Comparison of the safety of early enteral vs parenteral nutrition in mild acute pancreatitis

Impact of nutritional support routes on mortality in acute pancreatitis: A network meta-analysis of randomized controlled trials

BACKGROUND

Nutritional administration in acute pancreatitis (AP) management has sparked widespread discussion, yet contradictory mortality results across meta-analyses necessitate clarification. The optimal nutritional route in AP remains uncertain. Therefore, this study aimed to compare mortality among nutritional administration routes in patients with AP using consistency model.

METHODS

This study searched four major databases for relevant randomized controlled trials (RCTs). Two authors independently extracted and checked data and quality. Network meta-analysis was conducted for estimating risk ratios (RRs) with 95% confidence interval (CI) based on random-effects model. Subgroup analyses accounted for AP severity and nutrition support initiation.

RESULTS

A meticulous search yielded 1185 references, with 30 records meeting inclusion criteria from 27 RCTs (n = 1594). Pooled analyses showed the mortality risk reduction associated with nasogastric (NG) (RR = 0.34; 95%CI: 0.16-0.73) and nasojejunal (NJ) feeding (RR = 0.46; 95%CI: 0.25-0.84) in comparison to nil per os. Similarly, NG (RR = 0.45; 95%CI: 0.24-0.83) and NJ (RR = 0.60; 95%CI: 0.40-0.90) feeding also showed lower mortality risk than total parenteral nutrition. Subgroup analyses, stratified by severity, supported these findings. Notably, the timing of nutritional support initiation emerged as a significant factor, with NJ feeding demonstrating notable mortality reduction within 24 and 48 h, particularly in severe cases.

CONCLUSION

For severe AP, both NG and NJ feeding appear optimal, with variations in initiation timings. NG feeding does not appear to merit recommendation within the initial 24 h, whereas NJ feeding is advisable within the corresponding timeframe following admission. These findings offer valuable insights for optimizing nutritional interventions in AP.

Nil per os or Enteral Nutrition in Mild and Moderately Severe Acute Pancreatitis: A Case Series

BACKGROUND: There are controversies regarding the treatment of mild-to-moderate pancreatitis, especially when comparing the efficacy of nil per os regime versus the nasogastric feeding. While some sources suggest the benefits of the nasogastric feeding, there are meager data available toward the impact of the selected treatment vis-à-vis the length of hospital stay, and as of the final outcome. AIM: Authors collected data from two subgroups (treated with nil per os regime or nasogastric feeding, respectively) with the aim to define a safe and more efficacious regime. METHODS: This case series collection was carried out in the University Hospital Center in Tirana (UHC) at the Service of Gastroenterology. The period of the study was January 1, 2018–December 31, 2019. The patients were divided into two subgroups (the control group had a nil per os regime and patients in the intervention group received a nasogastric feeding) according to approved inclusion and exclusion criteria. RESULTS: Twenty subjects were allocated to the control group and 21 subjects were allocated to the intervention group. The length of hospital stay in the control group was 10.2 days compared with 8.4 days in the intervention group (p < 0.05). The days’ average spent with pain was 4.5 in the control group and 3.14 in the intervention group (p < 0.05). Oral feeding begun approximately 5.45 days since the admission in the control group and 3.14 days in the intervention group (p < 0.05). Oral food intolerance occurred in 6 patients (30%) in the control group and in one patient in the intervention group (4.8%) (p < 0.05). CONCLUSIONS: Nasogastric feeding seems to have significant benefits in the treatment of mild to moderate acute pancreatitis, when compared with the nil per os regime. Nasogastric feeding reduces length of stay in hospital and improves early the clinical outcomes.

Thirty-Day Readmission Among Patients with Alcoholic Acute Pancreatitis

BACKGROUND/OBJECTIVES

Alcoholic acute pancreatitis (AAP) comprises the second most common cause of acute pancreatitis in the USA, and there is lack of data regarding 30-day specific readmission causes and predictors. We aim to identify 30-day readmission rate, causes, and predictors of readmission.

METHODS

Retrospective analysis of the 2016 National Readmission Database of adult patients readmitted within 30 days after an index admission for AAP.

RESULTS

Totally, 76,609 AAP patients were discharged from the hospital in 2016. The 30-day readmission rate was 12%. The main cause of readmission was another episode of AAP. Readmission was not associated with higher mortality (1.3% vs. 1.2%; P = 0.21) or prolonged length of stay (5.2 vs. 5.0 days; P = 0.06). The total health care economic burden was $354 million in charges and $90 million in costs. Independent predictors of readmission were having Medicaid insurance, a Charlson comorbidity index score ≥ 3, use of total parenteral nutrition, opioid abuse disorder, prior pancreatic cyst, chronic alcoholic pancreatitis, and other chronic pancreatitis. Obesity was associated with lower odds of readmission.

CONCLUSION

Readmission rate for AAP is high and its primary cause are recurrent episodes of AAP. Alcohol and substance abuse pose a high burden on our health care system. Public health strategies should be targeted to provide alcohol abuse disorder rehabilitation and cessation resources to alleviate the burden on readmission, the health care system and to improve patient outcomes.

Mortality and overall and specific infection complication rates in patients who receive parenteral nutrition: systematic review and meta-analysis with trial sequential analysis

BACKGROUND

Parenteral nutrition (PN) is an available option for nutritional therapy and is often required in the hospital setting to overcome malnutrition.

OBJECTIVES

The aim of this study was to assess whether PN is associated with an increased risk of mortality or infectious complications in all groups of hospitalized patients compared with those receiving other nutritional support strategies.

METHODS

For this systematic review and meta-analysis MEDLINE, Embase, Cochrane Central, Scopus, clinicaltrials.gov, and Web of Science were searched for randomized controlled trials (RCTs) and observational studies with parallel groups that explored the effect of PN on mortality and infectious complications, published until March 2021. Two independent reviewers extracted the data and assessed the risk of bias. Fixed-effects meta-analysis was performed to compare the groups from RCTs. Trial sequential analysis (TSA) was used to identify whether the results were sufficient to reach definitive conclusions.

RESULTS

Of the 83 included studies that compared patients receiving PN with those receiving other strategies, 67 RCTs were included in the meta-analysis. PN was not associated with a higher risk of mortality (RR: 1.01; 95% CI: 0.95, 1.07). On the other hand, PN was associated with a higher risk of infectious events (RR: 1.23; 95% CI: 1.12, 1.36). PN was specifically associated with abdominal infection and catheter infection. The TSA showed that there were sufficient data to make numerical conclusions about mortality, any infectious event, and abdominal infectious complications.

CONCLUSIONS

This study suggests that although PN is not associated with greater mortality in hospitalized patients, it is associated with infectious complications. Through TSA, definite conclusions about survival and infection rates could be made.This review was registered at www.crd.york.ac.uk/prospero/ as CRD42018075599.

Can feeding strategies alter immune signaling and gut sepsis in critical illness?

The insult necessitating admission to the intensive care unit propels the patient along a course involving increasing oxidative stress, immune dysregulation, and adverse outcomes. As the largest immune organ with the greatest microbial burden, the gastrointestinal tract may change the speed and direction the patient follows along this pathway. The gut's influence is mediated by a complex process of cross-talk immune signaling between the intestinal epithelium, the liver, and the microbiome. Agents which invoke this response vary from mitochondrial DNA, inflammatory cytokines, and bacterial organisms to short chain fatty acids and bile salts. The site of action of these agents again varies widely from Pattern Recognition Receptors, G protein receptors, and Farnesoid X receptors in the gut and liver to transcriptional factors in epithelial cells, hepatocytes, macrophages, and neutrophils. While the initial focus of response may be local within the gastrointestinal tract and liver, the process extends in a systemic manner to affect immune tissue and various organs at distant sites. The gut can modulate this cross-talk signaling through numerous strategies in design of nutritional therapy. The physiologic response to luminal nutrients and short chain fatty acids, and more novel approaches like use phosphorylated polyethylene glycol, bovine serum-derived immunoglobulin, and specialized pro-resolving molecules may help slow disease progression and even reverse the patient's course toward one of health and recovery. The optimal benefit to be derived from nutritional therapy may have more to do with the degree to which immune cross-talk signaling can be modified by such innovative strategies. This article is protected by copyright. All rights reserved.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Percutaneous Gastrostomy in Necrotizing Pancreatitis: Friend or Foe?

BACKGROUND

Enteral nutrition plays a central role in managing necrotizing pancreatitis (NP). Although the nasojejunal (NJ) route is widely used, percutaneous gastrostomy (PEG-J) is an alternative technique that is also applied commonly. We hypothesized that NJ and PEG-J had similar morbidity in the setting of NP.

METHODS

All patients receiving preoperative enteral nutrition before surgical debridement for NP (2005-2015) were segregated into NJ or PEG-J.

RESULTS

A total of 242 patients had complete data for analysis (155 men/87 women; median age 54 years; 47% biliary and 16% alcohol-related pancreatitis). NJ was used exclusively in 187 patients (77%); 25 patients (10%) were fed exclusively by PEG-J; the remaining 30 patients (13%) had NJ first, followed by PEG-J. Equal proportions of NJ and PEG-J patients reached enteral feeding goal (67% vs. 68%, p ≈ 1) and increased serum albumin (39% vs. 36%, p = 0.87). No difference was seen in rate of pancreatic necrosis infection (NJ 53% vs. PEG-J 49%, p = 0.64). NJ patients had significantly more complications compared to PEG-J (51%vs.27%,p = 0.0015). However, NJ patients had more grade I/II complication, compared to PEG-J patients, who had more grade III/IV complication (Grade I/II: NJ 51%vs. PEG-J 16%; Grade III/IV NJ 0%vs. PEG-J 11%, p < 0.0001).

CONCLUSION

In necrotizing pancreatitis, NJ and PEG-J both delivered enteral nutrition effectively. Patients with NJ feeding had significantly more complications than those with PEG-J; however, NJ complications were less severe.

High protein versus medium protein delivery under equal total energy delivery in critical care: A randomized controlled trial

BACKGROUND

Appropriate protein delivery amounts during the acute phase of critical care are unknown. Along with nutrition, early mobilization and the combination are important. We conducted a randomized controlled trial during critical care to assess high-protein and medium-protein delivery under equal total energy delivery with and without active early rehabilitation.

METHODS

ICU patients of August 2018-September 2019 were allocated to a high-protein group (target energy 20 kcal/kg/day, protein 1.8 g/kg/day) or a medium-protein group (target energy 20 kcal/kg/day, protein 0.9 g/kg/day) with the same nutrition protocol by day 10. By dividing the study period, standard rehabilitation was administered during the initial period. Rehabilitation with belt-type electrical muscle stimulation was given from day 2 in the latter as a historical comparison. Femoral muscle volume was evaluated on day 1 and day 10 using computed tomography.

RESULTS

This study analyzed 117 eligible patients with similar characteristics assigned to a high-protein or medium-protein group. Total energy delivery was around 20 kcal/kg/day in both groups, but protein delivery was 1.5 g/kg/day and 0.8 g/kg/day. As a primary outcome, femoral muscle volume loss was 12.9 ± 8.5% in the high-protein group and 16.9 ± 7.0% in the medium-protein group, with significant difference (p = 0.0059). Persistent inflammation, immunosuppression, and catabolism syndrome were significantly less frequent in the high-protein group. Muscle volume loss was significantly less in the high-protein group only during the electrical muscle stimulation period.

CONCLUSIONS

For critical care, high protein delivery provided better muscle volume maintenance, but only with active early rehabilitation.

REGISTRATION

University Hospital Medical Information Network, UMIN000033783 Registered on 16 Aug 2018. https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000038538.

Nutrition management in acute pancreatitis: Clinical practice consideration

Acute pancreatitis (AP) is a common gastrointestinal disease and the leading cause of hospital admission and healthcare burden among gastrointestinal disorders in many countries. Patients can present with varying degrees of inflammation and disease severity, ranging from self-limiting mild AP to devastating and fatal severe AP. Many factors contribute to malnutrition in AP, especially abnormal metabolism and catabolism related to inflammation. The concept of “pancreatic rest” is not evidence-based. There is however, emerging evidence that supports the use of oral or enteral nutrition to improve nutrition status and to reduce local and systemic inflammation, complications, and death. In mild disease, patients are generally able to initiate solid oral diet and do not require specialized nutrition care such as enteral or parenteral nutrition. In contrast, nutrition interventions are imperative in moderately severe and severe AP. The current article aims to review the latest evidence and suggest practical nutrition interventions in patients with AP, including nutrition requirements, routes of nutrition treatment, types of formula, and the role of nutritional supplements, such as glutamine, probiotics, omega-3 fatty acids, and antioxidants.

Reduction in Healthcare Utilization With Transition to Peptide-Based Diets in Intolerant Home Enteral Nutrition Patients

BACKGROUND

Since the introduction of percutaneous endoscopic gastrostomy in the 1980s, the prevalence of home enteral nutrition (HEN) support has increased significantly. Despite these increases, many patients are unable to tolerate standard polymeric formulas (SPFs), resulting in significant healthcare resource utilization. Peptide-based diets (PBDs) have emerged as a viable option in SPF-intolerant patients; however, data in the HEN population are lacking.

METHODS

Retrospective review of our prospectively maintained HEN database was conducted to assess tolerance, efficacy, and impact on healthcare utilization in patients on PBDs.

RESULTS

From January 1, 2016, to May 1, 2018, 95 patients were placed on PBDs, with 53 patients being started directly and 42 patients being transitioned from SPFs. In patients transitioned to PBDs, symptoms of nausea and vomiting, diarrhea, abdominal pain, and distention improved significantly. Healthcare utilization also declined significantly, including mean number of phone calls (1.8 ± 1.6 to 1.1 ± 0.9, P = 0.006), mean number of emergency room visits (0.3 ± 0.6 to 0.09 ± 0.3, P = 0.015), and mean number of provider visits (1.3 ± 1.3 to 0.3 ± 0.5, P < 0.0001).

CONCLUSIONS

Overall, PBDs were well tolerated and resulted in significant improvements in symptoms of gastrointestinal distress and healthcare utilization in patients intolerant to SPFs.

Current trends in pharmacological approaches for treatment and management of acute pancreatitis – a review

Objectives

Acute pancreatitis (AP) is an inimical disorder associated with overall mortality rates between 10-15%. It is a disorder of the exocrine pancreas which is characterized by local and systemic inflammatory responses primarily driven by oxidative stress and death of pancreatic acinar cells. The severity of AP ranges from mild pancreatic edema with complete recuperative possibilities to serious systemic inflammatory response resulting in peripancreatic/pancreatic necrosis, multiple organ failure, and death.

Key findings

We have retrieved the potential alternative approaches that are developed lately for efficacious treatment of AP from the currently available literature and recently reported experimental studies. This review summarizes the need for alternative approaches and combinatorial treatment strategies to deal with AP based on literature search using specific key words in PubMed and ScienceDirect databases.

Summary

Since AP results from perturbations of multiple signaling pathways, the so called “monotargeted smart drugs” of the past decade is highly unlikely to be effective. Also, the conventional treatment approaches were mainly involved in providing palliative care instead of curing the disease. Hence, many researchers are beginning to focus on developing alternate therapies to treat AP effectively. This review also summarizes the recent trends in the combinatorial approaches available for AP treatment.

Infection rate among nutritional therapies for acute pancreatitis: A systematic review with network meta-analysis of randomized controlled trials

Background

Infection in acute pancreatitis (AP) is associated with nutritional therapies including naso-gastric (NG), naso-jejunal (NJ), and total parenteral nutrition (TPN). To examine infections among NG, NJ, TPN, and no nutritional support (NNS) in treating patients with AP.

Methods

The investigators completed comprehensive search in the Cochrane library, EMBASE, PubMed, Web of Science, and ClinicalTrials.gov without restriction on language and publication date before January 21, 2019. They also searched the reference lists of relevant studies for randomized controlled trials (RCTs) comparing NG, NJ, TPN, and NNS among patients with AP. Quantitative synthesis was conducted in a contrast-based network meta-analysis. To clarify effects, a network meta-analysis was conducted to calculate the surface under the cumulative ranking curve (SUCRA). Beside of overall infections, the event rates of infected pancreatic necrosis, bacteremia, line infection, pneumonia, urinary tract infection, and other types of infections were measured.

Results

The network meta-analysis of 16 RCTs showed that NJ had significantly lower overall infection rates compared with TPN (risk ratio: 0.59; 95% confidence interval: 0.38, 0.90); and NG had a larger effect size and higher rank probability compared with NJ, TPN, and NNS (mean rank = 1.7; SUCRA = 75.8). TPN was the least preferred (mean rank = 3.2; SUCRA = 26.6).

Conclusions

NG and NJ may be preferred therapies for treating patients with AP. Clinicians may consider NG as a first-line treatment for patients with AP (including severe AP) and even in patients receiving prophylactic antibiotics. In addition, we found that NNS should be avoided when treating patients with severe AP.

Nutritional Considerations in Pediatric Pancreatitis: A Position Paper from the NASPGHAN Pancreas Committee and ESPGHAN Cystic Fibrosis/Pancreas Working Group

OBJECTIVES

Wide variations exist in how physicians manage the nutritional aspects of children affected by acute pancreatitis (AP), acute recurrent pancreatitis (ARP), and chronic (CP) pancreatitis. Better consensus for optimal management is needed.

METHODS

This consensus statement on nutrition in pediatric pancreatic diseases was developed through a joint ESPGHAN-NASPGHAN working group that performed an evidence-based search of the literature on nutrition in AP, ARP, and CP with a focus on pediatrics. The literature was summarized, quality of evidence reviewed, and expert recommendations developed. The authorship met to discuss the evidence and statements. Voting on recommendations occurred over 2 rounds based on feedback. A consensus of at least 75% was required to approve a recommendation. Areas requiring further research were identified.

RESULTS AND DISCUSSION

The literature on nutrition in pediatric pancreatitis is limited. Children with mild AP benefit from starting an early nutritional regimen in the course of the attack. Early nutrition should be attempted in severe AP when possible; enteral nutrition is preferred over parenteral nutrition. Children with ARP are likely to tolerate and benefit from a regular diet. Children with CP need ongoing assessment for growth and nutritional deficiencies, exocrine and endocrine insufficiencies.

CONCLUSIONS

This document presents the first authoritative recommendations on nutritional considerations in pediatric pancreatitis. Future research should address the gaps in knowledge particularly relating to optimal nutrition for AP in children, role of diet or dietary supplements on recurrent attacks of pancreatitis and pain episodes, monitoring practices to detect early growth and nutritional deficiencies in CP and identifying risk factors that predispose children to these deficiencies.

Comparative effectiveness of elemental formula in the early enteral nutrition management of acute pancreatitis: a retrospective cohort study

Background

Although enteral nutrition has become one of the standard therapies for patients with acute pancreatitis, the optimal formulae for enteral nutrition have been under debate. Elemental formula is assumed to be suitable in the treatment of patients with acute pancreatitis because it has less stimulating effects for exocrine secretions of the pancreas, simultaneously maintaining gut immunity; however, clinical studies corroborating this assumption have been scarce.

Methods

We conducted a retrospective cohort study using a Japanese national administrative database between 2010 and 2015. Patients with acute pancreatitis who received enteral feeding within 3 days of admission were identified and divided into two groups according to whether elemental formula was administered. We assessed the impact of elemental formula for the outcomes (primary, in-hospital mortality; secondary, development of sepsis, hospital-free days at 90 days, and total health-care costs) using a multivariate mixed-effect regression analysis and propensity score matching analysis adjusted by a well-validated case-mix adjustment model. Analysis for the subpopulation of patients with severe acute pancreatitis was also performed.

Results

Of 243,312 patients with acute pancreatitis, 948 patients were identified and classified into the elemental formula group (N = 382) and the control group (N = 566). No significant differences were observed for in-hospital mortality [10.2% in the elemental formula group vs. 11.0% in the control group; adjusted adds ratio (95% confidence interval; CI) = 0.94 (0.53–1.67)], sepsis development [5.0 vs. 7.1%; adjusted adds ratio (95% CI) = 0.66 (0.34–1.28)], mean hospital-free days [54 days vs. 51 days; adjusted difference (95% CI) = 2 days (− 2 to 5)], and mean total health-care costs [$29,360 vs. $34,214; adjusted difference (95% CI) = − $4250 (− 8643 to 141)]. Similar results were also observed in patients with severe acute pancreatitis.

Conclusions

The results of our retrospective cohort study using a large-scale national database did not demonstrate the benefit of elemental formula compared to semi-elemental and polymeric formulae in patients with acute pancreatitis. Further assessment of alternative nutritional strategy is expected.

Electronic supplementary material

The online version of this article (10.1186/s13613-018-0414-6) contains supplementary material, which is available to authorized users.

Nutritional Aspects of Acute Pancreatitis

The goal of nutritional support in acute pancreatitis is to reduce inflammation, prevent nutritional depletion, correct a negative nitrogen balance, and improve outcomes. Enteral nutrition (EN) in severe acute pancreatitis (SAP) should be preferred to parenteral nutrition. It maintains the integrity of the gut barrier, decreases intestinal permeability, downregulates the systemic inflammatory response, maintains intestinal microbiota equilibrium, and reduces the complications of the early phase of SAP, improving morbidity and possibly improving mortality, and it is less expensive. Further studies to understand optimal timing of nutrition, route of delivery of EN, and the type of nutrition and nutrients are necessary.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016)

BACKGROUND AND PURPOSE

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 and published in the Journal of JSICM, [2017; Volume 24 (supplement 2)] 10.3918/jsicm.24S0001 and Journal of Japanese Association for Acute Medicine [2017; Volume 28, (supplement 1)] http://onlinelibrary.wiley.com/doi/10.1002/jja2.2017.28.issue-S1/issuetoc.This abridged English edition of the J-SSCG 2016 was produced with permission from the Japanese Association of Acute Medicine and the Japanese Society for Intensive Care Medicine.

METHODS

Members of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ) and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two-thirds (> 66.6%) majority vote of each of the 19 committee members.

RESULTS

A total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J-SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation, and its supporting evidence were also added to each recommendation statement. We conducted meta-analyses for 29 CQs. Thirty-seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for five CQs.

CONCLUSIONS

Based on the evidence gathered, we were able to formulate Japanese-specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non-specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016)

Background and Purpose

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 in Japanese. An English-language version of these guidelines was created based on the contents of the original Japanese-language version.

Methods

Members of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ), and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two-thirds (>66.6%) majority vote of each of the 19 committee members.

Results

A total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J-SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation and its supporting evidence were also added to each recommendation statement. We conducted meta-analyses for 29 CQs. Thirty seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for 5 CQs.

Conclusions

Based on the evidence gathered, we were able to formulate Japanese-specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non-specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals.

Management of Acute Pancreatitis in the Pediatric Population: A Clinical Report From the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas Committee

BACKGROUND

Although the incidence of acute pancreatitis (AP) in children is increasing, management recommendations rely on adult published guidelines. Pediatric-specific recommendations are needed.

METHODS

The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas committee performed a MEDLINE review using several preselected key terms relating to management considerations in adult and pediatric AP. The literature was summarized, quality of evidence reviewed, and statements of recommendations developed. The authorship met to discuss the evidence, statements, and voted on recommendations. A consensus of at least 75% was required to approve a recommendation.

RESULTS

The diagnosis of pediatric AP should follow the published INternational Study Group of Pediatric Pancreatitis: In Search for a CuRE definitions (by meeting at least 2 out of 3 criteria: (1) abdominal pain compatible with AP, (2) serum amylase and/or lipase values ≥3 times upper limits of normal, (3) imaging findings consistent with AP). Adequate fluid resuscitation with crystalloid appears key especially within the first 24 hours. Analgesia may include opioid medications when opioid-sparing measures are inadequate. Pulmonary, cardiovascular, and renal status should be closely monitored particularly within the first 48 hours. Enteral nutrition should be started as early as tolerated, whether through oral, gastric, or jejunal route. Little evidence supports the use of prophylactic antibiotics, antioxidants, probiotics, and protease inhibitors. Esophago-gastro-duodenoscopy, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography have limited roles in diagnosis and management. Children should be carefully followed for development of early or late complications and recurrent attacks of AP.

CONCLUSIONS

This clinical report represents the first English-language recommendations for the management of pediatric AP. Future aims should include prospective multicenter pediatric studies to further validate these recommendations and optimize care for children with AP.

Historical review of our knowledge of acute pancreatitis

Acute pancreatitis is one of most common causes of consultation due to abdominal pain in medical emergency units and it requires hospital admission. Although the majority of cases are mild and patients tend to recover quickly, a small percentage of cases is severe, with mortality in the region of 5-10%. This historical review considers how our understanding of this disease has changed since it was first described in 1579 thanks to the contributions of renowned experts such as Nicolaes Tulp, Reginald Fitz, Nicholas Senn and many others who, through their expertise and dedication, have improved the survival of patients with this disease.

Acute Pancreatitis: Etiology, Pathology, Diagnosis, and Treatment

Acute pancreatitis is a fascinating disease. In the United States, the two most common etiologies of acute pancreatitis are gallstones and excessive alcohol consumption. The diagnosis of acute pancreatitis is made with a combination of history, physical examination, computed tomography scan, and laboratory evaluation. Differentiating patients who will have a benign course of their pancreatitis from patients who will have severe pancreatitis is challenging to the clinician. C-reactive protein, pro-calcitonin, and the Bedside Index for Severity of Acute Pancreatitis appeared to be the best tools for the early and accurate diagnosis of severe pancreatitis. Early laparoscopic cholecystectomy is indicated for patients with mild gallstone pancreatitis. For patients who are going to have a prolonged hospitalization, enteral nutrition is preferred. Total parenteral nutrition should be reserved for patients who cannot tolerate enteral nutrition. Prophylactic antibiotics are not indicated for patients with pancreatic necrosis. Surgical intervention for infected pancreatic necrosis should be delayed as long as possible to improve patient outcomes.

High versus low energy administration in the early phase of acute pancreatitis (GOULASH trial): protocol of a multicentre randomised double-blind clinical trial

INTRODUCTION

Acute pancreatitis (AP) is an inflammatory disease with no specific treatment. Mitochondrial injury followed by ATP depletion in both acinar and ductal cells is a recently discovered early event in its pathogenesis. Importantly, preclinical research has shown that intracellular ATP delivery restores the physiological function of the cells and protects from cell injury, suggesting that restoration of energy levels in the pancreas is therapeutically beneficial. Despite several high quality experimental observations in this area, no randomised trials have been conducted to date to address the requirements for energy intake in the early phase of AP.

METHODS/DESIGN

This is a randomised controlled two-arm double-blind multicentre trial. Patients with AP will be randomly assigned to groups A (30 kcal/kg/day energy administration starting within 24 hours of hospital admission) or B (low energy administration during the first 72 hours of hospital admission). Energy will be delivered by nasoenteric tube feeding with additional intravenous glucose supplementation or total parenteral nutrition if necessary. A combination of multiorgan failure for more than 48 hours and mortality is defined as the primary endpoint, whereas several secondary endpoints such as length of hospitalisation or pain will be determined to elucidate more detailed differences between the groups. The general feasibility, safety and quality checks required for high quality evidence will be adhered to.

ETHICS AND DISSEMINATION

The study has been approved by the relevant organisation, the Scientific and Research Ethics Committee of the Hungarian Medical Research Council (55961-2/2016/EKU). This study will provide evidence as to whether early high energy nutritional support is beneficial in the clinical management of AP. The results of this trial will be published in an open access way and disseminated among medical doctors.

TRIAL REGISTRATION

The trial has been registered at the ISRCTN (ISRTCN 63827758).

Early management of acute pancreatitis: A review of the best evidence

In the 20th century early management of acute pancreatitis often included surgical intervention, despite overwhelming mortality. The emergence of high-quality evidence (randomized controlled trials and meta-analyses) over the past two decades has notably shifted the treatment paradigm towards predominantly non-surgical management early in the course of acute pancreatitis. The present evidence-based review focuses on contemporary aspects of early management (which include analgesia, fluid resuscitation, antibiotics, nutrition, and endoscopic retrograde cholangiopancreatography) with a view to providing clear and succinct guidelines on early management of patients with acute pancreatitis in 2017 and beyond.

Nutrition support in hospitalised adults at nutritional risk

BACKGROUND

The prevalence of disease-related malnutrition in Western European hospitals is estimated to be about 30%. There is no consensus whether poor nutritional status causes poorer clinical outcome or if it is merely associated with it. The intention with all forms of nutrition support is to increase uptake of essential nutrients and improve clinical outcome. Previous reviews have shown conflicting results with regard to the effects of nutrition support.

OBJECTIVES

To assess the benefits and harms of nutrition support versus no intervention, treatment as usual, or placebo in hospitalised adults at nutritional risk.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE (Ovid SP), Embase (Ovid SP), LILACS (BIREME), and Science Citation Index Expanded (Web of Science). We also searched the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp); ClinicalTrials.gov; Turning Research Into Practice (TRIP); Google Scholar; and BIOSIS, as well as relevant bibliographies of review articles and personal files. All searches are current to February 2016.

SELECTION CRITERIA

We include randomised clinical trials, irrespective of publication type, publication date, and language, comparing nutrition support versus control in hospitalised adults at nutritional risk. We exclude trials assessing non-standard nutrition support.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane and the Cochrane Hepato-Biliary Group. We used trial domains to assess the risks of systematic error (bias). We conducted Trial Sequential Analyses to control for the risks of random errors. We considered a P value of 0.025 or less as statistically significant. We used GRADE methodology. Our primary outcomes were all-cause mortality, serious adverse events, and health-related quality of life.

MAIN RESULTS

We included 244 randomised clinical trials with 28,619 participants that met our inclusion criteria. We considered all trials to be at high risk of bias. Two trials accounted for one-third of all included participants. The included participants were heterogenous with regard to disease (20 different medical specialties). The experimental interventions were parenteral nutrition (86 trials); enteral nutrition (tube-feeding) (80 trials); oral nutrition support (55 trials); mixed experimental intervention (12 trials); general nutrition support (9 trials); and fortified food (2 trials). The control interventions were treatment as usual (122 trials); no intervention (107 trials); and placebo (15 trials). In 204/244 trials, the intervention lasted three days or more.We found no evidence of a difference between nutrition support and control for short-term mortality (end of intervention). The absolute risk was 8.3% across the control groups compared with 7.8% (7.1% to 8.5%) in the intervention groups, based on the risk ratio (RR) of 0.94 (95% confidence interval (CI) 0.86 to 1.03, P = 0.16, 21,758 participants, 114 trials, low quality of evidence). We found no evidence of a difference between nutrition support and control for long-term mortality (maximum follow-up). The absolute risk was 13.2% in the control group compared with 12.2% (11.6% to 13%) following nutritional interventions based on a RR of 0.93 (95% CI 0.88 to 0.99, P = 0.03, 23,170 participants, 127 trials, low quality of evidence). Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.We found no evidence of a difference between nutrition support and control for short-term serious adverse events. The absolute risk was 9.9% in the control groups versus 9.2% (8.5% to 10%), with nutrition based on the RR of 0.93 (95% CI 0.86 to 1.01, P = 0.07, 22,087 participants, 123 trials, low quality of evidence). At long-term follow-up, the reduction in the risk of serious adverse events was 1.5%, from 15.2% in control groups to 13.8% (12.9% to 14.7%) following nutritional support (RR 0.91, 95% CI 0.85 to 0.97, P = 0.004, 23,413 participants, 137 trials, low quality of evidence). However, the Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.Trial Sequential Analysis of enteral nutrition alone showed that enteral nutrition might reduce serious adverse events at maximum follow-up in people with different diseases. We could find no beneficial effect of oral nutrition support or parenteral nutrition support on all-cause mortality and serious adverse events in any subgroup.Only 16 trials assessed health-related quality of life. We performed a meta-analysis of two trials reporting EuroQoL utility score at long-term follow-up and found very low quality of evidence for effects of nutritional support on quality of life (mean difference (MD) -0.01, 95% CI -0.03 to 0.01; 3961 participants, two trials). Trial Sequential Analyses showed that we did not have enough information to confirm or reject clinically relevant intervention effects on quality of life.Nutrition support may increase weight at short-term follow-up (MD 1.32 kg, 95% CI 0.65 to 2.00, 5445 participants, 68 trials, very low quality of evidence).

AUTHORS' CONCLUSIONS

There is low-quality evidence for the effects of nutrition support on mortality and serious adverse events. Based on the results of our review, it does not appear to lead to a risk ratio reduction of approximately 10% or more in either all-cause mortality or serious adverse events at short-term and long-term follow-up.There is very low-quality evidence for an increase in weight with nutrition support at the end of treatment in hospitalised adults determined to be at nutritional risk. The effects of nutrition support on all remaining outcomes are unclear.Despite the clinically heterogenous population and the high risk of bias of all included trials, our analyses showed limited signs of statistical heterogeneity. Further trials may be warranted, assessing enteral nutrition (tube-feeding) for different patient groups. Future trials ought to be conducted with low risks of systematic errors and low risks of random errors, and they also ought to assess health-related quality of life.

Nutrition in acute pancreatitis: a critical review

Severe acute pancreatitis poses unique nutritional challenges. The optimal nutritional support in patients with severe acute pancreatitis has been a subject of debate for decades. This review provides a critical review of the available literature. According to current literature, enteral nutrition is superior to parenteral nutrition, although several limitations should be taken into account. The optimal route of enteral nutrition remains unclear, but normal or nasogastric tube feeding seems safe when tolerated. In patients with predicted severe acute pancreatitis an on-demand feeding strategy is advised and when patients do not tolerate an oral diet after 72 hours, enteral nutrition can be started. The use of supplements, both parenteral as enteral, are not recommended. Optimal nutritional support in severe cases often requires a tailor-made approach with day-to-day evaluation of its effectiveness.

Enteral Access in Mechanically Ventilated Patients

The early institution of enteral nutrition is now accepted as the preferred route of feeding in critically ill patients with a functioning gastrointestinal tract. It is particularly important to establish early enteral nutrition in mechanically ventilated patients because of the metabolic demands associated with mechanical ventilation. The options for enteral access in mechanically ventilated patients are reviewed, with an emphasis on those techniques that may be performed at the bedside. The advantages, disadvantages, and complications of the different techniques will be considered.

The Incidence and Impact of Dextrose Dose on Hyperglycemia From Parenteral Nutrition (PN) Exposure in Hematopoietic Stem Cell Transplant (HSCT) Recipients

BACKGROUND

Short-term, transient hyperglycemia is associated with adverse outcomes in acutely ill populations. Because parenteral nutrition (PN) is dextrose based, we hypothesized that exposure to PN would be associated with hyperglycemia and that greater levels of dextrose infusion would be associated with higher glucose concentrations. Our objective was to examine the temporality, incidence, and dose response from dextrose load upon hyperglycemia using several serum glucose cut points in PN vs non-PN HSCT recipients.

METHODS

The medical records of adults admitted for initial autologous or allogeneic hematopoietic stem cell transplant (HSCT) at 2 university-affiliated hospitals between September 1999 and December 2003 were used in this retrospective cohort. To minimize the impact of disease acuity on serum glucose, patients with diabetes mellitus, steroid administration, patients with recently treated infections, or patients who died during therapy were eliminated from the study. Serum glucose values were recorded once per day from the first morning venous blood draw (2 AM-6 AM) to achieve uniformity among patients, to avoid measurements occurring more frequently among hyperglycemic patients, and to minimize the influence of oral intake. Hyperglycemia was examined using several serum glucose cut points (110, 125, 150, 175, and 200 mg/dL). Wilcoxon rank-sum tests were used to detect differences in hyperglycemic events between PN and non-PN subjects, and mixed-effects regression models were used to detect the association between PN exposure and hyperglycemia. To address the temporality and incidence of hyperglycemia between PN vs non-PN participants, before and "after" time frames were created. Preinfusion (before) and actual infusion (after) times were used for these intervals for PN patients; however, the average hospital days before (before) or during (after) PN infusion were used for comparison in non-PN recipients (ie, autologous non-PN before = hospital days 1-10, after = hospital days 11-21).

RESULTS

Of the 208 patients who qualified for inclusion 49% (n = 101/208) received PN, which provided on average 26 kcal per kg, 1.3 g of protein per kg, and 2.7 mg/kg/min of dextrose (range 1.3-3.9 mg/kg/min). The proportion of hyperglycemic days before was not different between groups; however, it was significantly greater after in PN vs non-PN patients, regardless of serum glucose cut point. A dose response between dextrose administered (mg/kg/min) and serum glucose concentrations was not seen. When longitudinally presented, the temporal relationship between serum glucose and PN initiation was reflected approximately on hospital day 9. Using regression models that account for repeated measures, the odds of having hyperglycemia (yes/no; glucose >110 mg/dL) after PN exposure were nearly 4 times (odds ratio 3.9; 95% confidence interval, 2.7-5.5) that of non-PN exposed, after controlling for donor type, race, age, and conditioning chemotherapy. PN was the only variable to significantly interact with time (p < .0001), signifying not only the change in odds over time but also as powerful evidence that PN was the causative agent of hyperglycemic events.

CONCLUSIONS

The broad use of PN at levels within current clinical guidelines in HSCT adults was associated with profound hyperglycemia; however, greater dextrose dose, within the narrow levels administered in this cohort, was not associated with higher glucose concentrations.

Meta-Analysis of Early Nutrition: The Benefits of Enteral Feeding Compared to a Nil Per Os Diet Not Only in Severe, but Also in Mild and Moderate Acute Pancreatitis

The recently published guidelines for acute pancreatitis (AP) suggest that enteral nutrition (EN) should be the primary therapy in patients suffering from severe acute pancreatitis (SAP); however, none of the guidelines have recommendations on mild and moderate AP (MAP). A meta-analysis was performed using the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P). The following PICO (problem, intervention, comparison, outcome) was applied: P: nutrition in AP; I: enteral nutrition (EN); C: nil per os diet (NPO); and O: outcome. There were 717 articles found in Embase, 831 in PubMed, and 10 in the Cochrane database. Altogether, seven SAP and six MAP articles were suitable for analyses. In SAP, forest plots were used to illustrate three primary endpoints (mortality, multiorgan failure, and intervention). In MAP, 14 additional secondary endpoints were analyzed (such as CRP (C-reactive protein), WCC (white cell count), complications, etc.). After pooling the data, the Mann-Whitney U test was used to detect significant differences. Funnel plots were created for testing heterogeneity. All of the primary endpoints investigated showed that EN is beneficial vs. NPO in SAP. In MAP, all of the six articles found merit in EN. Analyses of the primary endpoints did not show significant differences between the groups; however, analyzing the 17 endpoints together showed a significant difference in favor of EN vs. NPO. EN is beneficial compared to a nil per os diet not only in severe, but also in mild and moderate AP.

Nutritional and health benefits of semi-elemental diets: A comprehensive summary of the literature

AIM: To critically review and summarize the literature on nutritional and health outcomes of semi-elemental formulations on various nutritionally vulnerable patient populations who are unable to achieve adequate nutrition from standard oral diets.

METHODS: We conducted a comprehensive literature search of Pubmed and Embase databases. We manually screened articles that examined nutritional and health outcomes (e.g., growth, disease activity, gastrointestinal impairment, mortality, and economic impact) among various patient groups receiving semi-elemental diets. This review focused on full-text articles of randomized controlled clinical trials and other intervention studies, but pertinent abstracts and case studies were also included. Results pertaining primarily to tolerance, digestion, and absorption were summarized for each patient population in this systematic review.

RESULTS: Results pertaining primarily to tolerance, digestion, and absorption were summarized for each patient population. The efficacy of semi-elemental whey hydrolyzed protein (WHP) diet have been reported in various nutritionally high risk patient populations including - Crohn’s disease, short bowel syndrome, acute and chronic pancreatitis, cerebral palsy, cystic fibrosis, cerebrovascular accidents, human immunodeficiency virus, critically ill, and geriatrics. Collectively, the evidence from the medical literature indicates that feeding with a semi-elemental diet performs as well or better than parenteral or amino acid based diets in terms of tolerance, digestion, and nutrient assimilation measures across various disease conditions.

CONCLUSION: Based on this comprehensive review of the literature, patient populations who have difficulty digesting or absorbing standard diets may be able to achieve improved health and nutritional outcomes through the use of semi-elemental WHP diets.

Pilot study evaluating the efficacy, tolerance and safety of a peptide-based enteral formula versus a high protein enteral formula in multiple ICU settings (medical, surgical, cardiothoracic)

INTRODUCTION

Predigested, peptide-based enteral formulas are commonly used to promote GI tolerance in critically ill patients, but studies comparing these against polymeric enteral formulas are lacking. We performed a prospective, randomized clinical comparison pilot study to assess safety, tolerance and effectiveness of a peptide-based enteral product.

METHODS

Critically ill patients from ICUs, including medical, surgical, and cardiothoracic, were randomized to either of two enteral feeding products: Group A: Peptide-based, high Protein, high omega-3 fat (Vital AF^®, Abbott Nutrition); Group B: high protein standard enteral formula (Osmolite^®, Abbott Nutrition). Tolerance and comorbidities as well as enteral feeding volume were collected at baseline and then daily for up to 21 days, or until the patient was discharged from the ICU.

RESULTS

A total of 49 patients were included, 25 (51%) on group A, 24 (49%) on group B. Adverse events and undesired gastrointestinal events at baseline and mean intake (ml/d and percent of goal) post baseline were not different between the groups. There were significantly fewer days with adverse events (p = 0.0336, odds ratio = 3.02, standard error = 1.60, n = 24 per group) and undesired gastrointestinal events (p = 0.0489, odds ratio = 2.79, standard error = 1.48, n = 24 per group) in group A. There was no difference in other clinical outcomes.

CONCLUSION

This pilot study suggests that feeding a peptide-based formula to ICU patients may be associated with a statistically significant reduction in the number of days during which adverse events occurred as compared to a standard formula.

[Recent Advances in Management of Acute Pancreatitis]

Acute pancreatitis is common but remains a condition with significant morbidity and mortality. Despite a better understanding of the pathophysiology of acute pancreatitis achieved during the past few decades, there is no specific pharmacologic entity available. Therefore, supportive care is still the mainstay of treatment. Recently, novel interventions for increasing survival and minimizing morbidity have been investigated, which are highlighted in this review.

Experience in Bedside Placement, Clinical Validity, and Cost-Efficacy of a Self-Propelled Nasojejunal Feeding Tube

BACKGROUND

The procedures needed to insert nasojejunal tubes (NJTs) are often invasive or uncomfortable for the patient and require hospital resources. The objectives of this study were to describe our experience in inserting a self-propelling NJT with distal pigtail end and evaluate clinical validity and cost efficacy of this enteral nutrition (EN) approach compared with parenteral nutrition (PN).

MATERIALS AND METHODS

Prospective study from July 2009 to December 2010, including hospitalized noncritical patients who required short-term jejunal EN. The tubes were inserted at bedside, using intravenous erythromycin as a prokinetic drug. Positioning was considered correct when the distal end was beyond the ligament of Treitz. Migration failure was considered when the tube was not positioned into the jejunum within 48 hours postinsertion.

RESULTS

Fifty-six insertions were recorded in 47 patients, most frequently in severe acute pancreatitis (69.6%). The migration rates at 18 and 48 hours postinsertion were 73.2% and 82.1%, respectively. There was migration failure in 8.9% of cases, and 8.9% were classified null (the tube was no longer in the gastrointestinal tract at 18 hours). There were no reported or observed complications. The mean duration of the EN was 12 ± 10.8 days. Five different types of EN formula were used. The total study cost was 53.9% lower compared with using PN in all patients.

CONCLUSIONS

Our study demonstrated that bedside insertion of a self-propelling NJT is a safe, cost-effective, and successful technique for postpyloric enteral feeding in at least 73% of the patients, and only 18% of patients could eventually need other placement techniques. It can avoid the need for more aggressive or expensive placement techniques or even PN if we cannot achieve enteral access.

Timing of oral refeeding in acute pancreatitis: A systematic review and meta-analysis

BACKGROUND AND AIM

The optimal timing of oral refeeding in acute pancreatitis is unclear. This study aimed to perform a systematic review with meta-analysis of randomized controlled trials (RCTs) that compared early oral refeeding with standard oral refeeding in acute pancreatitis.

METHODS

PubMed, the Cochrane library, and the Igaku-Chuo-Zasshi database were searched in order to identify RCTs eligible for inclusion in the systematic review. The weighted mean differences (WMDs) or odds ratios (ORs) with 95% confidence intervals (CIs) were calculated.

RESULTS

Five eligible RCTs were included. Compared with standard oral refeeding, early oral refeeding significantly decreased the length of hospital stay (WMD: -2.22, 95%CI: -3.37 to -1.08, p = 0.0001). Although there was heterogeneity (I²= 56%, p = 0.06), subgroup analysis of the refeeding criteria (immediate group and hungry group) eliminated the heterogeneity. There was no significant difference between the early refeeding group and standard refeeding groups with respect abdominal pain and distension (OR 1.14; 95%CI 0.65-1.99 and OR 1.53; 95%CI 0.81-2.90).

CONCLUSIONS

Compared with standard oral refeeding, early oral refeeding safely reduced the length of hospital stay in patients with acute pancreatitis.

Early Enteral Nutrition and Aggressive Fluid Resuscitation are Associated with Improved Clinical Outcomes in Acute Pancreatitis

OBJECTIVES

To determine whether recommendations for treatment of acute pancreatitis (AP) in adults impact the outcomes of pediatric AP.

STUDY DESIGN

Adult guidelines regarding early management of AP were implemented through an admission order set at Cincinnati Children's Hospital Medical Center at the beginning of the year 2014. Recommendations included administering high rates of intravenous fluid (IVF) within 24 hours of admission and enteral nutrition within 48 hours of admission. A retrospective chart review of AP admissions before and after the implementation of the recommendations was undertaken. Outcomes studied were: hospital length of stay, intensive care unit transfer rates, development of severe AP, pulmonary complications, and readmission rates post discharge from the hospital.

RESULTS

The study included 201 patients. Children who received feeds within the first 48 hours and received greater than maintenance IVF within 24 hours had a shorter length of stay, less intensive care unit admissions and severe AP rates compared with the patients who remained nil per os during the first 48 hours and received lower rates of IVF.

CONCLUSION

Our data support that early enteral nutrition and early aggressive IVF improve outcomes of pediatric AP.