early enteral nutrition in acute pancreatitis

This patient has severe pancreatitis and has developed numerous complications from his disease, including acute respiratory failure from ARDS and acute renal failure. He has been stabilized over 2 days in the ICU and is now hemodynamically stable and improving from a respiratory standpoint. It is reasonable to consider a nutritional strategy for him at this time, as he is a few days into his disease course and is likely to be receiving ventilation for at least a few more days.

Numerous studies have demonstrated that patients with severe pancreatitis can be fed enterally without increasing complications or worsening outcomes. Given this patient’s alcohol use disorder, he is likely at increased risk for refeeding syndrome. Therefore, enteral nutrition should be started at a lower rate, with close monitoring of serum electrolyte levels, including potassium, phosphorus, and magnesium levels, during the first few days as nutritional support is increased to delivery of goal kilocalories.

Although some older guidelines recommend delaying nutritional support of patients who are critically ill for up to a week, continuing no nutritional support in this patient who may already have some malnutrition due to underlying severe alcohol use disorder beyond this fourth day of hospitalization will not improve outcomes and may worsen his malnutrition. In addition, numerous studies have demonstrated that keeping patients with pancreatitis NPO for longer than 3 days does not reduce complications or improve outcomes, whereas initiating enteral nutrition within the first 48 h may improve outcomes.

Initiating enteral nutrition at rates targeting daily goal kilocalorie delivery from the onset might be tolerated in some patients who are critically ill. However, this patient has pancreatitis and may be at higher risk for GI complications. In addition, this patient is at increased risk for refeeding syndrome. Both of these would favor starting enteral nutrition at a lower rate and increasing as tolerated.

Although more recent studies have suggested that a short duration of parenteral nutrition may result in outcomes similar to those seen with enteral nutrition in nonselected patients who are critically ill, enteral nutrition is still the preferred route in patients able to tolerate it. Total parenteral nutrition is more expensive and requires an indwelling central venous catheter for administration. In addition, studies have demonstrated worse outcomes for patients with severe pancreatitis when they are fed exclusively using parenteral compared with results in those receiving enteral nutrition. Parenteral nutrition is generally reserved for patients with pancreatitis who are unable to tolerate enteral nutrition.123456

Footnotes

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  3. Jablonska B, Mrowiec S. Nutritional support in patients with severe acute pancreatitis—current standards. Nutrients. 2021;13(5):1498. PubMed ↩

  4. Li JY, Yu T, Chen GC, et al. Enteral nutrition within 48 hours of admission improves clinical outcomes of acute pancreatitis by reducing complications: a meta-analysis. PLoS One. 2013;8(6):e64926. PubMed ↩

  5. Mirtallo JM, Forbes A, McClave SA, et al; International Consensus Guideline Committee Pancreatitis Task Force. International consensus guidelines for nutrition therapy in pancreatitis. JPEN J Parenter Enteral Nutr. 2012;36(3):284-291. PubMed ↩

  6. Taylor BE, McClave SA, Martindale RG, et al; Society of Critical Care Medicine; American Society of Parenteral and Enteral Nutrition. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Crit Care Med. 2016;44(2):390-438. PubMed ↩