Transcript Evaluation of Parenteral Nutrition Utilization in Oncology Patients
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