A Randomized Study of Early Nasogastric versus Nasojejunal Feeding in Severe

Acute PancreatitisAmerican Journal of

Gastroenterology, 2005

Original questionOriginal question

TPN traditionally mainstay of nutritional support for TPN traditionally mainstay of nutritional support for severe pancreatitis ? Suppression of pancreatic severe pancreatitis ? Suppression of pancreatic exocrine secretion by bowel restexocrine secretion by bowel rest

Does early enteral feeding confer a benefit in Does early enteral feeding confer a benefit in acute pancreatitis? Are there any other options?acute pancreatitis? Are there any other options?

BackgroundBackground

No studies have compared enteral or parenteral No studies have compared enteral or parenteral feeding vs no feeding in severe pancreatitisfeeding vs no feeding in severe pancreatitis

BackgroundBackground

At least 6 randomized trials have compared enteral At least 6 randomized trials have compared enteral vs. parenteral feedingvs. parenteral feeding -overall results favour enteral; decreased -overall results favour enteral; decreased infective complications, surgical intervention and infective complications, surgical intervention and LOSLOS

Possible disadvantages of nasojejunal feeding Possible disadvantages of nasojejunal feeding related to insertion of NJ tube ?more related to insertion of NJ tube ?more complications ?delay in introduction of feedingcomplications ?delay in introduction of feeding

BackgroundBackground

Novel questionNovel question

Is nasogastric and Is nasogastric and nasojejunal feeding in nasojejunal feeding in severe pancreatitis severe pancreatitis comparable?comparable?

Glasgow Royal InfirmaryGlasgow Royal Infirmary

AimsAims

Is nasogastric feeding as safe and as effective as Is nasogastric feeding as safe and as effective as nasojejunal feeding in severe pancreatitis?nasojejunal feeding in severe pancreatitis?

Does NG feeding result in reactivation of Does NG feeding result in reactivation of pancreatitis in any way?pancreatitis in any way?

Does NG feeding avoid some of the problems of Does NG feeding avoid some of the problems of NJ feeding?NJ feeding?

MethodMethod

50 pts at Glasgow Royal Infirmary from Oct 1997 50 pts at Glasgow Royal Infirmary from Oct 1997 to July 2000to July 2000

-clinical and biochemcal presentation of acute -clinical and biochemcal presentation of acute pancreatitis (AP) ; serum amylase 3x normalpancreatitis (AP) ; serum amylase 3x normal

-severe pancreatitis : Glasgow prog score -severe pancreatitis : Glasgow prog score ≥ 3, ≥ 3, APACHE II ≥ 6, CRP > 150APACHE II ≥ 6, CRP > 150

MethodMethod

Randomization by computerised random no. Randomization by computerised random no. generationgeneration

No blinding of participants or investigatorsNo blinding of participants or investigators

Parameters measured daily:Parameters measured daily: APACHE II, CRP, visual analogue scale for pain, total APACHE II, CRP, visual analogue scale for pain, total

analgesic requirements analgesic requirements

MethodMethod

NG tubes 8Fr Flocare NG tubes 8Fr Flocare NJ tubes placed at endoscopy – half 8Fr flocare, NJ tubes placed at endoscopy – half 8Fr flocare,

other half 7Fr nasobiliary catheterother half 7Fr nasobiliary catheter

Feeds commenced on avg 72 hrs post onset of Feeds commenced on avg 72 hrs post onset of pain at 30mL/hr, increasing over 24-48hrs to pain at 30mL/hr, increasing over 24-48hrs to 100mL/hr 100mL/hr

Low fat semi-elemental feed: carbo 75%, Low fat semi-elemental feed: carbo 75%, protein 16%, fat 9%protein 16%, fat 9%

Objective – to assess any difference Objective – to assess any difference between NG and NJ feedsbetween NG and NJ feeds

Primary outcome measuresPrimary outcome measures

CRP, APACHE II, pain score, total analgesia, CRP, APACHE II, pain score, total analgesia, need to convert to parenteral feedingneed to convert to parenteral feeding

Secondary outcome measuresSecondary outcome measures

length of stay in hospital and ICU, mortalitylength of stay in hospital and ICU, mortality

Power calc - 20% difference in CRPPower calc - 20% difference in CRP

Aetiology of pancreatitisAetiology of pancreatitis

Total 50pts – 1 excluded Total 50pts – 1 excluded

49pts49pts

⁄ ⁄ \\27 in NG gp 22 in NJ 27 in NG gp 22 in NJ

0

5Other

6

6Alcohol

16

16Gallstone

22 NJ27 NG Aetiology

Comparing the two gpsComparing the two gps

Demographics (age,sex) similar for both gpsDemographics (age,sex) similar for both gps

Time to commence feeds median Time to commence feeds median 72hrs and time 72hrs and time to full rate of feeds (an additional 36 hrs) similar to full rate of feeds (an additional 36 hrs) similar both gpsboth gps

36 of 49pts tolerated a rate of 75% of target within 36 of 49pts tolerated a rate of 75% of target within 48hrs (19/27 in NG) and (17/22 in NJ)48hrs (19/27 in NG) and (17/22 in NJ)

ResultsResults

ComplicationsComplicationsone pt had cardioresp arrest inserting NJone pt had cardioresp arrest inserting NJbloating - 1 NJbloating - 1 NJdiarrhoea – 3 NG and 1 NJdiarrhoea – 3 NG and 1 NJ

Death Death 12 of 49pts (24.5%)12 of 49pts (24.5%)

5/27 in NG gp vs. 7/22 in NJ gp5/27 in NG gp vs. 7/22 in NJ gpgallstones 9, alcohol 3gallstones 9, alcohol 3

Comparison of APACHE II scores similar for Comparison of APACHE II scores similar for both gpsboth gps

No statistical difference with levels of CRP No statistical difference with levels of CRP between the two gpsbetween the two gps

Similar pattern of pain as measured by VAS Similar pattern of pain as measured by VAS and analgesic requirementsand analgesic requirements

ConclusionsConclusions

No difference in outcome for all end-points No difference in outcome for all end-points between those receiving NG and NJ feedsbetween those receiving NG and NJ feeds

Nasogastric feeding in patients with severe Nasogastric feeding in patients with severe pancreatitis is simpler and cheaperpancreatitis is simpler and cheaper

DiscussionDiscussion

Study design : non blinded randomised Study design : non blinded randomised prospective trialprospective trial

- small study 49 pts- small study 49 pts

- largest study looking at enteral feeding in - largest study looking at enteral feeding in severe pancreatitissevere pancreatitis

- non-blinded esp. to assessors – observer bias- non-blinded esp. to assessors – observer bias

Achieved aims in showing no difference between Achieved aims in showing no difference between two gps of patientstwo gps of patients

DiscussionDiscussion

ApplicabilityApplicability-advantage of NG feeds in minimising delay -advantage of NG feeds in minimising delay butbut time to commencement of feeds 72hrstime to commencement of feeds 72hrs

Timing and composition of feeds may be of equal Timing and composition of feeds may be of equal importance ?addition of probioticsimportance ?addition of probiotics

Novel question – larger studies neededNovel question – larger studies needed

The End