the practice of parenteral nutrition in malaysian hospitals riyadh abdullah omar albat ani

43 Pages·2004·0.94 MB·English

THE PRACTICE OF PARENTERAL NUTRITION IN MALAYSIAN
HOSPITALS
by
RIYADH ABDULLAH OMAR ALBAT ANI
Thesis submitted in fulfillment of the requirements
for the degree of
Doctor of Philosophy
June 2008
ACKNOWLEDGEMENTS
I am extremely grateful to Dr.Mohd Baidi Bahari (School of pharmaceutical Sciences,
Universiti Sains Malaysia) for introducing me to scientific research and helping me
establish my overall direction. His advice and constructive criticism have been
invaluable in the fruition of this doctoral thesis for maintaining my focus and for his
insight guidance in picking up key findings that I may have overlooked. For his kinds of
introducing me to the "hands-on" practical work of clinical research and for his help in
conducting the studies which formed part of this doctoral thesis, I am thankful to his
constant encouragement and support, his warm presence and for consistently reminding
me to "Keep smiling". I am also thankful to Pn. Zalila Ali (USM Mathmatic School) for
introducing me to new approaches in analysing data, also thanks to Dr.A.F
Shammsuddin (Field-supervisor, HUKM Pharmacy Department), Mr. Amrahi Buang
(UMMC) and Mr. Dellimin Che Abdullah (HUSM). Thanks to Dr. Mohd Izham Mohd
Ibrahim (USM Social and Administrative Pharmacy) for assisting me in statistics. I am
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especially appreciative of the Yemen Government and specifically University of Sana' a
for granting me this opportunity to gain experience in a foreign country and to broaden
my horizons. I have been fortunate to have a large number of friends and colleagues who
have had a profound effect on me and on my research. Last, but not least, I would like
to dedicate this thesis to my family, especially to my parents for providing me with the
essential tools, during my formative years, to pursue and realise my dreams, my brothers
Fatima, Sefan and Mohd and my wife Amina for her support and endless patience when
I most needed it. They will always remain the guiding light in my life as I look forward
to new challenges in the near future.
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TABLE OF CONTENTS
Acknowledgements 11
Table of contents Ill
List of tables xi
List of abbrevations
XIV
Abstrak xvi
Abstract xviii
Part 1 Survey ofTPN practice in Malaysian hospital
1.1 Introduction and literature review
1.1.1 Background
1.1.2 Practices of PN 3
1.1.3 Problem statement 8
1.1.4 Rationale ofthe study 10
1.1.5 Objectives 11
1.1.6 Justification of the study 12
1.2 Methodology 13
1.2.1 Introduction 13
1.2.2 Parenteral nutrition practice in Malaysian hospitals 13
1.2.3 Study design of survey of evaluation of PN Practice in 14
Malaysian hospital
1.2.4 Determination the sample size 14
1.2.5 Subjects (hospitals) 16
111
1.2.5 (a) Selection of hospitals 16
1.2.5 (b) Inclusion criteria 17
1.2.5 (c) Exclusion criteria 17
1.2.6 Data Analysis 17
1.3 Results and discussion 19
1.3.1 Response rate 19
1.3.2 Classification of hospitals 20
1.3.3 PN services in Malaysian hospital 21
1.3.4 Hospital size 22
1.3.5 Availability of PN services 23
1.3.5 (a) PN services and mean of pharmacist and 23
pharmacist assistant
1.3.5 (b) Mean of preparation per day 24
1.3.6 Type of specialties 25
1.3.7 Type of Clinical Pharmacy services offered 26
1.3.8 Clinical services offered pharmacy department 27
according to type of hospitals.
1.3.9 Year started parenteral nutrition services 28
1.3.1 0 Ward with PN services 29
1.3.11 Places for preparation ofPN 30
1.3.12 Type of services related to PN 31
1.3.12 (a) Individualization 32
1.3.12 (b) Standard formulas 33
1.3.12 (c) Computer program 33
IV
1.3.13 Extent of pharmacist involved in PN 34
1.3.13 (a) PN pharmacist compounding 34
1.3.13 (b) PN monitoring and nutrition support team 35
1.3.14 Quality control of PN compounding 36
1.3.15 The use of commercially available standard product 39
1.3.16 Suggestions of services offered by PN 40
pharmacists
1.3.17 Type of solution used in PN 41
1.4 Summary and conclusion 43
1.4.1 PN Practices in Malaysian Hospital 43
1.4.2 The extend of the PN services 43
1.4.3 The personnel involve in PN services 43
1.4.4 The load of pharmacist 44
1.4.5 The role of pharmacist 44
Part 2 Compare service provided in four hospitals 45
2.1 Introduction and literature review 45
2.1.1 Indication 45
2.1.1.1 Parenteral nutrition in malnutrition 46
2.1.1.2 (a) Parenteral nutrition in premature 47
2.1.1.2 (b) Special considerations in premature nutritional 4 7
supplement
2.1.1.3 Parenteral nutrition in children 48
2.1.1.4 Parenteral nutrition in surgical case 49
2.1.15 Parenteral nutrition in cancer 49
v
2.12 Nutrient and substrate requirments for PN 50
2.12.(a) Protien 51
2.12 (b) Carbohydrate 53
2.12.(c) Fat 54
2.1.2(d) Electrolytes, vitamin and trace elements 55
2.1.2 (e) Energy requirments 57
2.1.2 (f) Fluid requirment 57
2.1.3 1he parenteral nutrition product in Malaysian hospitals 58
2.1.4 Route of parenteral nutrition 59
2.1.5 Outcomes of parenteral nutrition 60
2.1.6 Complication of parenteral nutrition 61
2.1.6 (a) Mechanical 62
2.1.6 (b) Infection 63
2.1.6 (c) Metabolic 65
2.1.7 Monitoring of parenteral nutrition 66
2.1.8 Cost of parenteral nutrition 66
2.1.9 Problem statement 68
2.1.10 Rationale of the study 69
2.1.11 Objectives 70
2.1.12 Scope (contribution) of the study 70
2.1.13 Justification of the study 70
2.2 Methodology 72
2.2.1 Introduction 72
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2.2.2 Development of data collection form 72
2.2.3 The pilot study 73
2.2.3 (a) Data analysis of the pilot study 73
2.2.3 (b) Result of the pilot study 73
2.2.3 (c) Discussion of pilot study 75
2.2.3 (d) Conclusion 76
2.2.4 The cost of solutions 76
2.2.5 Study design of the comparative study 79
2.2.6 Sites of the comparative study 79
2.2.7 Determination of sample size of comparatve study 79
2.2.8 Calculation of power and sample size of HPP 80
2.2.8 (a) Power calculation 80
2.2.8 (b) Calculation of power and sample size ofHUSM 82
2.2.8 (c) Calculation of power and sample size ofHUKM 84
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2.2.8 (d) Calculation of power and sample size of UMMC 86
2.2.9 Subjects 87
2.2.10 Inclusion criteria 87
2.2.11 Execlusion criteria 88
2.2.12 Data analysis 88
2.2.12 (a) Two way ANOV A 88
2.2.12 (b) Pearson chi square 89
2.3 Results and discussions 91
2.3.1 Introduction 91
2.3.2 Characterstics ofPN patients according to hospital 91
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2.3.3 Diagnosis of PN patients 92
2.3 .4 Reasons of PN patients 93
2.3.5 Diagnosis and reasons. 93
2.3.6 Outcome of PN patients 96
2.3.7 Complications due to PN 97
2.3.8 Type of complications & factors associated with complications 98
2.3.9 The route of PN 106
2.3.1 0 The cost per day 107
2.3.11 The duration ofPN 108
2.3.12 Energy requirements ofPN 109
2.3.13 Volume prepared ofPN 110
2.3.14 Macronutrient requirement 112
2.3.14 (a) Glucose supplement ofPN 112
2.3.14 (b) AA supplement of PN 113
2.3.14 (c) Lipid supplement ofPN 115
2.3.15 Vitamin requirements ofPN 118
2.3.16 Trace elements requirements ofPN 120
2.3.17 Electrolyte requirements of PN 121
2.3.17 (a) Sodium requirement of PN 121
2.3.17 (b) Potassium requirement of PN 123
2.3.17 (c) Magnesium requirement ofPN 125
2.3.17 (d) Calcium requirement ofPN 127
2.3.17 (e) Phosphate requirement ofPN 128
2.3.17 (f) Chloride supplement in PN 130
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2.3.18 Monitoring of body temperature 132
2.3.19 The monitoring of fluid input and output 133
2.3.20 The monitoring of fluid output in m1 135
2.3.21 The monitoring of fluid balance in ml 136
2.3.22 Monitoring of PC02 137
2.3.23 Monitoring of P02 138
2.3.24 Monitoring of 02 saturation 139
2.3.25 Monitoring of base excess BE 140
2.3.26 Monitoring of WBC 141
2.3.27 Monitoring of HB 143
2.3.28 Monitoring of platelet 144
2.3.29 The monitoring of PT 146
2.3.30 Monitoring of INR 147
2.3.31 Monitoring of APTT 148
2.4 Summary and conclusions 150
2.4.1 The outcomes of PN in four studied hospitals 150
2.4.2 Type of complication of PN patients 150
2.4.3 The cost per day and duration of PN patients 151
Bibliography 152
List of appendices 171
List of publications and seminars 186
IX
LIST OF TABLES
Page
Table l.l.l Total number of government hospitals providing PN 3
Services
Table 1.2.2 The total number of government and private hospitals 15
Table 1.2.3 The total number of government and private hospitals 16
Table 1.3.4 The classification ofthe hospitals 20
Table1.3.5 PN services in Malaysian hospital 21
Table 1.3.6 Hospital size in relation to hospital type 23
Table 1.3.7 Availability ofPN services according to class of hospital 23
Table 1.3.8 The specialties type offered by the Malaysian hospital 26
Table 1.3.9 Type of clinical pharmacy services offered pharmacy 27
department
Table 1.3.1 0 Clinical pharmacy services offered by pharmacy 28
department according to hospital type
Table 1.3.11 Year of PN service started 29
Table 1.3.12 Ward with PN services 30
Table 1.3.13 Places for preparation of PN 31
Table 1.3.14 Parenteral nutrition services offered by pharmacy 34
department
Table 1.3.15 Pharmacist involvement in parenteral nutrition services 36
Table 1.3.16 Monitoring of quality control during PN compounding 37
Table 1.3.17 The use of commercially available standard product 40
Table 1.3.18 Type of recommendation by pharmacist 40
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