我院全肠外营养医嘱审核综合分析

Comprehensive Review of Doctor’s Orders of Total Parenteral Nutrition in our Hospital

目的:分析全肠外营养(TPN)医嘱不合理使用情况,为临床合理使用TPN提供参考。方法:回顾2018年下半年至2019年上半年共4303份TPN医嘱,统计不合理的处方;结合患者的营养状况、临床诊断、实验室检查指标,对TPN的不合理使用情况进行综合分析。结果:4303张TPN医嘱中,经处方审核系统拦截的存疑医嘱再由药师人工判定为不合理的共334张。肠外营养稳定性评价中:热氮比、糖脂比、阳离子浓度、氨基酸浓度、葡萄糖浓度等不合理项目所占不合格医嘱的比例分别为71.86%、7.19%、5.39%、7.19%、1.80%;TPN组方错误占比6.29%。在合理性药物选择中:妊娠剧吐、胆囊炎或胆囊切除术、肾功能不全、肝功能不全、甘油三酯>4.5 mmol·L^-1、渗透压>900 mOsm·L^-1、钾离子浓度超标等不合理项目所占比例分别为0.30%、0.60%、2.99%、3.59%、1.50%、1.20%、0.30%。结论:智能审方系统能有效促进TPN合理用药。药师建议对于在TPN稳定性评价中,补充无脂肪乳的TPN中糖脂比、阳离子浓度、脂溶性维生素等的组方规则;在合理性药物选择判定中,针对严重肝肾功能不全患者,将肌酐清除率、CTP评分指标、凝血状况等纳入审方规则中予以完善。

Objective: To analyze the unreasonable use of total parenteral nutrition(TPN) in order to provide reference for clinical rational use of TPN. Methods: A total of 4303 TPN orders from July 2018 to June 2019 in our hospital were reviewed to screen the system for unreasonable use intercepted by manual audit. Combined with the nutritional status, clinical diagnosis and laboratory results of patients, the unreasonable use of TPN was analyzed comprehensively. Results: A total of 334 orders were found to be unreasonable. In the aspect of parenteral nutrition stability, the proportion of medical orders unreasonable in thermal nitrogen ratio, glycolipid ratio, cationic concentration, amino acid concentration and glucose concentration were 71.86%, 7.19%, 7.19%,5.39%, 7.19% and 1.8%, respectively;TPN formulation errors accounted for 6.29%. In the aspect of drug, choice the proportion of medical orders unreasonable for hyperemesis gravidarum, cholecystitis or cholecystectomy, renal insufficiency, liver insufficiency, TG >4.5 mmol·L^-1, osmotic pressure >900 mOsm·L^-1 and high potassium ion concentration were 0.30%, 0.60%, 2.99%, 3.59%, 1.50%, 1.20% and 0.30%, respectively. Conclusions: The intelligent TPN prescription audit system can improve the reasonable use of TPN. The pharmacist suggests more rules be added to the system: the parameters like ratio of sugar to lipid, cation concentrations and lipovitamins should be reconsidered when fat emulsion was not included in TPN;for severe hepatorenal function deficiency,creatinine clearance rate, CTP scores and blood coagulation status should be added to the rules.