Enteral vs. Parenteral Nutrition in Patients with Acute ...
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Enteral vs. Parenteral Nutrition in Patients with Acute ... Presentation Transcript

  • 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.
    • 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
  • 3.
    • Affects middle-aged adults
      • Men
      • Women
    • Degree of inflammation
      • Mild edema
      • Severe hemorrhagic necrosis
      • Marik, 2004, p. 1408
  • 4.
    • Common Causes
      • Gallbladder Disease
      • Chronic alcohol abuse
    • Less Common
      • Abdominal trauma
      • Viral infections
      • Duodenal ulcers
      • Marik, 2004, p. 1408
  • 5.
    • Premature activation of trypsin leads to increased pancreatic digestive enzymes.
    • Results in intrapancreatic inflammation,
    • leading to extrapancreatic inflammation.
    • Complications
      • sepsis
      • multiple organ dysfunction
      • acute respiratory syndrome
    • Siow, 2008, p. 20
  • 6. Acute Pancreatitis Hemorrhagic Pancreatitis
  • 7.
    • Left upper quadrant pain
    • Abdominal tenderness
    • Nausea and vomiting
    • Crackles present in lungs
    • Decreased or absent bowel sounds
    • Siow, 2008, p. 20
  • 8.
    • Pseudocyst
    • Pancreatic abscess
    • Pancreatic infection
    • - 13.5% of mortality rates are due to infection.
    • Siow, 2008, p. 20
  • 9.
    • No standard protocol for providing nutritional support.
    • Parenteral nutritional support common practice.
    • High levels of morbidity, cost, complications, and mortality.
  • 10.
    • 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?
  • 11.
    • Randomized control trials and 3 meta-analysis were reviewed to compare patient outcomes.
    • Databases used:
      • Ovid
      • CINAHL
      • MEDLINE
      • Cochrane Systematic Reviews
  • 12.
    • Studies compared:
      • Nutrition support
        • Enteral & Parenteral
      • Complications
      • Length of stay
      • Dietary improvement
      • Cost of care
  • 13.
    • Screening Methods
      • APACHE II score
      • Ranson criteria
      • Evaluation upon admission and 48 hours after admission
      • Algorithms to aid in addressing nutritional support
  • 14.
    • Adults with severe acute pancreatitis
    • Nutritional Intervention
      • Parenteral nutrition
      • Enteral nutrition
  • 15.
    • APACHE II score > 10
      • Classify severity of disease in ICU
      • Measured during the first 24 hours of admission
      • Point score system
      • Based on 12 routine physiological measurements
        • Blood pressure, heart rate, temperature, respiratory rate etc…
      • Siow, 2007, p. 27
  • 16.
    • Ranson score > 2
      • Predict severity of disease & mortality
      • Uses parameters such as:
        • Age
        • White blood cell count at admission
        • Hematocrit 48 hours after admission
        • Serum urea nitrogen level 48 hours after admission
        • Siow, 2007, p. 27
  • 17.
    • Dietary Improvement
      • 4.1 fewer days of nutritional support
      • 80% progressed to oral diet without problem
      • Nutritional level returned to baseline within 24 hours of enteral nutrition
      • Maintain gut integrity
      • Decreased incidence of hyperglycemia
    • Siow, 2007, p. 23
  • 18.
    • Complications related to parenteral nutrition
      • Sepsis
      • Catheter-related infection
      • Nosocomial infection
      • Prolonged starvation leads to bacterial overgrowth
      • Illeus up to 5 days longer
    • Siow, 2007, p. 23
  • 19.
    • Length of Stay
      • Median length of stay reduced by 2.9 days
    • Cost of Care
      • Parenteral vs. Enteral
        • $2608 vs. $1375
        • After sensitivity analysis : $2608 vs. $957
    • Siow, 2007, p. 23
    • Louie, 2005, p. 303
  • 20.
    • 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.
  • 21.
    • Identify early predictors of acute pancreatitis by using reliable scoring systems to indicate severity
      • Acute Physiology and Chronic Health Evaluation (APACHE II)
      • Ranson Criteria
  • 22.
    • Assess patients nutritional status
      • History of present illness
      • Physical assessment
      • Serum levels of protein and albumin
    • Obtain dietary consult
    • Insert nasogastric or nasojejunal tube
    • Siow, 2007, p. 28
  • 23.
    • 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
  • 24.
    • 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
  • 25.
    • The American College of Gastroenterology supports the use of enteral nutrition
      • Stabilize the gut barrier function
      • Prevent 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.
  • 26.
    • 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.
  • 27.
    • 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.
  • 28.
    • 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.
  • 29.
    • Siow, E. (2008). Enteral versus parenteral
    • nutrition for acute pancreatitis. Critical
    • Care Nurse, 28(4), 19-31.
  • 30.