Advisor(s)
Abstract(s)
O presente relatório desenvolve o tema da Nutrição Parentérica (NP) no adulto em meio hospitalar, estando organizado em 3 partes, A a C: A. Relatório de atividades. O relatório de atividades pretende dar uma visão geral sobre as principais atividades, desde a prescrição da NP e monitorização clínica do doente nos serviços de internamento, até à formulação e produção de bolsas de NP na farmácia hospitalar. Para cada processo apresenta-se um fluxograma de atividades, com a identificação da responsabilidade associada a cada atividade e os principais documentos e registos envolvidos. Como complemento apresentam-se tabelas com sínteses variadas que ajudam na compreensão ou tomada de decisão das referidas atividades. No processo de ‘Prescrição e Monitorização clínica’ sugere-se a participação do Serviço de Dietética e Nutrição para partilhar informação sobre a tolerância à nutrição entérica/oral na fase de sobreposição desta com a NP. Também seria vantajoso obter a avaliação antropométrica pelo Serviço de Dietética e Nutrição, em particular no doente com Nutrição Parentérica mais prolongada. Quanto ao processo de ‘Formulação’ seria útil considerar em revisões futuras as recomendações ASPEN (American Society for Parenteral and Enteral Nutrition) relativas a segurança dos sistemas de formulação em farmácia. O sistema deve ainda integrar o cálculo da osmolaridade e emitir alertas de erro quando são ultrapassados limites de formulação pré-especificados. Relativamente ao processo de ‘Produção’ sugere-se a introdução de alguns controlos de qualidade referidos pela ASPEN, nomeadamente a análise gravimétrica das bolsas produzidas e a análise química aleatória da concentração de glicose e electrólitos. B. Análise de recomendações. É analisada uma amostra de 495 bolsas de Nutrição Parentérica e os parâmetros desde a perfusão à composição em macronutrientes e micronutrientes são comparados com as recomendações. Verifica-se que os valores médios de aporte calórico e proteico, respectivamente 18 kcal/kg/dia e 0,8 g/kg/dia, são inferiores ao recomendado. O aporte de lípidos como fonte calórica e de ácidos gordos essenciais é fornecido em apenas 18% das bolsas.
Os oligoelementos ferro, cobre, manganésio e iodo estão mais elevados do que a dose recomendada mas a sua administração é feita em dias alternados. As vitaminas B1, B6, B9 e C apresentam valores abaixo das recomendações. No entanto foi observado que certos doentes tomam doses adicionais destas vitaminas hidrossolúveis fora da bolsa de Nutrição Parentérica. C. Estudo observacional. Apresenta-se um estudo observacional, transversal, prospetivo, que analisa a influência quer do estado nutricional na admissão quer da ingestão calórico-proteica durante o período de NP, no resultado clínico. Numa amostra de 28 indivíduos internados num centro hospitalar e sujeitos a Nutrição Parentérica em diversos serviços (cuidados intensivos, transplante de medula óssea, hematologia, cirurgia e medicina) verificou-se que: (a) O risco de mortalidade é superior no grupo de indivíduos com menor Índice de Massa Corporal (IMC); (b) A relação inversa entre o aumento da ingestão calórico-proteica e o tempo de internamento não foi demonstrada.
ABSTRACT - This report develops the theme of Parenteral Nutrition (PN) for adults in-hospital stay and is organized into 3 parts, A to C: A. Activities report. The activities report is intended to give an overview of the main activities from PN prescription and patient’s clinical monitoring within inpatient services, to the formulation and PN bags production in the hospital pharmacy. For each process, a flowchart of activities is presented, identifying the responsibility associated with each activity and the key documents and records involved. In addition, some tables with assorted syntheses are presented to help to understand the decision-making process under such activities. In the process of 'Prescription and Clinical monitoring' the participation of Dietetics and Nutrition Service is suggested to share information on enteral/oral nutrition tolerance when overlapping with PN. It would also be advantageous to obtain the anthropometric evaluation by that service, especially in patients with longer Parenteral Nutrition. As for the 'Formulation' process, it would be useful to consider, in future revisions, the ASPEN recommendations (American Society for Parenteral and Enteral Nutrition) on the safety of pharmacy formulation systems. The system should as well integrate the calculation of osmolarity and issue error alerts when pre-specified compounding thresholds are exceeded. For the 'Production' process the introduction of some quality checks referred to by ASPEN are suggested, including gravimetric analysis of the produced bags and random chemical analysis of the concentration of glucose and electrolytes. B. Analysis of recommendations. A sample of 495 Parenteral Nutrition bags is analyzed and parameters from perfusion to the composition of macronutrients and micronutrients are compared with the recommendations. It is found that the average values of caloric and protein intake, 18 kcal/kg/day and 0,8 g/kg/day respectively, are lower than recommended. The contribution of lipids as a source of calories and essential fatty acids is provided in only 18% of the bags. The trace elements iron, copper, manganese, and iodine are higher than the recommended dose but its administration is performed on alternate days. Vitamins B1, B6, B9 and C have values below the recommendations. However, it was observed that certain patients are taking additional doses of these water-soluble vitamins out of the Parenteral Nutrition bag. C. Observational study. An observational, transversal and prospective study is presented, which examines the influence on clinical outcome of both the nutritional status on admission or the calorie-protein intake during the Parenteral Nutrition period. In a sample of 28 individuals admitted to a hospital and subject to Parenteral Nutrition in various units (intensive care, bone marrow transplantation, hematology, surgery, and medicine) it was found that: (a) The risk of mortality is higher in the group of individuals with lower Body Mass Index (BMI); (b) An inverse relationship between the increase in caloric-protein intake and the length of hospital stay could not be demonstrated.
ABSTRACT - This report develops the theme of Parenteral Nutrition (PN) for adults in-hospital stay and is organized into 3 parts, A to C: A. Activities report. The activities report is intended to give an overview of the main activities from PN prescription and patient’s clinical monitoring within inpatient services, to the formulation and PN bags production in the hospital pharmacy. For each process, a flowchart of activities is presented, identifying the responsibility associated with each activity and the key documents and records involved. In addition, some tables with assorted syntheses are presented to help to understand the decision-making process under such activities. In the process of 'Prescription and Clinical monitoring' the participation of Dietetics and Nutrition Service is suggested to share information on enteral/oral nutrition tolerance when overlapping with PN. It would also be advantageous to obtain the anthropometric evaluation by that service, especially in patients with longer Parenteral Nutrition. As for the 'Formulation' process, it would be useful to consider, in future revisions, the ASPEN recommendations (American Society for Parenteral and Enteral Nutrition) on the safety of pharmacy formulation systems. The system should as well integrate the calculation of osmolarity and issue error alerts when pre-specified compounding thresholds are exceeded. For the 'Production' process the introduction of some quality checks referred to by ASPEN are suggested, including gravimetric analysis of the produced bags and random chemical analysis of the concentration of glucose and electrolytes. B. Analysis of recommendations. A sample of 495 Parenteral Nutrition bags is analyzed and parameters from perfusion to the composition of macronutrients and micronutrients are compared with the recommendations. It is found that the average values of caloric and protein intake, 18 kcal/kg/day and 0,8 g/kg/day respectively, are lower than recommended. The contribution of lipids as a source of calories and essential fatty acids is provided in only 18% of the bags. The trace elements iron, copper, manganese, and iodine are higher than the recommended dose but its administration is performed on alternate days. Vitamins B1, B6, B9 and C have values below the recommendations. However, it was observed that certain patients are taking additional doses of these water-soluble vitamins out of the Parenteral Nutrition bag. C. Observational study. An observational, transversal and prospective study is presented, which examines the influence on clinical outcome of both the nutritional status on admission or the calorie-protein intake during the Parenteral Nutrition period. In a sample of 28 individuals admitted to a hospital and subject to Parenteral Nutrition in various units (intensive care, bone marrow transplantation, hematology, surgery, and medicine) it was found that: (a) The risk of mortality is higher in the group of individuals with lower Body Mass Index (BMI); (b) An inverse relationship between the increase in caloric-protein intake and the length of hospital stay could not be demonstrated.
Description
Keywords
Nutrição Nutrição parentérica Prescrição clínica Macronutrientes Micronutrientes Índice de massa corporal Meio hospitalar Nutrition Parenteral nutrition Clinical prescription Macronutrients Micronutrients Body mass index IMC Hospital
Citation
Aguiar MM. Nutrição parentérica em meio hospitalar: prescrição, produção e acompanhamento clínico (estudo observacional sobre o impacto do IMC e da ingestão calórica-proteica no resultado clínico) [dissertation]. Lisboa: Escola Superior de Tecnologia da Saúde de Lisboa/Faculdade de Medicina da Universidade de Lisboa; 2016.
Publisher
Instituto Politécnico de Lisboa, Escola Superior de Tecnologia da Saúde de Lisboa