Real winter weather finally arrived in Virginia in February, delaying the return of team members from Clinical Nutrition Week, and making travel to work more interesting. Luckily, we have had spells of warmer weather between storms, so we have been spared the relentless snow accumulations that our more northern east coast neighbors have “enjoyed”. Our journal club article this month investigated the potential benefits of early enteral nutrition (EN) in the setting of severe acute pancreatitis.
Bakker OJ, van Brunschot S, van Santvoort HC, et al. Early versus on-demand nasoenteric tube feeding in acute pancreatitis. N Engl J Med. 2014;371(21):1983-1993.
This was a multicenter, randomized controlled study of the effects of early nasoenteric enteral nutrition (EN) in patients with acute pancreatitis compared to allowing an oral diet at 72 hours, and starting nasoenteric tube feeding only in those patients that did not tolerate adequate oral intake. Patients randomized to early enteral nutrition received a nasojejunal (NJ) tube within 24 hours after randomization and started a polymeric formula at 20 mL/hr X 24 hours, then advanced to goal feeding (25 kcals/kg for ICU and 30 kcals/kg for non-ICU patients) for a total of 7 days. Patients randomized to oral intake received only IV fluids for the first 72 hours, unless they requested food. If patients did not tolerate oral intake after 96 hours, a NJ tube was placed for EN.
The primary outcome of the study was a combination of major infection or death within 6 months after randomization. Major infection was defined as infected pancreatic necrosis, bacteremia, or pneumonia. The secondary outcomes included development of necrotizing pancreatitis 5 to 7 days after admission and the development of organ failure after randomization. Predefined subgroups included patients with an APACHE II score < 13 and those with a score of > 13 at randomization.
Inclusion and Exclusion Criteria were:
Adults with a first episode of acute pancreatitis at high risk of complications (APACHE II score 8 or more within 24 hours after presentation).
Recurrent acute or chronic pancreatitis, pancreatitis due to ERCP or malignancy, receiving home EN or PN, pregnancy, assessed (or transferred from other hospitals) more than 24 hours after presentation to the ER, or presented to the ER > 96 hours after symptom onset.
A total of 867 patients were assessed, with 208 patients (24%) enrolled and randomized and 3 patients who were incorrectly diagnosed with pancreatitis excluded. Ultimately, 101 patients received early EN and 104 received oral diet for the primary analysis. Baseline characteristics were similar between groups, except BMI was significantly greater (29±5) in the early EN group compared to the oral diet (27±5). EN in the early group was started a median of 23 hours after presentation to the emergency department,
as compared with initiation of a diet 72 hours after presentation in the oral-diet group. Five of 104 patients (5%) assigned to oral diet requested/received food within the first 72 hours after presentation.
There was no significant difference between groups in the primary composite end point of major infection or death (30% early EN, 27% oral diet). Overall mortality was 11% in the early EN group, as compared with 7% in the on-demand group (P = 0.33). There was no significant difference between the groups in the development of necrotizing pancreatitis or need for ICU admission. There was no significant difference between groups in indices of inflammatory response as measured by APACHE II score, C-reactive protein, abdominal pain or number of patients with SIRS. There was also no significant difference between the predefined subgroup based on APACHE II score or 2 post-hoc subgroups based on SIRS score at randomization or BMI < 25 versus those > 35.
In the on-demand group, 32 patients (31%) eventually required nasoenteric tube feeding: with 9 of these 32 patients (28%) requiring EN due to need for mechanical ventilation. The oral diet group with on-demand tube feeding had a significantly shorter time to full tolerance of an oral diet (9 days with early EN vs. 6 days with the on-demand strategy, P = 0.001). The incidence of gastrointestinal adverse events (nausea, emesis, aspiration, ileus, diarrhea) did not differ significantly between the groups.
The authors concluded that this study did not demonstrate a benefit of early nasoenteric tube feeding in patients with acute pancreatitis who were at high risk for complications, and that their results challenge the concept of the gut mucosa–preserving effect of early enteral feeding during acute pancreatitis.
This was a well conducted study that did an admirable job of identifying, consenting and starting EN early in the course of acute pancreatitis.
One of the questions that our group had was exact position of the feeding ports during “nasoenteric” feeding. In practice, we have observed patients that reportedly had an “NJ”, who actually had the tip of the tube near the Ligament of Treitz, but the feeding ports in the distal duodenum – with resolution of abdominal symptoms when the tube was advanced into a more distal position. The methods also specify that the position of the feeding tube was not monitored during the study, so some patients may have been fed in a way that could stimulate the pancreas. There was also 44% dislodgement of feeding tubes during the study in the early EN group – again, with some potential for early stimulation of the pancreas.
On the other end of the spectrum, it is worthwhile to note that feedings were started at a very low rate for the first 24 hours, so that “adequate mucosal nutrition” (if there is such a thing) may not have been achieved until later. Based on the feeding progression, if there were no interruptions or displaced tubes, patients in the early EN group would not have received near full feeding rates until 72 hours after admission
Although the primary point of the study was to investigate the effects of early enteral nutrition, it is also important to consider that the primary endpoint was measured over 6 months, and the duration of EN was only 7 days. It is possible that some patients may require a longer period of jejunal EN to realize a long-term benefit outcome benefit in regard to long-term infections or resolution of complications of pancreatitis. This would of course require additional study.
Our Take Home Message (s)
1. In acute pancreatitis, early nasoenteric EN does not appear to have significant outcome advantage compared to a strategy of providing EN only to those patients that do not tolerate oral intake after 72 hours.
2. There is a need for additional studies to explore the potential benefit of jejunal EN in the management of the complications of acute pancreatitis – especially in those patients that do not have early resolution of pancreatitis.
Other News on the UVAHS GI Nutrition Website: (www.ginutrition.virginia.edu):
Check out What’s New:
–“Nutrition Support Blog”
Latest Practical Gastroenterology article:
–Parrish CR, DiBaise J. Part III: Hydrating the Adult Patient with Short Bowel Syndrome. Practical Gastroenterology 2015;XXXVIII(2):10.
Joe Krenitsky MS, RD
Carol Rees Parrish MS, RD
PS – Please feel free to forward on to friends and colleagues.