胰腺炎的营养治疗课件

1、Nutrition in Acute Pancreatitis“An Evidence Based Approach” Which patients benefits from nutritional support in acute pancreatitis? All patients with acute pancreatitis? (Mild pancreatitis is different from severe pancreatitis) Enteral or parenteral?Where is the evidence?Severity (Clinical, laborato

2、ry and radiological signs)Nutritional status Outcome predictors- Mild form (80%)- Severe form (20%)Severity assesmentMild form (80%)- Ranson signs 3- CRP 3- CRP 120 mg/l- APACHE II score 8- Balthazars-CT-score 3 1068 patients, mean age 52.8 yrs, 589 edematous AP, 479 severe APMORTALITY: total 7.8%,

3、mild aP 1%, severe aP 16.1%Severity and outcomeMortality can increase to up to 40% if sepsis and MOF occurESPEN GuidelinesEnteral Nutrition:Clinical Nutrition Vol 25 (2), April 2006Parenteral Nutrition: Clinical Nutrition Vol 28, July 2009 /education/ guidelines.htm Severity of acute pancreatitis ca

4、n be assessed adequatelyFor artificial nutritional interventions mild pancreatitis has to be separated from severe pancreatitisNutritional status has to be assessed on admission and during the course of the diseaseRecommentation IMain goals for nutrition in acute pancreatitisTo provide calories with

5、 EN or PN to reverse protein catabolism without stimulation of the exocrine pancreatic secretionTo improve or to avoid nutritional depletionTo reduce morbidity and mortality How should nutritional support be done?Parenteral or enteral? Gastral or jejunal?EN vs PN and acute pancreatitisMild to modera

6、te pancreatitisEarly EN (ED, NJ) vs PNPRCT N=32 EN PN n = 16 n = 16Caloric goal (day 4) 72% 86%Days to normal amylase 4.8 0.6 6.8 1.5Days to diet by mouth 5.6 0. 7.1 1.1LOH (days) 9.7 1.3 11.9 2.6Lengh of ICU stay (days) 1.3 0.9 2.8 1.3% Nosocomial infection 12.5 8.5 12.5 8.5Mortality (%) 0.0 0.0Cos

7、t (US$) 761 50.3 3294 551.9*McClave et al, JPEN, 1997 * p 0.05 Is the situation differentin mild to moderate or severe pancreatitis?EN vs PN and acute pancreatitis Severe pancreatitisEN (SED, NJ) vs PNPRCTN=38 EN PN n = 18 n = 20LOH (d) 40 (25-83) 39(22-73)LOICU (d) 10 (5-21) 12 (5-24)Complication -

8、septic (Tot.nb) 5 (6) 10 (15)*- Hyperglycaemia 4 9- Pancr. necrosis 1 4Pneumonia 2 4Costs 3 times higherKalfarentzos et al, B J Surg, 1997EN vs PN and acute pancreatitisSevere pancreatitis EN (NJ Hypocaloric) vs PNPRCTN=156Enroled patients87% mild10% moderate 3% severe 75% improved on 48h bowel rest

9、 and iv. fluids discharged within 4 days Rest randomized to jejunal EN or PNAbou-Assi, et al, Am J Gastroenterology, 2002Results of the randomized patients n = 27 n = 26Ransons Criteria 2.5 (0.5) 3.1 (0.6)Nutr. Goal 88%* 54%Hyperglycemia (MOF) 14 pt.* (8) 4 pt.(7)Catheter Sepsis 9 pt.* 1 pt.Death 6

10、pt. 8 pt.Duration of feeding (d) 10.8* 6.7Hosp. Days 18.4 (2.9)* 15.2 (2.6)Hosp. Costs (US dollar) lower in EN (saving 2360.-)*p 195 mg/L107 Patients 54 TPN 115 kJ/KG/d 1,2 g N 250 ml 20% Intralipid 53 TEN 115 kJ/KG/d 1,5 g N Survimed jejunalAPACHE II 16 4CRP 218 8 APACHE II 14 2CRP 211 9 Wu et al,

11、Pancreas 2010EN vs PN and severe acute pancreatitisWu et al, Pancreas 2010EN vs PN and severe acute pancreatitis Enteral nutrition (N= 25)TPN(N=25)P valueInfection 16 (64.0%) 15 (60.0%)1.000ICU stay (days; median and range) 10 (0-44) 15 (0-60)0.625Hospital stay (days; median and range) 42 (15-108) 3

12、6 (20-77)0.755Mortality 5 (20.0%) 4 (16.0%)1.000Doley et al, J Pancreas 2009EN vs PN in acute pancreatitisOlah et al, Langenbecks Arch Surg 2010847 patients16 RCTRecommendation IIThere is no evidence that neither EN or PN has a clinical beneficial effect on clinical outcome in patients with mild pan

13、creatitis, if you can predict that the patient can consume normal food in between 5 days (A)If oral nutrition is not possible in 5 days enteral nutrition should be started immetiately (C) If this is true in patients with malnutrition is not known ESPEN, Guidelines 2006/2009Treatment mild pancreatiti

14、sAssessment of severity of acute pancreatitismild to moderatefasting (2-5 days) analgesics i.v. fluid/electrolytesno pain, enzymesrefeeding (3-7 days) diet rich in CH diet moderate in protein/fatnormal dietRecommendation IIINutritional support in essential in patients with severe disease and nutriti

15、onal risk factors (A)The route of nutrient delivery (parenteral/enteral) should be determined by the patient toleranceEN should be attempted in all patients first (C)Intakes should be monitored carefully to ensure adequate nutritional supportWhen enteral nutrition is not sufficient combine it with P

16、N (C)ESPEN, Guidelines 2006/2009Treatment severe pancreatitisAssessment of severity of acute pancreatitissevereearly continuous enteral nutrition (naso-jejunal tube) elemental diet or polymeric diet or immune-enhancing diet?enteral nutrition is not possibleadd parenteral nutrition- all in one - or s

17、ingle component solutions (CH, protein (AS), fat) TPN and continuous small amount of an enteral diet (10-30 ml/h) perfused to the jejunumnutritional goal not reached Recommendation IVPatients with severe disease, complications or theneed for surgery require early nutritional support toprevent the ad

18、verse effects of nutrient deprivationContinous early enteral jejunal feeding over 24h is recommended (A)When side effects occur or the caloric goal can not be achieved, PN should be combined with EN (C)How nutrients should be applied?4 trials showed that jejunal tubes are well toleratedthere was no

19、exacerbation of pancreatitis-related symptomsMcClave, JPEN, 1997Cravo, Clin Nutr, 1989Kudsk, Nutr Clin Pract, 1990Nakad, Pancreas, 1998Nasogastric or nasojejunal feeding in patients with severe pancreatitis?Nasogastric vs nasojejunal feeding in patients with acute pancreatitisPetrow et al, JOP 2008N

20、utritional intolerancePain exazerbationNasogastric vs nasojejunal feeding in patients with acute pancreatitisPetrow et al, JOP 2008DiarrheaMortalityNasogastric vs nasojejunal feeding in patients with acute pancreatitisPetrow et al, JOP 2008; 9(4):440-448.Recommendation VJejunal tube placement is saf

21、e and well tolerated (C)If nasogastric tube feeding is a useful and practical approach can not be answered up to now!Which formula should be used? Elemental, semielemental, polymeric, or immunenhancing (Arg, RNA, n-3-FA, Glu) Enteral diet with pre- or probiotics TPN and glutamine and or n-3-FAThere

22、is no clear consensus about the preferred formula but most trials were performed with semielemental dietsTiengou et al, JPEN, 2006 Semielemental vs polymeric diet in acute pancreatitisEN (immunmodulating) vs EN (standard) HospitalICUMortalityNStayStayEN (Arg/Glu)27.2 d* 8.6 d* 22.2%vs 1)16EN (STD)38

23、.4 d34.8 d 28.6%EN (n-3-FA)13.1 d * 7.1%vs 2)28EN (STD)19.3 d 14.2%* p 0.051) Hallay et al, Hepatogastroenterol, 20012) Lasztity et al, Clin Nutr, 2005Algorythm for using enteral formulaSevere acute pancreatitisGI-function NormalGI-function ImpairedPolymeric dietElemental- or semielemental dietGI-fu

24、nction ImpairedElemental- or semielemental diatGI-function NormalPolymeric dietSynbiotics* in severe pancreatitis Incidence of infected necrosis and abscess 4.5 30.4% (p 0.02) LOHS 13.7 21.4 d (ns) Need for re-surgery 1 7 (p 0.02)Olah et al, Br J Surg 2002Enteral nutrition with 10g oat fibre (-gluca

25、n) and Lactobacillus plantarum 299, 109Rand, db, controlled trial (N = 45), 1 week*ProbioProbiotics Control pSynbiotics* in severe pancreatitis Probiotics Control p MOF 15% 31% sig Septic complicatios 27% 52% ns LOHS (d) 15 20 ns Need for surgery 12% 24% ns Mortality 6% 21% nsOlah et al, Hepatogastr

26、oenterol 2007Enteral nutrition with 10g -glucan, inulin, pectin, resistant starch and Lb plantarum 299, pediacoccus, leuconostoc, paracasei, 1010 Rand, db, controlled trial (N = 62), 1 week*Synbiotic 2000Synbiotics* in severe acute pancreatitis Probiotics Placebo N=152 N=144 Infectious compl. 30% 28

27、% Bowel ischaemia (N) 9* 0 Mortality 24 (16%)* 9 (6%)Multifibre diet plus and cornstarch, maltodextrin Besselink et al, Lancet 2008 and 4 Lactobacilli, 2 Bifidobacteria 1010, twice dailyRand, db, placebo-controled trial, N= 298, 4 weeks*Ecolocgic 641(*/* sig)Comparison of the 3 studies using probiot

28、ics in acute pancreatitis Olah 2002Olah 2007Besselink 2008ProbioControlSynbioticControlEcologicControl(n = 22)(n = 23)(n = 33)(n = 29)(n = 152)(n = 144) BaselineAPACHE II8.99.411.710.48.68.4Imrie Scores2.52.82.93.13.33.4Mean CRP 206188216191268270% Alcohol59%70%60%62%18%19% Necrosis41%48%60%62%30%24

29、%Age44.146.547.546.060.459.9What went wrong?Aggressive enteral Nutrition (30kcal/Tag)Patients with vasoactive treatmentMultifibre diet plus prebiotics (30g fibre/day)6 probiotic strains (2x/day 1010)- For the first time Bifidobacteria)Fermentation distension ischaemia?PN (immunmodulating) vs PN (sta

30、ndard)GlutamineN- 3 fatty acidsMcClave et al, JPEN, 2006Acute pancreatitisGlutamine vs standard PNComplicationsRR 0.68CI: 0.42-1.09p= 0.11Acute pancreatitisGlutamine vs standard PN3 further randomized controlled trials Significant reduction of complications (N=40) Significant reduction of mortality

31、Sahin et al, Eur J Cin Nutr 2007 Significant reduction of complications (N= 44) Fuentes-Orozco et al, JEPN 2008 Significant reduction in the length of organ failure N=76) Reduction of infection (early vs late) 8 vs 23% Reduction of surgery (early vs late) 13 vs 43% Reduction of mortality (early vs l

32、ate) 5 vs 21% Xue et al, W J Gastroenterol 2008 N-3-FA in TPN in patients with severe acute pancreatitisN=40ControlN-3-FA SIRS ratio9/204/20ARDS ratio5/204/20Infectious complication, n5/203/20Renal dysfunction, n2/201/20CRRT, days263.4 182.3ICU, days27.55.621.44.2Length of hospital stay, days70.59.165.27.3Wang et al, JPEN 2008Prospective, randomized, double-blind study, PN over 5 daysN-3-FA in TPN in patients with severe acute pancreatitisPatients supplemented with fish oilhad significantly lower CRP levels after 5 days of parentera