A L Riyadh

Batani

Mohd Baidi Bahari

Noraini Abd Kadir

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Malaysian Journal of Pharmaceutical Sciences,  
Vol. 4, No. 2, 25—32 (2006)   
 
                                                
EVALUATION OF THE PARENTERAL NUTRITION SERVICES 
IN HOSPITAL PULAU PINANG 
 
RIYADH AL BATANI*, NORAINI ABD. KADIR AND MOHD. BAIDI BAHARI 
School of Pharmaceutical Sciences , Universiti Sains Malaysia, 
11800 USM Pulau Pinang, Malaysia 
 
 
Parenteral nutrition (PN) has been practiced in Hospital Pulau Pinang, Malaysia since 1986.  
However, there is no published data on the cost, complications and outcome of patients receiving 
PN in this hospital.  A retrospective study was carried out to evaluate the cost, complications and 
outcome of PN.  Data were obtained from patient medical records and analysed using SPSS version 
11. From 2003 to 2005, 429 PN cases were evaluated.  Of the PN cases, 65% were neonates, 28.2% 
adults and 6.8% paediatric, where 60.8% of patients were male and 38.5% were female. Malay 
patients constituted 57.3%, Chinese 30.8% and Indian 11.9%.  The reasons for PN were feeding 
intolerence (86.7%), oral intake restrictions (9.3%), poor oral intake (1.4%) and others (2.6%). The 
average cost for PN in a neonate was found to be RM185 ± 69, RM 233 ± 126 for a paediatric 
patient and RM 235 ± 107 for an adult. PN-associated complications were bacterial sepsis (30.4%), 
metabolic acidosis (13.0%), catheter dislodgment (8.7%), long line swelling (8.7%), hepatic 
complication (21.8%), long line blockage (4.4%) and catheter-related infection (13.0%).  A total of 
82.7% of cases tolerated oral nutrition after PN, 7.4% expired, 5.3% developed PN complications 
and others were discharged, transferred to other ward, transferred to another hospital, or discharged 
at own risk (0.3%). The study showed a significant difference in the cost of PN in each group of 
patients (p = 0.002).  We concluded that PN services in Hospital Pulau Pinang were associated 
with low PN-related complications and good outcomes.   
 
Keywords: Parenteral Nutrition, Cost, Outcome, Complication, Malaysia         
 
 
INTRODUCTION 
 
Modern clinical nutrition was introduced around 35 years ago by Dudrick 
and Rhoads (1971). Parenteral nutrition (PN) provides life-sustaining 
therapy for patients who are unable to consume conventional dietary 
therapy either orally or enterally. It is a relatively new therapeutic tool 
used in the clinical management of patients. It is also known as 
hyperalimentation or intravenous nutrition. Hyperalimentation, which is 
the provision of nutrients at high concentration intravenously, was used 
during the early days of PN. It was associated with most of the adverse 
effects of PN therapy. Nowadays, the term PN is widely used in the 
 
* Corresponding author: Riyadh Al Batani, e-mail: ralbatani@yahoo.com 
Riyadh Al Batani et al.                                                                                                                      26 
 
literature to denote the administration of nutrients intravenously 
(Shamsuddin 2003). 
 Basically, there are two types of parenteral nutrition, namely total 
parenteral nutrition (TPN) and partial parenteral nutrition (PPN).  TPN is 
used when the whole of nutritional requirements is administered 
parenterally. PPN on the other hand, is the concurrent intravenous 
administration of nutrients together with oral or enteral nutrition for the 
same therapeutic objective.  The nutritional components of a standard PN 
regimen include the macronutrients (amino acids, carbohydrate and fats), 
electrolytes, micronutrients (trace elements and vitamins) and water. 
Carbohydrate (in the form of glucose or dextrose) and lipids are the major 
sources of energy (Shamsuddin 2003). 
In Malaysia, PN service was introduced in 1986 at two general 
hospitals; Hospital Kuantan and Hospital Pulau Pinang (Bahari 1990).  
Since then, many studies on the PN practice in Malaysian hospitals have 
been reported (Bahari 1990; Shamsuddin and Bahari 1994; Bahari 1999; 
Yusuf and Bahari 1999). However, studies reporting complications and 
costs of PN in Malaysian hospitals are lacking.  Therefore, this study was 
carried out to determine the current PN practice in Hospital Pulau Pinang 
and to evaluate the outcomes and costs associated with it. 
 
 
METHODS 
 
This retrospective study was carried out at Hospital Pulau Pinang, 
Malaysia using data from all PN cases from 2003 to 2005. A specially-
designed data collection form was used to collect data on the 
demographic of PN patients, diagnosis, complications, outcomes and the 
costs of PN. The cost of personnel and other indirect costs were not 
included because there were no data available for the PN preparation 
time. All data was analysed using SPSS version 11 and descriptive 
statistic was used as appropriate. Analysis of variance was used to test 
the difference in cost of PN between groups.  A p value of < 0.05 was 
considered significant. 
The cost of  PN solution was calculated from the cost of each 
individual nutrient added into the PN bag. They were Vaminolact®, 
Vamin G®, Aminoplasma® 10%, Aminoplasma® 12.5%, dextrose, calcium 
gluconate, magnessium sulphate, pottassium chloride, sodium chloride 
0.9%, sodium chloride 0.3%, pottassium hydrogen phosphate, Addamel®, 
27                                                      Evaluation of the Parenteral Nutrition Services  
Peditrace®, Soluvit-N®, Lipofundin® 20%, Intralipid® 20% and water for 
injection.  The total cost was calculated by multiplying the daily cost with 
the number of PN days.  
 
 
RESULTS AND DISCUSSION 
 
There were 429 PN cases between 2003 to 2005.  The majority of these 
cases were premature neonates 279 (65%) followed by adults 121 (28.2%) 
and paediatrics 29 (6.8%). There were 261 (60.8%) male, 165 (38.5%) 
female, one (0.2%) anomalous genitalia and two (0.5%) were not recorded.  
There were 246 Malay patients (57.3%), 132 Chinese (30.8%) and 51 Indian 
(11.9%).  Table 1 gives  the details of patient demography.  
The findings of this study corresponded to the study by Bahari and 
Razak (1996) that found adult patients receiving PN to be less than 
paediatric patients.  In their study, they found that PN cases were 67.1% 
in paediatrics and 32.9% in adults. Both studies have shown that 
paediatrics were the main group receiving PN.  In this study, the majority 
of our subjects were premature (65%) and usually premature cases have 
some degree of gastrointestinal tract (GIT) malfunction that require GIT 
rest.  This could be due to the immaturity of their digestive systems and 
inability to absorb adequate calories to meet their high calorific 
requirements.  
 
Table 1: Demographic data of patients receiving parenteral nutrition 
  
 
Number 
 
Percentage 
 
Age group Premature 279 65.0 
 Paediatric 29 6.8 
 Adult 121 28.2 
Race Malay 246 57.3 
 Chinese 132 30.8 
 Indian 51 11.9 
Sex Male 261 60.8 
 Female 165 38.5 
 Anomalous 
genitalia 
Not mentioned 
 
1 
2 
0.2 
0.5 
 
 
 
 
 
 
Riyadh Al Batani et al.                                                                                                                      28 
                                                              
Table 2: Diagnosis and reasons of parenteral nutrition 
  
 
Frequency 
 
 
Percent % 
 
Diagnosis Prematurity       227      52.9 
 Post operation                              43 10.0 
 Perforation of GIT                      14 3.3 
 Sepsis+shock                              8 1.9 
 Cancer of the stomach               8 1.9 
 End stage renal failure on 
dialysis                               
7 1.6 
 Necrotizing enterocolitis          7 1.6 
 Peritonitis 7 1.6 
 Cancer of the rectum                 5 1.2 
 Upper GIT bleeding                  5 1.2 
 Diaphragmatic hernia 5 1.2 
 Others 93 21.6 
Reason for PN Feeding intolerance                   372 86.7 
 Oral intake restrictions 
(NBM)                         
40 9.3 
 Poor oral intake                          6 1.4 
 Others 11 2.6 
 
Table 2 shows the diagnosis and the reasons for the PN. 86.7% of all 
cases were due to feeding intolerance.  This could be due to prematurity 
(52.9%), post-surgery (10%), perforated GIT (3.3%) and other conditions 
requiring GIT rest. This is also in accordance to the indications of PN and 
the hospital PN policy (Bahari 1996).  
Table 3 shows the outcome of PN in our patients.  A total of 82.7% of 
patients tolerated oral feeding, while death occurred in 7.4%. This finding 
is better than the finding of previous study (Bahari and Razak 1996), 
which found only 45% to 50% of patients, tolerated feeding and 11% to 
45% died. The differences in the outcomes could be due to the general 
improvement of the PN services over the years. 
Table 4 shows the complications of PN in our patients. Majority of 
patients did not experience any PN complications (82.7%). The study 
found that of those who developed complications, almost one third were 
due to sepsis or 1.6% of the total number of PN cases.  Our results showed 
a lower rate of complications compared to a previous study by Bahari 
(1990).  Bahari (1990) showed that the PN-related sepsis occurred in 50% 
of adult and 41% of paediatric patients.  The author also reported a higher 
frequency of metabolic complications in their patients (28% to 45%).   
 
 
 
29                                                      Evaluation of the Parenteral Nutrition Services  
Table 3: Outcomes of parenteral nutrition 
 
Outcome   
 
   Frequency 
 
Percent % 
 
 
Tolerating feeding 
 
          355 
 
82.7 
Death     32 7.4 
PN complications 23 5.3 
Patient very ill  9 2.1 
Discharged home  3 0.7 
Transferred to other ward        2 0.5 
Transferred to another hospital     3 0.7 
Went for surgery   1 0.3 
Discharged home at own risk   
 
 
1 0.3 
 
Knafelz et al. (2003) found that mechanical complications and 
infections occurred in 52% and 26% of their patients, respectively. Other 
PN-related complications reported were, metabolic acidosis (3%) and 
hepatic complications (19%).  The difference in complications could be 
due to the improvement in facilities and techniques with time. These 
could also indicate the improvement in the patient selection and patient 
monitoring by the health care providers in Hospital Pulau Pinang.  
Some patients were already having sepsis prior to PN.  This has made 
it difficult to differentiate whether the sepsis was related to PN or not 
related to PN. However, in practice the PN will be discontinued 
whenever the patient develops fever regardless of the source of infection.  
It will then be resumed once the fever resolved.        
Melville et al. (1997) explained the reasons for the possible cause of 
sepsis in PN patients. These include malnutrition, structural intestinal 
defects, alteration in the immune system such as in congenital defects, the 
use of immunosuppressive drugs, viruses’ infections such as the 
immunodeficiency virus and extreme age.  Sepsis may also occur due to 
the mishandling of catheter and its site of insertion such as improper 
dressing and the use of PN line for the administration of drugs and blood 
products.  
The percentage of death in our patients is high (7.4%), with the 
majority of them occurred among premature and very low birth weight 
neonates.  Out of those who died, only two were sepsis-related.  Majority 
of the subjects were able to tolerate feeding (82.7%). Previous study by 
Festen et al. (2002) on the outcome of PN in apple peel atresia (intestinal 
atresia) patients showed a declining in the number of death from 70% to 
26% and 14% in 1960’s, 1970’s and 1990’s, respectively. Most frequent 
causes of death were sepsis (22%) and anastomotic dysfunction (20%), 
Riyadh Al Batani et al.                                                                                                                      30 
                                                              
followed by intestinal gangrene (12%).  The differences in the death rate 
could be due to the difference in the population of the subjects between 
both studies.  
The average daily cost of adult patients receiving TPN was found to 
be RM 235 ± 107, as compared to paediatric patients RM 233 ± 126 and 
premature RM 185 ± 69. In addition, the cost of PN per day was 
increasing with different age group (ANOVA, p = 0.002).  This difference 
could be due to the high nutritional requirement of adult. The cost 
estimation in this study is only for the PN solutions, bag and devices for 
the preparation of PN. However the average cost is higher than 
previously reported by Bahari (1996).  The author reported that the cost 
for paediatric PN ranged from RM 60 to RM 100 daily and for adult TPN 
ranged from RM 105 to RM 140 daily.  The increase in cost could be due 
to the escalating cost of raw materials such as TPN bags, solutions and 
devices.  The finding of the study is similar to the study done by Zaleski 
et al. (1997) that showed the daily cost of TPN was (US$57) which include 
the cost of nutrients (US$50), supplies such as gloves, mask and syringes 
(US$2), and cost of labor (US$5).  The indirect costs were not included in 
the study because the data on the preparation time was not recorded in 
the PN record.  
 
Table 4: Complications of parenteral nutrition   
  
 
Frequency 
 
Percent % 
 
 
Complications due to TPN   
 
Complication 
    
       23 
 
 5.4 
 Tolerating feeding                     355       82.7 
 Record not available      51 11.9 
Type of complications             
  Metabolic Complication Acidosis        3 13.0 
  Mechanical complications Catheter dislodgment                    2   8.7 
 Long line swelling                        2   8.7 
 Long line blockage                       1   4.4 
  Infections Bacterial sepsis                             7 30.4 
 Catheter-related infections            3 13.0 
  Hepatic complications Hepatic complication         5 21.8 
 
 
 
 
 
 
 
 
31                                                      Evaluation of the Parenteral Nutrition Services  
CONCLUSION 
 
As PN services in Malaysia is still new, the evaluation of its impact, 
outcome and cost is very important.  The finding of this study shows that 
PN service is not associated with high rate of complications as expected 
and has favourable outcomes.    
 
 
ACKNOWLEDGEMENT 
  
We would like to acknowledge the Director, Hospital Pulau Pinang for 
her consent in allowing us to conduct and publish the study. We also 
acknowledge the chief pharmacist, senior clinical pharmacist, pharmacist 
incharge of parenteral nutrition and staffs of the pharmacy department 
and record office, Hospital Pulau Pinang for their support during the 
study. 
 
 
REFERENCES 
 
BAHARI, M. B. (1990) Total parenteral nutrition in Malaysia, First Pan Pacific Asian 
Congress of Clinical Pharmacy, 23rd – 26th November, Pulau Pinang, Malaysia. pp. 112–117. 
BAHARI, M. B. & RAZAK, H. A. (1996) Review of parenteral nutrition services in 
Hospital USM in Kelantan, Federation of Asian Pharmaceutical Association, 17—21st 
November, K. Lumpur. p. C6. 
BAHARI, M. B. (1999) Nutrition support services in Malaysia, 5th Congress of the Parenteral 
and Enteral Nutrition Society of Asia, 28—30th October, Kuala Lumpur, p. 59. 
DUDRICK, S. J. & RHOADS, J. E. (1971) New horizon for intravenous feeding, Journal of 
American Medical Association, 215: 939–949. 
FESTEN, S., BREVOORD, J. C. D., GOLDHOORN, G. A., FESTEN, C., HAZEBROEK, F. W. 
J., VAN HEURN, L. W. E., DE LANGEN, Z. J., VAN DER ZEE, D. C. & ARONSON, D. C. 
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home central venous catheter survival, Journal of Hospital Infection, 35: 197–205. 
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SHAMSUDDIN, A. F. & BAHARI, M. B. (1994) Role of clinical pharmacist in nutritional 
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EVALUATION OF THE PARENTERAL NUTRITION SERVICES IN HOSPITAL PULAU PINANG

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EVALUATION OF THE PARENTERAL NUTRITION SERVICES IN HOSPITAL PULAU PINANG

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