A PROSPECTIVE AUDIT OF TOTAL PARENTERAL-NUTRITION AT A MAJOR TEACHINGHOSPITAL

Objective: To examine patterns of use and clinical outcomes of total p arenteral nutrition (TPN). Design: A prospective six-month audit (Dece mber 1992 - June 1993). Patients and setting: All inpatients administe red TPN at a metropolitan teaching hospital during the audit period. M ain study measures: Process measures included data about TPN initiatio n (bodyweight, period not receiving oral/nasogastric feeding, serum al bumin level, compliance with hospital guidelines), TPN delivery data ( kilojoules, and nutrient and electrolyte content), and bases for cessa tion or changes of TPN (biochemistry data, gastric and intestinal func tion). Outcome measures included body mass change, infection rate dete ction of biochemical abnormalities, and death. Results: During the aud it 168 consecutive patients received 175 TPN courses. These patients w ere followed until discharge or death; 49 patients (29%) died. Intensi ve care units accounted for 57.7% of TPN use. Deviations from approved hospital guidelines for initiation of TPN were common. Only a minorit y of patients were malnourished on objective audit criteria; 18% of me n 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. Compl ications included bacteraemia (9.1% of patients tested) and catheter-t ip sepsis (55.2% of 87 catheters tested). Four patients died; line sep sis caused one death and probably a further two. The incidence of gluc ose intolerance was 36.5%, and 25% had markers of abnormal liver funct ion. Conclusions: 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 proc edures avoidance of substrate overload (particularly glucose), and ear lier change to enteral nutrition.