Malnütrisyon saptanan palyatif bakım hastalarında beslenme tedavisi yaklaşım sonuçlarının değerlendirilmesi
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Dosyalar
Tarih
2020
Yazarlar
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Yayıncı
Kırıkkale Üniversitesi
Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
Malnütrisyon palyatif bakım hastalarında önemli problemlerdendir. Bu hastalarda beslenme tedavisinin hasta sonuçlarına etkisine dair çelişkili sonuçlar bildirilmektedir. Bu çalışmada malnütrisyon risk skoru yüksek palyatif bakım hastalarında beslenme şekillerinin, hastaların aktivite ve performans skorlarına, semptom düzeylerine, laboratuvar parametlerine, antropometrik ölçümlerine ve mortaliteye olan etkileri incelenmiştir. Çalışmaya dahil edilen ortalama yaşları 69,5 ± 14,4 yıl olan 103 (42 kadın, 61 erkek) hasta, günlük kalori ihtiyacının %60'tan fazlasını hangisiyle sağlandığına dayanarak enteral (n=73) ve parenteral (n=30) beslenme gruplarına ayrıldı. Her iki grup arasında yaş, cinsiyet, vücut kitle indeksi, sigara kullanımı, malignite ve diğer komorbid hastalıklar ile başlangıç inflamatuvar belirteçler ve diğer laboratuvar parametrelerinde ve üst kol çevresi ve baldır çevresini içeren antropometrik ölçümlerde anlamlı farklılık yoktu. Parenteral beslenen hasta grubunda ödem ve bası yarası oranı daha fazlaydı (p<0,01, p<0,01). Palyatif Bakım Servisinde ortalama 22 ± 2 gün izlem sonunda, enteral beslenen hastalarda nötrofil/lenfosit, platelet/lenfosit, CRP ve CRP/albümin değerlerinin düştüğü, parenteral beslenen hastalarda ise nötrofil/lenfosit ve CRP/albümin değerlerinin yükseldiği gözlendi. Antropometrik ölçümlerden üst kol çevresi ve baldır çevresi izlem sonunda enteral beslenenlerde parenteral beslenenlere göre anlamlı düzeyde artmıştı (p=0,01, p<0,01). Aktivite ve performans durumları Karnofsky Performans Skalası, Palyatif Performans Skalası ve Barthel Aktivite İndeksi ile değerlendirilen hastalardan enteral beslenme grubunda olanların başlangıç skorları parenteral beslenenlere daha iyiydi. İzlem sonunda enteral beslenen grubun performans skorlarında iyileşme saptanırken parenteral beslenen grupta kötüleşme görüldü. Yatış ve çıkış semptom düzeyleri Edmonton Semptom Tanılama Ölçeği ile değerlendirildiğinde, enteral beslenen hastaların parenteral beslenen hastalara kıyasla başlangıç semptomlarının daha hafif olduğu ve izlem sonunda tüm semptomların gerilediği, ancak parenteral beslenen hastalarda sadece ağrı, yorgunluk, uykusuzluk, kendini kötü hissetme ve iştahsızlık yakınmalarında gerileme olduğu gözlendi. Enteral ve parenteral beslenenler arasında Palyatif Bakım Servisi'nde ortalama kalış süresi ve enfeksiyon sıklığında farklılık saptanmazken, parenteral beslenen hasta grubunda antibiyotik kullanım süresi daha uzun, yoğun bakım servisine devir (%74'e karşılık %12, p<0,05) ve mortalite (%13'e karşılık %4, p<0,05) oranları anlamlı olarak daha yüksek saptandı. Yoğun bakıma devredilen hastaların da sonraki süreçte hepsinin öldüğü bilgisine dayanarak sağ kalan (n=65) ve ölen (n=38) hastalar arasında yapılan karşılaştırmalarda beslenme şekli, ödem ve bası yarası varlığı ile başlangıç aktivite indeksi ile performans skorları anlamlı farklı bulundu. Parenteral beslenen hasta grubunda anemi ve ödem varlığı, enteral beslenen hasta grubunda ise yüksek lökosit sayımı ile enfeksiyon ve pulmoner emboli varlığı mortalite ile ilişkili faktörler olarak belirlendi. Ancak tüm hastalarda mortaliteye etki eden faktörlerin değerlendirildiği çok yönlü lojistik regresyon analizinde sadece parenteral beslenme ihtiyacı, (OR=22,8 p<0,001), ödem varlığı (OR=3,6 p<0,05) ve başlangıç kötü Karnosfky performans skoru (OR=0,9 p<0,05) mortaliteyi belirleyen bağımsız faktörler olarak öne çıktı. Sonuç olarak, bu çalışmadan elde edilen veriler malnütrisyonu olan palyatif bakım hastalarında aktivite ve performans skorları daha düşük olan hastaların daha fazla parenteral beslenme ihtiyacı duyduğunu ve parenteral beslenme ihtiyacı, ödem ve başlangıçtaki kötü performansın mortalitenin bağımsız belirleyicileri olduğunu göstermiştir. Malnütrisyonu olan hastalarda erken tanı koyularak öncelikli olarak enteral beslenme ile tedavi düşünülmeli, parenteral tedavi ihtiyacı mümkün olduğunca engellenmeli veya geciktirilmelidir. Malnütrisyonun bir sonucu olarak gelişebildiği gibi komorbid hastalıklara bağlı olarak da görülebilen ödemin hastaların sağ kalımını olumsuz etkilediği, diğer taraftan anemi ve enfeksiyonun morbidite ve mortalite üzerine olası etkileri düşünülerek bu durumların önlenmesi veya etkin tedavisi sağlanmalıdır. Malnütrisyonu olan palyatif bakım hastalarında beslenme şekli başta olmak üzere mortaliteye etki edebilecek faktörlerin çok yönlü araştırıldığı daha geniş çalışmalara ihtiyaç vardır.
Malnutrition is one of the major problems in palliative care patients and conflicting results have been reported regarding the effect of nutritional therapy on outcomes in these patients. In this study, the effects of nutritional patterns on activity and performance scores, symptom levels, laboratory parameters, anthropometric measurements and mortality in palliative care patients with a high malnutrition risk score were investigated. 103 (42 females, 61 males) patients with a mean age of 69.5 ± 14.4 years were divided into enteral (n = 73) and parenteral (n = 30) nutrition groups as a predominant diet. There were no significant differences between the two groups in terms of age, gender, body mass index, smoking, malignancy and other comorbid diseases, and baseline inflammatory markers and other laboratory parameters, and anthropometric measurements including upper arm circumference and calf circumference. The rates of edema and pressure sores were higher in the parenteral nutrition group (p<0,01, p<0,01). After an average of 22 ± 2 days of follow-up in the Palliative Care Service, it was observed that the values of neutrophils/lymphocytes, platelets/lymphocytes, CRP and CRP/albumin decreased in patients receiving enteral nutrition, while the ratios of neutrophil/lymphocyte and CRP/albumin increased in patients receiving parenteral nutrition. Among the anthropometric measurements, upper arm circumference and calf circumference increased significantly in enteral nutrition group compared to parenteral nutrition group at the end of the follow-up (p=0,01, p<0,01). The baseline scores of patients with enteral feeding whose activity and performance status were evaluated with the Karnofsky Performance Scale, Palliative Performance Scale and Barthel Activity Index were better than the parenterally fed group (p <0.05). As a result of repeated evaluations while leaving the Palliative Care Service, improvement was observed in the performance scores of the enterally fed group, while deterioration was observed in the parenterally fed group (p <0.05 for all). When the symptom levels of the patients which were evaluated with the Edmonton Symptom Diagnostic Scale both at admission and upon leaving the Palliative Care Service, it was observed that enterally fed patients had milder initial symptoms compared to parenterally fed patients, and all symptoms regressed at the end of follow-up. However, there was a regression at only pain, fatigue, insomnia, feeling unwell and anorexia in parenterally fed patients. While there was no difference in mean stay at Palliative Care Service and infection frequency between enteral and parenterally fed patients, antibiotic use was longer in the parenterally fed patient group, and transfer to intensive care unit (74% versus 12%, p <0.05) and mortality (13% versus 4%, p <0.05) rates were found to be significantly higher. In the comparisons between the survivors (n=65) and the patients who died (n=38) based on the knowledge that all of the patients transferred to the intensive care unit died in the next period, the type of nurition, edema and pressure sores were found to be significantly different. While anemia and edema were prominent factors affecting survival in parenterally fed patients, high leukocyte count and presence of infection and pulmonary embolism were determined as factors affecting mortality in enterally fed patients. However, when the factors affecting mortality were evaluated with multiple regression analysis in all patients, only parenteral nutrition need (OR = 22.8 p <0.01), edema (OR = 3.6 p <0.05) and low Karnofsky Performance Score (OR = 0.9 p <0.05) stood out as independent factors predicting mortality. In conclusion, the data obtained from this study showed that among palliative care patients with malnutrition the patients who have lower activity and performance scores need more parenteral nutrition, and parenteral nutrition need, edema and poor performance status are independent determinants of mortality. Patients with malnutrition should be diagnosed early, enteral nutrition should be considered primarily, and the need for parenteral treatment should be prevented or delayed as much as possible. Considering that edema, which can develop as a result of malnutrition or due to comorbid diseases, negatively affects the survival of patients, and considering the possible effects of anemia and infection on morbidity and mortality, effective preventive measures and treatment of these conditions should be provided. There is a need for larger studies investigating the factors, especially the type of nutrition, that may affect mortality in palliative care patients with malnutrition.
Malnutrition is one of the major problems in palliative care patients and conflicting results have been reported regarding the effect of nutritional therapy on outcomes in these patients. In this study, the effects of nutritional patterns on activity and performance scores, symptom levels, laboratory parameters, anthropometric measurements and mortality in palliative care patients with a high malnutrition risk score were investigated. 103 (42 females, 61 males) patients with a mean age of 69.5 ± 14.4 years were divided into enteral (n = 73) and parenteral (n = 30) nutrition groups as a predominant diet. There were no significant differences between the two groups in terms of age, gender, body mass index, smoking, malignancy and other comorbid diseases, and baseline inflammatory markers and other laboratory parameters, and anthropometric measurements including upper arm circumference and calf circumference. The rates of edema and pressure sores were higher in the parenteral nutrition group (p<0,01, p<0,01). After an average of 22 ± 2 days of follow-up in the Palliative Care Service, it was observed that the values of neutrophils/lymphocytes, platelets/lymphocytes, CRP and CRP/albumin decreased in patients receiving enteral nutrition, while the ratios of neutrophil/lymphocyte and CRP/albumin increased in patients receiving parenteral nutrition. Among the anthropometric measurements, upper arm circumference and calf circumference increased significantly in enteral nutrition group compared to parenteral nutrition group at the end of the follow-up (p=0,01, p<0,01). The baseline scores of patients with enteral feeding whose activity and performance status were evaluated with the Karnofsky Performance Scale, Palliative Performance Scale and Barthel Activity Index were better than the parenterally fed group (p <0.05). As a result of repeated evaluations while leaving the Palliative Care Service, improvement was observed in the performance scores of the enterally fed group, while deterioration was observed in the parenterally fed group (p <0.05 for all). When the symptom levels of the patients which were evaluated with the Edmonton Symptom Diagnostic Scale both at admission and upon leaving the Palliative Care Service, it was observed that enterally fed patients had milder initial symptoms compared to parenterally fed patients, and all symptoms regressed at the end of follow-up. However, there was a regression at only pain, fatigue, insomnia, feeling unwell and anorexia in parenterally fed patients. While there was no difference in mean stay at Palliative Care Service and infection frequency between enteral and parenterally fed patients, antibiotic use was longer in the parenterally fed patient group, and transfer to intensive care unit (74% versus 12%, p <0.05) and mortality (13% versus 4%, p <0.05) rates were found to be significantly higher. In the comparisons between the survivors (n=65) and the patients who died (n=38) based on the knowledge that all of the patients transferred to the intensive care unit died in the next period, the type of nurition, edema and pressure sores were found to be significantly different. While anemia and edema were prominent factors affecting survival in parenterally fed patients, high leukocyte count and presence of infection and pulmonary embolism were determined as factors affecting mortality in enterally fed patients. However, when the factors affecting mortality were evaluated with multiple regression analysis in all patients, only parenteral nutrition need (OR = 22.8 p <0.01), edema (OR = 3.6 p <0.05) and low Karnofsky Performance Score (OR = 0.9 p <0.05) stood out as independent factors predicting mortality. In conclusion, the data obtained from this study showed that among palliative care patients with malnutrition the patients who have lower activity and performance scores need more parenteral nutrition, and parenteral nutrition need, edema and poor performance status are independent determinants of mortality. Patients with malnutrition should be diagnosed early, enteral nutrition should be considered primarily, and the need for parenteral treatment should be prevented or delayed as much as possible. Considering that edema, which can develop as a result of malnutrition or due to comorbid diseases, negatively affects the survival of patients, and considering the possible effects of anemia and infection on morbidity and mortality, effective preventive measures and treatment of these conditions should be provided. There is a need for larger studies investigating the factors, especially the type of nutrition, that may affect mortality in palliative care patients with malnutrition.
Açıklama
Anahtar Kelimeler
İç Hastalıkları, Internal diseases
