A 76-year-old male is admitted to the ICU with acute lung injury causing respiratory failure, secondary to acute pancreatitis.
a) Outline how you would establish enteral nutrition in this patient, including in the answer your nutritional targets.
b) List the complications that need to be considered with the use of enteral nutrition.
c) When might you consider parenteral nutrition?
a)
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 (e.g.: Harris-Benedict equation) or simplistic formulae (25-30kcal/kg/day) with at least 1.2-
2g/kg/day of protein.
b)
1) Tube complications
2) Feed complications
c)
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.
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
a) Outline how you would establish enteral nutrition in this patient, including in the answer your nutritional targets.
For this, the candidate could fall back on either the ASPEN guidelines (2009) or the ESPEN guidelines (2002).
A comparison of these guidelines is offered below.
ASPEN guidelines
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ESPEN guidelines :
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The college seems to be using generic guidelines for nutrition in the critically ill in their answer, rather than any specific pancreatitis guidelines. "Any reasonable approach OK".
As far as specific guidelines go, apart from the elderly 2002 ESPEN position and the somewhat less elederly 2009 ASPEN statement, we can turn to the 2012 "International consensus guidelines for nutrition therapy in pancreatitis."
In summary, these guidelines make the following recommendations:
b) List the complications that need to be considered with the use of enteral nutrition.
Complications of enteral nutrition are well describe in a chapter from the "Required reading" section.
In brief, the complications are:
c) When might you consider parenteral nutrition?
The college refer to a certain 2011 NEJM study, which I assume is the "early vs late PN" trial by Casaer et al. "Late initiation of parenteral nutrition was associated with faster recovery and fewer complications", they said. Of course, that is not a study which regarded pancreatitis specifically.
The ASPEN guidelines recommend you wait for 5 days of good-quality EN trials before you resort to TPN. Both ASPEN and ESPEN recommend the addition of TPN if it is clear that nutritional goals are not being met. The 2012 international guidelines recommend PN "when EN is contraindicated or not well tolerated".
Casaer, Michael P., et al. "Early versus late parenteral nutrition in critically ill adults." N Engl J Med 365.6 (2011): 506-517.
Specifically, section K of the 2009 statement
ESPEN guidelines :
specifically,
MACFIE, J., and ESPEN CONSENSUS GROUP. "ESPEN guidelines on nutrition in acute pancreatitis." Clinical Nutrition 21.2 (2002): 173-183.
Mirtallo, Jay M., et al. "International consensus guidelines for nutrition therapy in pancreatitis." Journal of Parenteral and Enteral Nutrition (2012): 0148607112440823.