将蛋白质和脂肪的补充量由百分比改为按体重计算对儿科肠外营养人群的效果
2010-03-12 20:15:33   来源：丁香园   作者：  评论：0 点击：

目的：提供足够的热量，才能充分实现补充蛋白质的益处（否则蛋白质将被作为热量消耗而浪费）。在CPOE系统使用之前，盖辛格医学中心（GMC）儿科PN采用最终量的百分比处方宏量营养素。患者接受的宏量营养素量随着所提供PN的总量而变化。因此，患者每日营养量是变化的。《肠外营养安全实践（2004）》推荐使用PN时，宏量营养素应以g/kg体重计算，而非百分比。随着计算机化医嘱录入系统（CPOE）的使用，我们可实现下列目标：1）修改实际医嘱使其符合安全实践指南；2）利用医嘱作为教学工具，为临床医生提供指导；3）提供通用的、简易的医嘱，适用于所有儿科患者，不必考虑年龄、体重和输注部位（周围和中心）；4）帮助缺乏儿科NSS的儿科患者实现营养目标。一个由医生、临床营养师和药剂师组成的多学科综合小组为CPOE使用新的PN医嘱制定了新的指南和标准建议。这是一项回顾性分析，为了观察如果将蛋白质和脂类医嘱从百分比转换为g/kg体重以及采用CPOE的PN医嘱系统提供标准营养建议对接受PN的住院儿科患者实现蛋白质和热量需求是否有益。

　　方法：回顾分析了采用CPOE系统前后3个月接受PN的所有儿科患者。排除初生婴儿、记录不全的患者以及营养师会诊后信息不全患者。所有其他儿科患者均进行评估，测定蛋白质和脂类需求百分数，由临床营养师决定，每袋PN制品均提供。这些百分比的平均值由PN制品下列各组决定：CPOE前TPN，CPOE前PPN，CPOE后TPN和CPOE后PPN。

　　结果：CPOE前TPN组84.5%的蛋白质需求和78.8%热量需求由TPN提供。CPOE前PPN组71%的蛋白质需求和60.4%的热量需求由PPN提供。采用CPOE系统后TPN组100%的蛋白质需求和91.2%的热量需求由TPN提供。CPOE后PPN组100%的蛋白质需求和67.4%的热量需求由PPN提供。

　　结论：儿科PN医嘱中宏量营养素由百分比方式转变为蛋白质和脂类g/kg体重方式可显著改善TPN和PPN提供蛋白质和热量计算。COPE医嘱系统是一种非常有用的工具，可以使儿科PN医嘱标准化，可以更加精确地提供推荐营养量。

Clinical Nutrition Week 2010 Nutrition Practice Abstracts

Abstract of Distinction. Also appeared in Symposium H40 Your Responsibility in Parenteral Nutrition Safety:

Nutr Clin Pract. 2010 Feb;25(1):95-6.

P6 - Effects of Converting Macronutrients Protein and Lipids from Percentage to Grams/Kilogram Following CPOE Implementation in Pediatric PN Population.

Carl W. Naessig, RPh.1; Ann Searfoss, Pharmacy Student2

1System Therapeutics, Geisinger Medical Center, Danville, PA; 2Nesbitt School of Pharmacy, Wilkes University, Wilkes-Barre, PA.

Introduction: The full benefit of protein administration is realized when adequate calories are provided. At Geisinger Medical Center (GMC), prior to CPOE, pediatric PN macronutrients were ordered as a percentage of the final volume. The amount of macronutrients a patient received varied based on the total volume of PN ordered. Consequently, the patient's daily nutrition was variable. Safe Practices for Parenteral Nutrition (2004) recommends that when ordering PN, the macronutrients should be ordered as grams per kilogram, not as percentages. With the implementation of computerized physician order entry (CPOE), we saw this as an opportunity to accomplish the following goals; 1) to modify ordering practices to be compliant with safe practices guidelines, 2) to utilized the order as an educational tool to provide guidance for the physician, 3) to provide a universal, easy to use order that could be utilized for all pediatric patients regardless of age, weight, and administration site (peripheral and central), 4) to meet the nutrition goals of the pediatric patient population in the absence of a pediatric NSS. A multidisciplinary team including a physician, clinical dietician, and pharmacist developed new guidelines and standard recommendation for the new PN order set to be implemented with CPOE. This was a retrospective analysis to determine if converting the order for protein and lipids from percentage to gm/kg and providing standard nutrition recommendations on the CPOE PN order set would have a beneficial effect in meeting protein and calorie needs in the hospitalized pediatric population receiving PN. Methods: All pediatric patients who received PN three months pre-and post-CPOE implementation were reviewed. Patients were excluded from this study if they were neonates, patients with incomplete charts, and patients with inadequate information provided by dietician consult. All remaining pediatric patients were reviewed and evaluated to determine what percentage of the protein and calorie needs, as determined by the clinical dietician, were being provided in each bag of PN. Averages of these percentages were then determined for all PN bags in each of the following groups; pre-CPOE TPN, pre-CPOE PPN, post-CPOE TPN, and post CPOE PPN. Results: The pre-CPOE TPN group had 84.5% of the protein needs and 78.8% of the calorie needs provided by TPN. The pre-CPOE PPN group had 71% of the protein needs and 60.4% of the calorie needs provided by PPN. Post-CPOE implementation TPN group had 100 % of the protein needs and 91.2% of the calorie needs provided by TPN. Post-CPOE PPN group had 100 % of the protein needs and 67.4% of the calorie needs provided by PPN. Conclusions: The conversion from a pediatric PN order form that utilized percentages of macronutrients to a system that utilized gram per kilogram for protein and lipids resulted in a significant improvement in the amount of protein and calories provided in both TPN and PPN. CPOE order sets are a useful tool for standardizing ordering of PN in pediatric patients in order to more accurately provided recommended nutrition.