{"id":615,"date":"2015-02-01T01:00:20","date_gmt":"2015-02-01T06:00:20","guid":{"rendered":"https:\/\/med.virginia.edu\/ginutrition\/?p=615"},"modified":"2023-01-24T14:24:01","modified_gmt":"2023-01-24T19:24:01","slug":"february-2015-e-journal-club","status":"publish","type":"post","link":"https:\/\/med.virginia.edu\/ginutrition\/2015\/02\/01\/february-2015-e-journal-club\/","title":{"rendered":"February 2015 E-Journal Club"},"content":{"rendered":"

Greetings,<\/strong><\/p>\n

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.\u00a0 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 \u201cenjoyed\u201d.\u00a0 Our journal club article this month investigated the potential benefits of early enteral nutrition (EN) in the setting of severe acute pancreatitis.<\/p>\n

February Citation:<\/strong><\/p>\n

Bakker OJ, van Brunschot S, van Santvoort HC, et al.\u00a0 Early versus on-demand nasoenteric tube feeding in acute pancreatitis.\u00a0 N Engl J Med. 2014;371(21):1983-1993.<\/span><\/p>\n

Summary:\u00a0<\/strong><\/p>\n

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.\u00a0 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.\u00a0 Patients randomized to oral intake received only IV fluids for the first 72 hours, unless they requested food.\u00a0 If patients did not tolerate oral intake after 96 hours, a NJ tube was placed for EN.<\/p>\n

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.\u00a0 Predefined subgroups included patients with an APACHE II score < 13 and those with a score of > 13 at randomization.<\/p>\n

Inclusion and Exclusion Criteria were:<\/strong><\/p>\n

Inclusion criteria<\/em>:<\/p>\n

Adults with a first episode of acute pancreatitis at high risk of complications (APACHE II score 8 or more within 24 hours after presentation).<\/p>\n

Exclusion criteria<\/em>:<\/p>\n

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.<\/p>\n

Major Results:<\/strong><\/p>\n

A total of 867 patients were assessed, with 208 patients (24%) enrolled and randomized and 3 patients who were incorrectly diagnosed with pancreatitis excluded.\u00a0 Ultimately, 101 patients received early EN and 104 received oral diet for the primary analysis.\u00a0 Baseline characteristics were similar between groups, except BMI was significantly greater (29\u00b15) in the early EN group compared to the oral diet (27\u00b15).\u00a0 EN in the early group was started a median of 23 hours after presentation to the emergency department,<\/p>\n

as compared with initiation of a diet 72 hours after presentation in the oral-diet group.\u00a0 Five of 104 patients (5%) assigned to oral diet requested\/received food within the first 72 hours after presentation.<\/p>\n

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).\u00a0 There was no significant difference between the groups in the development of necrotizing pancreatitis or need for ICU admission.\u00a0 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.\u00a0 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.<\/p>\n

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.\u00a0 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.<\/p>\n

Author\u2019s Conclusions:<\/strong><\/p>\n

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\u2013preserving effect of early enteral feeding during acute pancreatitis.<\/p>\n

Evaluation:<\/strong><\/p>\n

This was a well conducted study that did an admirable job of identifying, consenting and starting EN early in the course of acute pancreatitis.<\/p>\n

One of the questions that our group had was exact position of the feeding ports during \u201cnasoenteric\u201d feeding. In practice, we have observed patients that reportedly had an \u201cNJ\u201d, who actually had the tip of the tube near the Ligament of Treitz, but the feeding ports in the distal duodenum \u2013 with resolution of abdominal symptoms when the tube was advanced into a more distal position.\u00a0 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.\u00a0 There was also 44% dislodgement of feeding tubes during the study in the early EN group \u2013 again, with some potential for early stimulation of the pancreas.<\/p>\n

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 \u201cadequate mucosal nutrition\u201d (if there is such a thing) may not have been achieved until later.\u00a0 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<\/p>\n

Although the primary point of the study was to investigate the effects of early<\/em> 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.\u00a0 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.\u00a0 This would of course require additional study.<\/p>\n

Our Take Home Message (s)<\/strong><\/p>\n

1.\u00a0\u00a0 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.<\/p>\n

2.\u00a0\u00a0 There is a need for additional studies to explore the potential benefit of jejunal EN in the management of the complications of acute pancreatitis \u2013 especially in those patients that do not have early resolution of pancreatitis.<\/p>\n

Other News on the UVAHS GI Nutrition Website:<\/u><\/em><\/strong> (www.ginutrition.virginia.edu<\/a>):<\/strong><\/p>\n

Check out What\u2019s New<\/strong>:<\/p>\n

–\u201cNutrition Support Blog\u201d<\/p>\n

–\u201c Resources for the Nutrition Support Clinician<\/a>\u201d<\/p>\n

Latest Practical Gastroenterology article<\/strong>:<\/p>\n

–Parrish CR, DiBaise J. Part III: Hydrating the Adult Patient with Short Bowel Syndrome. Practical Gastroenterology 2015;XXXVIII(2):10.<\/p>\n

 <\/p>\n

Joe Krenitsky MS, RD<\/p>\n

Carol Rees Parrish MS, RD<\/p>\n

 <\/p>\n

PS \u2013 Please feel free to forward on to friends and colleagues.<\/em><\/strong><\/p>\n","protected":false},"excerpt":{"rendered":"

Greetings, 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.\u00a0 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 \u201cenjoyed\u201d.\u00a0 […]<\/p>\n","protected":false},"author":208,"featured_media":0,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"footnotes":"","_links_to":"","_links_to_target":""},"categories":[6],"tags":[],"class_list":["post-615","post","type-post","status-publish","format-standard","hentry","category-ejournal"],"acf":false,"yoast_head":"\nFebruary 2015 E-Journal Club - GI Nutrition Support Team<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/med.virginia.edu\/ginutrition\/2015\/02\/01\/february-2015-e-journal-club\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"February 2015 E-Journal Club - 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