Ioannides-Demos L L, Liolios L, Topliss D J, McLean A J
Alfred Hospital, Melbourne, VIC.
Med J Aust. 1995 Sep 4;163(5):233, 235-7. doi: 10.5694/j.1326-5377.1995.tb124556.x.
To examine patterns of use and clinical outcomes of total parenteral nutrition (TPN).
A prospective six-month audit (December 1992-June 1993).
All inpatients administered TPN at a metropolitan teaching hospital during the audit period.
Process measures included data about TPN initiation (bodyweight, period not receiving oral/nasogastric feeding, serum albumin level, compliance with hospital guidelines), TPN delivery data (kilojoules, and nutrient and electrolyte content), and bases for cessation or changes of TPN (biochemistry data, gastric and intestinal function). Outcome measures included body mass change, infection rate, detection of biochemical abnormalities, and death.
During the audit 168 consecutive patients received 175 TPN courses. These patients were followed until discharge or death; 49 patients (29%) died. Intensive care units accounted for 57.7% of TPN use. Deviations from approved hospital guidelines for initiation of TPN were common. Only a minority of patients were malnourished on objective audit criteria; 18% of men and 13% of women were underweight by body mass index criteria and 36% were malnourished when serum albumin level (< 30 g/L) was considered. Early initiation of TPN outside accepted guidelines was common. Complications included bacteraemia (9.1% of patients tested) and catheter-tip sepsis (55.2% of 87 catheters tested). Four patients died; line sepsis caused one death and probably a further two. The incidence of glucose intolerance was 36.5%, and 25% had markers of abnormal liver function.
TPN use is associated with a high risk of morbidity, and a 1.7% mortality. We recommend better patient selection for TPN, more appropriate use of enteral feeding, better infection control procedures, avoidance of substrate overload (particularly glucose), and earlier change to enteral nutrition.
研究全胃肠外营养（TPN）的使用模式及临床结局。
一项为期6个月的前瞻性审计（1992年12月至1993年6月）。
审计期间，一家大都市教学医院中所有接受TPN治疗的住院患者。
过程指标包括TPN起始相关数据（体重、未接受口服/鼻饲喂养的时长、血清白蛋白水平、是否符合医院指南）、TPN输注数据（千焦、营养素及电解质含量）以及TPN停止或变更的依据（生化数据、胃肠功能）。结局指标包括体重变化、感染率、生化异常的检测及死亡率。
审计期间，168例连续患者接受了175个TPN疗程。这些患者随访至出院或死亡；49例患者（29%）死亡。重症监护病房使用TPN的比例为57.7%。TPN起始时偏离医院批准指南的情况很常见。根据客观审计标准，只有少数患者存在营养不良；按照体重指数标准，18%的男性和13%的女性体重过轻，若考虑血清白蛋白水平（<30g/L），则36%的患者存在营养不良。在公认指南之外过早开始使用TPN的情况很常见。并发症包括菌血症（9.1%的受检患者）和导管尖端脓毒症（87根导管中的55.2%受检）。4例患者死亡；导管脓毒症导致1例死亡，可能还导致另外2例死亡。葡萄糖不耐受的发生率为36.5%，25%的患者有肝功能异常指标。
TPN的使用与高发病风险及1.7%的死亡率相关。我们建议更好地选择TPN患者，更合理地使用肠内营养，改善感染控制措施，避免底物超载（尤其是葡萄糖），并更早地转为肠内营养。
