Applied nutritional investigationAssessment of parenteral nutrition prescription in Canadian acute care settings
Introduction
Parenteral nutrition (PN) is an expensive treatment and should be used only when the gastrointestinal tract is not functional or cannot be accessed or the patient's nutrient needs cannot be met by oral or enteral nutrition (EN) [1], [2]. Indications include intestinal obstruction, ileus or severe dysmotility, severe pancreatitis, high-output fistula, short bowel syndrome, and complications of severe intestinal inflammatory disease [3], [4]. The European Society for Parenteral and Enteral Nutrition guidelines recommend the use of PN in this patient population with various types of intestinal failure (IF) [5]. To improve outcome of acute IF, treatment should be provided by a multidisciplinary team in a specialized facility or rehabilitation center rather than in acute care hospitals. PN alone or in combination with EN is often the preferred option in IF as a result of altered absorption of the gastrointestinal tract.
Complications associated with PN are not negligible and include catheter infections, hyperglycemia, hepatic dysfunction, hyperlipidemia, and refeeding syndrome [4], [6], [7], [8]. Furthermore, PN used without oral or enteral intake is associated with gut atrophy, loss of intestinal barrier function, altered gut microflora, increased bacterial adherence, increased microbe translocation, and B- and T-cell dysfunction [3], [9]. In addition, in the intensive care unit (ICU) setting, PN may be associated with higher infection rate, longer length of stay (LOS), and higher mortality compared with EN [10], [11].
Bloodstream infection rates vary widely among PN patients from 1.3% to 39% [12], [13]. Even though there is evidence on how to reduce catheter-related infections, studies have still found high rates in patients on PN [14]. One cohort study in patients with central venous catheters (CVC) found that PN was an independent risk factor for bloodstream infections [15]. Another study in 19 Canadian hospitals found an overall rate of bloodstream infections of 4.9%. PN increased the risk of bloodstream infection fourfold [16].
The aim of this study was to assess PN care in acute care settings by determining whether PN was provided in the appropriate patient population, PN prescription and monitoring were adequate, and PN-related complications were within or less than rates reported in the literature.
Section snippets
Patients and procedures
This was a prospective cohort study in adults admitted to Toronto General Hospital or Princess Margaret Hospital, Toronto, Ontario, Canada, both part of the University Health Network, Toronto.
Patients at nutritional risk admitted on medical, surgical, or ICU wards were initially identified by attending physicians and nurses and assessed by the ward dietitian. When indicated, patients were referred to the nutrition support team (NST) for PN. Consecutive patients receiving PN were recruited
General characteristics
The study included 147 patients described in Table 1. The most common diagnosis at admission was cancer (36.7%), followed by digestive diseases (25.9%). Most patients were hospitalized in surgical units (59%). Even though there was a high prevalence of normal or higher BMI, most patients were at least moderately malnourished (SGA rating B or C). There was no difference in BMI and SGA when comparing patients by wards (data not shown). Nevertheless, patients hospitalized in medical units had a
Discussion
Our data indicate that most patients received PN during their hospitalization because of gastrointestinal disorders and prolonged ileus. The energy requirements calculated by different equations had agreement; however, a high percentage of patients received on average less than 90% of their calculated energy and protein requirements with a slow progression toward goals. The most common complications were catheter sepsis and hyperglycemia. Patients' conditions were complex, with prolonged LOS
Conclusion
In this prospective study conducted in an acute care setting, most patients starting PN were malnourished. Although PN was prescribed appropriately, the increase in the provision of energy and protein was slow and did not meet the requirements. Complications from PN were within reported ranges but mortality was high, possibly because of complex diseases.
Disclosures
Daniela Adjemian received a partial postdoctoral research fellowship from Baxter Corporation Canada. Johane Allard received unrestricted grants from Baxter Corporation Canada. Bianca Arendt had no conflict of interest.
This study was partially funded by Baxter Corporation Canada. The sponsor did not participate in study design, collection, analysis, data interpretation, writing or in the decision to submit the article for publication.
Acknowledgments
Bianca Arendt and Johane Allard equally contributed to the conception and design of the research. All authors drafted and revised the manuscript, agree to be fully accountable for ensuring the integrity and accuracy of the work, and read and approved the final manuscript.
We thank Baxter Corporation Canada for partially funding the study; the members of the NST: Olivia Saqui, Lydia Fairholm, Mary Baun, and Millie Yeung, for their help in discussing some patient charts; Nilima Raina, Rezvaneh
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