0.05}.

DISCUSSION

 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)

CONCLUSION

 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….