Evaluation of Parenteral Nutrition Utilization in Oncology Patients CPA-MPS Conference Malaysia 2007 Evaluation of Parenteral Nutrition Utilization in Oncology Patients Sivakami Janahiraman, SM Yew, Che Ton Saari Pharmacy Division, Hospital Kuala Lumpur (HKL)

INTRODUCTION 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)

INTRODUCTION 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)

INTRODUCTION The use of nutritional therapy in cancer patients is tailored to complement the primary treatment PN support in surgery PN support during chemotherapy PN in radiation therapy

GENERAL OBJECTIVE To elucidate the appropriateness of PN support in cancer patients using the criteria of nutritional status and ultimate outcome

SPECIFIC 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

METHODOLOGY 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 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 CHART SCREENING OF PATIENTS’ RECORD IN TPN PHARMACY (n=159) PATIENTS FIT INCLUSION / EXCLUSION CRITERIA SELECTED AS SUBJECTS (n=69) DATA COLLECTION RECORD UNIT

(filling up incomplete details) STUDY FLOW CHART K 2, SOPD, RT & UN DATA COMPLETION (filling up incomplete details) COMPLETE DATA (n=56) INSUFFICIENT DATA DATA ANALYSIS REJECTED (n=13) CONCLUSION

METHODOLOGY Nutritional 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 & DISCUSSION

Distribution of patients by age and gender DEMOGRAPHIC 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).

Route of PN administration Peripheral – 1 to 15 days (mean 5 + 7days) Central – 1 to 25 days (mean 10 + 9days)

Total PN preparations provided to patients

23% of the patients received compounded PN upon initiation (n=13).

93% malnourished 70% malnourished 73% malnourished

55% malnourished 48% malnourished 37% malnourished Nutritional status correlated positively with albumin, total protein and total lymphocyte count (r=0.312, p<0.01).

No significant difference in nutritional status among cancer patients with regard to duration of PN provided {F(1,54) = 0.238, p>0.05}.

No significant difference in outcome and duration of PN supplementation

DISCUSSION 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)

CONCLUSION 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….