=

PhilSPEN Online Journal of Parenteral and Enteral Nutrition

(Article 140 | POJ_0132)

Original Clinical Investigation

Parenteral Nutrition Utilization in St. Luke's Medical Center, Quezon City, Philippines - report for the years 2004 and 2016

Abstract | Introduction | Methodology | Results | Discussion | Conclusion | References | Back to Total Name and Codes page2

Submitted: | Posted:

Authors:

Luisito O. Lllido MD; Clinical Nutrition Service, St. Luke's Medical Center, Quezon City, Philippines; delivered in one of the PENSA 2017 lectures.

Institution where research was conducted

Clinical Nutrition Sevice, St. Luke’s Medical Center, E. Rodriguez Avenue, Quezon City, Metro-Manila, Philippines

 

ABSTRACT: | Back

Background:

Under PhilSPEN (Philippine Society of Parenteral and Enteral Nutrition) there are now 34% of tertiary care hospitals with an active nutrition team. St. Luke’s Medical Center – Quezon City has a nutrition team. (1)

Objective:

To show the presence of parenteral nutrition practice in the Philippines in the years 2004 (2) and in 2016 (3) and to note differences in the way parenteral nutrition was used.

Methodology:

Some key studies on parenteral nutrition in the Philippines are presented together with their changes in practice whether these are adequate and/or lacking in essential practices.

Results:

Three official studies are shown which depicts the following (5,6,7): a) who sees the patients in terms of nutrition practice, whether physicians or dietitians, b) who sees patients in the critical care units, regular care and special cases and which areas show the value of the physicians in taking care of these patients and c) value of placing physicians in critical care units which by intents and purposes show how they approach management. These show the value of placing physicians with nutrition expertise in the critical care units with almost 95% providing immediate intensive care in these areas.

Conclusion:

The practice of parenteral nutrition has evolved with more physicians interested in providing parenteral nutrition and use of protocols that make care of these issues better and safe.

 

KEYWORDS: Parenteral nutrition, calorie and protein requirements per day

 

INTRODUCTION | Back

The initial three days of nutrition on admission to the ICU (Intensive Care Unit) are great opportunities for the following: gut mucosa maintenance, prevention of bacterial translocation, improved GALT functions (increased immunologic response) leading to counteracting te effects of injury and infection (4,5). Therefore these questions are determined: do patients receive adequate intake in terms of protein and carbohydrate on the first three days of admssion. Do they receive a minimum of 70% intake in these first three days in as much as any much as these organs are still in the prime acceptance of entry and process of induction of the immunologic pathways? (6) It does not matter what route of entry as long as either enteral or parenteral nutrition is given.

The ASPEN/SCCM critical care guidelines recommend early enteral feeding for these patients witihin 24-48 hours (1). Calories were to be calculated at 25-30 kcal/kg/day however on the first day giving as little as 10-20 kcal/hr (200-250 kcal/day) may be allowed. Protein at 1-2 gm/kg/day was also indicated (5,6,7). Parenteral nutrition was to be given at only once a week, however when the gut cannot be used it can be given on the first day. The ESPEN 2009 guidelines recommend calories to start at 25 kcal/kg/day and then increase it as the days increase enterally. If the intake cannot be fulfilled by enteral nutrition supplemental PN if recommended (1,3). This was a far cry from the 2003 practice of feeding only on the third day of admission (1,3)

In one of the reports from this institution (St. Luke's Medical Center) done in 2006 showed that elderly patients in the ICU had inadequate intake of calories and protein in the first three days of ICU stay with calories reaching only 71% and proteins at 24% on the third day. (2-6) Elke et al. showed that achieving close to the calculated requirements of both calories and protein (around 70% of calories and 60% of protein) was associated with a lower 60-day mortality and increase in ventilator-free days (7). EN was given on the first 48 hours of admission and although the mean calorie intake was at 65% and protein intake at 57% and as long as the calories was >1000 kcal/day and protein at >45 gms per day it was more than adequate. (8) This study was done to answer the following questions:  a) what is the mean calories and protein delivered on the first three days? b) is the practice as good or better compared to the previous reports? c) is the route mainly by EN or is there use of supplemental PN? d) how soon is EN started after ICU admission? (9.10)


METHODOLOGY | Back

The initial report on parenteral nutrition came in the year 1997. This was followed by the report from year 2004 which is based from the PhilSPEN Online Journal of Parenteral and Enteral Nutrition report from the Philippines regarding nutritional practice from January to August 2017, came. (4)

  • "The clinical nutrition service program – report from a nutrition team in a private tertiary care hospital in the Philippines from January to August 2017"
  • By Authors: Karna Igasan MD, Gail Turalba MD, Precy Gem Calamba MD, Melissa Sy MD, Julie T. Cajayon RND, and Butch Navarette RND

These states that for all intents and purposes 70% is the basic required intake to fulfill adequate requirement.

Actual intake for adult patients or pediatric patients:

  • Adult/elderly: 2520 (94.4%);
  • Pediatrics: 147 (5.5%)
  • Mean age: 63y, all sexes

Seen by the team (clinical nutrition team) - from their records:

  • Those seen by the dietitians: 438/2667 (16.4%)
  • Those seen by physicians (fellows): 2196/2667 (82.3%)

Type of care by the clinical nutrition team: - from their records:

  • Total critical care seen: 973/2667 (36%)
  • Total regular care seen: 1694/2667 (64%)
Regular nutrition care of patients and type of nutrition care delivery
  • Those seen by dietitians: 421/1694 (24.8%),
  • Those seen by physicians: 1246/1694 (73.5%).

These are the types of regular nutrition care delivery:

  • Per orem: 1143/2022 (56.5%)
  • Enteral nutrition: 351/2022 (17.4%)
  • Parenteral nutrition: 528/2022 (26.1%)

These critical care patients are the following:

  • Those seen by dietitians: 17/973 (1.2%)
  • Those seen by physicians: 950/973 (98.8%)

Critical care nutrition delivery:

  • Per orem: 365/1014 (36%)
  • Enteral nutrition: 447/1014 (44%)
  • Parenteral nutrition: 202/1014 (20%)

 

RESULTS | Back

pcform1

pcform3pcform4

Parenteral nutrition together with oral and or enteral nutrition fulfills the needed requirements of the patient.

 

DISCUSSION: | Back

This study on critical care nutrition delivery was asked and the following questions answered.

  • This was from the period of May 2016 to June 2017 as the Clinical Nutrition Delivery Report covering the same year.
  • By Authors: Karna Igasan MD, Gail Turalba MD, Precy Gem Calamba MD, Melissa Sy MD, Julie T. Cajayon RND, and Butch Navarette RND

How many critical care patients were given the following?

  • Per orem: 365/1014 (36%)
  • Enteral nutrition: 447/1014 (44%)
  • Parenteral nutrition: 202/1014 (20%)

How many Regular Patients were given the following nutrition care delivery?

  • Per orem: 1143/2022 (56.5%)
  • Enteral nutrition: 351/2022 (17.4%)
  • Parenteral nutrition: 528/2022 (26.1%)

Analysis of PN Utilization was done:

  • Period covered: May 2016 – June 2017
  • N=667 records

It asked how much Calories were given?:

  • Mean computed calorie requirement/day = 1,533 kcal (sd=248)
  • Mean actual calories delivered/day = 1,101.7 kcal/day
  • Mean actual calorie percent intake/day = 72.4% (sd=28.8)

How much Protein were given?:

  • Mean computed protein requirement/day = 72.5 gm/day (sd=15.7)
  • Mean actual protein delivered/day = 48.33 gm/day
  • Mean actual protein percent intake/day = 68% (sd=30.3)

These are the Types of parenteral nutrition given (Nutrition source: PN=36%; EN=64%)

  • “Three in one bags” = 147/667 (22%)
  • Single protein solution = 16/667 (2%)
  • Intravenous dextrose = 80/667 (12%)
  • All had vitamin and trace element incorporation daily

These are the Parenteral nutrition component profile:

  • Mean calories from PN alone = 703.4 kcal/day (sd=386.05)
  • Mean percent calories from PN alone = 66.8% (sd=29.44)
  • Mean protein from PN alone = 33 gm/day (sd=17.19)
  • Mean protein from PN alone = 72.9% (sd=28.8)n percent

In effect the additional of parenteral nutrition was able to fulfill the needs of the patients daily.

Then another study was done which covered parenteral nutrition. Its title was "Critical car nutrition update: does the nutrition team still achieve adequate intake with good outcomes?"

  • Authors: Precy Gem Calamba MD and Luisito Llido MD
  • Institution: Clinical Nutrition Service, St. Luke’s Medical Center – Quezon City

The questions asked were the following:

  • Is the clinical nutrition service able to deliver adequate nutrition?
  • Is nutrition risk score a determinant of mortality outcome?
  • Is adequate intake a determinant of mortality outcome?

These were the outcomes gathered:

  • N=210
  • Patients with positive calorie balance: 144/182 (79%)
  • Patients with positive protein balance: 156/182 (86%)
  • Mean ICU days = 6.5 (3.29)
    • Mortality rate = 5/34 (15%)
    • Mortality rate for patients with nutrition risk score < 5 = 0/16 (0%)
    • Mortality for patients with nutrition risk score > 5 = 5/16 (31%)
    • Mortality rate in patients with inadequate calories or protein (< 70% of calculated) = 2/5 (40%).

Observatons:

  • The current volume of parenteral nutrition utilization has gone down since the 2004 report
  • The current awareness of the value of parenteral nutrition has not been appreciated in the recent “countrywide” survey, hence its low utilization rate
  • Proper utilization of parenteral nutrition is done in centers where a clinical nutrition service or program is present
  • It has gone down a bit with the current principle of utilizing the gut first before filling up the deficits as soon as detected
  • It is thus required to keep a good updating in order to keep an adequate and accurate record.
  • Why? Adequate intake is associated with good outcome


CONCLUSION: | Back

From 1997, 2004 and 2016/2017 the practice of parenteral ntrition showed an increase in implementation and when accompanied with adequate observations of guidelines showed a safe and easy delivery of this type of nutrition delivery.

 

REFERENCES: | Back

  1. Llido LO, Sioson M, Inciong JF, and Manuales G. Nutrition team supervision on nutrient intake in critical care patients: report of a ten year experience in the Philippines (years 2000 to 2011). Philippine Online Journal of Parenteral and Enteral Nutrition. Article 2; POJ-0007; Jan 2010-2012: 9-16 pages.
  2. Llido LO, Parenteral nutrition practice from years 1994 to 1996 in St. Luke's Medical Center. A locel study - unpublished (1997).
  3. Llido LO. Nutrition support team: impact on parenteral nutrition implementation practice, 2004. Local study - unpublished (2004)
  4. Igasan K MD, Turalba G MD, Calamba PJ MD, Sy M MD, Cajayon JT RND and Navarette B RND. Clinical nutrition service program - report from a nutrition team in a private tertiary care hospital in the Philippines from January to August 2017. Philippine Journal of Parenteral and Enteral Nutrition. Art _; 2016-17: _ pages.
  5. Clinical Nutrition Service Report: parenteral nutrition utilization in SLMC, QC from May 2016 to June 2017. Philippine Online Journal of Parenteral and Enteral Nutrition. Art _; POJ_0133; _2018-19: _ pages.
  6. Calamba PJ MD and Llido LO MD. Critical care nutrition update: does the nutrition team still achieve adequate intake? Philippines Online Abstract of Parenteral and Enteral Nutrition. Abstract ID (81). PENSA 2017 Congress.
  7. Elke et al. Clinical outcome of critically ill septic patients: secondary analysis of a large international nutrition database: analysis of daily intake within one week. Critical Care 2014; 18: R29.
  8. Wischmeyer et al. A randomized trial of supplemental parenteral nutrition in underweight and overweight critically ill patients: the TOP-UP pilot trial. Critical Care 2017; 21: 142 pages.
  9. Dimaano J MD and Llido LO MD. The First Philippine Hospital Nutrition Summit - report on the presence of nutrition teams and current status of clinical nutrition practice in the Phillippines, 2014. Art _; POJ_0120: _ pages.
  10. The Unrisk Study Group, Philippine Society of Parenteral and Enteral Nutrition. The Undernutrition Risk and Underfeeding Status among in-patients and out-patients n hospital in the Philippines ("The Unrisk Study"), Art 28; POJ_0022; Issue Jan 2016 - June 2016: 121-133 pages.

 

Abstract | Introduction | Methodology | Results | Discussion | References | Back to Total Name and Codes page2