Enteral vs. Parenteral Nutrition in Patients with Acute

Michelle Mann, R.N. Mary Sawyer, R.N.Erika Rumble, R.N.

Chanda Vlanich, R.N. Paul Vlanich, R.N.

University of Oklahoma

Health Sciences Center

May 01, 2009

The incidence of new cases is 17:100,000 persons in the United States.

Mortality rates of 80% occur that are due to complications.

Siow, 2008, p. 20

Affects middle-aged adultsMenWomen

Degree of inflammation Mild edemaSevere hemorrhagic necrosis

Marik, 2004, p. 1408

Common CausesGallbladder DiseaseChronic alcohol abuse

Less CommonAbdominal traumaViral infectionsDuodenal ulcers

Marik, 2004, p. 1408

Premature activation of trypsin leads to increased pancreatic digestive enzymes.

Results in intrapancreatic inflammation, leading to extrapancreatic inflammation.

Complications sepsismultiple organ dysfunction acute respiratory syndrome

Siow, 2008, p. 20

Acute Pancreatitis

Hemorrhagic Pancreatitis

Left upper quadrant pain

Abdominal tenderness

Nausea and vomiting

Crackles present in lungs

Decreased or absent bowel sounds

Siow, 2008, p. 20

Pseudocyst

Pancreatic abscess

Pancreatic infection- 13.5% of mortality rates are due to infection.

Siow, 2008, p. 20

No standard protocol for providing nutritional support.

Parenteral nutritional support common practice.

High levels of morbidity, cost, complications, and mortality.

In adult patients with acute pancreatitis, which nutritional intervention, enteral or parenteral feeding, improves dietary intake, results in fewer treatment complications, and decreases length of hospitalization?

Randomized control trials and 3 meta-analysis were reviewed to compare patient outcomes.

Databases used:OvidCINAHLMEDLINECochrane Systematic Reviews

Studies compared: Nutrition support

Enteral & Parenteral ComplicationsLength of stay Dietary improvementCost of care

Screening Methods

APACHE II score

Ranson criteria

Evaluation upon admission and 48 hours after admission

Algorithms to aid in addressing nutritional support

Adults with severe acute pancreatitis

Nutritional InterventionParenteral nutritionEnteral nutrition

APACHE II score > 10Classify severity of disease in ICU

Measured during the first 24 hours of admission

Point score system

Based on 12 routine physiological measurementsBlood pressure, heart rate, temperature,

respiratory rate etc…

Siow, 2007, p. 27

Ranson score > 2

Predict severity of disease & mortality

Uses parameters such as:AgeWhite blood cell count at admissionHematocrit 48 hours after admissionSerum urea nitrogen level 48 hours after

admission

Siow, 2007, p. 27

Dietary Improvement4.1 fewer days of nutritional support80% progressed to oral diet without problemNutritional level returned to baseline within 24

hours of enteral nutrition Maintain gut integrityDecreased incidence of hyperglycemia

Siow, 2007, p. 23

Complications related to parenteral nutritionSepsisCatheter-related infectionNosocomial infectionProlonged starvation leads to bacterial

overgrowthIlleus up to 5 days longer

Siow, 2007, p. 23

Length of StayMedian length of stay reduced by 2.9 days

Cost of CareParenteral vs. Enteral

$2608 vs. $1375After sensitivity analysis : $2608 vs. $957

Siow, 2007, p. 23 Louie, 2005, p. 303

In the reviewed studies, evidence showed that patients receiving enteral nutrition therapy had fewer treatment complications, experienced dietary improvement, had a shorter length of hospitalization, and a lower cost of care.

Identify early predictors of acute pancreatitis by using reliable scoring systems to indicate severity

Acute Physiology and Chronic Health Evaluation (APACHE II)

Ranson Criteria

Assess patients nutritional statusHistory of present illnessPhysical assessmentSerum levels of protein and albumin

Obtain dietary consult

Insert nasogastric or nasojejunal tube

Siow, 2007, p. 28

Initiate enteral nutrition within first 48 hours

Continue enteral nutrition until patient may begin oral feedings

Advance oral feedings as tolerated

If patient does not tolerate enteral nutrition begin parenteral nutrition

Increase sample size in future studies

Standardize operational definitions of study outcome variables so that studies may be compared.

Standardize severity scoring systems in future studies

The American College of Gastroenterology supports the use of enteral nutrition Stabilize the gut barrier functionPrevent complications associated with bacterial

infection

The reviewed studies provided evidence that the use of enteral nutrition is the choice of nutritional therapy for patients with acute severe pancreatitis.

Nurses can play an important role in the healthcare team by influencing the team members to use the appropriate nutritional intervention in patients with acute severe pancreatitis.

Al-Omran, M., Groof, A., Wilke, D. (2008). Enteral versus parenteral nutrition for acute pancreatitis. The Cochrane Database of Systematic Reviews. Vol. 4.

Louie, B. E., Noseworthy, T., Hailey, D., Gramlich, L. M., Jacobs, P., Warnock, G. L., (2004). Enteral or parenteral nutrition for severe pancreatitis: a randomized controlled trial and health technology assessment. Canadian Journal of Surgery, 48, (4), 299-306.

Marik, P. (2004). Meta-analysis of parenteral nutrition versus Enteral nutrition in patients with acute pancreatitis. British Medical Journal, 328, 1407-1412.

McClave, S.A. (2007). Nutrition Support in Acute Pancreatitis. Gastroenterology Clinics, 36, 1-7.

Siow, E. (2008). Enteral versus parenteral nutrition for acute pancreatitis. Critical Care Nurse, 28(4), 19-31.