Parenteral Nutrition In Acute Pancreatitis Research Articles

Early nasojejunal tube feeding versus nil-by-mouth in acute pancreatitis: A randomized clinical trial

Background/objectivesThere is substantial evidence of superiority of enteral nutrition (EN) to parenteral nutrition in acute pancreatitis (AP) treatment, but few studies evaluated its effectiveness compared to no intervention. The objective of our trial was to compare the effects of EN to a nil-by-mouth (NBM) regimen in patients with AP. MethodsPatients with AP were randomized to receive either EN via a nasojejunal tube initiated within 24 h of admission or no nutritional support. Systemic inflammatory response syndrome (SIRS) was assessed as the primary outcome. Secondary outcomes included mortality, organ failure, local complications, infected pancreatic necrosis, surgical interventions, length of hospital stay, adverse events and inflammatory response intensity. Outcomes were compared using Student's t-test and Mann–Whitney U test as appropriate. Results214 patients were randomized in total, 107 to each group. SIRS occurrence was similar between groups, with 48 (45%) versus 51 (48%), respectively (RR 0.94; 95% CI 0.71–1.26). No significant reduction of persistent organ failure (RR 0.81; 95% CI 0.52–1.27) and mortality (RR 0.59; 95% CI 0.28–1.23) was present in the EN group. There were no significant differences in other outcomes between the groups. When analyzing the occurrence of SIRS and mortality in subgroup of patients with severe disease no significant differences were noted. ConclusionOur results showed no significant reduction of persistent organ failure and mortality in patients with AP receiving early EN compared to patients treated with no nutritional support (NCT01965873).

Potential Influence of Intravenous Lipids on the Outcomes of Acute Pancreatitis

Parenteral nutrition (PN) has been associated with a higher rate of adverse outcomes compared with enteral feeding in patients with acute pancreatitis (AP). However, PN may be necessary when feeding via the enteral route is poorly tolerated or impossible, and PN is recommended as a second-line nutrition therapy in AP. Intravenous (IV) lipids are commonly used as a part of PN in patients with AP. While the adverse outcomes related to the use of PN in AP have commonly been attributed to infectious complications, data suggest that the unsaturated fatty acids in the triglycerides used in IV lipids may contribute to the development of organ failure. We discuss the clinical and experimental data on this issue and the alternative lipid emulsions that are being studied.

CALL FOR PAPERS: Examination of Basic Nursing Care

Basic nursing care serves nearly all people in their lifetimes. Infants, adults, and elderly alike may need physical or psychosocial nursing care as a result of disease or incapacity, either temporarily or permanently. Also, basic care is generic across medical conditions and care settings. Yet, this most common type of nursing care is surprisingly illinformed by evidence, and its quality can be insufficient.In the nursing literature over the years, both the quality and clinical relevance of nursing research have shown limitations (Rahm Hallberg, 2009), with limited contributions to the body of knowledge in nursing as a result. Moreover, nursing research has shown increasing development in specialist areas (e.g., cancer nursing, cardiovascular nursing, neurology nursing, etc.). Generating and synthesizing evidence on generic basic care have received less attention. This is reflected in the overview of systematic reviews on nursing care available in the Cohrane Library (www.cncf.cochrane.org), where systematic reviews in important generic areas such as respiration, temperature control, sleep and rest, oral care, nutrition, and dehydration are lacking, both for inpatient and outpatient or communitybased nursing care. If reviews on these care issues are performed at all, they focus on very specific conditions, such as oral care following tonsillectomy (Fedorowicz, Al-Muharraqi, Nasser, Al-Harthy, & Carter, 20 1 1 ) or parenteral nutrition in acute pancreatitis (Al-Omran, AlBalawi, Tashkandi, & Al-Ansary, 2010).While the development of evidence on basic nursing care needs urgent attention, it would be oversimplistic to claim a total absence of evidence in this area. Especially in the area of prevention of common complications, substantial evidence and guidelines are available to inform nursing actions. Pressure ulcer prevention (www.epuap.org/guidelines) and infection prevention through hand hygiene (www.who.int/gpsc/en/) are clear examples of this. In these and similar areas, however, a lack of implementation is seen (Van Achterberg, Schoonhoven, &* Grol, 2009). Though many have already tried to increase the uptake of hand hygiene guidelines, for instance, evidence of effects commonly refer to short-term follow-up, and substantial room for improvement still remains (Huis, van Achterberg, de Bruin, Grol, Schoonhoven, &· Hulscher, 2012). So while generating evidence for basic nursing care needs to be addressed, we also need to look into the implementation of the evidence that is already there.Exactly what is "basic nursing care?" Its nature is probably best described by Kitson and colleagues (2010), who recently undertook a meta -narrative review aimed at defining what they refer to as the fundamentals of care. Though Kitson and colleagues encountered a large variety of terminology and variable agreement between authors, their review arrived at a first set of elements to illustrate what basic care or the fundamentals of care are about. …

Community-Based Appraisal of the Effects of Parenteral Nutrition Versus Enteral Nutrition on the Quality of Care for Patients With Acute Pancreatitis.

BackgroundEnteral nutrition (EN) rather than parenteral nutrition (PN) has been advocated in treatment guidelines for acute pancreatitis (AP) as endorsed in randomized studies or meta-analyses. The findings derived from those studies would recognize the criticism of smaller sample sizes or limited patient case-mixes. To determine the generalizability of those findings, community-based appraisal on the advantages of EN over PN is required. Using a Japanese administrative database between 2006 and 2010, we determine whether EN is superior to PN in the real clinical settings.MethodsA total of 24,913 patients diagnosed with AP at admission in 1,000 hospitals were identified. Among them, we analyzed 1,803 patients of ≥ 15 years who received EN or PN for AP across 480 hospitals. Among three nutrition categories of PN only, EN only and PN with EN, we examined patient characteristics, comorbidities, complications, AP severity score determined by the Ministry of Health, Labor and Welfare, surgical procedures for the biliary/pancreatic system, use of artificially assisted ventilation and hemodialysis proxy of multiple organ failures and hospital teaching status. To identify the variables associated with PN use, a logistic regression model was used and the propensity score (PS) was calculated to control for the selection bias of patient case-mix preferring PN use. Then, we compared mortality, length of hospital stay (LOS), total charges (TC) and commencement day of oral food intake between EN and PN.ResultsA total of 1,191 PN patients, 330 EN patients and 282 mixed EN and PN patients were identified. EN was indicated for patients with mild AP and procedures for the pancreas. PS matching analysis indicated that PN had a higher mortality compared with EN, and PN significantly increased LOS and TC compared with EN. PN deterred the commencement of oral food intake.ConclusionsCommunity-based study has shown that EN was employed in the less severe case-mixed. Even though considering that selection bias, EN was still superior to PN in AP. Physicians should be aware of the guidelines for the advocacy of EN and need to carefully consider the indications for EN to optimize the quality of AP care.

Review: enteral nutrition reduces infections, need for surgical intervention, and length of hospital stay more than parenteral nutrition in acute pancreatitis

Marik PE, Zaloga GP. Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis. BMJ 2004;328:1407. [OpenUrl][1][Abstract/FREE Full Text][2] Q What is the efficacy and safety of enteral...

P0088 PP* ENERGY REQUIREMENTS IN ACUTE PANCREATITIS IN CHILDREN

Introduction: The management of acute pancreatitis involves resting the pancreas to reduce secretion of pancreatic enzymes. Nutrition support is often provided as total parenteral nutrition and nil orally. The calorie requirements in children with this condition are undefined. However, it is thought that energy requirements in adults with acute pancreatitis are increased by 20% (1). Our aim was to define energy requirements in acute pancreatitis in children given total parenteral nutrition. Methods: We reviewed a series of 8 children with acute pancreatitis who were given total parenteral nutrition for over 1 week. We looked at the non-nitrogen energy provided in the parenteral nutrition needed to stabilize body weight. Energy provision met with Estimated Average Requirements (2) in the first instance. This was thought to be an acceptable starting point for parenteral nutrition, as the increased requirements in pyrexia and trauma are balanced by a lack of activity, a lack of energy required for digestion and absorption, and the lack of consideration for nitrogen calories provided (the anomaly in parenteral prescriptions). All in the series had careful fluid and electrolyte balance studies to ensure any weight deviation was not related to hydration status. All in the series had periodic mild to moderate pyrexia, which responded to antibiotics. Results: The aetiology in these children were: trauma (n=4); pancreatic divisum (n=1); gallstones (n=1); and idiopathic (n=2). All aged between 8–13 years. The mean duration of parenteral nutrition required was 19 days (range 7–40 days). Most in our series (n=6) initially lost weight (range 1–3kg), the rest remained stable (n=2). An increase in energy provision was required of 110% (n=4) and 120% (n=2) Estimated Average Requirement to prevent further weight loss. Conclusion: Energy requirements in this small group were clearly on average above the Estimated Average Requirement. In future prescriptions of parenteral nutrition in acute pancreatitis in children, we will use 110% Estimated Average Requirement for initiation of non-nitrogen energy provision. In severe sepsis 120% Estimated Average Requirement would be fortuitous.

Should enteral feeding be the standard of care for acute pancreatitis?: Abou-Assi S, Craig K, O'Keefe SJD, Hypocaloric jejunal feeding is better than total parenteral nutrition in acute pancreatitis: results of a randomized comparative study. Am J Gastroenterol 2002;97:2255–62

This study was performed prospectively to define outcomes including length of hospital stay, duration of feeding, complications, hospital costs, and indications for nutritional support in patients admitted with acute pancreatitis (AP). Patients who failed to improve after 48 h of conservative treatment or who could not tolerate an oral diet were randomized to receive either nasojejunal (NJ) or total parenteral (TPN) feeding. The majority of cases were related to alcohol consumption or gallstones. The goal feeding rates were intended to provide 1.5 g protein/kg/day and 25–30 Kcal/kg/day. The two nutritionally supported groups were compared on an intention to treat basis. In all, 75% of patients admitted for AP improved after conventional therapy within 48 h and did not require nutritional support. Of the patients, 27 patients were randomized to TPN and 26 to NJ feeding. Three patients in the NJ group were switched to TPN (two needed surgery and one could not tolerate the NJ feeds), and two in the TPN group were converted to NJ feeding because of sepsis. The average length of hospital stay was shorter in the NJ group versus the TPN group (14 vs 18 days) but the difference was not significant. The introduction of oral feeding was tolerated better in the NJ group, with 80% advancing to an oral diet without difficulty in comparison to 63% in the TPN group. The average length of nutritional support was significantly shorter in the enteral nutrition (EN) patients who were fed by NJ tube than in patients on TPN (6.7 vs 10.8 days, p < 0.001). However, the EN group received fewer calories (49% vs 85%) and protein (42% vs 85%) in comparison to the TPN group ( p < 0.005). The disease severity as well as the serum pancreatic enzyme levels on admission and thereafter were comparable between the groups. Nutrition associated complications were significantly more common in the TPN group. These included hyperglycemia, septic complications, and catheter-related infections requiring prolonged therapy. The incidence of severe complication and death was similar in the two groups. A post hoc analysis of patients with severe pancreatitis showed similar results, with significantly more rapid resolution of the disease process in the NJ group. The average cost per hospital stay was considerably lower for patients who improved sufficiently to forgo nutritional support ($4,597) in comparison to patients who required nutritional support. Patients who received enteral feeding had a lower total average hospitalization cost of $26,464 versus $34,530 for those who required parenteral nutrition, based on intention to treat analysis. The significantly lower average nutritional costs in the enteral group of $394 per patient in comparison to $2,756 per patient in the parenteral group ( p = 0.0004) could be explained by the combination of the lower daily costs of enteral feeding ($23.3/day vs $222/day), and the shorter duration of feeding (6.7 vs 10.8 days). Consequently, the proportion of hospital costs resulting from enteral feeding was significantly lower than for parenteral feeding (1.8% vs 8.4%, p < 0.0001). The authors concluded that NJ feeding initiated 48 h postadmission for patients with AP was safer than TPN, and does not exacerbate the disease, is well tolerated and less costly than TPN.

Hypocaloric jejunal feeding is better than total parenteral nutrition in acute pancreatitis: results of a randomized comparative study

OBJECTIVES: The aims of this study were to define the indications for, and to evaluate the cost-effectiveness of, nutritional support in patients with acute pancreatitis. METHODS: All admissions during the 12-month period from January through December 2000, were entered into a common management protocol consisting of an initial 48-h fast with i.v. fluids and analgesics. After 48 h, those patients who were improving were restarted on oral feeding (group O). The remaining patients were randomized to receive naso-jejunal (group EN) or parenteral feeding (group TPN). The randomization study was continued until 50 patients had been accrued. Outcomes in the three groups were compared with respect to length of hospital stay, duration of feeding, complications, and hospital costs. RESULTS: A total of 156 admissions were evaluated in the first 12 months. Of these, 87% patients had mild disease, 10% moderate, and 3% severe; 62% were related to alcohol abuse, 18% gallstones, and 8% idiosyncratic drug reactions. Of the patients, 75% improved on 48 h bowel rest and i.v. fluids, and were discharged within 4 days. The remainder were randomized to jejunal elemental (n = 26) or parenteral (n = 27) feeding. Duration of feeding was shorter with EN (6.7 vs 10.8 days, p < 0.05) and nutrition costs were lower, representing an average cost saving of $2362.00 per patient fed. EN was less effective in meeting estimated nutritional requirements (54 vs 88%, p < 0.0001), but metabolic ( p < 0.003) and septic complications ( p = 0.01) were lower. Subgroup analysis of patients with severe disease showed similar findings. CONCLUSION: Despite concerns that metabolic expenditure is increased and that food-stimulated pancreatic secretion might exacerbate the disease process, hypocaloric enteral feeding seems to be safer and less expensive than parenteral feeding and bowel rest in patients with acute pancreatitis.

Enteral and parenteral nutrition in acute pancreatitis

In the last 5 years naso-enteric feeding has increasingly been used in clinical practice in patients with severe acute pancreatitis. Randomized clinical studies in both mild and severe forms of the disease have demonstrated not only the feasibility but also the safety of this approach. The majority of patients have been fed by variously placed nasojejunal tubes with varied problems in maintaining both location and patency. Most have been surprised to find that it is possible to feed the patients in this way with the potential of improving gut barrier function and immune response, at reduced cost and greater safety than with parenteral nutrition. The current evidence points to nasojejunal feeding being preferable to parenteral feeding, but evidence has yet to be produced to prove beyond reasonable doubt that such feeding is an improvement on conservative management without feeding. Finally, the most recent development has indicated that fine-bore nasogastric feeding may well be a realistic alternative to nasojejunal feeding even in the more severe forms of this disease. A small percentage of patients may still need parenteral nutrition.

Enterale Ernährung bei akuter Pankreatitis

The metabolism of acute pancreatitis is characterized by hypermetabolism and catabolism. Evidence for glucose intolerance occurs in anywhere from 40 to 90% of cases and urine urea nitrogen may increase up to 40 g/day. The most important aspect when considering nutritional therapy is determining the severity of the pancreatitis. The APACHE-II-scoring-system and the time honored Ranson criteria are useful for differentiating severe from mild pancreatitis. Despite some limitations in sensitivity and specificity, studies have suggested that patients with 2 or less Ranson criteria and an APACHE-II-score of 9 or less have mild pancreatitis, while patients with 3 or more Ranson criteria and an APACHE-II-score of 10 or more have severe pancreatitis. Evidence of organ failure on clinical presentation and pancreatic necrosis on dynamic CT scan are also important factors in determining severity of pancreatitis and are probably the two major indicators of patient outcome. Only 3 prospective randomized controlled trials have compared enteral to parenteral nutrition for pancreatitis. All studies described successful use of enteral feeding without exacerbating the disease process although a mild stimulation of exocrine pancreatic secretion could not be prevented, even when the tube was placed below the ligament of Treitz. Kalfarentzos [11] and McClave [14] could show that hyperglycemia was worse in the parenteral feeding patients compared to the enteral feeding group and Windsor [24] concluded with respect to the results of his study, that enteral feeding modulates the inflammatory response in acute pancreatitis. Conclusions regarding the use of enteral or parenteral nutrition in acute pancreatitis are difficult to form, as there is a need of more prospective studies. As ileus may be a problem in patients with greater severity of pancreatitis, limiting the application of early enteral feeding, the route of nutritional support should be determined by the clinical course and the severity of the disease.

Enteral Nutrition Support in Acute Pancreatitis

To review the controversies surrounding the use of nutritional interventions, particularly enteral support, in patients with acute pancreatitis. Articles were obtained through a MEDLINE search (1966-June 1999). Additionally, several textbooks containing information on the diagnosis and management of acute pancreatitis were reviewed. The bibliographies of retrieved publications and textbooks were reviewed for additional references. All original investigations in humans pertaining to the use of enteral nutritional support in acute pancreatitis were reviewed for inclusion. Studies that investigated parenteral nutrition in acute pancreatitis were also reviewed, with preference given to controlled comparisons with enteral regimens or no nutritional support. The primary outcomes extracted from the literature were time to oral feeding tolerance, complications (e.g., infection) associated with nutritional support, and length of stay. The duration of pancreatitis and time to oral feedings is similar whether patients receive enteral (i.e., jejunal tube feedings) or parenteral nutrition. Additionally, complications, length of stay, and costs are either similar or decreased with enteral versus parenteral nutrition. Current evidence suggests that the enteral rather than parenteral route should be used to provide nutrition to patients with acute pancreatitis. Parenteral nutrition should be reserved for patients in whom nasojejunal feeding is not possible.

NUTRITIONAL MANAGEMENT IN ACUTE AND CHRONIC PANCREATITIS

Patients with severe pancreatitis, characterized by multiple organ failure and pancreatic necrosis on CT scan (identified by an Acute Physiology and Chronic Health Evaluation II score of > or = 10 with > or = 3 Ranson criteria), most likely require aggressive nutritional support. Use of the enteral route of feeding may help contain the hypermetabolic stress response, reduce morphologic change and atrophy of the gut, and theoretically decrease late complications of nosocomial infection and organ failure. Evidence that decreasing degrees of stimulation of the pancreas occur as the site of feeding descends in the gastrointestinal tract and evidence from perspective, randomized trials suggest that jejunal feeding appears at least as safe and well tolerated as total parenteral nutrition in acute pancreatitis.

Early total parenteral nutrition in acute pancreatitis: Lack of beneficial effects

To determine the effect of early aggressive parenteral support in pancreatitis, 54 patients with acute pancreatitis were randomized to receive either conventional therapy (control group) or conventional therapy plus the institution of total parenteral nutrition within 24 hours. The two groups were similar demographically. The total parenteral nutrition group had a significantly higher rate of catheterrelated sepsis than did an additional group of contemporaneous patients without pancreatitis who received total parental nutrition (10.5 percent and 1.47 percent, respectively; p < 0.01). There was no advantage to the use of early total parenteral nutrition; that is, there was no difference in the number of days to oral intake, total hospital stay, or number of complications of pancreatitis. Patients with zero or one Ranson's criterion on admission were more likely to be eating by the seventh hospital day than were those with two or more Ranson's criteria (80 percent and 54 percent, respectively; p < 0.05). The early institution of total parenteral nutrition in patients with acute pancreatitis did not appear to improve the outcome. Its use should be limited to prolonged periods of no oral intake or treatment of a specific complication, such as a pseudocyst.