Parenteral Beslenen Hastaların Endikasyonları Ne Kadar Uygun?

Amaç: Parenteral nütrisyon (PN), intravenöz beslenme sağlayan bir tedavi yöntemidir. PN klinik sonuçları iyileştirebildiği gibi, komplikasyonlara bağlı olarak mortalite ve morbiditede artışa neden olabilmektedir. Bu çalışmamızın amacı, PN endikasyonlarını değerlendirmek, uygun olmayan PN başlanma oranını belirlemek ve kalori yeterliliğini incelemektir. Yöntem: PN başlanan tüm hastalar, nütrisyon hemşiresi ve diyetisyen tarafından hastane veri tabanından belirlenerek ziyaret edildi. Hastaların demografik verileri, yattığı servisi, tanısı, PN uygunluğuna, endikasyonlarına, alınan kalori miktarı ve yeterliliğine bakıldı. PN alan her bir hasta, Avrupa Klinik Beslenme ve Metabolizma Derneği (ESPEN) klavuzuna göre incelenerek “uygun” ve “uygun olmayan” olarak sınıflandırıldı. Ayrıca PN alan hastalar, Periferal PN, Santral PN, Enteral+PN, Oral+PN olarak 4 kategoriye ayrıldı. Bulgular: Hastanemizde altı aylık süre boyunca 333 hastaya PN uygulandığı saptandı. PN’na, beslenmeye engel kusma (%37), obstrüktif bağırsak hastalığı (%27), ağır diyare (%12) ve ağır malabsorbsiyon (%12) nedeniyle başlanmıştı. Hastaların 153 (%45.9)’üne uygun olmayan endikasyon ile başlanmıştı. Uygun olmayan endikasyon nedenleri arasında en sık doktorun konservatif olarak PN tercih etmesinin (142 olgu, %92.8) olduğu görüldü. PN başlanan hastaların 256’sı (%76.9) yetersiz kalori almaktaydı. Hastaların beslenmesinde en sık periferik parenteral nütrisyon (PPN) (155 olgu, %46.5) yol tercih edilmiş, uygun olmayan endikasyon ile PN (%40) ve yetersiz kalori ile beslenme de (%98.1) bu grupta görülmüştür. Sonuç: Herhangi bir nedenle yeterli oral veya enteral beslenemeyen hastalara, tek başına PN veya enteral nütrisyona ek olarak PN başlanmaktadır. PN ile ilgili risklerin en aza indirilmesi için PN endikasyonları iyi bilinmeli, bunun için beslenme odaklı eğitimler planlanmalıdır. Uygun olmayan endikasyon ve yetersiz kalori uygulanma riskine karşı hastane nütrisyon destek ekibi (NDE)’nin önerilerinin dikkate alınması gerektiğini düşünüyoruz.

How Appropriate Are the Indications for Parenteral Nutrition Patients?

Objective: Parenteral nutrition (PN) is a treatment method that provides intravenous nutrition. PN may improve clinical outcomes and may lead to an increase in mortality and morbidity due to complications. The aim of this study was to evaluate the indications of PN, to determine the incidence of inappropriate initiation of PN , and to investigate caloric adequacy. Method: All patients who started to receive PN were identified from the hospital database and visited by the nutrition nurse and dietician. Demographic data, service, diagnosis, PN compliance, indications, calorie intake and adequacy of the patients were evaluated. Each patient receiving PN was examined according to the guidelines of the European Association of Clinical Nutrition and Metabolism (ESPEN) and classified as “appropriate” and “inappropriate”. In addition, patients receiving PN were divided into 4 categories as Peripheral PN, Central PN, Enteral+PN, Oral+PN. Results: In our hospital, 333 patients underwent PN for six months. PN was started due to vomiting preventing oral intake (37%), obstructive bowel disease (27%), severe diarrhea (12%) and severe malabsorption (12%). In 153 (45.9%) patients PN were started with inappropriate indication. The most frequent reasons for inappropriate indication were the preference of the doctor for conservative PN (142 cases, 92.8%). While 256 (76.9%) of the patients who started PN were receiving inadequate calorie intake. Peripheral parenteral nutrition (PPN) (155 cases, 46.5%) was most frequently preferred in the nutrition of the patients, inappropriate indication for PN (40%) and inadequate calorie intake (98.1%) were seen in this group. Conclusion: In patients who cannot receive adequate oral or enteral nutrition for any reason, PN is initiated alone or in addition to enteral nutrition. In order to minimize the risks associated with PN, PN indications should be well known and nutrition-oriented training should be planned. We believe that the recommendations of the hospital nutritional support team (NDE) should be taken into consideration against the risk of inappropriate indication and insufficient calorie administration.

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1. Chan S, Mc Cowen KC, Blackburn GL. Nutrition Management in the ICU. Chest. 1999;115:145-8. https://doi.org/10.1378/chest.115.suppl_2.145S
2. McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016;40:159-211. https://doi.org/10.1177/0148607115621863
3. Bozzetti F, Forbes A. The ESPEN clinical practice guidelines on Parenteral Nutrition: Present status and perspectives for future research. Clin Nutr. 2009;28:359- 64. https://doi.org/10.1016/j.clnu.2009.05.010
4. Smyth ND, Neary E, Power S, Feehan S, Duggan SN. Assessing appropriateness of parenteral nutrition usage in an acute hospital. Nutr Clin Pract. 2013;28:232-6. https://doi.org/10.1177/0884533612469988
5. Sorensen J, Kondrup J, Prokopowicz J, et al. EuroOOPS: An international, multicentre study to implement nutritional risk screening and evaluate clinical outcome. Clin Nutr. 2008;27:340-9. https://doi.org/10.1016/j.clnu.2008.03.012
6. Cotogni P. Management of parenteral nutrition in critically ill patients. World J Crit Care Med. 2017;6:13. https://doi.org/10.5492/wjccm.v6.i1.13
7. Van Gossum A, Cabre E, Hébuterne X, et al. ESPEN Guidelines on Parenteral Nutrition: Gastroenterology. Clin Nutr. 2009;28:415-27. https://doi.org/10.1016/j.clnu.2009.04.022
8. Chima CS, Barco K, Dewitt MLA, Maeda M, Carlos Teran J, Mullen KD. Relationship of nutritional status to length of stay, hospital costs, and discharge status of patients hospitalized in the medicine service. J Am Diet Assoc. 1997;97:975-8. https://doi.org/10.1016/S0002-8223(97)00235-6
9. Bistrian BR. Comment on “guidelines for the provision and assessment of nutrition support therapy in the adult critically Ill patient.” JPEN J Parenter Enteral Nutr. 2010;34:348-9. https://doi.org/10.1177/0148607110361902
10. Thibault R, Heidegger C, Berger M, Pichard C. Parenteral nutrition in the intensive care unit: cautious use improves outcome. Swiss Med Wkly. 2014;144:13997. https://doi.org/10.4414/smw.2014.13997
11. Berger MM, Pichard C. Development and current use of parenteral nutrition in critical care - an opinion paper. Crit Care. 2014;18:1-10. https://doi.org/10.1186/s13054-014-0478-0
12. Sugrue D, Jarrell AS, Kruer R, et al. Appropriateness of peripheral parenteral nutrition use in adult patients at an academic medical center. Clin Nutr ESPEN. 2018;23:117-21. https://doi.org/10.1016/j.clnesp.2017.11.004
13. Gura KM. Is there still a role for peripheral parenteral nutrition? Nutr Clin Pract. 2009;24:709-17. https://doi.org/10.1177/0884533609351318
14. Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. J JPEN J Parenter Enteral Nutr. 2003;27:355- 73. https://doi.org/10.1177/0148607103027005355
15. Twomey PL, Patching SC, Twomey PL, Patching SC, Twomey PL, Patching SC. Cost-effectiveness of nutritional support. JPEN J Parenter Enteral Nutr. 1985;9:3- 10. https://doi.org/10.1177/014860718500900103
16. Kochevar M, Guenter P, Holcombe B, Malone A, Mirtallo J. A.S.P.E.N. statement on parenteral nutrition standardization. JPEN J Parenter Enteral Nutr. 2007;31:441-8. https://doi.org/10.1177/0148607107031005441
17. Maurer J, Weinbaum F, Turner J, , et al. Reducing the inappropriate use of parenteral nutrition in an acute care teaching hospital. JPEN J Parenter Enteral Nutr. 1996;20:272-4. https://doi.org/10.1177/0148607196020004272
18. Singer P, Berger MM, Van den Berghe G, et al. ESPEN Guidelines on Parenteral Nutrition: Intensive care. Clin Nutr. 2009;28:387-400. https://doi.org/10.1016/j.clnu.2009.04.024
19. Trujillo EB, Young LS, Chertow GM, et al. Metabolic and Monetary Costs of Avoidable Parenteral Nutrition Use. JPEN J Parenter Enteral Nutr. 1999;23:109-13. https://doi.org/10.1177/0148607199023002109
20. Chan SL, Luman W. Appropriateness of the use of parenteral nutrition in a local tertiary-care hospital. Ann Acad Med Singapore. 2004;33:494-8.
21. Katz SJ, Oye RK. Parenteral nutrition use at a university hospital. Factors associated with inappropriate use. West J Med. 1990;152:683-6.
22. Martin K, Delegge M, Nichols M, Chapman E, Sollid R, Grych C. Assessing appropriate parenteral nutrition ordering practices in tertiary care medical centers. JPEN J Parenter Enteral Nutr. 2011;35:122-30. https://doi.org/10.1177/0148607110362992
23. Worthington P, Balint J, Bechtold M, et al. When is parenteral nutrition appropriate? JPEN J Parenter Enteral Nutr. 2017;41:324-77. https://doi.org/10.1177/0148607117695251
24. Ponta ML, Rabbione L, Borgio C, et al. Assessing the appropriateness of parenteral nutrition use in hospitalized patients. A comparison on parenteral nutrition bag prescription in different wards and nutritional outcomes. Clin Nutr ESPEN. 2018;25:87-94. https://doi.org/10.1016/j.clnesp.2018.01.072
25. Cekmen N, Dikmen E. Yoğun Bakım Hastalarında Enteral Ve Parenteral Nütrisyon. Toraks Cerrahisi Bülteni. 2014;5:187-97. https://doi.org/10.5152/tcb.2014.030
26. Kennedy JF, Nightingale JMD. Cost savings of an adult hospital nutrition support team. Nutrition. 2005;21:1127-33. https://doi.org/10.1016/j.nut.2005.08.002
27. Jensen GL, Compher C, Sullivan DH, Mullin GE. Recognizing Malnutrition in Adults:Definitions and Characteristics, Screening, Assessment, and Team Approach. JPEN J Parenter Enteral Nutr. 2013;37:802-7. https://doi.org/10.1177/0148607113492338
28. Soguel L, Revelly JP, Schaller MD, Longchamp C, Berger MM. Energy deficit and length of hospital stay can be reduced by a two-step quality improvement of nutrition therapy: The intensive care unit dietitian can make the difference. Crit Care Med. 2012;40:412-9. https://doi.org/10.1097/CCM.0b013e31822f0ad7