Question 12

College Answer

a. How would you approach his enteral nutrition after a successful ERCP?

Access: Nasojejunal tube although nasogastric appears safe and well tolerated.
Any reasonable approach OK

1. Determine target rate for enteral nutrition, commencing 30ml/hour and increasing as tolerated and delivered as a continuous infusion to maximise chances of achieving nutritional target rates.
2. Prokinetics could be considered if large aspirates are experienced. A feeding protocol should be utilised to maximise the chances of achieving nutritional target rates.
3. Nutritional targets in the critically ill can be determined by either indirect calorimetry, predictive equations (eg: Harris-Benedict equation) or simplistic formulae (25-30kcal/kg/day) with at least 1.2-2g/kg/day of protein.
4. Avoid probiotics (the only multi-centre RCT showed increased mortality and incidence of MOF in treatment group)

b. List the complications that need to be considered with utilising enteral nutrition?

1. Tube complications
   Misplacement: Pneumothorax, inadvertent pulmonary infusion
   Sinusitis
   Pressure areas on nose/lip
   Trauma to nasopharynx, oesophagus, stomach and haemorrhage
2. Feed complications
   Inadequate caloric intake from gastric stasis
   Diarrhoea
   Ventilator associated pneumonia
   Electrolyte abnormalities
   Hyperglycaemia

c. When might you consider parenteral nutrition?

Despite following a rigorous enteral feeding protocol, there is inadequate caloric intake after five days. Combined enteral and parenteral nutrition to meet targets may be beneficial. Recent NEJM article June 2011 comparing early (day 2) with late (day 8) TPN in ICU patients not meeting nutritional targets with EN showed better outcomes in late TPN group

Discussion

The college preambles the answer with "any reasonable approack OK". This to me suggests that there may not be a scholarly consensus of experts regarding this.The college answer consists of answers picked from the most recent Guidelines. 

Furthermore, here we have the red herring of "successful ERCP". Judging by the college answer, it was thrown in to confuse and bewilder the candidate. One might take this to mean that the patient now has normal exocrine pancreatic fnction, and no loger requires "pancreatic rest", even if that was a real issue.

The real question should read "Briefly discuss the management of enteral nutrition in severe pancreatitis and acute lung injury".

The role of enteral nutrition in the management of pancreatitis is discussed elsewhere, as are the complications of enteral nutrition and the complex problem of determining nutritional requirements in the critically ill patients.

In short, nutrition for the pancreatitis patient who has had a successful ERCP should be approached thus:

• Mild-moderate pancreatitis:
  • Safe to not feed at all for ~ 7 days
  • Consider enteral therapy if they fail to preogress to oral diet at the end of one week
• Severe pancreatitis:
  • Enteral nutrition should start early
  • If enteral nutrition is poorly tolerated,
    • Change to a fat-free feed formulation
    • Change from whole protein to peptide fragments
    • Move the NG tube tip beyond the ligament of Treitz
    • If the feeds are still not tolerated, one may start TPN... but it is better to wait until day 5 or later.

Complications of enteral nutrition are as follows:

• Aspiration
• Diarrhoea
• Constipation
• Dehydration
• Malnutrition (owing to intolerance)
• Complications relating to the feeding tube:
  • Poor placement, eg. into the lung
  • Oesophageal or gastric perforation
  • Increased tendency towards gastro-oesophageal reflux
  • Pressure areas due to prolonged tube dwell time (eg. pressure on the nares)
  • Sinusitis (for nasal tubes)
  • Poor oral hygiene( for oral tubes)
  • Oesophageal stricture
  • Discomfort in the awake patient

Society Of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient. Crit Care Med 2009 Vol. 37, No. 5 , 2009

Eatock FC, Chong P, Menezes N, Murray L, McKay CJ, Carter CR, Imrie CW. A randomized study of early nasogastric versus nasojejunal feeding in severe acute pancreatitis. Am J Gastroenterol. 2005 Feb;100(2):432-9.

Windsor AC, Kanwar S, Li AG, et al. Compared with parenteral  nutrition, enteral feeding attenuates the acute phase response and improves disease severity in acute pancreatitis. Gut. 1998;42: 431-435.

Ragins H, Levenson SM, Signer R, Stamford W, Seifter E Intrajejunal administration of an elemental diet at neutral pH avoids pancreatic stimulation. Studies in dog and man. .Am J Surg. 1973 Nov;126(5):606-14.

B. W. M. Spanier,1, M. J. Bruno, E. M. H. Mathus-Vliegen Enteral Nutrition and Acute Pancreatitis: A Review Gastroenterol Res Pract. 2011; 2011: 857949. Published online 2010 August 3.

Kudsk KA, Croce MA, Fabian TC, et al. Enteral versus parenteral feeding: effects on septic morbidity after blunt and penetrating abdominal trauma. Ann Surg. 1992;215:503-513.

Lewis SJ, Egger M, Sylvester PA, Thomas S SO Early enteral feeding versus "nil by mouth" after gastrointestinal surgery: systematic review and meta-analysis of controlled trials. BMJ. 2001;323(7316):773.

Society Of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient. Crit Care Med 2009 Vol. 37, No. 5 , 2009

Luft VC, Beghetto MG, de Mello ED, Polanczyk CA. Role of enteral nutrition in the incidence of diarrhea among hospitalized adult patients. Nutrition. 2008 Jun;24(6):528-35. Epub 2008 Apr 15.

Montejo JC Enteral nutrition-related gastrointestinal complications in critically ill patients: a multicenter study. The Nutritional and Metabolic Working Group of the Spanish Society of Intensive Care Medicine and Coronary Units. .Crit Care Med. 1999 Aug;27(8):1447-53.

Rushdi TA, Pichard C, Khater YH Control of diarrhea by fiber-enriched diet in ICU patients on enteral nutrition: a prospective randomized controlled trial. Clin Nutr. 2004;23(6):1344.

M.D. Bastow; Complications of enteral nutrition. Gut, 1986, 27, SI, 51-55

S. M. Mostafa, S. Bhandari, G. Ritchie, N. Gratton, R. Wenstone. Constipation and its implications in the critically ill patient. Br. J. Anaesth. (2003) 91 (6): 815-819.