Background One activity of the Hospital Pharmacist is the monitoring and adjustment of nutritional support in hospitalised patients.

Purpose To describe the interventions of the Pharmacy Service in the adjustment of Parenteral Nutrition (PN) in patients hospitalised in a postoperative intensive care unit.

Material and methods Retrospective six-month study. All pharmaceutical care for patients being treated with TPN were recorded in the electronic patient medical record and in an Excel database.

Results PN was initiated in 40 patients. 29 cases of postsurgical paralytic ileus, 6 peritonitis and 5 gastrointestinal bleeding.

All patients were interviewed and were screened to estimate the prior nutritional status. We also considered the presence of stress factors and based on all these factors, we estimated our patients’ caloric and protein requirements.

During this period 442 interventions were performed. A median of 11 interventions per patient was described:

• Detect food allergy (n = 4, 1%)

• Prevent refeeding syndrome: start nutritional support with 25% of caloric requirements and 100% of micronutrients and electrolytes in patients with moderate to severe malnutrition (n = 48, 11%).

• Adjust the ratio of non-protein kilocalories/gram of nitrogen to be 80–100 to achieve protein anabolism (n = 80, 18%).

• Skew caloric intake in favour of lipids in patients with respiratory distress (n = 30, 7%).

• Restrict lipids in hypertriglyceridemia (n = 14, 3%).

• Prevent and treat hepatobiliary complications (lipid restriction, nutrition cycling). (n = 22, 5%).

• Restrict carbohydrates in hyperglycaemia (n = 18, 4%).

• Administer glutamine and Omega 3 fatty acids according to hospital protocol (n = 60, 14%).

• Correct electrolyte imbalances. (n = 136, 31%).

• Restrict fluids and electrolytes in nephropathy and heart disease (n = 26, 6%).

Conclusion These results show a high demand for pharmaceutical attention in patients with TPN.

Incorporation of the pharmacist in this unit makes it possible to monitor patient nutrition during hospitalisation.

References and/or Acknowledgements No conflict of interest.