Best pharmaceutical practices in a nutrition support team : an in-depth scientific analysis with focus on parenteral nutrition in an established nutritional team in a swiss university hospital

Malnutrition in hospitalised patients is a serious and often underestimated problem. It is well established that the recognition and adequate treatment of malnutrition upon hospitalisation is of highest importance for a successful patient outcome. Nevertheless, the knowledge level for most health care professionals insofar as nutritional assessment and appropriate nutritional support is still low and training inadequate, especially that of the attending physicians who have first contact with patients. Errors in medication and nutritional therapy lead to increased morbidity and mortality, as well as prolonged treatment. Prevention of these oversights enables optimised and safe clinical nutritional therapy and also medication treatment. An interdisciplinary nutrition support team (NST) comprising a physician, dietitian, nurse and pharmacist is necessary for the good nutritional management of a patient from admission until discharge as well as further care at home. Their function includes nutritional assessment, evaluation and determination of individual nutritional requirements, recommendations for nutritional therapy and management of the nutritional care plan. There are different forms of clinical nutrition therapy to prevent and treat malnutrition when physiological feeding is not possible or insufficient. In particular, patients who are to receive home parenteral nutrition (HPN) require continuous monitoring by a well-educated NST. From the outset, the patient will be in steady contact with the hospital due to the need for long-term follow-up and mandatory monitoring for this complex and challenging treatment.1,2 The pharmacy profession is undergoing major transformations, therefore additional skills and knowledge are required to achieve best pharmaceutical practice and care. Many changes have occurred and thus, interdisciplinary cooperation becomes more important and HPN is used more and more, increasing the challenges of the pharmacist with these complex parenteral nutrition (PN) formulations. Technical and pharmaceutical developments have helped to establish safe, convenient and effective HPN. The pharmacist, as a member of an NST, can contribute by defining and evaluating best practices and efficiency to prevent medication errors, thus ensuring an increased quality of life (QoL). The role of the pharmacist as part of an NST depends on specific pharmaceutical expertise, including knowledge, experience and skills in the field of clinical nutrition, particularly in PN. Nutritional therapy as part of a patient’s overall treatment plan and therefore embedded in the medication therapy, requires the involvement of the pharmacy.3 This thesis investigates pharmaceutical aspects in the field of clinical nutrition, focusing on aspects of PN in particular. The main objective of this thesis is to illustrate the various pharmaceutical activities in an NST throughout the clinical nutrition process with a focus on PN. To clarify, the research aims are: • What role should the pharmacist play in an NST? • Is he/she prepared for the professional challenges? • Which best practices can the pharmacist provide to increase the quality of treatment, safety and QoL for a patient? To this end, four independent projects were defined in order to reach the aims: (I) What is the importance and role of the pharmacist? • Identification of malnourished patients or patients at nutritional risk, where the pharmacist can make an important contribution. • Responsibility for maintenance of professional competence in nutrition support management by providing education and skills training. (II a +b) Which contributions can the pharmacist give to provide a safe and effective drug and nutritional therapy and therefore an improved QoL? • Monitoring and optimisation of nutrition support therapies including care for HPN patients and management of good nutritional supply, providing safe and effective treatment and therefore improving the patient’s QoL. Specific focus was given to the so far not prospectively analysed situation in Swiss adult HPN patients and benefit of HPN on QoL in patients with specific disease. (III) Which compounding related questions arise and which stability and compatibility assessments have to be done to ensure medication safety? • Patients with long-term PN or critically ill patients especially need additional components or medications added to a PN admixture, requiring strict aseptic compounding and previous stability and compatibility assessments

Parenterale Ernährung - Grundlagen und Durchführung (Parenteral nutrition - basics and good practice)

The physiological nutrition goes by the oral route. If an adequate and sufficient nutrition enterally is not more possible, a parenteral nutrition allows a partial or total feeding. Fluids and nutrients are usually administered as all-in-one admixtures using a central venous access. A parenteral nutrition (PN) is contraindicated when enteral nutrition is possible. Compared to enteral, PN is more complex, more demanding and potentially accompanied by serious or even fatal complications. PN requires a strict aseptic working, a pharma- ceutical correct admixture of suited macro- and micronutrients to ensure the necessary stability and compatibility. The dosing and ad- ministration of the (reactive) components have to respect the me- tabolic needs and the metabolic capacity (tolerance) of the patient and need appropriate monitoring. Medical, pharmaceutical, nutri- tional advice and nursing support is required. In addition, the nec- essary administrative and cost-related tasks and the periodically re- view of the indication, of the composition of the nutrition regimen including the administration details have to be regularly checked. An efficacious PN requires experience, an adequate monitoring and quality assurance and regular, documented training of the nutrition support team, the patient and the family member involved. Since the PN is a complex, a therapeutically demanding treatment with involvement of different partners in and outside of the hospital (in- terfaces), the incidence of “medication errors” can be prevented or reduced

Praxisnahe Scores für die Erfassung der Mangelernährung

Malnutrition occurs in 30 - 60 % of hospitalized medical or surgical patients, as well as out-patients. Serious consequences at various levels were observed. Malnutrition influences negatively the quality of life, the immune system, muscle strength and worsens the prognosis of the patient. Interventions for a rapid and simple identification and effective treatment of this condition are essential and cost saving. Screening tools for the identification of patients at nutritional risk are very useful in daily practice. The systematic identification of patients with potential or apparent malnutrition is very important allowing an effective nutritional treatment at an early time. The medical team in charge should perform the nutritional risk screening and the following assessment to recognize the nutritional problems and to solve them in an interdisciplinary and -professional team.Eine Mangelernährung besteht bei ca. 30 – 60 % der hospitalisierten als auch der ambulanten medizinischen oder chirurgischen Patienten. Schwerwiegende Folgen werden auf diversen Ebenen beobachtet. Sie beeinträchtigt die Lebensqualität, schwächt das Immunsystem und die Muskulatur und verschlechtert die Prognose der Patienten. Interventionen zur Erkennung und Behandlung der Mangelernährung sind wirksam und kostensparend. Im Alltag sind einfache standardisierte Screeningtests für die Erfassung von Risikopatienten sehr nützlich. Die systematische Identifikation von Patienten mit potenzieller oder manifester Mangelernährung ist fundamental, um eine adäquate Ernährungstherapie schnellstmöglich einzuleiten. Das Screening und anschließende Assessment sollte vom betreuenden medizinischen Team durchgeführt werden, damit es die ernährungsbezogenen Probleme in einem interdisziplinären und -professionellen Team erkennen und lösen kann

6.1.4. Pharmaceutical aspects in enteral feeding and drugs

The main factors to be considered upon co-administration of drugs wiith tube feeding are presented. The pharmaceutical aspects and properties of the drug formulation, the nutrient and the feeding tube (dimesno, location, and material) are the most important issues to check for potential incompatibilities and for the therapeutic efficacy and safety of the combined nutrient and drug treatment. Therefore, pharmaceutical advice from the NST is needed. Complications, such as occlusion of the tube, should be considered preventable medication errors. A careful evaluation and stepwise approach presented in an algorithm allow for the definition of good practices for administering necessary drugs in tube-fed patients

Akute Pankreatitis

Eine spezifische Therapie der akuten Pankreatitis (AP) existiert nicht. Die wichtigsten therapeutischen Massnahmen neben einer ausreichenden Analgesie ist eine möglichst frühe adäquate Volumen- und Ernährungstherapie. Diesbezüglich hat in den letzten zwei Dekaden ein Paradigmenwechsel stattgefunden. Bei einem milden bis moderaten Verlauf einer AP (miAP, moAP) soll frühzeitig eine orale Nahrungsaufnahme versucht werden, sofern dies aufgrund der Schmerzen und der oft vorliegenden Darmparalyse durchführbar ist. Bei einer schweren AP (sAP) sollte eine früh eingeleitete enterale Ernährung (EE) erfolgen; die Indikation zur parenteralen Ernährung (PE) sollte wegen möglicher Infekt-assoziierter Komplikationen mit Zurückhaltung gestellt werden. Durch diese Massnahmen können Morbidität und Mortalität gesenkt werden. Der Einsatz von Probiotika ist umstritten. Eine Indikation für eine generelle Antibiotikaprophylaxe besteht auch bei sAP nicht. Eine Antibiotikatherapie wird lediglich beim Vorliegen einer Cholangitis oder bei infizierten Nekrosen/Pseudozysten empfohlen

Eine nicht alltägliche Diagnose

We report on a 61-year-old patient who suffered from severe protein-energy malnutrition due to an inadequately treated exocrine pancreatic insufficiency. In this context, a thiamine deficiency was not recognized and there were clinical manifestations of beriberi disease with decompensated biventricular heart failure. In the course of time, a manifest niacin deficiency (pellagra) with dermatitis, diarrhea and persistent delirium occurred, which was recognized and could be treated. We highlight differential diagnostic considerations about the consequences and the treatment of malnutrition, with special focus on the classical deficiency diseases beriberi and pellagra

Auf die leichte Schulter genommen

A 78 year old patient with type 2 diabetes mellitus was hospitalized because of weakness and poor nutritional status. For several years, he suffered from an unintended weight loss and chronic, pulpy diarrhea. On examination, we found a severe loss of muscle and fat tissue as well as difficulty swallowing. An adequate nutritional therapy with combined parenteral and enteral nutrition was implemented under regular monitoring of electrolytes and volume status, under which the state of health improved noticeably, while steatorrhea improved under substitution of pancreatic enzymes