Evaluation of The Utilization of Parenteral Preparations for Fluid, Electrolyte and Nutrition Management in Two Tertiary Hospitals in Southeast Nigeria

Background: In this era of ongoing identification and analysis of medical errors, fluid and electrolyte management has trailed behind the medical decisions that have immediate obvious adverse consequences. This predicament may reflect a lack of understanding of the importance of considering individual volume and electrolyte abnormalities as a separate variable that can significantly alter a patient course and outcome.


Background
Parenteral nutrition is the intravenous administration of a nutritionally balanced and physicochemical stable sterile emulsion or solution. It is indicated when the GIT is inaccessible, inadequate or inappropriate to meet the patients on going nutritional needs or gut rest is indicated. Parenteral nutrition (PN) is a complex therapy containing more than 40 components, including dextrose, amino acids, fat emulsions, water, electrolytes, trace elements, and vitamins. To order PN appropriately, clinicians need to have a good understanding of body composition, fluid balance, electrolyte assessment, and acid-base balance. Human cells consist of 65% to 90% water, water and solutes pass through cell membranes both actively and passively, specific fluid and electrolyte concentrations are necessary in order for cell metabolism to occur, and these balances are affected by different stresses including trauma, surgery, and critical illness [1][2][3][4]. While fluid loss both measurable and insensible, occurs with these stressors, replacement and maintenance fluids are commonly administered without consideration of specific patient needs. Protocols and order sets allow for one size fits all fluid management that, though the time efficient, may not optimize patient recovery and may be detrimental. A patient fluid and electrolyte status affects all organ systems. Improper dosing can exacerbate already injured systems.
The human body in a state of wellness has a remarkable capacity to make small and large adjustments in fluid and electrolyte intake and mobilization for specific needs. In a state of illness these compensatory mechanisms are disrupted, and recovery is dependent on restoration of an appropriate balance [4][5][6].
Fluid, electrolyte, and nutrition management is important because most infants in a neonatal intensive care unit (NICU) require intravenous fluids (IVFs) and have shifts of fluids between intracellular, extracellular, and vascular compartments. Therefore, careful attention to fluid and electrolyte balance is essential. If inappropriate fluids are administered, serious morbidity may result from fluid and electrolyte imbalances. Inadequate attention to nutrition in the neonatal period leads to growth failure, osteopenia of prematurity and other complications. They are utilized to ensure an adequate delivery of calories and protein when patients are unable to take sufficient food by either the oral route or via feeding tube. PN is utilized in a variety of patient populations, including surgical patients, severely malnourished patients, and the critically ill ones at intensive care unit. Nutritional support is a recognized determinant of outcome in critically ill patients. Development of critical care services in Nigeria has not been accompanied by certain appropriate ancillary support services such as adequate nutritional support [7][8][9]. Parenteral preparations is mostly prescribed for surgery and patients in intensive care units. In this era of ongoing identification and analysis of medical errors, fluid and electrolyte management has trailed behind the medical decisions that have immediate obvious adverse consequences, perhaps because the effects of fluid mismanagement appear as multiple organ system failings that are attributed instead to progression of the underlying disease in the patient. This predicament may also reflect a lack of understanding of the importance of considering individual volume and electrolyte abnormalities as a separate variable that can significantly alter a patient course and outcome [8][9].
The evaluation of utilization of parenteral preparations in the aforementioned health facilities have not been carried out as no previous published literature were found. The study therefore, seeks to document a comprehensive parenteral utilization report of the health facilities and generate evidence-based information for intervention studies, and add to knowledge in promoting value based services, resource allocation, planning and better health care service delivery in our health facilities. This study evaluated the utilization of parenteral preparation for fluid electrolyte and nutrition, and document information for interventions and policy.

Study Location and Study Site
The study was carried out in two hospitals in Anambra State

Study Population
The study was carried out using eligible folders that met the inclusion criteria for in-patients who were admitted in the hospitals as inpatient within January 2017 and December 2018.

Sampling Method
All the eligible folders that met the inclusion criteria in the medical wards, surgical wards, and accident and emergency units were utilized to increase reliability.

Data Collection and Assessment of Collected Data
Data was collected using structured observational check list for parenteral utilization, patient care and health facility indicators. Data covering parenteral utilization was obtained from medical records retrospectively and filled in structured check list accordingly with careful observation.

Study Period
The study lasted from March 2018 to October 2018.

Statistical Analysis
The data was checked, cleansed and analyzed using the SPSS software program version. Descriptive statistics frequency, percentage, means and standard deviation was used to summarize the data.

Inclusion Criteria
a) All folders/patient records with parenteral preparation that felled between the stated periods but were ineligible b) All the inpatients folders of patients that contained parenteral preparations.

Exclusion Criteria
a) All folders/patient records that contains parenteral within the period which b) All folders containing other health devices and aids apart from parenteral.

c)
All patients that are not inpatients.

Ethical Consideration
Ethical approval was obtained from the Research and Ethics

Committee of Chukwuemeka Odumegwu Ojukwu University
Teaching Hospital Nnewi before commencement of the study. Every form of patient's identification was concealed in line with global best practices.  Table 3, revealed a statistically significant association (χ2 = 15.873, p = 0.001) between total dosage frequency of drugs prescribed in COOUTH and SCBH as shown in Table 3.  Table   4.       Chi-square test shown in Table 5, revealed a statistically significant association (χ2 = 9.765, p = 0.002) between total number of brands and generic prescription in COOUTH and SCBH. Ailments diagnosed at COOUTH and SCBH.

The Use of Parenteral Preparation in The Hospitals
In view of the clinical relevance of using parenteral forms, evidenced in different studies, it is essential that they be administered adequately. A tool that contributes to this goal is the adoption of good intravenous therapy practices in healthcare services [10,11].
Infusions form an essential part of inpatients prescription especially in tertiary hospitals with critically ill patients. Good understanding of their utilization pattern will aid procurement and eliminate the out of stock syndrome especially in emergency situations [12,13]. Delays in rational use of infusions and parenteral preparations is usually associated with life threatening emergencies and fatalities [14,15]. The study suggested that infusions were predom- and in vitro studies [16,17]. TPN is recommended for extended period in complications like pulmonary embolism [18].
Similarly, at SCBH, anti-microbial drugs, infusions and antimalarial appeared as the most commonly prescribed medications found in majority and occurring within the first three drugs prescribed to patients. This suggests that malnutrition is a common problem in most hospitalized patients. Surgical patients with malnutrition have around three times more post-operative complications and four times greater risk of death than well-nourished patients with similar operations [19]. The outcome of the class of drugs frequently prescribed in the two hospitals indicated that parenteral antibiotics were the leading infusions in the two hospitals.
This supports a study in Nigeria by Enwere et al. which reported high prescription of parenteral antibiotics [20].

Infusion Use and Prescription Practices in The Hospitals
Most of the infusions were predominantly administered either once or twice daily in the two hospitals. This is associated with the level of patients need and clinician's judgement and practices. Most hospitalized patients are either critically ill or have undergone surgeries and needs calories, proteins and other total parenteral nutritional substituents and electrolyte replacement. The study observed that the first, second and third medicine prescribes had higher prescription rates than the fourth and fifth drugs in both hospitals. This suggests indications for the predominant cases in commonly prevalent at the locations and suitability of frequently occurring medications [21]. However, a study suggested that clinicians usually prefer newer effective preparations with better profile to other existing options [22,23]. Prior drug utilization studies suggested that the tolerability of a drug may have more impact on the long term retention when compared to efficacy while changes in outcomes of therapy decides the retention of complement agents [24][25][26].The outcome showed that the dosage frequency in the two hospital varied significantly. Once a day dosing occurred more in the two hospitals assessed. It could be attributed to the nature and availability of preparations which usually applied most times in emergency situation before switching over to oral ones. Most of the infusions administered lasted for one to five days. Prolonged infusion of antibiotic in resistant infections has been demonstrated to have positive impacts on pharmacotherapy [27,28].

Categories and Types of Medications Available
More generic drugs prescriptions were common to both hospitals compared to branded prescriptions. However, the percentage generic prescription still felled below standards for the two hospitals. Previous study suggested that generic prescribing reduces patient's confusion and medication errors [29]. Another study saw it as, "an indication of good practice" and a way of viable low-cost medications [30][31][32]. Generic prescribing in the hospitals was in conformity with the WHO recommendations and international best practices [33]. The idea of prescribing generic drugs will leave the patients with some many options on the costeffective drugs to purchase, hence encouraging compliance. The generic prescription pattern from this study was better than the outcome in another work done in a teaching hospital in western Nigeria where the percentage of generic prescription from the study were much lower than that obtained in this study [34].
Other studies in the western and northern parts of Nigeria indicated values below 50% generic prescribing [35][36][37]. A study on the knowledge perception and, attitude of physicians on generic medicine prescribing suggested that therapeutic failure was a major concern that discourages generic prescribing [38]. However, another study in western Nigeria indicated that decline in generic prescribing was associated with the activities of pharmaceutical marketers who press for the prescription of their brands [37]. The list of ailments and individual parenteral medications prescribed indicated critically ill and emergency conditions which validated the use of parenteral preparations and infusions [38][39][40][41][42].

Conclusion
The use of parenteral preparations in the hospitals was achieved and the trend of prescription and utilization was determined.
The categories and types of parenteral nutrition available were assessed and the disease pattern associated with their utilization were ascertained which mostly indicated electrolyte imbalance.
The generic prescription and substitution practices of parenteral drugs in the two hospitals were assessed and were concluded to be more of generic than branded drug prescription. Thus, it can be concluded from the research that parenteral preparation can be inferred to be frequently used in the two hospitals assessed in South-eastern part of Nigeria.