This document provides guidance on pharmacokinetic studies for new medicinal products to assist in interpreting EU directives. It discusses studying absorption, distribution, elimination, interactions and adverse reactions. Key factors include determining bioavailability, protein binding, metabolism, excretion routes and changes in special populations. Methodology should use appropriate administration schemes in healthy volunteers and patients, validated analytical methods, and statistical analysis to interpret results. The goal is to understand dose-concentration profiles and establish safe, effective dosing regimens.
This document discusses drug utilization evaluation (DUE), which is defined as an ongoing quality improvement process to optimize drug use. It describes the types of DUE as drug-focused, indication-focused, quantitative, and qualitative. The roles of the DUE committee and pharmacists in DUE are also outlined. The key aspects of the DUE cycle are planning, data collection, evaluation, feedback, interventions, and re-evaluation. Common metrics used in DUE like defined daily dose and criteria for conducting the DUE cycle are also summarized.
This study explored the qualifications of pharmacists dispensing drugs in Chennai, India through a survey of 131 pharmacies. The results found that most dispensers had relatively low qualifications - 40% had a D Pharm degree, 20% a B Pharm, while 18% only had a higher secondary education. Despite many years of experience, the dispensers' knowledge was still poor. The study concludes that improving dispenser knowledge through training programs and policy changes could help enhance patient health outcomes when visiting community pharmacies in India.
This document discusses drug utilization review (DUR), which is a systematic process to ensure appropriate medication use. DUR involves reviewing patient medication and health histories before, during, and after dispensing. It can help prevent unnecessary drug use, adverse reactions, and improve effectiveness. The document outlines the classification, goals, and steps to establish a basic hospital DUR program, including forming a committee, developing policies/procedures, identifying drugs for review, establishing criteria, collecting/evaluating data, implementing interventions if needed, and re-evaluating the program annually.
Drug utilization evaluation(DUE) & Drug utilization review)Pooja Anothra
Drug utilization evaluation (DUE) is a systematic, ongoing evaluation of drug therapy that ensures medications are used appropriately and meet current standards of care. The goals of DUE include promoting optimal medication therapy, creating guidelines for appropriate drug use, and controlling costs. The DUE process involves establishing responsibility, developing review criteria, collecting and analyzing data, providing feedback to prescribers, and conducting follow-up evaluations. Drug utilization review (DUR) similarly involves ongoing review of prescribing, dispensing, and drug use, and can be prospective, concurrent, or retrospective to identify problems and improve medication therapy.
This presentation describes the objectives, approach and application of Drug Utilization studies in Pharmacotherapeutics. This emphasizes on how to conduct a drug utilization studies.
This document outlines a course syllabus for an intermediate pharmacy practice course at the University of Zambia School of Medicine. The course aims to develop competencies for effective pharmacy practice, management, leadership, and professional development. It covers topics like the social context of health and illness, rational medicine use, supply chain management, the dispensing process, and more. Students will be assessed through tests, assignments, laboratory reports, and course competencies. The course utilizes lectures, tutorials, laboratory sessions, and other active learning methods over 120 total hours to facilitate students achieving the learning objectives.
This document provides guidance on pharmacokinetic studies for new medicinal products to assist in interpreting EU directives. It discusses studying absorption, distribution, elimination, interactions and adverse reactions. Key factors include determining bioavailability, protein binding, metabolism, excretion routes and changes in special populations. Methodology should use appropriate administration schemes in healthy volunteers and patients, validated analytical methods, and statistical analysis to interpret results. The goal is to understand dose-concentration profiles and establish safe, effective dosing regimens.
This document discusses drug utilization evaluation (DUE), which is defined as an ongoing quality improvement process to optimize drug use. It describes the types of DUE as drug-focused, indication-focused, quantitative, and qualitative. The roles of the DUE committee and pharmacists in DUE are also outlined. The key aspects of the DUE cycle are planning, data collection, evaluation, feedback, interventions, and re-evaluation. Common metrics used in DUE like defined daily dose and criteria for conducting the DUE cycle are also summarized.
This study explored the qualifications of pharmacists dispensing drugs in Chennai, India through a survey of 131 pharmacies. The results found that most dispensers had relatively low qualifications - 40% had a D Pharm degree, 20% a B Pharm, while 18% only had a higher secondary education. Despite many years of experience, the dispensers' knowledge was still poor. The study concludes that improving dispenser knowledge through training programs and policy changes could help enhance patient health outcomes when visiting community pharmacies in India.
This document discusses drug utilization review (DUR), which is a systematic process to ensure appropriate medication use. DUR involves reviewing patient medication and health histories before, during, and after dispensing. It can help prevent unnecessary drug use, adverse reactions, and improve effectiveness. The document outlines the classification, goals, and steps to establish a basic hospital DUR program, including forming a committee, developing policies/procedures, identifying drugs for review, establishing criteria, collecting/evaluating data, implementing interventions if needed, and re-evaluating the program annually.
Drug utilization evaluation(DUE) & Drug utilization review)Pooja Anothra
Drug utilization evaluation (DUE) is a systematic, ongoing evaluation of drug therapy that ensures medications are used appropriately and meet current standards of care. The goals of DUE include promoting optimal medication therapy, creating guidelines for appropriate drug use, and controlling costs. The DUE process involves establishing responsibility, developing review criteria, collecting and analyzing data, providing feedback to prescribers, and conducting follow-up evaluations. Drug utilization review (DUR) similarly involves ongoing review of prescribing, dispensing, and drug use, and can be prospective, concurrent, or retrospective to identify problems and improve medication therapy.
This presentation describes the objectives, approach and application of Drug Utilization studies in Pharmacotherapeutics. This emphasizes on how to conduct a drug utilization studies.
This document outlines a course syllabus for an intermediate pharmacy practice course at the University of Zambia School of Medicine. The course aims to develop competencies for effective pharmacy practice, management, leadership, and professional development. It covers topics like the social context of health and illness, rational medicine use, supply chain management, the dispensing process, and more. Students will be assessed through tests, assignments, laboratory reports, and course competencies. The course utilizes lectures, tutorials, laboratory sessions, and other active learning methods over 120 total hours to facilitate students achieving the learning objectives.
This document discusses drug utilization reviews (DUR), also known as drug utilization evaluations (DUE) or medication utilization evaluations (MUE). DURs involve comprehensive review of patient prescription and medication data before, during, and after dispensing to ensure appropriate medication decisions and positive outcomes. DURs aim to promote optimal medication therapy, prevent medication-related problems, evaluate medication effectiveness, improve patient safety, and stimulate improvements in medication use processes. The document also outlines the value of DUR programs in helping health systems understand and improve prescribing, administration, and medication use.
1. Drug Use Evaluation (DUE) is a performance improvement method that focuses on evaluating and improving medication use processes to optimize patient outcomes.
2. Clinical pharmacists can positively impact mortality rates through services like DUE, patient education, adverse drug reaction management, and participating on patient rounds.
3. The DUE process involves establishing criteria to evaluate medication use, collecting and analyzing data, developing and implementing improvement plans, and repeating the cycle for ongoing enhancements.
This document outlines the scope and objectives of a Pharmacotherapeutics course. The course will enable students to understand pathophysiology of common diseases and their drug-based management. It will cover topics like cardiovascular diseases, respiratory diseases, endocrinology and general prescribing guidelines. Assessment methods include theory exams, practicals, assignments and case presentations. The aim is to impart knowledge around rational drug use and individualized treatment plans.
This document is a resume for Nasim Sobhani, a pharmacy intern. It summarizes her education, including a Doctor of Pharmacy degree anticipated in 2015 from California Northstate University, as well as previous degrees. It also outlines her licenses, certificates, pharmacy practice experiences including APPEs and IPPEs, academic experience, work experience including as a clinical laboratory scientist, and professional memberships and honors.
Drug Utilization in a regulated EnviormentAlok Anand
Tracking drugs across the supply chain in a regulated environment. This white paper brief on would be drug utilization approach of Life Science Industry. This white paper is just a step forward to show future life science industry process automation
Franks_Know your patients_2Sep14_finalBilly Franks
This document discusses the importance of using patient registries alongside claims data and electronic health records for comparative effectiveness research. Sequencing of therapies and use of combination therapies can introduce biases if not properly accounted for. An example study on type 2 diabetes medications found some limitations in fully adjusting for severity factors. The document recommends that registries can help address gaps by collecting additional clinical data not found in other sources, and by assessing outcomes at standardized time points. Registries complement but cannot replace large claims/EHR data sources due to their more limited size and scope.
Introduction to Premarketing Phase
Limitation of Premarketing Phase and Importance of Phase IV period
Definition of DUS
History of DUS
Objectives of DUS
Types of Drug Use Information
Drug Utilization Cycle
The document discusses documenting clinical pharmacy services. It states that documenting activities is essential for providing services and involves recording patient information, interventions, workload statistics, and quality indicators. The objectives of documentation are to improve patient care, communicate with other providers, demonstrate pharmacist accountability and assess service quality. Clinical activities that should be documented include information in health records, departments records, interventions, and workload/performance indicators.
Clinical pharmacokinetics and its application--
1)definition
2) APPLICATIONS OF CLINICAL PHARMACOKINETICS
Design of dosage regimens:
a) Nomograms and Tabulations in designing dosage regimen,
b) Conversion from intravenous to oral dosing,
c) Determination of dose and dosing intervals,
d) Drug dosing in the elderly and pediatrics and obese patients.
Pharmacokinetics of Drug Interaction:
a) Pharmacokinetic drug interactions
b) Inhibition and Induction of Drug metabolism
c) Inhibition of Biliary Excretion.
Therapeutic Drug monitoring:
a) Introduction
b) Individualization of drug dosage regimen (Variability – Genetic, Age and Weight, disease, Interacting drugs).
c) Indications for TDM. Protocol for TDM.
d) Pharmacokinetic/Pharmacodynamic Correlation in drug therapy.
e) TDM of drugs used in the following disease conditions: cardiovascular disease, Seizure disorders, Psychiatric conditions, and Organ transplantations
Dosage adjustment in Renal and Hepatic Disease.
a. Renal impairment
b. Pharmacokinetic considerations
c. General approach for dosage adjustment in renal disease.
d. Measurement of Glomerular Filtration rate and creatinine clearance.
e. Dosage adjustment for uremic patients.
f. Extracorporeal removal of drugs.
g. Effect of Hepatic disease on pharmacokinetics.
Population Pharmacokinetics.
a) Introduction to Bayesian Theory.
b) Adaptive method or Dosing with feedback.
c) Analysis of Population pharmacokinetic Data
Monitoring the effectiveness of risk minimisation in patients treated with pi...Valeria Antonella Aguirre
1. BACKGROUND
2. OBJECTIVES
3. METHODS
3.1 SOURCE POPULATION AND STUDY POPULATION
3.2 STUDY DESIGN AND STUDY PERIOD
3.3 EXPOSURE
3.4 ENDPOINTS
3.5 ANALYSIS PLAN
4. LIMITATIONS
5. QUALITY ASSURANCE, FEASIBILITY AND REPORTING
5.1 DATA STORAGE
5.2 METHODS FOR QUALITY ASSURANCE
5.3 DATA QUALITY
5.4 FEASIBILITY AND TIMELINES
5.5 REPORTING AND DISSEMINATION OF RESULTS
5.6 AMENDMENTS
5.7 INDEPENDENT REVIEW OF STUDY RESULTS
6. ETHICAL ISSUES
7. DATA SOURCES
8. REFERENCES
This document outlines various aspects of quality assurance in pharmaceutical services including definitions, types of quality assurance services, methods of assessment, and evaluation techniques. It discusses patient counseling evaluation, audit types and cycles, and methods for monitoring quality at input, process, and output levels. The key aspects of quality assurance are ensuring quality of practice and services through performance appraisal, audit, and evaluating structures, processes, and outcomes of pharmaceutical activities.
Quality assurance of clinical pharmacy servicesvarshawadnere
This document discusses quality assurance in clinical pharmacy services. It defines quality assurance as ensuring quality of practice and outcomes. The main objectives are to ensure appropriate patient care, monitor medicine needs, and evaluate service standards. Key quality assurance services discussed include patient counseling, adverse drug reporting, and drug information. The document outlines methods for assessing these services, including performance appraisal, peer review, and clinical audit. It also evaluates patient counseling and quality assurance in drug information services.
This study analyzed 4,607 medical prescriptions from 63 health centers in Belo Horizonte, Brazil. The prescriptions were grouped as either internal (from municipal health centers) or external (from other facilities). The following were found:
1) On average, there were 2.4 drugs prescribed per consultation for both internal and external prescriptions.
2) 84.3% of internal prescriptions and 85.5% of external prescriptions provided no instructions for medication use. Information on dosage regimen was present in over 50% of prescriptions but varied between groups.
3) Generic drug names were specified for 51.9% of internal prescriptions but only 28.
This document describes an online academy and courses related to pharmaceutical care, clinical pharmacy, and healthcare management. It provides links to relevant journals and opportunities to become a user or co-author through emailing the contact. The academy aims to advance skills of pharmacists and healthcare professionals through education and research to improve health outcomes. Courses cover topics like drug information, clinical trials, patient care, and more with a practice-oriented methodology.
Therapeutic drug monitoring (TDM) involves measuring drug concentrations in body fluids to aid in drug prescribing and management. TDM enables assessment of drug efficacy and safety in different clinical settings and individualizes treatment regimens for optimal patient outcomes. Key aspects of TDM include understanding the relationship between drug concentrations and effects, defining therapeutic ranges, selecting target concentrations, and interpreting test results based on pharmacokinetic and patient factors. Proper sample collection and timing are important for accurate TDM interpretation and dosage adjustments.
The document discusses drug use evaluation (DUE), which is a systematic, criteria-based process for evaluating drug use and ensuring medications are used appropriately. It describes the DUE cycle, which involves planning, data collection, evaluation, feedback, interventions, and re-evaluation. The goals are to promote optimal medication therapy and ensure drug use meets standards of care. Key aspects of the DUE process include identifying drugs for study, designing the study, defining criteria, collecting and analyzing data, providing feedback, developing and implementing interventions, and re-evaluating drug use to determine if improvements were made.
Therapeutic drug monitoring measures drug concentrations in body fluids like plasma to help optimize drug dosage, enhance efficacy and reduce toxicity for certain drugs that have a narrow therapeutic range, variable pharmacokinetics between patients, or toxicity risks. The selection of drugs for monitoring considers factors like the relationship between concentrations and effects, an established target range, and availability of assays. Therapeutic drug monitoring aims to individualize treatment for patients based on their measured drug levels and clinical response.
This document provides an overview of therapeutic drug monitoring (TDM). It defines TDM as the measurement of drug concentrations in blood or plasma to guide dosage adjustments for effective and safe treatment. The goals of TDM are to ensure maximal therapeutic benefit and minimal toxicity by achieving appropriate drug concentrations at the site of action. Several factors can cause variability in individual drug response, including pharmacokinetic factors like absorption and clearance, as well as pharmacodynamic factors like genetic polymorphisms and drug interactions. TDM is indicated for drugs with a narrow therapeutic index, a lack of clinical endpoints, or significant inter-individual variability. It involves collecting samples at standardized times, measuring drug levels, and interpreting the results with clinical context to optimize individual patient dos
In Österreich sind die Unternehmen noch weit von einem „grünen“ Fuhrpark entfernt, haben aber schon etwas mehr in diese Richtung unternommen als deutsche Firmen: 47 Prozent können sich vorstellen, Fahrzeuge mit alternativem Antrieb anzuschaffen, 14 Prozent haben sie bereits in ihrer Firmenwagenflotte und 20 Prozent haben dies konkret geplant. Das sind die Ergebnisse einer Kienbaum-Umfrage – eine Kooperation zwischen Kienbaum Beratungen GmbH und dem Forum Personal des ÖPWZ, unter 246 österreichischen Firmen, deren Angaben in den „Firmenwagenreport 2016 - Österreich“ eingeflossen sind.
1. El documento describe los diferentes componentes de un sistema informático, incluyendo el hardware, software, humanware e infoware. 2. Explica los componentes principales de una computadora como la CPU, ALU, unidad de control, memoria y puertos USB. 3. Clasifica los periféricos en categorías como entrada, salida, almacenamiento y conectividad.
Este documento presenta un Plan Integrado de Intervención Sanitaria y Ambiental para la provincia de Espinar en Cusco. El plan propone evaluaciones ambientales y de salud en la zona para mejorar las condiciones del agua, suelo y salud de la población. Incluye planes de monitoreo del agua, suelos, salud humana y animal liderados por agencias como OEFA, ANA, MINSA y SENASA. El objetivo general es establecer las condiciones ambientales y de salud actuales y mejorarlas a trav
This document discusses drug utilization reviews (DUR), also known as drug utilization evaluations (DUE) or medication utilization evaluations (MUE). DURs involve comprehensive review of patient prescription and medication data before, during, and after dispensing to ensure appropriate medication decisions and positive outcomes. DURs aim to promote optimal medication therapy, prevent medication-related problems, evaluate medication effectiveness, improve patient safety, and stimulate improvements in medication use processes. The document also outlines the value of DUR programs in helping health systems understand and improve prescribing, administration, and medication use.
1. Drug Use Evaluation (DUE) is a performance improvement method that focuses on evaluating and improving medication use processes to optimize patient outcomes.
2. Clinical pharmacists can positively impact mortality rates through services like DUE, patient education, adverse drug reaction management, and participating on patient rounds.
3. The DUE process involves establishing criteria to evaluate medication use, collecting and analyzing data, developing and implementing improvement plans, and repeating the cycle for ongoing enhancements.
This document outlines the scope and objectives of a Pharmacotherapeutics course. The course will enable students to understand pathophysiology of common diseases and their drug-based management. It will cover topics like cardiovascular diseases, respiratory diseases, endocrinology and general prescribing guidelines. Assessment methods include theory exams, practicals, assignments and case presentations. The aim is to impart knowledge around rational drug use and individualized treatment plans.
This document is a resume for Nasim Sobhani, a pharmacy intern. It summarizes her education, including a Doctor of Pharmacy degree anticipated in 2015 from California Northstate University, as well as previous degrees. It also outlines her licenses, certificates, pharmacy practice experiences including APPEs and IPPEs, academic experience, work experience including as a clinical laboratory scientist, and professional memberships and honors.
Drug Utilization in a regulated EnviormentAlok Anand
Tracking drugs across the supply chain in a regulated environment. This white paper brief on would be drug utilization approach of Life Science Industry. This white paper is just a step forward to show future life science industry process automation
Franks_Know your patients_2Sep14_finalBilly Franks
This document discusses the importance of using patient registries alongside claims data and electronic health records for comparative effectiveness research. Sequencing of therapies and use of combination therapies can introduce biases if not properly accounted for. An example study on type 2 diabetes medications found some limitations in fully adjusting for severity factors. The document recommends that registries can help address gaps by collecting additional clinical data not found in other sources, and by assessing outcomes at standardized time points. Registries complement but cannot replace large claims/EHR data sources due to their more limited size and scope.
Introduction to Premarketing Phase
Limitation of Premarketing Phase and Importance of Phase IV period
Definition of DUS
History of DUS
Objectives of DUS
Types of Drug Use Information
Drug Utilization Cycle
The document discusses documenting clinical pharmacy services. It states that documenting activities is essential for providing services and involves recording patient information, interventions, workload statistics, and quality indicators. The objectives of documentation are to improve patient care, communicate with other providers, demonstrate pharmacist accountability and assess service quality. Clinical activities that should be documented include information in health records, departments records, interventions, and workload/performance indicators.
Clinical pharmacokinetics and its application--
1)definition
2) APPLICATIONS OF CLINICAL PHARMACOKINETICS
Design of dosage regimens:
a) Nomograms and Tabulations in designing dosage regimen,
b) Conversion from intravenous to oral dosing,
c) Determination of dose and dosing intervals,
d) Drug dosing in the elderly and pediatrics and obese patients.
Pharmacokinetics of Drug Interaction:
a) Pharmacokinetic drug interactions
b) Inhibition and Induction of Drug metabolism
c) Inhibition of Biliary Excretion.
Therapeutic Drug monitoring:
a) Introduction
b) Individualization of drug dosage regimen (Variability – Genetic, Age and Weight, disease, Interacting drugs).
c) Indications for TDM. Protocol for TDM.
d) Pharmacokinetic/Pharmacodynamic Correlation in drug therapy.
e) TDM of drugs used in the following disease conditions: cardiovascular disease, Seizure disorders, Psychiatric conditions, and Organ transplantations
Dosage adjustment in Renal and Hepatic Disease.
a. Renal impairment
b. Pharmacokinetic considerations
c. General approach for dosage adjustment in renal disease.
d. Measurement of Glomerular Filtration rate and creatinine clearance.
e. Dosage adjustment for uremic patients.
f. Extracorporeal removal of drugs.
g. Effect of Hepatic disease on pharmacokinetics.
Population Pharmacokinetics.
a) Introduction to Bayesian Theory.
b) Adaptive method or Dosing with feedback.
c) Analysis of Population pharmacokinetic Data
Monitoring the effectiveness of risk minimisation in patients treated with pi...Valeria Antonella Aguirre
1. BACKGROUND
2. OBJECTIVES
3. METHODS
3.1 SOURCE POPULATION AND STUDY POPULATION
3.2 STUDY DESIGN AND STUDY PERIOD
3.3 EXPOSURE
3.4 ENDPOINTS
3.5 ANALYSIS PLAN
4. LIMITATIONS
5. QUALITY ASSURANCE, FEASIBILITY AND REPORTING
5.1 DATA STORAGE
5.2 METHODS FOR QUALITY ASSURANCE
5.3 DATA QUALITY
5.4 FEASIBILITY AND TIMELINES
5.5 REPORTING AND DISSEMINATION OF RESULTS
5.6 AMENDMENTS
5.7 INDEPENDENT REVIEW OF STUDY RESULTS
6. ETHICAL ISSUES
7. DATA SOURCES
8. REFERENCES
This document outlines various aspects of quality assurance in pharmaceutical services including definitions, types of quality assurance services, methods of assessment, and evaluation techniques. It discusses patient counseling evaluation, audit types and cycles, and methods for monitoring quality at input, process, and output levels. The key aspects of quality assurance are ensuring quality of practice and services through performance appraisal, audit, and evaluating structures, processes, and outcomes of pharmaceutical activities.
Quality assurance of clinical pharmacy servicesvarshawadnere
This document discusses quality assurance in clinical pharmacy services. It defines quality assurance as ensuring quality of practice and outcomes. The main objectives are to ensure appropriate patient care, monitor medicine needs, and evaluate service standards. Key quality assurance services discussed include patient counseling, adverse drug reporting, and drug information. The document outlines methods for assessing these services, including performance appraisal, peer review, and clinical audit. It also evaluates patient counseling and quality assurance in drug information services.
This study analyzed 4,607 medical prescriptions from 63 health centers in Belo Horizonte, Brazil. The prescriptions were grouped as either internal (from municipal health centers) or external (from other facilities). The following were found:
1) On average, there were 2.4 drugs prescribed per consultation for both internal and external prescriptions.
2) 84.3% of internal prescriptions and 85.5% of external prescriptions provided no instructions for medication use. Information on dosage regimen was present in over 50% of prescriptions but varied between groups.
3) Generic drug names were specified for 51.9% of internal prescriptions but only 28.
This document describes an online academy and courses related to pharmaceutical care, clinical pharmacy, and healthcare management. It provides links to relevant journals and opportunities to become a user or co-author through emailing the contact. The academy aims to advance skills of pharmacists and healthcare professionals through education and research to improve health outcomes. Courses cover topics like drug information, clinical trials, patient care, and more with a practice-oriented methodology.
Therapeutic drug monitoring (TDM) involves measuring drug concentrations in body fluids to aid in drug prescribing and management. TDM enables assessment of drug efficacy and safety in different clinical settings and individualizes treatment regimens for optimal patient outcomes. Key aspects of TDM include understanding the relationship between drug concentrations and effects, defining therapeutic ranges, selecting target concentrations, and interpreting test results based on pharmacokinetic and patient factors. Proper sample collection and timing are important for accurate TDM interpretation and dosage adjustments.
The document discusses drug use evaluation (DUE), which is a systematic, criteria-based process for evaluating drug use and ensuring medications are used appropriately. It describes the DUE cycle, which involves planning, data collection, evaluation, feedback, interventions, and re-evaluation. The goals are to promote optimal medication therapy and ensure drug use meets standards of care. Key aspects of the DUE process include identifying drugs for study, designing the study, defining criteria, collecting and analyzing data, providing feedback, developing and implementing interventions, and re-evaluating drug use to determine if improvements were made.
Therapeutic drug monitoring measures drug concentrations in body fluids like plasma to help optimize drug dosage, enhance efficacy and reduce toxicity for certain drugs that have a narrow therapeutic range, variable pharmacokinetics between patients, or toxicity risks. The selection of drugs for monitoring considers factors like the relationship between concentrations and effects, an established target range, and availability of assays. Therapeutic drug monitoring aims to individualize treatment for patients based on their measured drug levels and clinical response.
This document provides an overview of therapeutic drug monitoring (TDM). It defines TDM as the measurement of drug concentrations in blood or plasma to guide dosage adjustments for effective and safe treatment. The goals of TDM are to ensure maximal therapeutic benefit and minimal toxicity by achieving appropriate drug concentrations at the site of action. Several factors can cause variability in individual drug response, including pharmacokinetic factors like absorption and clearance, as well as pharmacodynamic factors like genetic polymorphisms and drug interactions. TDM is indicated for drugs with a narrow therapeutic index, a lack of clinical endpoints, or significant inter-individual variability. It involves collecting samples at standardized times, measuring drug levels, and interpreting the results with clinical context to optimize individual patient dos
In Österreich sind die Unternehmen noch weit von einem „grünen“ Fuhrpark entfernt, haben aber schon etwas mehr in diese Richtung unternommen als deutsche Firmen: 47 Prozent können sich vorstellen, Fahrzeuge mit alternativem Antrieb anzuschaffen, 14 Prozent haben sie bereits in ihrer Firmenwagenflotte und 20 Prozent haben dies konkret geplant. Das sind die Ergebnisse einer Kienbaum-Umfrage – eine Kooperation zwischen Kienbaum Beratungen GmbH und dem Forum Personal des ÖPWZ, unter 246 österreichischen Firmen, deren Angaben in den „Firmenwagenreport 2016 - Österreich“ eingeflossen sind.
1. El documento describe los diferentes componentes de un sistema informático, incluyendo el hardware, software, humanware e infoware. 2. Explica los componentes principales de una computadora como la CPU, ALU, unidad de control, memoria y puertos USB. 3. Clasifica los periféricos en categorías como entrada, salida, almacenamiento y conectividad.
Este documento presenta un Plan Integrado de Intervención Sanitaria y Ambiental para la provincia de Espinar en Cusco. El plan propone evaluaciones ambientales y de salud en la zona para mejorar las condiciones del agua, suelo y salud de la población. Incluye planes de monitoreo del agua, suelos, salud humana y animal liderados por agencias como OEFA, ANA, MINSA y SENASA. El objetivo general es establecer las condiciones ambientales y de salud actuales y mejorarlas a trav
Este documento resume un curso taller sobre un nuevo decreto que regula los asentamientos en suelo no urbanizable en Andalucía. El curso fue organizado por el Colegio Oficial de Aparejadores, Arquitectos Técnicos e Ingenieros de Edificación de Málaga y contó con la participación de varios expertos. El curso incluyó una sesión de preguntas y respuestas moderada por la presidenta del colegio.
Este documento resume las diferencias entre el sistema educativo español y los sistemas británico y americano según un foro con directores de colegios extranjeros en Valencia. 1) Los sistemas británico y americano ponen más énfasis en el aprendizaje de idiomas, el desarrollo de habilidades prácticas y la autonomía de los estudiantes. 2) Estos sistemas usan más el "refuerzo positivo" y consideran las necesidades individuales de cada estudiante. 3) La directora general de educación valenciana qui
La Unión Europea ha acordado un paquete de sanciones contra Rusia por su invasión de Ucrania. Las sanciones incluyen restricciones a las transacciones con bancos rusos clave y la prohibición de la venta de aviones y equipos a Rusia. Los líderes de la UE esperan que las sanciones aumenten la presión económica sobre Rusia y la disuadan de continuar su agresión contra Ucrania.
El documento describe el Young Americas Business Trust (YABT), una organización internacional sin fines de lucro que trabaja con la OEA para desarrollar jóvenes emprendedores a través de programas de entrenamiento, liderazgo, tecnología y alianzas estratégicas. También describe la competencia TIC Américas, un acelerador empresarial para jóvenes menores de 36 años que presentan planes de negocios en sectores como ambiente, comercio y tecnología. Las ediciones 2007 y 2008 tuvieron más de 5,000 participantes
True Move provides iPhone support services in Thailand through its iPhone Care Center. The Center aims to deliver great customer experiences through innovation, high performance technical skills, and a productive workforce. It handles inbound and outbound customer service through various contact channels. True Move focuses on personalized service, proactive communication, and ensuring first call resolutions. It emphasizes recruitment, training, motivation, recognition and career development to engage its customer service agents. The Center meets or exceeds key performance metrics like service level agreements and achieves high customer satisfaction ratings.
El documento habla sobre el uso y evolución de las redes sociales. Explica que las redes sociales han existido desde siempre aunque han ido cambiando con el tiempo, pasando de comunicaciones cara a cara o por carta a comunicaciones a través de plataformas como Facebook, Twitter y otras. También describe las diferentes razones por las que las personas y empresas usan las redes sociales como mantenerse en contacto, compartir noticias e información, encontrar personas afines y promocionar marcas y eventos.
HSBC Ireland implemented eircom IP Networking to reduce costs for fax and telephony services. This resulted in a 79% reduction in international fax charges by hosting fax services in Dublin rather than Bermuda. Implementing IP Networking for external calls also reduced HSBC Ireland's phone bill by 29%. The network has provided reliable service with no required maintenance. HSBC Ireland plans to continue exploring cost savings opportunities through eircom IP Networking.
El documento define el aborto y explica sus diferentes tipos, incluyendo aborto espontáneo, inducido legal e ilegal. También discute los aspectos físicos y psicológicos del aborto y las etapas del proceso de sufrimiento por una pérdida.
Este documento presenta a UDAPI & Asociados, una firma especializada en propiedad industrial e intelectual fundada en 1896. Explica que ofrecen asesoramiento personalizado y de alta calidad en España y a nivel internacional a través de una red de corresponsales. También detalla los servicios y especializaciones que ofrecen en materia de patentes, marcas, derechos de autor y más.
On February 12, 2013, the Canada Mining Innovation Council held its 2nd Annual Signature Event, a mining conference bringing representatives from industry, government, academia, and other sectors together in Toronto to discuss the role of innovation in the industry's future. Through her presentation, Patricia Mohr, VP Economics & Commodity Market Specialist at Scotiabank, showed how innovation and cost control are linked to profitability.
Phase 1 of the idea challenge involves setting up the challenge. This includes defining goals, splitting the goals into manageable subquestions, and broadcasting the challenge to a private community on yutongo.com as well as a public community on yutongo.com through email, social media, and ads.
Phase 2 involves crowdsourcing creative content by having participants submit idea fragments in categories such as "Google" and "Bedtime Stories", which are then merged into complete ideas by other participants.
Phase 3 involves evaluating and managing the ideas that emerged from Phase 2. This includes sorting, selecting, and organizing the top ideas as well as searching for ways to improve them.
This document discusses persistent IU pacing, also known as Extended Distance FICON. It begins with legal disclaimers and an abstract. Then it provides an agenda and discusses the basics of persistent IU pacing, including what it is and is not. It explains sequences, open exchanges, and information units in FICON protocols. It discusses IU pacing and how persistent IU pacing functions to help avoid performance degradation over long distances by implementing a new pacing protocol. It notes the hardware requirements and discusses how IU pacing and persistent IU pacing work to control data flows.
Este documento presenta información sobre la educación de género y sexualidad en España a través de la historia. Explica cómo las nociones de sexo, género y orientación sexual han sido definidas y cómo afectan a la educación y desarrollo personal. También discute la importancia de enseñar sobre diversidad e inclusión para promover el respeto a los derechos humanos.
Almas y cuerpo en una tradición indigena tzeltal pedro pitarchEliandro Kienteca
Este documento describe las creencias sobre el alma de los tzeltales, un pueblo indígena de Chiapas, México. Los tzeltales creen que cada persona tiene tres partes del alma: 1) un pequeño pájaro alojado en el corazón que es responsable de los latidos, 2) un ch'ulel o alma principal alojada en el corazón y en una montaña sagrada, y 3) varios lab u otras entidades animicas. El documento explica las creencias sobre cada parte del alma y cómo estas afectan la vida y la
Winning Email Practices In Retail MarketingRichard Evans
The document discusses best practices for email marketing based on several studies. It found that registration and opt-in practices are key, such as placing opt-in options prominently and incentivizing opt-ins. For email creative, using branding, offers, incentives and tailored formats increased engagement. Sending emails at times tailored to individual open patterns increased revenue. Opt-out processes should be simple and confirm the action. Competitors are focusing on prominent opt-ins, easy sign-ups, confirmation messages, creative designs, and including sharing and discount details.
Herramienta Didactica para un Diganostico ReumatologicoHector Garcia Neri
Este documento describe un proyecto de investigación para desarrollar una herramienta didáctica automatizada llamada HDDR que guíe a estudiantes de medicina en el diagnóstico de afecciones reumáticas utilizando la experiencia de un experto en reumatología. Actualmente no existen software especializados para diagnósticos reumatológicos. El proyecto busca aplicar inteligencia artificial para proveer diagnósticos confiables basados en la experiencia humana y mejorar la enseñanza médica.
Diabetic nursing visits for better A1C control in patients Discussion.pdfsdfghj21
Diabetic nursing visits can help improve A1C control in patients through education on lifestyle changes, diet, medications, and monitoring. Studies have found uncontrolled diabetes leads to complications like eye, kidney and cardiovascular issues. Nurses play an important role in helping patients manage their diabetes tighter through regular visits focused on glycemic control.
AbstractBackground Hypertension is the most common non-.docxbartholomeocoombs
Abstract
Background:
Hypertension is the most common non-communicable disease and the leading cause of cardiovascular disease in the world. Current management of hypertension stressed the importance of salt and diet modifications. Unfortunately, many hypertensive patients do not have proper knowledge of this, which results to inadequate practice. Therefore, there is need to develop strategies that will help to improve knowledge and practice of salt and diet modifications among hypertensive.
Objective
: To determine the effect of nursing intervention on knowledge and practice of salt and diet modifications among hypertensive patients.
Materials and Methods
: A quasi experimental design was conducted using purposive sampling to select the sample size of 38 participants. A researcher-developed questionnaire derived from the literature review and Hypertension Self-Care Activity Level Effects (H-SCALE) adapted from Warren-Find low and Seymour (2011) was used to measure knowledge and practice of salt and diet modification among the participants. Data gathered from participants were expressed using tables and percentages while research questions were answered with descriptive statistics of mean and standard deviation through statistical package for the social science software version 21.
Results
: the study revealed that higher percentage of the participants (81.6%) had poor of knowledge of salt and diet modification pre-intervention, also 92.1% of the participants reported poor practice before intervention. Intervention was given to the participants and results showed a positive change in knowledge and practice of salt and diet practice post-intervention.
Conclusion
: regular training should be given to hypertensive patients by nurses to improve their knowledge and practice of salt and diet modification for effective blood pressure control.
Keywords
:
Hypertension, Knowledge, Practice, Salt and Diet modification, Nigeria
Introduction
The burden of hypertension and other noncommunicable diseases is rapidly increasing and this poses a serious threat to the economic development of many nations. Hypertension is a global public health challenge due to its high prevalence and the associated risk of stroke and cardiovascular diseases in adults.
Globally, hypertension is implicated to be responsible for 7.1 million deaths and about 12.8% of the total annual deaths (World Health
Organization (WHO), 2018). Africa, among other WHO regions was rated highest with increased prevalence of high blood pressure, estimated at 46% from age 25 years and above in which Nigeria contributes significantly to this increase (Okwuonu, Emmanuel, & Ojimadu 2014; Ekwunife, Udeogaranya, & Nwatu, 2018; WHO, 2018). This is so in spite of the availability to safe and potent drugs for hypertension and existence of clear treatment guidelines, hypertension is still grossly not controlled in a large proportion of.
This summarizes the outcomes of a 6-month pharmacist-provided diabetes management program for employees of the City of Toledo. The program showed improvements in clinical outcomes like A1c and blood pressure. It also improved humanistic outcomes such as patient satisfaction, knowledge, and adherence. Economic outcomes like healthcare utilization and costs improved as well, with a 62.69% reduction in total costs. The study demonstrates positive short-term outcomes across clinical, humanistic and economic domains from a pharmacist-led diabetes management program.
Malnutrition is common in cancer patients, affecting 40-80% during their disease course. It negatively impacts treatment outcomes, mortality, and quality of life. Early screening and nutritional interventions can help prevent weight loss and treatment interruptions. A multidisciplinary team approach is needed to address nutritional status from diagnosis onward through cancer treatment. Screening tools help identify at-risk patients who need comprehensive assessment and individualized nutritional support through diet, oral supplements, enteral feeding, or parenteral nutrition as needed. Exercise should also be encouraged to preserve muscle mass. Prioritizing nutritional care represents good clinical practice that can optimize cancer treatment.
Case management involves coordinating healthcare services for people with diabetes. The Task Force found strong evidence that diabetes case management improves glycemic control. Case management includes appointing a case manager to oversee services, assessing needs, developing care plans, implementing plans, and monitoring results. A review of 15 studies found case management reduced average HbA1c levels by 0.53% when combined with disease management and 0.40% without it. However, the evidence was insufficient to determine the effectiveness on other health outcomes.
This document outlines several diabetes risk reduction programs:
1. A quality improvement program at community health centers that significantly improved processes of care for diabetes and asthma but not outcomes.
2. A lifestyle intervention program and metformin treatment that both reduced incidence of type 2 diabetes, with lifestyle changes proving more effective.
3. A study finding that increased colonic propionate reduced brain responses to high-calorie foods and led to less food appeal and calorie intake.
4. A nutrition education program tailored for low-literacy adults that significantly improved fat-related knowledge and behaviors over general nutrition classes.
5. An online health promotion program for older workers that significantly improved diet and exercise self-effic
The document provides an overview of clinical pharmacy, including its definition, development, scope, and the functions and responsibilities of clinical pharmacists. It discusses key aspects of clinical pharmacy practice such as medication chart review, clinical review, pharmacist intervention, ward round participation, medication history, and pharmaceutical care. The summary is as follows:
Clinical pharmacy deals with the safe and effective use of drugs in patient care. It aims to optimize medication use and promote health. Clinical pharmacists are involved in medication monitoring, patient education, and ensuring rational drug therapy.
Key responsibilities of clinical pharmacists include collecting patient data, identifying drug-related problems, establishing treatment goals, evaluating and modifying drug regimens, and monitoring treatment outcomes.
Alive pd protocol and descriptive paperGladys Block
Alive-PD is a fully automated tailored diabetes prevention program. This journal article describes its features, and describes the protocol of the randomized controlled trial.
Alive-PD protocol and descriptive paperGladys Block
The document describes a randomized controlled trial protocol to evaluate the effectiveness of a fully automated 1-year diabetes prevention program called Alive-PD. 340 subjects with pre-diabetes were randomized to either the Alive-PD intervention group (n=164) or a delayed-entry control group (n=176). The primary outcomes are changes in HbA1c and fasting glucose levels from baseline to 6 months. Secondary outcomes include changes in additional biometric measures at 3, 6, 9, and 12 months. The intervention involves weekly tailored goal setting, challenges, and other online interactions to encourage diet and physical activity changes to prevent diabetes progression. The trial will provide evidence on the efficacy of this web-based program in reducing gly
This document provides guidelines for clinical nutrition in the intensive care unit (ICU) developed by an expert panel. It defines key aspects of nutritional support for critically ill patients such as assessing nutritional status, determining energy needs, choosing the route of nutrition (enteral vs parenteral), and adapting support for various clinical conditions. Special conditions like trauma, surgery, and sepsis are also addressed. The guidelines aim to provide evidence-based recommendations to optimize nutritional therapy and identify gaps in knowledge to guide future research.
This document provides guidelines for clinical nutrition in the intensive care unit (ICU) developed by an expert panel. It defines key aspects of nutritional support for critically ill patients such as assessing nutritional status, determining calorie and protein needs, choosing an enteral or parenteral route, and adapting support for various clinical conditions. Special conditions like trauma, surgery, and sepsis are also addressed. The guidelines aim to provide best practices for nutritional therapy and identify gaps in knowledge to help guide future research.
This document provides guidelines for clinical nutrition in the intensive care unit (ICU) developed by an expert panel. It defines key aspects of nutritional support for critically ill patients such as assessing nutritional status, determining calorie and protein needs, choosing an enteral or parenteral route, and adapting support for various clinical conditions. Special conditions like trauma, surgery, and sepsis are also addressed. The guidelines aim to provide evidence-based recommendations to optimize nutritional therapy and identify gaps requiring further research.
This document provides guidelines from the European Society for Clinical Nutrition and Metabolism (ESPEN) on clinical nutrition for patients in the intensive care unit (ICU). It defines who is at nutritional risk, how to assess a patient's nutritional status, how to determine energy needs, and the appropriate route (enteral vs parenteral) and progression of nutrition support. Recommendations are given for the amount and composition of macronutrients (carbohydrates, fat, protein) to provide. Special clinical situations like dysphagia, trauma, sepsis, and obesity are also addressed. The guidelines aim to guide practitioners in providing optimal evidence-based medical nutrition therapy to critically ill patients.
1601Rev Bras Enferm. 2019;72(6)1601-8. httpdx.doi.org10.1.docxaulasnilda
1601Rev Bras Enferm. 2019;72(6):1601-8. http://dx.doi.org/10.1590/0034-7167-2018-0731
ABSTRACT
Objective: to evaluate the contributions of an educational program for capillary blood
glucose self-monitoring. Method: a quasi-experimental study performed in an outpatient
unit of a tertiary health care service in a sample of 25 people with Type 2 Diabetes Mellitus,
from July 2016 to December 2017, developed through interactive tools for care with
capillary blood glucose self-monitoring. Results: among the items of capillary blood
glucose self-monitoring that showed improvement after participation in the educational
program, the most noteworthy are the “postprandial blood glucose values” (p=0.0039),
“Interpretation of capillary blood glucose results with meals and medications” (p=0.0156),
“recognition of the ‘weakness’ symptom for hyperglycemia” (p=0.0386) and “administration
of medications correctly” for hyperglycemia prevention (p=0.0063). Conclusion: the study
made it possible to recognize the main characteristics of blood glucose self-monitoring that
may contribute to the care for the person with diabetes.
Descriptors: Diabetes Mellitus; Health Education; Blood Glucose Self-Monitoring; Self-
Care; Nursing Care.
RESUMO
Objetivo: avaliar as contribuições de um programa educativo para a automonitorização da
glicemia capilar. Método: estudo quase-experimental, realizado em unidade ambulatorial de
um serviço de atenção terciária à saúde, em amostra de 25 pessoas com Diabetes Mellitus tipo
2, no período de julho de 2016 a dezembro de 2017, desenvolvido por meio de ferramentas
interativas para o cuidado com a automonitorização da glicemia capilar. Resultados: entre os
itens da automonitorização da glicemia capilar que apresentaram melhora após a participação
no programa educativo, destacam-se os “valores da glicemia pós-prandial” (p=0,0039),
“interpretação dos resultados de glicemia capilar com as refeições e medicamentos” (p=0,0156),
“reconhecimento do sintoma ‘fraqueza’ para a hiperglicemia” (p=0,0386) e “administração de
medicamentos corretamente” para prevenção da hiperglicemia (p=0,0063). Conclusão: o
estudo possibilitou reconhecer as principais características da automonitorização da glicemia
que poderão contribuir para o cuidado à pessoa portadora da doença.
Descritores: Diabetes Mellitus; Educação em Saúde; Automonitorização da Glicemia;
Autocuidado; Cuidados de Enfermagem.
RESUMEN
Objetivo: evaluar las contribuciones de un programa educativo para la automonitorización de
la glucemia capilar. Método: el estudio cuasi-experimental, realizado en unidad ambulatoria
de un servicio de atención terciaria a la salud, en muestra de 25 personas con Diabetes
Mellitus tipo 2, en el período de julio de 2016 a diciembre de 2017, desarrollado por medio de
herramientas interactivas para el cuidado con la automonitorización de la glucemia capilar.
Resultados: entre los ítems de la automonitorización de la glucemia capilar que ...
This document describes a quality improvement project to improve blood glucose management for inpatient diabetic patients through better coordination of meal delivery, blood glucose monitoring, and insulin administration. The intervention implemented signage to increase communication between dietary staff, nurses, and patients about meal tray arrival times. Data was collected before and after the intervention on whether nurses were aware of meal times and administered insulin within 15 minutes. Results found a statistically significant improvement, with known meal times increasing by 13.7% and standards being met 17.3% more often after the intervention through improved communication.
In this slides included clinical pharmacy introduction and pharmaceutical care, also explanation about the goals and objectives of the clinical pharmacy requirements
This study conducted a meta-analysis of 8 randomized controlled trials comparing the efficacy and safety of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) to insulin in inadequately controlled type 2 diabetes patients. The analysis found that compared to insulin, GLP-1 RAs resulted in greater reductions in HbA1c, weight, and fasting plasma glucose, as well as lower rates of hypoglycemia. However, GLP-1 RAs were associated with higher rates of gastrointestinal adverse events. The study concludes that GLP-1 RAs are promising agents compared to insulin, but more long-term trials are needed to fully evaluate their effectiveness and safety.
CLINICAL INQUIRIES From theFamily PhysiciansInquiries Networ.docxclarebernice
This study explored how patients' explanatory models of hypertension and their social contexts relate to reported daily hypertension self-management behaviors through qualitative interviews. The researchers found that patients' perceptions of the cause and course of hypertension, experiences of hypertension symptoms, and beliefs about treatment effectiveness related to different self-management behaviors. Additionally, patients' daily lived experiences like an isolated lifestyle, serious competing health issues, lack of routines, barriers to exercise, and lifestyle priorities interfered with optimal management. The study proposes a new conceptual model that incorporates explanatory models and daily experiences to improve understanding of self-management behavior.
This document summarizes a study that evaluated whether restricting dietary advanced glycation end products (AGEs) could significantly improve markers of non-alcoholic fatty liver disease (NAFLD). The study simulated patient data to analyze the effects of a low-AGE and high-AGE diet. Most markers did not change as expected, and the conclusion was that dietary restrictions did not significantly improve NAFLD patient health. Suggestions for future studies included analyzing marker correlations and providing standardized diets.
Similar to Pharmaceutical interventions in metabolic and nutritional follow-up of surgical patients receiving parenteral nutrition (20)
Este documento resume la actualización de 2019 de las guías para el tratamiento antirretroviral. Revisa los objetivos del tratamiento, los parámetros para monitorear la respuesta como los linfocitos CD4 y la carga viral, y las recomendaciones para el tratamiento inicial incluyendo iniciar el tratamiento para todos los pacientes con VIH y utilizar una combinación de tres fármacos que incluya dos inhibidores nucleosídicos de la transcriptasa inversa más un inhibidor no nucleosídico de la transcriptasa inversa o un inhibidor de la proteasa potenciado
El documento compara las diferencias entre el nuevo potenciador farmacocinético Cobicistat y el potenciador Ritonavir. Cobicistat es un inhibidor más selectivo del CYP3A4 y un inhibidor débil de CYP2D6, mientras que Ritonavir es un inhibidor no selectivo del CYP3A4 e inductor de otras isoformas del CYP. Esto significa que Cobicistat tiene menos probabilidades de interacciones farmacológicas que Ritonavir.
Este documento presenta tres puntos clave sobre el punto de vista del farmacéutico en relación con el tratamiento antirretroviral (TARV) desde una perspectiva de coste-eficacia:
1) Existen múltiples combinaciones posibles para el TARV inicial con diferentes costes, por lo que es importante evaluar la eficiencia de cada opción.
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Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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Pharmaceutical interventions in metabolic and nutritional follow-up of surgical patients receiving parenteral nutrition
1. ORIGINALES
Pharmaceutical interventions in metabolic
and nutritional follow-up of surgical patients
receiving parenteral nutrition
J. Llop-Talaverón, B. Gracia-García, J.J. Machí-Ribes, M. Perayre-Badia, M.B. Badia-Tahull
y R. Jódar-Masanes
Servicio de Farmacia. Hospital Universitari de Bellvitge-IDIBELL. L’Hospitalet de Llobregat. Barcelona. España.
Resumen
Objetivo: Evaluar un protocolo de control de las alteraciones de los
parámetros metabólicos en el contexto de un programa de atención
farmacéutica dirigido a pacientes quirúrgicos con nutrición parenteral, a través del impacto de las intervenciones farmacéuticas en las
complicaciones metabólicas asociadas.
Metodo: Estudio prospectivo de intervención de 2 meses de duración. Se estudia a pacientes quirúrgicos con nutrición parenteral.
Como variables de estudio se incluyen los parámetros bioquímicos
predefinidos en el perfil metabólico-nutricional. Se establecen 4 categorías para clasificar el grado de alteración de cada parámetro:
a) sin complicación; b) alteración no asociada con complicación;
c) complicación moderada, y d) complicación grave. El tipo de intervención del farmacéutico se realiza mediante intervención directa o
consejo. Las diferencias estadísticamente significativas entre los valores medios de los valores de los parámetros analíticos previos y posteriores a la intervención farmacéutica se establecen con pruebas paramétricas y no paramétrica (p < 0,05).
Resultados: Se evaluaron 1055 parámetros correspondientes a
44 pacientes. En total, 239 (22,6%) presentaron alteración, lo que
correspondió a 162 complicaciones (para definir algunas complicaciones se utiliza más de un parámetro), de las cuales 93 (57,4%) se
intentaron corregir mediante intervención directa y 16 (9,9%),
mediante consejo. Los resultados mostraron diferencias estadísticamente significativas o una tendencia hacia la significación cuando el
objetivo de la intervención directa fue incrementar la albúmina, la
prealbúmina, el potasio y el fosfato, y disminuir la PCR, la glucosa y
los triglicéridos. Cuando no se realizó ninguna intervención no se en-
El trabajo ha sido comunicado previamente en el 35th European Symposium
on Clinical Pharmacy (Viena Octubre 2006) en formato poster.
Correspondencia: Josep Llop Talaverón.
Servicio de Farmacia. Hospital Universitari de Bellvitge.
Feixa Llarga, s/n. 08197 Hospitalet de Llobregat. Barcelona. España.
Correo electrónico: josep.llop@csub.scs.es
Recibido: 04-01-08
216
Aceptado: 03-04-08
Farm Hosp. 2008;32(4):216-25
contraron diferencias significativas o con tendencia hacia la significación.
Conclusiones: A pesar de que los parámetros evaluados pueden estar influidos por otros factores ajenos al tratamiento con nutrición parenteral, los resultados de este estudio indican que el seguimiento
sistemático de éstos puede ser un método eficaz para conseguir el
éxito de la terapia nutricional, tanto en la mejora del estado nutricional como en la prevención y el control de las complicaciones asociadas.
Palabras clave: Nutrición parenteral. Estudio de seguimiento. Atención farmacéutica.
Abstract
Purpose: To assess a control protocol concerning alterations in metabolic follow-up parameters in the context of a pharmaceutical care
program designed for surgical patients receiving parenteral nutrition,
through determination of the impact of pharmaceutical interventions
on associated metabolic complications.
Methods: Prospective interventional study of two-months’ duration
performed in surgical patients receiving parenteral nutrition. The
study variables included predefined biochemical parameters within
the metabolic-nutritional profile. Four categories were established to
classify the degree to which each parameter was altered: a) no alteration (within normal range); b) alteration with no associated complication; c) moderate complication, and d) severe complication. The
type of pharmaceutical intervention carried out included a direct intervention on their part or a recommendation. Statistical differences
between the mean analytical values before and after the intervention
were assessed by parametric and non-parametric tests (P<.05).
Results: A total of 1055 analytical determinations corresponding to
44 patients were evaluated. Among them, 239 determinations
(22.6%) presented some degree of alteration which corresponded to
162 complications. Complication is often defined whit more than
one parameter. Ninety-three (57.4%) corrective interventions were
carried out by direct intervention and 16 (9.9%) by recommendation.
2. Llop-Talaverón J et al. Pharmaceutical interventions in metabolic and nutritional follow-up of surgical patients receiving parenteral nutrition
The results showed statistically significant differences or significant
trend when the purpose of the pharmaceutical direct intervention
was to increase albumin, prealbumin, potassium or phosphate levels
or to decrease C-reactive protein, glucose or triglycerides. Significant
differences or significant trend were not seen when no intervention
was performed.
Conclusion: Despite the fact that the parameters assessed may have
been influenced by factors other than the parenteral nutrition treatment received, our findings show that systematic monitoring of specific analytic parameters can be effective for attaining success in nutritional therapy, in terms of improvement in nutritional status and
prevention and control of associated complications.
Key words: Parenteral nutrition. Follow-up study. Pharmaceutical care.
INTRODUCTION
Therapy with parenteral nutrition (PN) can be complex because
of the characteristics and amount of nutrients administered, and
the type of patients that are candidates for this treatment. With
the progressive advances in enteral nutrition, the use of PN has
become restricted to severely ill patients, generally with acute
processes. These patients can present problems in assimilating
nutrients and are often in a hypercatabolic state with intense proteolysis, hydroelectrolytic imbalance and organ dysfunction that
compromises normal metabolic function; hence, nutritional
management of these patients is difficult1.
The preparation of PN is handled by the hospital Pharmacy
Department because of the requirements of sterility and the complexity of the formulations. Over the years and coinciding with
advances in Clinical Pharmacy, the hospital pharmacist has become increasingly more implicated in the development of guidelines and protocols, as well as other health care activities in the
field of nutrition2,3.
Automation of the formulation processes and systems for dispensing treatment, as well as data integration into computer networks (e.g., clinical and analytical reports, pharmacological
treatment administered) facilitate continuous information exchange and enhance the development of evidence- and efficiency-based clinical interventions in this area: that is, pharmaceutical care4,5.
In practice, pharmaceutical care implies the establishment of
protocols, work flow-charts, and methods for recording the interventions applied, in order to assess the activity in terms of
health benefits, reduce variation in the patients’ clinical response, and generate information that will promote continuing
improvement in the care provided.
The Parenteral Nutrition Unit of our Pharmacy Department
(PNU) have a set of action procedures and protocols, such as nutritional assessment of PN candidates, caloric requirement analyses, the registry, follow-up and prevention of catheter-related
complications, the surveillance of the nutritional treatment adherence and the registry of events derived from PN administration.
In total PN nutritional support multidisciplinary teams must
provide a high quality nutritional assistance based on evidence
and daily follow-up of patients with total PN6. In a general context, the PNU is part of a multidisciplinary team which includes
endocrines, nutritionists, ICU attendings and surgeons. The
PNU actively participates in nutritional design (protocols and
guides), nutritional assessment (with its own programme), formulae selection, monitoring and follow-up. In surgical services,
the surgeon prescribes the initial PN. From the PNU, the indication of the parenteral support is evaluated and according to nutritional assessment the initially composition is discussed and adjusted during therapy according to clinical and metabolic data.
The Endocrinology and Dietetic Services, in charge of the Nutritional Unit, are responsible for the transition to oral or enteral
diet and the nutritional follow-up of patients with long evolution
artificial nutrition.
In this study we present a control protocol concerning alterations in metabolic follow-up parameters in the context of a pharmaceutical care program for surgical patients receiving PN, developed in the Parenteral Nutrition Unit of the Pharmacy Department
with the aim of standardizing, systematizing, and documenting interventional pharmaceutical activity in the hospital setting for patients at a certain level of complexity. The pharmaceutical care
program is assessed by determining the impact pharmaceutical interventions have on the patients’ metabolic complications.
METHOD
This is a prospective, interventional study of two months’duration.
Hospitalized patients receiving PN in the General Surgery and
Gastrointestinal Surgery Units during the months of October and
November 2005 were included. Patients referred from intensive
care units and patients with incomplete records were excluded.
The PN protocol of our unit standardizes the nutritional formulas prescribed depending on the patient’s anthropometric
characteristics, degree of hypercatabolism and clinical status.
Based on the underlying diagnosis, indication, and the patient’s
clinical condition, the physician prescribes the most appropriate
Table 1. Analytic parameters evaluated
Function measured
Parameter assessed
Kidney function
Plasma creatinine and urea
Liver function
gamma-glutamyltransferase (GGT), alkaline
phosphatase (AP), alanine-aminotransferase
(ALT), total bilirubin (Bb)
Synthesis-inflammation
Albumin, prealbumin and C-reactive protein
(CRP)
Substrate metabolism
Glucose and triglycerides
Electrolytes
Sodium, potassium, magnesium,
phosphates, calcium, chloride
Farm Hosp. 2008;32(4):216-25
217
3. Llop-Talaverón J et al. Pharmaceutical interventions in metabolic and nutritional follow-up of surgical patients receiving parenteral nutrition
Table 2. Protocol for interventions in metabolic follow-up
Parameter
(normal range)
Degree of alteration
Intervention
Assess
Albumin
(35-50 g/L)
Moderate complication: 25-35 g/L
Severe complication: < 25 g/L
Increase nitrogen supply (N) in PN
Add 50 mL glutamine (2 g N) in PN
Add 100 mL glutamine(4 g N) in PN
Degree of stress
Estimated start of oral intake
Administration intravenous albumin
Prealbumin level
Prealbumin
(21-41 mg/dL)
Moderate complication: 15-20 mg/dL
Severe complication: <15 mg/dL
Increase nitrogen supply (N)
Add 50 mL glutamine (2 g N) in PN
Add 100 mL glutamine(4 g N) in PN
Degree of stress
Estimated start of oral intake
Patient has sepsis or polytrauma
RF
Glucose
Alteration: 6.9-7.8 mmol/L
(4.1-6.9 mmol/L) Moderate complication:
7.8-10, or 3-4 mmol/L
Severe complication: >10 or <3 mmol/L
Hyperglycemia >10 Reduce glucose supply PN
Hyperglycemia >7.8 and <10 Reduce glucose supply
PN if caloric requirements covered
Severe hypoglycemia Administer dextrose 10% solution
+ potassium
Monitor plasma glucose
Hypercatabolism
Correct insulin dosage
Fluid therapy (extra supply)
Triglycerides
(≤ 2.3 mmol/L)
Alteration: 2.3-3 mmol/L
Moderate complication: 3-5 mmol/L
Severe complication:> 5 mmol/L
Hypertriglyceridemia >5
Eliminate PN lipids and increase glucose
Hypertriglyceridemia >3 and <5:
Reduce PN lipid supply
Assess switch from LCT to MCT/LCT
Reduce PN lipid supply on alternate days
Liver function
Pancreatitis
RF, sepsis or elevated plasma
glucose levels
Treatment with corticoids,
cyclosporine, heparin or propofol.
CRP (≤ 5 mg/L)
Alteration: 5-100 mg/L
Moderate complication: 100-200 mg/L
Severe complication: > 200 mg/L
Use immunomodulators
Glutamine (100 mL) in PN: patient has
hypercatabolism and/or inflammation (CRP>200)
and/or intestinal failure
ω-3 FA (100 mL) in PN: patient critical and
inflammatory states (CRP>50)
CRP 50-200: Add 50 mL ω-3 FA
CRP>200: Add 100 mL ω-3 FA
Prealbumin and nitrogen balance
RF or liver disease
Urea
Moderate complication: 8.6-15 mmol/L
(3.6-8.6 mmol/L) Severe complication: > 15 mmol/L
Acute RF, not under dialysis:
Reduce PN supply of nitrogen, lipids and ions.
Use histidine-rich essential amino acids
Acute RF, under dialysis:
Adjust nitrogen supply with pattern of high biological
value
Decrease lipid supply
Extrarenal uremia, due to excess supply. Reduce
nitrogen
Cause is renal, extrarenal or
iatrogenic
If creatinine values are normal:
liver function, bleeding, diet protein
intake
Creatinine
Alteration: 111-200 mmol/L
(≤ 111 µmmol/l) Moderate complication: 200- 500mmol/L
Severe complication: > 500 mmol/L
Acute RF, not under dialysis: Same criteria as urea
Acute RF, under dialysis: Same criteria as urea
Patient under dialysis or not? If yes,
intermittent or continuous?
Hepatic
dysfunction
GGT, AP, ALT and bilirubin to
Severe cholestatic jaundice:
Alteration: Mild hepatic dysfunction
calculate degree of hepatic
Lipids with low phytosterol content.
(GGT ≥ 3.5or FA ≥ 4.5) +(BIL ≤ 25 +
dysfunction
Reduce PN lipid supply.
ALT ≤ 0.83)
Assess switch LCT to MCT/LCT.
Moderate complication: Moderate hepatic
Reduce PN lipid supply to alternate days.
dysfunction (GGT ≥ 3.5 or FA ≥ 4.5) +
Eliminate PN lipids and increase glucose.
(BIL ≤ 25 + ALT ≥ 0.83)
Hepatic encephalopathy: Aromatic amino acids reduction
Severe complication: Severe cholestatic
jaundice (GGT ≥ 3.5 or FA ≥ 4.5)+ BIL ≥ 25 and adjust nitrogen
(Continued)
218
Farm Hosp. 2008;32(4):216-25
4. Llop-Talaverón J et al. Pharmaceutical interventions in metabolic and nutritional follow-up of surgical patients receiving parenteral nutrition
Table 2. Protocol for interventions in metabolic follow-up (Continuation)
Parameter
(normal range)
Degree of alteration
Sodium
Alteration: 130-134 mEq/L
(135-147 mEq/L) Moderate complication: 120-130 or
147-150 mEq/L
Severe complication: <120 or ≥ 150 mEq/L
Intervention
Assess
Dilutional hyponatremia: Restrict fluids
Hyponatremia due to loss: Replace sodium
Hypernatremia: control supply
Calculate plasma osmolarity
Assess renal function
Hydric balance
Modify dose according to criteria:
Potassium
Alteration: 4.7-5.2 mmol/L
K+
(3.5-4.7 mmol/l) Moderate complication: 2.5-3.5 mmol/L
Supply(mEq/L)
Severe complication: > 5.2 or < 2.5 mmol/L
< 2.9
80
Hyperpotassemia ≥ 5.2
3-3.4
60
Hypopotassemia ≤ 3.6
3.5-4.7 40
4.8-5.2 20
> 5.2
0
Hyperpotassemia:
Rule out RF, hyperglycemia,
hypoaldosteronism
Control potassium supply by
alternative options other than PN
Control diuretic use
Magnesium
Alteration: 1-1.66 mmol/L
(0.625-1 mmol/L) Moderate complication: 0.42-0.625
or 1.66-5.2 mmol/L
Severe complication: < 0.42 or
> 5.2 mmol/L
Hypermagnesemia ≥1:
Decrease magnesium supply
Hypomagnesemia ≤ 0.625.
Increase magnesium supply
True calcium
Alteration: 2.15-2.2 or 2.54-2.6 mmol/L
(2.2-2.54 mmol/L) Moderate complication: 1.88-2.15
or 2.6-3.25 mmol/L
Severe complication: < 1.88 or
> 3.25 mmol/L
Hypercalcemia ≥ 2.6:
Decrease calcium supply
Hypocalcemia ≤ 2.15.
Increase calcium supply
True total calcium
True total = (43 -albumin (g/L))*
0.0204 + calcium (mmol/L)
Phosphate
Alteration: 0.7-0.85 mmol/L
(0.85-1.5 mmol/L) Moderate complication: 0.3-0.7 or
>1.5 mmol/L
Severe complication: ≤ 0.3 or > 2 mmol/L
Hyperphosphatemia > 1.55.
Decrease phosphate supply
Hypophosphatemia: Increase phosphate supply
Hyperphosphatemia: RF
Hypophosphatemia: refeeding
syndrome, glucose supply
Chloride
Hyperchloremia ≥ 116
(98-116 mmol/L) Hypochloremia ≤ 98
Hyperchloremia ≥ 116: Decrease cloride supply
Hypochloremia ≤ 98: Increase chloride supply
Hyperchloremia: Metabolic acidosis
ALT: Alanine aminotransferase, AP: Alkaline phosphatase, CRP: C-reactive protein, GGT: Gamma glutamyltransferase, LCT: Long-chain triglycerides, MCT: Medium-chain triglycerides, PN: Parenteral nutrition,
RF: Renal failure, ω-3 FA: omega-3 fatty acids.
formula to start nutritional support, according to the hospital
protocol. This protocol does not establish the amino acid and
lipid patterns or set exact amounts of nutrients; instead, it establishes ranges. Once nutritional therapy is started, clinical and
metabolic follow-up of the patient is performed up to completion
of treatment. For this purpose, the Parenteral Nutrition Unit requests weekly determination of the patient’s analytical and nutritional profile, and, if is deemed necessary, the pharmacist assesses, adjusts and modifies the composition of the PN formula
according to the patient’s metabolic status.
Several parameters that are predefined in the general protocol
are recorded in the weekly monitoring of metabolic profile (table 1). Four categories were defined to classify the degree of alteration of each parameter: a) no alteration: The value falls within the normal analytical range; b) alteration: the value is outside
the normal range, but is considered to have no clinical relevance
within the context of the patient’s condition; c) moderate com-
plication: the value lies outside the normal range with potential
clinical consequences, considered to be moderate in nature, and
d) severe complication: the value for the parameter is outside the
normal range, with potential clinical consequences considered to
be severe in nature.
The type of intervention pharmacists initiated was a direct intervention on their part, or a recommendation. In cases in which
the pharmacist acted directly, formula is modified according to
the decision algorithm and analytic values. Recommendations to
prescribing physicians were carried out in a therapeutic monitoring context already implemented in our service, which includes
electronic recordings (unitary doses programme) of the recommendations, its acceptance and impact.
For the analysis of the results, the analytical parameters have
been grouped into 5 categories: electrolytes, liver function markers, kidney function markers, substrate metabolism, and synthesis-inflammation (table 1).
Farm Hosp. 2008;32(4):216-25
219
5. Llop-Talaverón J et al. Pharmaceutical interventions in metabolic and nutritional follow-up of surgical patients receiving parenteral nutrition
To standardize the pharmaceutical care provided for a metabolic alteration, a protocol or decision algorithm was designed
based on clinical evidence and clinical practice guidelines (table 2). This protocol is an essential tool to assure that the activity is reproducible and to optimize the efficiency of the process.
To assess the impact of pharmaceutical interventions on metabolic complications, differences in the mean analytical values
before and after the intervention were analyzed using a parametric test (t-test) and a non-parametric test (Wilcoxon t-test). The
statistical analysis was done with SPSS, version 13.0, and significance was set at a P-value of <0.05.
RESULTS
The study included 44 patients. Demographic characteristics are
described in table 3. A total of 2011 analytical values were
recorded for the parameters studied. Among them, 1055 were
matched results from before and after the pharmaceutical intervention and these were selected for evaluation.
The determinations considered for the analysis were classified
according to the complication and the type of corrective pharmaceutical intervention carried out (table 4). Among the parameters
studied, 239 (22.6%) presented some degree of alteration, which
represented 162 complications in 40 patients, some complications are defined with more than one altered parameter. Following evaluation of the analytical results, estimation of when oral
Table 3. Demographic characteristics
Sex
Men
Women
Mean age
61.5 years
Surgery
Hemicolectomy
Exploratory laparotomy
Gastroenterostomy
Esophaguectomy
Duodenopancreatectomy
Hepatectomy
Catheter colocation
Total gastrectomy
Colecistectomy
Other
Non surgical
Pancreatitis
Main reasons NP
Paralitic ileum
Esophag disease
Intraabdominal process- perforation
Bowel stenosis
Acute pancreatitis
Piloric stenosis
Malabsorption
Other
220
Farm Hosp. 2008;32(4):216-25
28 (65.3%)
16 (33.7%)
intake would start and assessment of the patient’s clinical status,
the pharmacist carried out 93 direct interventions (57.4%of complicacions) involving 30 patients and 16 (9.9% of complicacions) interventions by recommendation involving 14 patients.
Interventions consisting of recommendations to the prescribing
physician are described in table 5. In contrast to what would be
expected in light of the patients’ analytic results and energetic,
caloric and protein needs, it was decided not to conduct intervention in 53 cases defined as complications. The pharmacist based
this decision on short- or long-term estimation of when oral or
enteral ingestion would start and to reduce risk in patients with
hyperglycemia, hypertriglyceridemia, considerable hepatic alterations or renal dysfunction (table 6).
Among the various parameters studied, those encompassed in
the group of synthesis-inflammation (albumin, prealbumin, and
C-reactive protein [CRP]) presented the largest number of alterations and were more often associated with, complications
(n= 83, 51.2 %). The renal function parameters showed relatively
few complications (n= 9, 5.5 %) (table 4).
Following the pharmaceutical interventions, the mean difference was calculated between the pre- and post-intervention
mean values (table 7). Statistically significant differences or
trend to signification were found for interventions aimed toward
increasing albumin, prealbumin, potassium and phosphate levels, and for decreasing CRP, glucose and triglycerides. For some
of the objectives contemplated, such as decreasing creatinine,
potassium and phosphate, or increasing sodium and magnesium,
the alterations in these parameters were small and the sample
studied was insufficient to reflect statistical differences. The objective of decreasing liver function parameters (GGT, AP, ALT
and bilirubin) was achieved, but did not show statistically significant differences.
8
6
3
3
3
3
2
2
1
10
(19.5%)
(14.6%)
(7.3%)
(7.3%)
(7.3%)
(7.3%)
(4.8%)
(4.8%)
(2.4%)
(24.4%)
3
16
6
6
5
4
3
2
2
(36.4%)
(13.6%)
(13.6%)
(11.4%)
(9.1%)
(6.8%)
(4.5%)
(4.5%)
DISCUSSION
In a general context, the PNU activities take part in a model of
Pharmaceutical Care from our Pharmacy Service, this implies to
assume responsibilities in the assistance team and in pharmacotherapy design, including monitoring and evaluation.
The protocol presented here allows for a series of interventions that, among others (clinical, hight quality…) can be included in the patient’s final results assessment.
Numerous studies have assessed the importance of protocolled nutrition for the prevention and treatment of various diseases1,3,7-16. Although some of these publications defend the
idea that the pharmacist’s contribution in the prescription
process achieves more successful PN therapy4,5, there are few
descriptions of pharmaceutical care in parenteral nutrition based
on adjusting the composition of PN formulas according to the
clinical status of individual patients at each point of their clinical
process. Anoz Jiménez et al17 identificated medication errors
and/or drug-related problems associated with both total parenteral nutrition and other pharmacological treatments.
6. Llop-Talaverón J et al. Pharmaceutical interventions in metabolic and nutritional follow-up of surgical patients receiving parenteral nutrition
Table 4. Complications in analytic parameters and type of interventions (PI)
Group
Complication
n
Parameters
n
Direct intervention
Advice
Key criteria
Synthesis and
inflammation
Protein synthesis
markers reduction
64
Albumin
< 35 mmol/L
Prealbumin
< 20.01 mmol/L
Prealbumin +
albumin
22
9
—
Prealbumin
> albumin
3
2
—
39
(78)
22
—
Inflammatory response
increase
Liver function
Electrolytes
19
17
—
Hyperglycemia
25
Glucose
> 7.8 mmol/L
25
8
13
0
Glucose
< 4.01 mmol/L
—
—
—
Hypertriglyceridemia
Renal function
C reactive protein
> 9,99 mg/L
Hypoglycemia
Nutritional
metabolism
19
6
Triglycerides
> 2.31 mmol/L
6
5
—
Renal failure
9
Urea
> 8.6 mmol/L
Creatinine > 199.99
7
1
1
2
2
–
Moderate hepatic
dysfunction
(GGT ≥ 3.5 or
AP ≥ 4.5) + (BIL ≤
25 + ALT ≥ 0.83)
Severe cholestatic
jaundice (GGT ≥ 3.5 or
AP ≥ 4.5)+ BIL ≥ 25
5
(20)
2
—
8
(31)
6
—
Hepatic dysfunction
13
2
Sodium
< 130.01 mmol/L
2
1
1
Hypopotasemia
10
Potassium
< 3.50 mmol/L
10
9
1
Hyperpotasemia
1
Potassium
> 5.19 mmol/L
1
1
—
Hypomagnesemia
2
Magnessium
< 0.62 mmol/L
2
1
—
Hypophosphatemia
5
Phosphate
< 0.71 mmol/L
5
4
—
Hyperphosphatemia
2
Phosphate
> 1.5 mmol/L
2
2
—
Hypocloremia
TOTAL
Hyponatremia
4
Chloride
< 98 mmol/L
4
1
—
162
(239)
93
16
162
It is clear that the response obtained in the present study has a
multifactorial aspect; nevertheless the results show that protocolled pharmaceutical interventions have an impact on the clinical and metabolic outcome of patients receiving PN. These inter-
ventions mainly consisted of changes in the PN formula and additional support measures.
Increases in plasma albumin and prealbumin concentrations
are related to improvements in nutritional status, by indicating
Farm Hosp. 2008;32(4):216-25
221
7. Llop-Talaverón J et al. Pharmaceutical interventions in metabolic and nutritional follow-up of surgical patients receiving parenteral nutrition
Table 5. Therapeutic recommendations given to prescribing physicians
Group
Complication
Advice
Nutritional metabolism
Hyperglycemia
Modify insuline regimen
Review complementary fluid therapy
Substitute dextrose 5%
Renal function
Renal failure
Review electrolytic balance and consult nephrology service
Electrolytes
Hypopotasemia
Review electrolytic balance and complementary fluid therapy
Hyponatremia
Review electrolytic balance and complementary fluid therapy
Table 6. Criteria and reasons for non-intervention in patients with metabolic complications
Group
No intervention criteria
No intervention reason
Synthesis and inflammation
Nitrogen supply maintenance and/or
no glutamine addition
No omega 3 fatty acids
Oral/enteral tolerance
Oral intake in short-time period
Post-surgery moderate hypoalbuminemia with acceptable prealbumin levels
Nitrogen supply in the upper limit
Encephalopathy risk
Not worsening renal function
Hipertriglyceridemia
Substrate metabolism
Maintenance glucose supply
Maintenance lipid supply
Moderate hyperglycemia and need to keep caloric supply
Hypertriglyceridemia with minimum lipid supply
Renal function
Maintenance nitrogen supply
High urea levels not related with renal failure or excessive nitrogen supply
(normal plasmatic creatinine levels)
Liver function
Maintenance lipid supply
Oral/enteral tolerance
Oral intake in short-time period
Electrolytes
Maintenance initial supply
Moderate hypophosphatemia
Moderate and transitory hypocloremia
an increase in protein synthesis or a decrease in proteolysis. In
the present study the results for albumin did not show significant
changes following the pharmaceutical intervention, a fact possibly attributable to problems of postoperative hemodilution or the
elevated half-life of this protein. In contrast, the results for prealbumin indicate that it is more suitable than albumin as an early
indicator of improved protein synthesis, both for assessing the
clinical evolution of the patient and for evaluating the impact of
the nutrients provided.
Prealbumin levels are reduced in malnourished patients and
are used as markers of acute malnutrition, mainly due to its short
half-life18. For many years prealbumin has been used as an indicator to evaluate the impact of the nutrients administered, as reduced prealbumin levels can be reversed with refeeding19.
In spite of this, authors like López Hellín et al20 have questioned pre-albumin’s role, and they have proposed to substitute it
for other indicators with a minor artifactation, such as insulinlike growth factor-1, in order to assess the nutritional supply during the stress phase after surgery.
With the development of the pharmaceutical-nutrient concept,
prealbumin has been also considered a response marker in im-
222
Farm Hosp. 2008;32(4):216-25
munologic-nutrition treatments (e.g., glutamine, omega 3).
Experimental studies have found a direct relationship between
the adding of immunologic nutrients and prealbumin levels.
This association has also proven to be significant in several
studies13,20-26.
To attain an increase in prealbumin values, the nitrogen supply
was increased. In the cases associated with post-stress hypercatabolism, this was accomplished with glutamine dipeptides.
Glutamine favors faster enterocyte recovery and recuperation of
immunocompetence7-11,27.
Decreases in CRP concentration were used as a marker of improvement in the inflammatory state associated with post-stress
aggression. When substantially elevated CRP values were noted,
the interventional protocol established that omega-3 fatty acids
should be added to the PN formula. There is now a sufficiently
solid theoretical basis indicating the important immunomodulating and anti-inflammatory activity of omega 3 fatty acids12-14.
Omega 3 fatty acids addition was made keeping w3/w6 ratios
between 1:2 to 1:3. Lipid emulsions with omega-3 to omega-6
ratio of 1:2 exert the highest LTC5/LTC 4 (leukotriene) ratio and
a better immune modulating effect28.
8. Llop-Talaverón J et al. Pharmaceutical interventions in metabolic and nutritional follow-up of surgical patients receiving parenteral nutrition
Table 7. Comparison between analytic values before and after pharmaceutical intervention (PI)
Paramete
and objective
Intervention
n
Pre-Pi
Mean Value
Post-Pi
Mean Value
Mean
Difference
T
W
Increase albumin
(g/L)
Direct
No
Advice
31
30
—
24.51
27.30
–
25.96
27.33
—
–1.45
–0.03
—
0.085
0.96
—
0.057
0.79
—
Increase prealbumin
(mg/dL)
Direct
No
Advice
24
18
—
10.08
14.46
—
14.61
15.53
–
–4.61
–1.05
–
0.001
0.52
–
0.002
0.50
–
Decrease C-reactive
protein (mg/L)
Direct
No
Advice
17
2
—
220.48
207.40
—
133.12
101.70
—
87.35
105.70
—
0.003
0.141
—
0.006
0.180
—
Decrease glucose
(mmol/L)
Direct
No
Advice
8
4
13
10.88
9.22
10.68
8.52
9.95
7.63
2.36
–0.72
3.04
0.107
0.31
0.002
0.092
0.27
0.001
Decrease triglycerides
(mmol/L)
Direct
No
Advice
5
1
—
4.40
4.90
—
2.74
5.50
—
1.66
–0.6
—
0.053
—
—
0.08
—
—
Decrease Urea
(mmol/L)
Direct
No
Advice
1
5
1
34.7
14.28
21.4
20.5
17.30
14.9
14.2
–3.02
6.5
—
0.67
—
—
0.89
—
Decrease creatinine
(µmol/L)
Direct
No
Advice
2
—
—
217.5
—
—
102.00
—
—
115.5
—
—
0.08
—
—
0.18
—
—
Increase sodium
(mEq/L)
Direct
No
Advice
1
—
1
130
—
129
137
—
148
–7
—
–19
—
—
—
—
—
—
Decrease potassium
(mmol/L)
Direct
No
Advice
1
—
—
5.63
—
—
4.40
—
—
—
—
—
—
—
—
—
—
—
Increase potassium
(mmol/L)
Direct
No
Advice
9
—
1
3.21
—
2.58
4.31
—
4.45
–1.10
—
–1.87
0.016
—
—
0.066
—
—
Increase magnesium
(mmol/L)
Direct
No
Advice
1
1
—
0.56
0.61
—
0.70
0,6
—
–0.14
0.01
—
—
—
—
—
—
—
Decrease phosphate
(mmol/L)
Direct
No
Advice
2
—
—
1.61
—
—
1.47
—
—
0.13
—
—
0.54
—
—
0.65
—
—
Increase phosphate
(mmol/L)
Direct
No
Advice
4
1
0.40
0.66
1.05
1.1
–0.64
–0.44
0.06
—
0.068
—
Increase chloride
(mmol/L)
Direct
No
Advice
1
3
—
89
94
—
91
103
—
–2
–9
—
—
—
—
—
—
—
Decrease GGT
(µkat/L)
Direct
No
Advice
5
8
—
6.06
6.22
—
5.12
5.43
—
0.94
0.79
—
0.45
0.38
—
0.34
0.39
—
(Continued)
Farm Hosp. 2008;32(4):216-25
223
9. Llop-Talaverón J et al. Pharmaceutical interventions in metabolic and nutritional follow-up of surgical patients receiving parenteral nutrition
Table 7. Comparison between analytic values before and after pharmaceutical intervention (PI) (Continuation)
Parameter
and objective
Intervention
n
Pre-Pi
Mean Value
Post-Pi
Mean Value
Mean
Difference
T
W
Decrease AP
(µkat/L)
Direct
No
Advice
6
9
—
7.55
11.71
—
9.20
9.32
—
–1.65
2.38
—
0.32
0.52
—
0.46
0.86
—
Decrease ALT
(µkat/L)
Direct
No
Advice
7
8
—
5.21
2.04
—
1.83
2.03
—
3.38
0.01
—
0.33
0.96
—
0.23
0.41
—
Decrease bilirubin total
(µmol/L)
Direct
No
Advice
4
4
—
408
180.5
—
245.3
159.7
—
162.7
20.8
—
0.32
0.20
—
0.28
0.14
—
PI: pharmaceutical intervention; t: t-test, w: Wilcoxon t-test
Adequate control of glucose and triglycerides is essential in
nutritional therapy, since elevated levels of these parameters indicate inefficient metabolism and are associated with the development of clinical complications. The interventions to decrease
hyperglycemia included reducing glucose content in the PN formula, adjusting fluid therapy, and providing recommendations
for modifying insulin dosing. All recommendations were accepted.
To decrease hypertriglyceridemia, lipid content in the PN was
decreased and lipid emulsions with faster and more effective
plasma clearance were used, such as medium-chain triglyceride
emulsions29,30.
One important limitation in PN therapy is the development of
hepatic complications associated with the lack of oral intake and
factors related to toxicity or deficiencies31-35. Therefore, the protocol required routine monitoring of various parameters related
to liver function and established several interventions to prevent
or minimize hepatic alterations. These include limiting potential
glucose overload and particularly, decreasing the lipid content,
while assuring an adequate caloric supply at all times. The results obtained with protocolled interventions for this purpose in
the present study did not show a significant decrease in analytical liver function alterations. Nevertheless, these parameters did
not worsen, and given their tendency to increase over the duration of PN, this can be considered a positive achievement for the
patient’s clinical evolution.
The study did not include patients in intensive care units, since
this population presents a high incidence of multiorgan failure.
Renal failure is of particular concern because of the problems involved in nutritional management of this condition. Exclusion of
these patients explains the relatively low level of alterations in
hydroelectrolytes and parameters associated with renal failure.
There were, however, statistically significant post-intervention
increases in potassium and phosphate values in patients with abnormally low results for these parameters. The PN formulas
were adjusted to the patients’ hydoelectrolyte status when the
analytic and therapeutic situation required an intervention, in
keeping with standard practice36. The specific action of the phar-
224
Farm Hosp. 2008;32(4):216-25
macist established for these cases consisted of increasing the
amount of potassium and phosphate in the PN formula.
In conclusion, with regard to clinical and metabolic status,
candidates for PN are complex and difficult to treat with standardize nutritional interventions derived from simple criteria.
Nevertheless, the findings of this study indicate that systematic
monitoring of specific analytic parameters can be an effective
means for attaining success in nutritional therapy, in terms of improvements in nutritional status and prevention and control of
associated complications. Therefore, even though the parameters assessed may be influenced by several factors other than the
PN treatment received, the results obtained in this study provide
further evidence of the importance of protocolled, quantified
pharmaceutical interventions in surgery patients.
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