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.