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….