Despite mounting evidence, a question still exists as to the true clinical relevance of varying degrees of malnutrition, the role of currently measured nutritional parameters in identifying malnutrition and predicting clinical risk in individual patients, and the efficacy of nutritional therapy. This study was designed to document the usefulness of the Prognostic Nutritional Index (PNI) as a predictor of clinical course. The nutritional assessments and clinical records of 328 subjects in a Veterans Administration Hospital were reviewed, PNI and complication rates were determined for each of the subjects, and the data statistically analyzed. The PNI was found to be a useful indicator of malnutrition and predictor of clinical course. The PNI appeared to be a more sensitive index of clinical outcome than did comparison of individual nutritional parameters to accepted norms, although it accounted for only 17% of the information needed to predict clinical course perfectly.
BackgroundSubcutaneous (SC) fluids have been shown in several randomised controlled trials to be as effective as intravenous (IV) fluids for the treatment of mild-moderate dehydration, and are probably superior in confused patients. They are associated with reduced equipment costs, nursing time, fewer complications and less patient discomfort. However, they are often underused due to reliance on, and familiarity with the IV route.AimsTo assess how many patients were receiving fluids within a 32 bed UK hospice and review what proportion could have been appropriate for SC rather than IV fluids.Methods140 consecutive hospice inpatient admissions, for which notes were available, were reviewed retrospectively.Data was collected on demographics, indications for fluids as well as type and delivery of fluids. An algorithm to enable selection of SC fluids versus IV fluids within the hospice was drawn up and then used to assess retrospective use.Results21 patients (15%) received 26 episodes of fluids during their admission (all via the IV route). All had a malignant disease and had a mean hospice stay of 19 days. 16/21 patients died and 5 were discharged. Fluids were given for an average of 53 hours with 24 episodes delivering 2 litres of fluid or less per 24 hours. Indications were: infection (7), renal impairment/dehydration (6), hypercalcaemia (5), other (8). 24 episodes were assessed as having been suitable for SC fluid delivery although 16 had IV access for another reason. 7 episodes had a documented complication of fluid use, 5 of which related to cannulation.ConclusionsAll the patients in this study were given fluids exclusively via the IV route, but most would have been suitable for SC fluid administration. There is scope for a change in policy to administration more routinely via the SC route.
BackgroundDelirium is a common condition seen in all areas of clinical medicine, particularly in patients with advanced disease. Its prevalence is expected to rise from the current level of 28-90% with the use of more aggressive anti-cancer treatments. The condition is often under recognised but can be distressing for both patients and their relatives.AimsThe objective of this study was to establish how palliative care physicians in the UK assess and treat delirium (including drug treatment).MethodsA questionnaire was developed and sent via the Association of Palliative Medicine to all UK members. The questionnaire contained 10 questions with multiple choice answers but also allowed space for free text.ResultsThe results highlighted that currently physicians most commonly use no screening tools for diagnosing delirium (35%). They also highlighted that when treating delirium, conservative measures, such as quiet environment and reassurance, are opted for first, as well as identifying and treating reversible causes. However, when drug treatments are required haloperidol is the most popular choice (88.1%).ConclusionsThere is current consensus amongst surveyed UK palliative care physicians that conservative management of delirium should be used prior to medications, and that all reversible causes should be investigated. When drug treatment is required Haloperidol is the most popular drug which is in keeping with current NICE guidance. Recommendations for broader research include a screening tool for distress that could be validated in a palliative care population. It is also recognised that there is a lack of high quality evidence about which drugs to use when trying to restore cognitive function in palliative care patients. However, it may be that we should consider extrapolating the evidence from the NICE guidance to our patients, given the characteristics of the patients in the studies included.
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