University of Virginia Nutrition
Our trainees this month were able to experience Mr. Jefferson’s town at the peak of it’s Spring beauty. The Dogwoods and the Redbuds were in full bloom, and the Spring flowers are out. The weather was most cooperative – the only rain came on the day we went to visit Continuum (of course…). Visiting Charlottesville at this time of year makes it hard to go home,…no matter where you live! This month our trainees hailed from Baltimore, Maryland and Dubois, Pennsylvania.
Eatock, FC, Chong, MB, et al. A Randomized Study of Early Nasogastric versus NasojejunalFeeding in Severe Acute Pancreatitis. Am J of Gastroenterol 2005;100:432-439.
Study Question (s):
Is NG feeding as safe & effective as NJ feeding in severe, acute pancreatitis?Would NG feeding exacerbate or reactivate pancreatitis?
Would NG feeds avoid the problems related to insertion / use of NJ tubes?
A total of 50 patients with acute pancreatitis were randomized to receive either NG or NJ feeds (not a blinded study).
Primary outcomes were:
APACHE II score
Visual acuity pain score
Secondary outcomes were:
Hospital and intensive care unit length of stay
All patients received a 1 calorie/ml semi-elemental formula (9% fat calories). Feeding goal for all patients was 2000 calories per 24 hours, regardless of their age or weight.
27 patients received NG feedings, and 22 received NJ feedings (1 patient was discovered not to have pancreatitis based on CT scan).
There were no significant differences between the groups in terms of patient demographics, APACHE II score, CRP, pain score or analgesic requirements. There were no significant differences in ICU or hospital stay between the groups. Feeding tolerance was similar between groups, with approximately 74% of patients tolerating at least 75% of goal needs at 48 hours. Only one patient in the NJ group required conversion to parenteral nutrition. Overall mortality was 24.5% with no significant difference between groups.
This is a very interesting randomized study that explores the feasibility of enteral feeding of patients with severe acute pancreatitis with a nasogastric rather than a jejunal placed tube. The same authors had previously published a feasibility study in 2000, on a group of 26 patients with pancreatitis fed with a nasogastric tube.
The goal of the research was to study severe pancreatitis, however the protocol entered patients with an APACHE II score of > 6. An international symposia has defined severe pancreatitis as an APACHE II score > 8. The authors only report the median, but not the mean APACHE II scores of each group, and do not give the ranges. The median APACHE II score of the NJ group started at 12 on day 1 and dropped 50% to a score of 6 on day 4 of the study. The APACHE II score of the NG group dropped only 30% by day 4. However, the major concern was the use of median, and not mean, scores.
Another concern was the apparent high mortality (24.5%) for patients with this modest severity of illness. Previous studies have found that mortality for pancreatitis with an APACHE II score of 10-14 would be only 15%. The authors report that there was no significant difference in mortality between the two groups, but this study did not have adequate numbers to allow conclusive statements about mortality. The researchers reported that a power calculation determined that 854 patients would be required to detect a 20% difference in mortality. In addition, it is remarkable that median pain scores for severe pancreatitis would be 0 for all patients by day 4 of the study, and that no patients required any pain medication by day 5 of the study. In general, at our institution, patients that have no abdominal pain, and do not require pain medications by day 5 do not require enteral feedings of any kind (nor further hospitalization). Furthermore, it is not uncommon for patients with severe pancreatitis to have a functional gastric outlet obstruction (GOO) as a result of duodenal compression from the pancreatic inflammation necessitating gastric decompression. Gastric feedings would be impossible in this setting.
The mean length-of-stay is reported as 15-16 days, but those
patients who developed multi-organ failure had a LOS up to 58 days – It
is unknown if some patients had mild disease and were discharged quite
early (only 2 patients died prior to day 14). There appear to be
some inconsistencies in the reported lengths of stay. The NG
group length of stay (LOS) was16 days (range 10-22 days) and the NJ
group LOS was 15 days (range 10-42 days) (Table 3). However Table
4 lists “Days in Hospital” for those patients who died, and the LOS of
several patients was far longer than the range listed in table 3 – some
NG with a LOS of 50 and 24 days, and some NJ patients with a LOS of 44,
56 and 58 days. Does this mean that those patients who died
during the admission were not included in all of the analysis???
The other unknown factor is how many patients developed complicated pancreatitis. There is mention of 4 patients who developed infected pancreatic necrosis but complications of pancreatitis (pseudocyst or necrosis) were not planned outcomes, and therefore not reported. It would be essential to know that gastric feeding did not result in increased development of late complications before routine use of NG feedings in pancreatitis could be recommended. The researchers only report on APACHE II score, pain and CRP over the first 5 days, so there is no way to know if there were significant difference between the groups after 5 days.
Take home message:
This is an extremely interesting study, and it would simplify management of acute pancreatitis if it is possible to safely provide intragastric semi-elemental feedings. However, the concerns over the high mortality rate, and the apparent rapid recovery of many patients (no pain or pain medications in 5 days, or need for gastric decompression) reduce the potential impact of this study. The most important take home message is that this study is too small to make any conclusions about patient outcome such as length of stay or mortality. The size of the study only allows conclusions on the surrogate marker of CRP. Obviously larger studies that have the power to make conclusions about actual patient outcomes are needed before intragastric feedings can be recommended for patients with pancreatitis, but we cannot discount the possibility that in some pts with pancreatitis, intragastric feedings with semi-elemental feedings may be tolerated.
The Confirm Now website (CO2 detection for feeding tube placement) is up and running and can be found at www.CO2NFIRMNOW.com
Sheryl De Santos from the University Medical Center, Fresno, CA is our Tyco Kendall NS Scholarship winner!
Check out the latest Practical Gastroenterology articles available at: http://www.healthsystem.virginia.edu/pub/digestive-health/nutrition.html
Sheean PM. Nutrition support of blood or marrow transplant recipients: how much do we really know? Practical Gastroenterology 2005;XXIX(4):84.
Joe Krenitsky MS, RD
Carol Parrish RD, MS
PS – Please feel free to send this on to friends and colleagues.