Improvement of the algotithm of enteral nutrition in patients with a severe course of acute pancreatitis

Abstract

Acute pancreatitis is a common disease that accounts for 5-10% of urgent pathologies of the abdominal cavity [1]. In the case of severe acute pancreatitis, the early start of enteral nutrition (24-72 hours from the moment of hospitalization) by means of nasogastric or nasojejunal administration of the mixture is considered appropriate, which is associated with a 24% decrease in the frequency of infectious complications and a 32% decrease in mortality [2]. However, 30.5-65.7% of patients may develop intolerance to this type of nutritional support [3]. The aim of the study was to improve the results of treatment of patients with severe acute pancreatitis by improving enteral nutrition technologies. Materials and methods. There were 101 patients with severe acute pancreatitis took part in the study, who were divided into the main group, where enteral nutrition was carried out according to the improved protocol - 34 patients, comparison group No.1, where standard nasogastric nutrition was carried out - 34 patients, and comparison group No.2, where standard enteral nutrition – 33 patients. The local protocol for enteral nutrition in patients with severe acute pancreatitis developed in the clinic was based on own research and recommendations of the European Society of Clinical Nutrition and Metabolism (ESPEN) [4] and included the following provisions: - in patients with a severe course of acute pancreatitis, enteral nutrition is preferred compared to parenteral, while it should be started 48 hours after the start of treatment with a preliminary determination of the state of recovery of intestinal absorption by using a test with a 3% solution of potassium iodide; - contraindications to the start of enteral nutrition are uncontrolled shock, hypoxemia, acidosis, gastrointestinal bleeding from the upper parts of the digestive tract, secretion of stagnant gastric contents in the amount of >500 ml/6 h, ischemic damage to the small intestine, intestinal obstruction, abdominal compartment syndrome; - enteral nutrition should be started with nasogastric administration of the mixture, and in case of complications, use nasojejunal administration; - with an increase in intra-abdominal pressure >15 mm Hg. preference is given to nasojejunal administration of feeding mixtures at a rate of 20 ml/h, and with intra-abdominal pressure >20 mm Hg. enteral nutrition should be stopped and parenteral nutrition should be started; - nutrition begins with drip administration of a glucose-electrolyte solution through a probe at a rate of 100 ml/hour, followed by control after 2 hours by the method of passive or active aspiration for 15 minutes. If the volume of the residual liquid exceeds 100 ml - the probe is used for decompression and injection of the solution in the lavage mode in the previous time mode. In the presence of a smaller amount of residual fluid - the volume of infusion increases by 50% with further monitoring every 3-4 hours; - on the second day of therapy, the introduction into the probe of a 20% solution of an oligomeric (elemental or semi-elemental) mixture for enteral nutrition in the volume of up to 300 ml/day (1 kcal in 1 ml) with the introduction of simethicone emulsion in a dose of 2 ml (80 mg) is additionally prescribed 3- 5 times a day; - in the absence of complications associated with the use of oligomeric mixtures, their number increases by 2 times the next day (the rate of administration does not change). In case of complications, the rate of introduction of the mixture should be reduced by 2 times. In case of persistent intestinal dyspepsia, it is necessary to temporarily (for 12-24 hours) return to the introduction of only glucose-electrolyte solution; - starting from the third day, ⅔ of the injected volume can be polymer mixtures, while the amount of nutritional support for patients for 5–6 days should be 20–25 kcal/kg and protein 1–1.2 g/kg per day (nitrogen-conserving effect in the first three days, it is achieved by parenteral administration of 150 g/day of 10% glucose solution and 25-50 g/day of lipids in the form of 10-20% fat emulsions), in case of persistent hyperglycemia over 10 mmol/l, specialized polymer mixtures should be used; - removal of probes and transition to oral fractional use of mixtures for enteral nutrition by the sipping method (more often it is 6-7 days), as well as the subsequent transition to a gentle medical diet is possible in the absence of signs of gastroduodenostasis, enteropathy and amylasemia, elimination of endotoxicosis phenomena, stabilization of the patient's condition, presence of appetite, preservation of swallowing function. The effectiveness of enteral nutrition in the studied groups was evaluated by analyzing and comparing biochemical indicators of blood serum, frequency of intolerance to nutritional support, infected local complications, mortality, duration of multiple organ failure and stay of patients in the hospital. Results of the research. When using the proposed protocol of enteral nutrition in patients with a severe course of acute pancreatitis, 14 days after the start of treatment, a significant difference was obtained between the content of albumin, creatinine, cholesterol and K+ blood serum (p<0.05) between patients of the main group and the comparison groups , as well as the content of Na+ in blood serum (p<0.05) between patients of the main group and the group of standard nasogastric tube feeding. Application of the proposed protocol of enteral nutrition significantly reduces the frequency of intolerance of nutritional support in the first 7 days of treatment by 23.6% (χ2=5.7, 95% CI 4.41-41.56, p=0.01) compared to the control group patients, where standard nasogastric tube feeding is used, by 21.5% (χ2=4.87, 95% CI 2.34-39.48, p=0.02) compared to the group of standard enteral tube feeding, as well as the duration of multiple organ failure from 12.2±1.7 days to 10.5±1.9 days in comparison with the group of patients where standard nasogastric tube feeding was used (p=0.0002) and from 11.5±1.9 days to 10.5±1.9 days compared to the group of standard enteral tube feeding (p=0.03). Conclusions. Determination of the terms of recovery of intestinal absorption is one of the main criteria for the initiation of enteral nutrition in patients with severe acute pancreatitis. The use of the proposed technology of enteral nutrition in patients with a severe course of acute pancreatitis improves treatment results by reducing the duration of multiple organ failure and the frequency of intolerance to this type of nutritional support. References: 1. Petrov MS, Yadav D. Global epidemiology and holistic prevention of pancreatitis. Nat Rev Gastroenterol Hepatol. 2019 Mar;16(3):175-184. doi: 10.1038/s41575-018-0087-5 2. Purschke B, Bolm L, Meyer MN, Sato H. Interventional strategies in infected necrotizing pancreatitis: Indications, timing, and outcomes. World J Gastroenterol. 2022 Jul 21;28(27):3383-3397. doi: 10.3748/wjg.v28.i27.3383 3. Kolosovych I, Hanol I. Evaluation of the efficiency of nasogastral nutrition in patients with severe acute pancreatitis. Med. Sci. of Ukr. [Internet]. 2022Jun.30;18(2):10-6. https://doi.org/10.32345/2664-4738.2.2022.02 4. Cañamares-Orbís P, García-Rayado G, Alfaro-Almajano E. Nutritional Support in Pancreatic Diseases. Nutrients. 2022 Oct 31;14(21):4570. doi: 10.3390/nu14214570