Upload
amena
View
81
Download
2
Tags:
Embed Size (px)
DESCRIPTION
Nutrition Therapy in Acute Pancreatitis. Gila Greenbaum , Dietetic Intern, Sodexo 2014. Objectives. Define acute pancreatitis (AP) Differentiate between mild vs. severe AP (SAP) - PowerPoint PPT Presentation
Citation preview
NUTRITION THERAPY IN ACUTE PANCREATITIS
Gila Greenbaum, Dietetic Intern, Sodexo 2014
Objectives
I. Define acute pancreatitis (AP)II. Differentiate between mild vs. severe AP
(SAP)III. Review research to determine
recommended nutrition therapy (NT) for AP: I. Timing: when to initiate feedingsII. Diet: how to initiate feedings III. Enteral vs. Parenteral Nutrition
IV. Review current guidelines: ACG, ASPEN, ESPEN
Case Study
Mrs. M is 88 year old female, c/o n/v, abdominal pain. Diagnosed with AP, and currently NPO with IV fluids for 5 days. She is anxious, and questions, “When will I be able to eat real food, and what foods can I eat?”
What would you answer Mrs. M?
http://www.connecttoresearch.org/publications/2
What is AP?
Inflammatory disorder Digestive enzymes damage the
pancreas Primary causes: alcohol abuse,
gallstonesSigns &
SymptomsLab Tests
Abdominal pain, tenderness WBC
Nausea, vomiting Amylase
Fever Lipase
Mild vs. Severe AP
MILD SEVERE80% of cases 20% of cases
Self-limiting: resolves within 48 hours to 5 days
Local or regional complications, e.g. necrosis,
fluid collections, develop after 48 hours
Absence of organ failure and/or pancreatic necrosis
Presence of SIRS, sepsis, persistent organ failure (MODS) and/or death
occurring past 48 hours
Alcohol Gallstones
How to diagnose mild vs. severe AP?
Ranson’s Criteria: Clinical signs ≥3 associated with severe course
Acute Physiology and Chronic Health Evaluation (APACHE) II: physiologic measurements, age, PMH ≥ 8 associated with severe course
CT Severity Index (CTSI): based on extent of inflammation/complications on scan
Goal of Nutrition Therapy in AP
Reduce burden of disease Maintain positive nitrogen balance
without over-stimulating pancreatic fluids
Dietary improvement and/or advancement
What have we done in the past?
Prolonged fasting/NPO until normalization of enzymes, resolution of pain & inflammation
Oral feedings initiated with clear liquid diet
If oral feeding not possible: TPN
What is the recommended NT in AP?
Let’s see what the current research has to say…….
I. Timing: when to initiate feedingsII. Diet: how to initiate feedings III. Enteral Nutrition (EN) vs.
Parenteral Nutrition (PN)
I. Timing: when to initiate feedings
4 studies reviewed in this section:
• Eckerwall, Clinical Nutrition, 2007
• Chebli, Journal of Gastroenterology and Hepatology 2005
• Baker, currently ongoing• Hegazi, JPEN, 2011
1) Eckerwall, 2007
Immediate feeding vs. traditional fasting Methods: 60 patients, randomized to
fasting or immediate oral feeding group Findings:
(1) No differences between groups concerning pancreatic enzyme levels, pain or GI symptoms(2) LOH shorter in the oral feeding group (4 vs. 6 days)
Early oral refeeding may stimulate pancreatic secretion, increase inflammation, cause relapse of abdominal pain
Pain relapse during oral refeeding relatively high on day 1-2 since admission
Pain relapse increased hospital stay and overall costs on disease treatment
2) Chebli, 2005
Does starting EN within 24 hrs reduce infections compared to starting EN and/or oral diet 3-4 days after admission?
208 patients randomized: EN within 24 hours (group A), or oral diet plus EN 72 hours (group B)
Group A: started at 20ml/hr, with goal rate 65ml/hr within 72 hrs
Group B: NPO for 72 hrs, then oral diet and/or EN
3) Baker, ongoing
Investigated early initiation DJF Retrospective chart analysis Nutrition Intervention: 20-
25kcal/kg (IBW), 1.5g/kg protein via DJT
Results: (1) Early initiation: reduced mortality, fewer complications (2) Early achievement of feeding goal rate: shorter LOS (9d vs. 19d)
4) Hegazi, 2011
Most studies: feeding can be initiated within 24-48 hrs
American College of Gastroenterology (ACG) Guidelines (2013)
Timing to initiate feedings remains controversial
Feedings can be started when there is no n/v, and abdominal pain has resolved
Mean time between hospital admission and 1st meal: 1.5 days
--- Recap on Timing ---
2 studies reviewed in this section:
• Sathiaraj,Aliment Pharmacol Ther, 2008
• Jacobsen,Clinical Gastroenterologyand Hepatology, 2007
II. Diet: how to initiate feedings
Tolerance of soft diet (SD) vs. clear liquid diet (CLD) in feeding initiation
Methods: 101 patients randomized to CLD (458kcal/d, 11g fat/d) or SD (1040kcal/d, 20g fat/d)
Findings: SD patients had decreased LOH post feeding (4 vs. 6d), reduced total LOHS (5 vs. 8d), no differences in pain
1) Sathiaraj, 2008
Low fat solid diet (LFSD) vs. CLD Patients fed within 1-3 days post
admission Results: (1) LFSD was well tolerated, (2)
Did NOT result in shorter LOH Significance: LFSD can be considered for
patients who desire greater dietary choice when initiating feeding after mild AP
2) Jacobsen, 2007
SD and LF solid diet are tolerated compared with CLD
ACG Guidelines (2013): Appropriate diet when initiating
feedings: low fat low residue (soft) diet
--- Recap on Diet ---
2 studies reviewed in this section:
• Eckerwall, Annals of Surgery, 2006• Hegazi, J Parenter
Enteral Nutr, 2011
III. Enteral vs. Parenteral Nutrition
Nutrition Support
New Research: EN vs. PN
EN: Encourages gut function, reduces bacterial overgrowth, fewer overall infections and complications
EN vs. PN: 1. 4.1 fewer days of nutritional support 2. Progressed to full oral feeding 1 day earlier
Cost savings: PN ($3294/pt) vs. EN ($761/pt)
50 patients, randomized to EN or TPN group Nutrition initiated within 24 hours Only benefit of EN: improved blood glucose
levels Findings do not support suggested benefits
of EN
1) Eckerwall, 2006
PN offers nutrients without pancreatic stimulation
PN associated with infections, metabolic complications
Pancreatic stimulation minimized during EN using mid to distal jejunum (40-60cm distal to the ligament of Treitz)
http://www.normanallan.com/Misc/mingmen.htm
2) Hegazi, 2011
--- Recap on Enteral vs. Parenteral ---
Most research: EN has eclipsed PN as the new "gold standard" of NT in AP
ACG Guidelines (2013) PN should be avoided in SAP unless
EN not possible (e.g. paralytic ileus) or tolerated
ESPEN Guidelines
EN has no positive impact on mild AP, only recommended for patients NPO > 5 days
EN is recommended for SAP Only supplement with PN if needed EN should be continuous, peptide-
based formula
ASPEN Guidelines
Energy Requirements: Calories: 25–35 kcal/kg/dProtein: 1.2–1.5 g/kg/d
Mild-moderate AP: 1. NPO, gradual advancement to oral diet within 3-4d2. Only consider nutrition support if NPO > 5d
EN: preferred over PN, initiate first if feasible EN Formula: small peptide-based MCT,
continuous feeding PN used only if EN not tolerated/indicated
Summary
I. Timing: remains controversial, within 24-48 hours, with no n/v or abdominal pain
II. Diet: low fat low residue diet (usually with mild to moderate AP)
III. EN preferred over PN when possible (usually with SAP)
Siow. Critical Care Nurse, 2008.
RBMC Guidelines
There are currently no guidelines in place at the facility for nutrition therapy in AP
This research can help create standards of care
Back to the case study…….Mrs. M is 88 year old female, c/o n/v,
abdominal pain. Diagnosed with AP, and currently NPO with IV fluids for 5 days. She is anxious, and questions, “When will I be able to eat real food, and what foods can I eat?”
What would you answer Mrs. M? Is your answer different from your initial answer?
References
1. Eckerwall et al. Immediate oral feeding in patients with mild acute pancreatitis is safe and may accelerate recovery—A randomized clinical study. Clinical Nutrition, Vol 26, Issue 6, 758-763, 2007.
2. Siow. Enteral Versus Parenteral Nutrition for Acute Pancreatitis. Critical Care Nurse, 28, 19-30, 2008.
3. Mirtallo et al. International Consensus Guidelines for Nutrition Therapy in Pancreatitis. JPEN J Parenter Enteral Nutr 36, 284-291, 2012.
4. Chebli et al. Oral refeeding in patients with mild acute pancreatitis: Prevalence and risk factors of relapsing abdominal pain. Journal of Gastroenterology and Hepatology, Vol 20, 9, 1385–1389, 2005.
5. Tenner et al. American College of Gastroenterology Guideline: Management of Acute Pancreatitis. Am J Gastroenterol, 108, 1400-1415, 2013.
6. Sathiaraj et al. Clinical trial: oral feedings with a soft diet compared with clear liquid diet as initial meal in mild acute pancreatitis. Aliment Pharmacol Ther, 28, 777-781, 2008.
References cont.
7. Jacobsen et al. A Prospective, Randomized Trial of Clear Liquids Versus Low-Fat Solid Diet as the Initial Meal in Mild Acute Pancreatitis. Clinical Gastroenterology and Hepatology, 5, 946-951, 2007.
8. Hegazi et al. Early Jejunal Feeding Initiation and Clinical Outcomes In Patients with Severe Acute Pancreatitis. J Parenter Enteral Nutr Vol. 35, 1, 91-96, 2011.
9. Baker et al. Pancreatitis, very early compared with normal start of enteral feeding (PYTHON trial): design and rationale of a randomized controlled multicenter trial. Trials 12, 73, 2011.
10. Eckerwall et al. Early Nasogastric Feeding in Predicted Severe Acute Pancreatitis, A Clinical, Randomized Study. Annals of Surgery, Vol 244, 6, 959-967, 2006.
11. Ioannidis et al. Nutrition Support in Acute Pancreatitis. J Pancreas, 9, 4, 375-390, 2008.
12. Takeda et al. JPN Guidelines for the management of acute pancreatitis: medical management of acute pancreatitis. J Hepatobiliary Pancreat Surg, 13, 42-47, 2006.
13. Meier et al. Nutrition in Pancreatitis. Best Pract Res Clin Gastroenterol, 20, 3, 507-529, 2006.