Michelle Mann, R.N.  Mary Sawyer, R.N. Erika Rumble, R.N. Chanda Vlanich, R.N.  Paul Vlanich, R.N. University of Oklahoma ...
<ul><li>The incidence of new cases is 17:100,000 persons in the United States.  </li></ul><ul><li>Mortality rates of 80% o...
<ul><li>Affects middle-aged adults </li></ul><ul><ul><li>Men </li></ul></ul><ul><ul><li>Women </li></ul></ul><ul><li>Degre...
<ul><li>Common Causes </li></ul><ul><ul><li>Gallbladder Disease </li></ul></ul><ul><ul><li>Chronic alcohol abuse </li></ul...
<ul><li>Premature activation of trypsin leads to increased pancreatic digestive enzymes. </li></ul><ul><li>Results in intr...
Acute Pancreatitis Hemorrhagic Pancreatitis
<ul><li>Left upper quadrant pain </li></ul><ul><li>Abdominal tenderness </li></ul><ul><li>Nausea and vomiting </li></ul><u...
<ul><li>Pseudocyst </li></ul><ul><li>Pancreatic abscess </li></ul><ul><li>Pancreatic infection </li></ul><ul><li>- 13.5% o...
<ul><li>No standard protocol for providing nutritional support. </li></ul><ul><li>Parenteral nutritional support common pr...
<ul><li>In adult patients with acute pancreatitis, which nutritional intervention, enteral or parenteral feeding, improves...
<ul><li>Randomized control trials and 3 meta-analysis were reviewed to compare patient outcomes.  </li></ul><ul><li>Databa...
<ul><li>Studies compared:  </li></ul><ul><ul><li>Nutrition support </li></ul></ul><ul><ul><ul><li>Enteral & Parenteral  </...
<ul><li>Screening Methods </li></ul><ul><ul><li>APACHE II score </li></ul></ul><ul><ul><li>Ranson criteria </li></ul></ul>...
<ul><li>Adults with severe acute pancreatitis </li></ul><ul><li>Nutritional Intervention </li></ul><ul><ul><li>Parenteral ...
<ul><li>APACHE II score > 10 </li></ul><ul><ul><li>Classify severity of disease in ICU </li></ul></ul><ul><ul><li>Measured...
<ul><li>Ranson score > 2 </li></ul><ul><ul><li>Predict severity of disease & mortality </li></ul></ul><ul><ul><li>Uses par...
<ul><li>Dietary Improvement </li></ul><ul><ul><li>4.1 fewer days of nutritional support </li></ul></ul><ul><ul><li>80% pro...
<ul><li>Complications related to parenteral nutrition </li></ul><ul><ul><li>Sepsis </li></ul></ul><ul><ul><li>Catheter-rel...
<ul><li>Length of Stay </li></ul><ul><ul><li>Median length of stay reduced by 2.9 days </li></ul></ul><ul><li>Cost of Care...
<ul><li>In the reviewed studies, evidence showed that patients receiving enteral nutrition therapy had fewer treatment com...
<ul><li>Identify early predictors of acute pancreatitis by using reliable scoring systems to indicate severity </li></ul><...
<ul><li>Assess patients nutritional status </li></ul><ul><ul><li>History of present illness </li></ul></ul><ul><ul><li>Phy...
<ul><li>Initiate enteral nutrition within first 48 hours </li></ul><ul><li>Continue enteral nutrition until patient may be...
<ul><li>Increase sample size in future studies </li></ul><ul><li>Standardize operational definitions of study outcome vari...
<ul><li>The American College of Gastroenterology supports the use of enteral nutrition  </li></ul><ul><ul><li>Stabilize th...
<ul><li>Nurses can play an important role in the healthcare team by influencing the team members to use the appropriate nu...
<ul><li>Al-Omran, M.,   Groof, A., Wilke, D. (2008). Enteral versus parenteral nutrition for acute pancreatitis.  The Coch...
<ul><li>Marik, P. (2004). Meta-analysis of parenteral nutrition versus Enteral nutrition in patients with acute pancreatit...
<ul><li>Siow, E. (2008).  Enteral versus parenteral  </li></ul><ul><li>nutrition for acute pancreatitis.  Critical  </li><...
 
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Enteral vs. Parenteral Nutrition in Patients with Acute ...

  1. 1. 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
  2. 2. <ul><li>The incidence of new cases is 17:100,000 persons in the United States. </li></ul><ul><li>Mortality rates of 80% occur that are due to complications. </li></ul><ul><li>Siow, 2008, p. 20 </li></ul>
  3. 3. <ul><li>Affects middle-aged adults </li></ul><ul><ul><li>Men </li></ul></ul><ul><ul><li>Women </li></ul></ul><ul><li>Degree of inflammation </li></ul><ul><ul><li>Mild edema </li></ul></ul><ul><ul><li>Severe hemorrhagic necrosis </li></ul></ul><ul><ul><li>Marik, 2004, p. 1408 </li></ul></ul>
  4. 4. <ul><li>Common Causes </li></ul><ul><ul><li>Gallbladder Disease </li></ul></ul><ul><ul><li>Chronic alcohol abuse </li></ul></ul><ul><li>Less Common </li></ul><ul><ul><li>Abdominal trauma </li></ul></ul><ul><ul><li>Viral infections </li></ul></ul><ul><ul><li>Duodenal ulcers </li></ul></ul><ul><ul><li>Marik, 2004, p. 1408 </li></ul></ul>
  5. 5. <ul><li>Premature activation of trypsin leads to increased pancreatic digestive enzymes. </li></ul><ul><li>Results in intrapancreatic inflammation, </li></ul><ul><li>leading to extrapancreatic inflammation. </li></ul><ul><li>Complications </li></ul><ul><ul><li>sepsis </li></ul></ul><ul><ul><li>multiple organ dysfunction </li></ul></ul><ul><ul><li>acute respiratory syndrome </li></ul></ul><ul><li>Siow, 2008, p. 20 </li></ul>
  6. 6. Acute Pancreatitis Hemorrhagic Pancreatitis
  7. 7. <ul><li>Left upper quadrant pain </li></ul><ul><li>Abdominal tenderness </li></ul><ul><li>Nausea and vomiting </li></ul><ul><li>Crackles present in lungs </li></ul><ul><li>Decreased or absent bowel sounds </li></ul><ul><li>Siow, 2008, p. 20 </li></ul>
  8. 8. <ul><li>Pseudocyst </li></ul><ul><li>Pancreatic abscess </li></ul><ul><li>Pancreatic infection </li></ul><ul><li>- 13.5% of mortality rates are due to infection. </li></ul><ul><li>Siow, 2008, p. 20 </li></ul>
  9. 9. <ul><li>No standard protocol for providing nutritional support. </li></ul><ul><li>Parenteral nutritional support common practice. </li></ul><ul><li>High levels of morbidity, cost, complications, and mortality. </li></ul>
  10. 10. <ul><li>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? </li></ul>
  11. 11. <ul><li>Randomized control trials and 3 meta-analysis were reviewed to compare patient outcomes. </li></ul><ul><li>Databases used: </li></ul><ul><ul><li>Ovid </li></ul></ul><ul><ul><li>CINAHL </li></ul></ul><ul><ul><li>MEDLINE </li></ul></ul><ul><ul><li>Cochrane Systematic Reviews </li></ul></ul>
  12. 12. <ul><li>Studies compared: </li></ul><ul><ul><li>Nutrition support </li></ul></ul><ul><ul><ul><li>Enteral & Parenteral </li></ul></ul></ul><ul><ul><li>Complications </li></ul></ul><ul><ul><li>Length of stay </li></ul></ul><ul><ul><li>Dietary improvement </li></ul></ul><ul><ul><li>Cost of care </li></ul></ul>
  13. 13. <ul><li>Screening Methods </li></ul><ul><ul><li>APACHE II score </li></ul></ul><ul><ul><li>Ranson criteria </li></ul></ul><ul><ul><li>Evaluation upon admission and 48 hours after admission </li></ul></ul><ul><ul><li>Algorithms to aid in addressing nutritional support </li></ul></ul>
  14. 14. <ul><li>Adults with severe acute pancreatitis </li></ul><ul><li>Nutritional Intervention </li></ul><ul><ul><li>Parenteral nutrition </li></ul></ul><ul><ul><li>Enteral nutrition </li></ul></ul>
  15. 15. <ul><li>APACHE II score > 10 </li></ul><ul><ul><li>Classify severity of disease in ICU </li></ul></ul><ul><ul><li>Measured during the first 24 hours of admission </li></ul></ul><ul><ul><li>Point score system </li></ul></ul><ul><ul><li>Based on 12 routine physiological measurements </li></ul></ul><ul><ul><ul><li>Blood pressure, heart rate, temperature, respiratory rate etc… </li></ul></ul></ul><ul><ul><li>Siow, 2007, p. 27 </li></ul></ul>
  16. 16. <ul><li>Ranson score > 2 </li></ul><ul><ul><li>Predict severity of disease & mortality </li></ul></ul><ul><ul><li>Uses parameters such as: </li></ul></ul><ul><ul><ul><li>Age </li></ul></ul></ul><ul><ul><ul><li>White blood cell count at admission </li></ul></ul></ul><ul><ul><ul><li>Hematocrit 48 hours after admission </li></ul></ul></ul><ul><ul><ul><li>Serum urea nitrogen level 48 hours after admission </li></ul></ul></ul><ul><ul><ul><li>Siow, 2007, p. 27 </li></ul></ul></ul>
  17. 17. <ul><li>Dietary Improvement </li></ul><ul><ul><li>4.1 fewer days of nutritional support </li></ul></ul><ul><ul><li>80% progressed to oral diet without problem </li></ul></ul><ul><ul><li>Nutritional level returned to baseline within 24 hours of enteral nutrition </li></ul></ul><ul><ul><li>Maintain gut integrity </li></ul></ul><ul><ul><li>Decreased incidence of hyperglycemia </li></ul></ul><ul><li>Siow, 2007, p. 23 </li></ul>
  18. 18. <ul><li>Complications related to parenteral nutrition </li></ul><ul><ul><li>Sepsis </li></ul></ul><ul><ul><li>Catheter-related infection </li></ul></ul><ul><ul><li>Nosocomial infection </li></ul></ul><ul><ul><li>Prolonged starvation leads to bacterial overgrowth </li></ul></ul><ul><ul><li>Illeus up to 5 days longer </li></ul></ul><ul><li>Siow, 2007, p. 23 </li></ul>
  19. 19. <ul><li>Length of Stay </li></ul><ul><ul><li>Median length of stay reduced by 2.9 days </li></ul></ul><ul><li>Cost of Care </li></ul><ul><ul><li>Parenteral vs. Enteral </li></ul></ul><ul><ul><ul><li>$2608 vs. $1375 </li></ul></ul></ul><ul><ul><ul><li>After sensitivity analysis : $2608 vs. $957 </li></ul></ul></ul><ul><li>Siow, 2007, p. 23 </li></ul><ul><li>Louie, 2005, p. 303 </li></ul>
  20. 20. <ul><li>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. </li></ul>
  21. 21. <ul><li>Identify early predictors of acute pancreatitis by using reliable scoring systems to indicate severity </li></ul><ul><ul><li>Acute Physiology and Chronic Health Evaluation (APACHE II) </li></ul></ul><ul><ul><li>Ranson Criteria </li></ul></ul>
  22. 22. <ul><li>Assess patients nutritional status </li></ul><ul><ul><li>History of present illness </li></ul></ul><ul><ul><li>Physical assessment </li></ul></ul><ul><ul><li>Serum levels of protein and albumin </li></ul></ul><ul><li>Obtain dietary consult </li></ul><ul><li>Insert nasogastric or nasojejunal tube </li></ul><ul><li>Siow, 2007, p. 28 </li></ul>
  23. 23. <ul><li>Initiate enteral nutrition within first 48 hours </li></ul><ul><li>Continue enteral nutrition until patient may begin oral feedings </li></ul><ul><li>Advance oral feedings as tolerated </li></ul><ul><li>If patient does not tolerate enteral nutrition begin parenteral nutrition </li></ul>
  24. 24. <ul><li>Increase sample size in future studies </li></ul><ul><li>Standardize operational definitions of study outcome variables so that studies may be compared. </li></ul><ul><li>Standardize severity scoring systems in future studies </li></ul>
  25. 25. <ul><li>The American College of Gastroenterology supports the use of enteral nutrition </li></ul><ul><ul><li>Stabilize the gut barrier function </li></ul></ul><ul><ul><li>Prevent complications associated with bacterial infection </li></ul></ul><ul><li>The reviewed studies provided evidence that the use of enteral nutrition is the choice of nutritional therapy for patients with acute severe pancreatitis. </li></ul>
  26. 26. <ul><li>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. </li></ul>
  27. 27. <ul><li>Al-Omran, M., Groof, A., Wilke, D. (2008). Enteral versus parenteral nutrition for acute pancreatitis. The Cochrane Database of Systematic Reviews. Vol. 4. </li></ul><ul><li>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. </li></ul>
  28. 28. <ul><li>Marik, P. (2004). Meta-analysis of parenteral nutrition versus Enteral nutrition in patients with acute pancreatitis. British Medical Journal, 328, 1407-1412. </li></ul><ul><li>McClave, S.A. (2007). Nutrition Support in Acute Pancreatitis . Gastroenterology Clinics , 36, 1-7. </li></ul>
  29. 29. <ul><li>Siow, E. (2008). Enteral versus parenteral </li></ul><ul><li>nutrition for acute pancreatitis. Critical </li></ul><ul><li>Care Nurse, 28(4), 19-31. </li></ul>

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