胰腺炎胃管课件.ppt

1、Nasogastric or NasojejunalAbstractNasojejunal tube feeding is considered the current standard of care in patients with severe and critical acute pancreatitis.However,it is not known whether enteral nutrition is best delivered into the jejunum.This Commentary discusses recent clinical studies that ha

2、ve shown that tube feeding into the stomach is safe and well tolerated in the vast majority of patients with acute pancreatitis,thus overthrowing the notion of putting the pancreas at rest.Development of a new conceptual framework is warranted to further advance nutritional management of patients wi

3、th acute pancreatitis.backThe study by Chang and colleagues 1 adds an important perspective to the discussion regarding the pancreatic rest concept,which is perhaps the oldest dogma in the management of AP.The central tenet of this concept is that enteral nutrition delivered into any part of the upp

4、er gastrointestinal tract other than the jejunum stimulates pancreatic secretion and,consequently,exacerbates the severity of AP.backThe corollary is that non-stimulatory nutrition had been widely advocated,being total parenteral nutrition two to three decades ago and nasojejunal tube feeding in the

5、 past decade.That is why the majority of randomised controlled trials in the past studied non-stimulatory regimens as both intervention and comparator,that is,either parenteral nutrition versus nil peros,or parenteral nutrition versusjejunal tube feeding,or jejunal tube feeding versus nil peros 7,8.

6、Definitions of the four severity categoriesThe recent international multidisciplinary classification of AP has redefined the severe category of severity and introduced the new critical category of severity(Table 1),thus putting a high emphasis on the need to optimise manage ment of these most challe

7、nging patients.(Peri)pancreatic necrosis is:1.nonviable tissue located in the pancreas alone,2.or in the pancreas and peripancreatic tissues,3.or in peripancreatic tissues alone.It can be solid or semisolid(partially liquefied)and is without a radiologically defined wall.Sterile(peri)pancreatic necr

8、osis is the absence of proven infection in necrosis.Definitions of the four severity categoriesInfected(peri)pancreatic necrosis is defined when at least one of the following is present:1.gas bubbles within(peri)pancreatic necrosis on computed tomography;2.a positive culture of(peri)pancreatic necro

9、sis obtained by image guided fine-needle aspiration;3.a positive culture of(peri)pancreatic necrosis obtained during the first drainage and/or necrosectomy.Organ failure is defined for three organ systems(cardiovascular,renal,and respiratory)on the basis of the worst measurement over a 24-hour perio

10、d.In patients without pre-existing organ dysfunction,organ failure is defined as either a score of 2 or more in the assessed organ system using the SOFA(Sepsis-related Organ Failure Assessment)score or when the relevant threshold is breached,as shown:Cardiovascular,need for inotropic agent;Renal,cre

11、atinine 171 mol/L(2.0 mg/dl);Respiratory,PaO2/FiO2(partial pressure of oxygen/fractional inspired oxygen concentration)300 mmHg(40 kPa).Definitions of the four severity categoriesPersistent organ failure is the evidence of organ failure in the same organ system for 48 hours or more.Transient organ f

12、ailure is the evidence of organ failure in the same organ system for less than 48 hours.Definitions of the four severity categoriesThe systematic literature review has appraised the current best evidence regarding the use of nasogastric tube feeding(presumed to be stimulatory)in patients with AP.It

13、demonstrates that the evidence base is(still)relatively small but does show that enteral nutrition given via the nasogastric route is well tolerated in more than 90%of patients with AP 9-11.NewIn line with the previous systematic review 2,it shows no statistically significant difference between non-

14、stimulatory and stimulatory regimens in terms of morbidity and mortality.The new,and somewhat surprising,finding here is that both routes of enteral feeding appear to be equivalent in terms of delivery of target calories.NewThere are two possible explanations for the observed results.First,tube feed

15、ing into the stomach might have been non-stimulatory in patients with AP.Unfortunately,little is known about the secretory response of the pancreas during the acute phase of clinical AP,let alone the effect of feeding on it 12.But a study in healthy volunteers demonstrated that both oral and duodena

16、l tube feeding stimulate pancreatic enzyme secretion in comparison with placebo 13.Moreover,the degree of pancreatic stimulation is very similar between oral and duodenal tube feeding.Second,tube feeding into the stomach might have stimulated the pancreas in patients with AP but it has no clinical r

17、amifications,essentially meaning that the concept of pancreatic rest might have been fallacious.Although it has become deeply entrenched in the management of AP,it is worth noting that the pancreatic rest concept was never proven in randomised controlled trials.Moreover,the recent MIMOSA(MIld to MOd

18、erate acute pancreatitis:early naSogastric tube feeding compared with pAncreatic rest)trial compared in a randomized fashion early nasogastric tube feeding(commenced within 24 hours after hospital admission)with nil peros and found that nasogasric feeding does not exacerbate the course of AP and eve

19、n reduces the risk of oral food intolerance 14.Similarly,an earlier randomised controlled trial compared early nasogastric tube feeding(commenced within 24 hours after hospital admission)with parenteral nutrition and found no diff erence between non-stimulatory and stimulatory regimens 15.In conclus

20、ion,accumulating evidence indicates that the site of enteral tube feeding does not affect major clinical outcomes in patients with AP.Given that tube feeding into the stomach is more practical than into the jejunum in the majority of clinical settings,it should be considered as the first-line approa

21、ch for patients with severe and critical AP.The pancreatic rest concept can now be put to rest.There is a need and justification for developing a contemporary conceptual framework concerning nutritional management of AP.AbstractIntroduction:Enteral feeding can be given either through the nasogastric

22、 or the nasojejunal route.Studies have shown that nasojejunal tube placement is cumbersome and that nasogastric feeding is an effective means of providing enteral nutrition.However,the concern that nasogastric feeding increases the chance of aspiration pneumonitis and exacerbates acute pancreatitis

23、by stimulating pancreatic secretion has prevented it being established as a standard of care.We aimed to evaluate the differences in safety and tolerance between nasogastric and nasojejunal feeding by assessing the impact of the two approaches on the incidence of mortality,tracheal aspiration,diarrh

24、ea,exacerbation of pain,and meeting the energy balance in patients with severe acute pancreatitis.Method:We searched the electronic databases of the Cochrane Central Register of Controlled Trials,PubMed,and EMBASE.We included prospective randomized controlled trials comparing nasogastric and nasojej

25、unal feeding in patients with predicted severe acute pancreatitis.Two reviewers assessed the quality of each study and collected data independently.Disagreements were resolved by discussion among the two reviewers and any of the other authors of the paper.We performed a meta analysis and reported su

26、mmary estimates of outcomes as Risk Ratio(RR)with 95%confidence intervals(CIs).Results:We included three randomized controlled trials involving a total of 157 patients.The demographics of the patients in the nasogastric and nasojejunal feeding groups were comparable.Nasogastric feeding was not infer

27、ior to nasojejunal feeding.There were no significant differences in the incidence of mortality(RR=0.69,95%CI:0.37 to 1.29,P=0.25);tracheal aspiration(RR=0.46,95%CI:0.14 to 1.53,P=0.20);diarrhea(RR=1.43,95%CI:0.59 to 3.45,P=0.43);exacerbation of pain(RR=0.94,95%CI:0.32 to 2.70,P=0.90);and meeting ene

28、rgy balance(RR=1.00,95%CI:0.92 to 1.09,P=0.97)between the two groupsConclusions:Nasogastric feeding is safe and well tolerated compared with nasojejunal feeding.Study limitations included a small total sample size among others.More high-quality large-scale randomized controlled trials are needed to

29、validate the use of nasogastric feeding instead of nasojejunal feeding.(Pancreas 2012;41:153Y159)Objective:This study aimed to determine the noninferiority of early enteral feeding through nasogastric(NG)compared to nasojejunal(NJ)route on infectious complications in patients with severe acute pancr

30、eatitis(SAP).Methods:Patients with SAP were fed via NG(candidate)or NJ(comparative)route.The primary outcome was the occurrence of any infectious complication in blood,pancreatic tissue,bile,or tracheal aspirate.Secondary end points were pain in refeeding,duration of hospital stay,intestinal permeab

31、ility assessed by lactulose/mannitol excretion,and endotoxemia assessed by endotoxin core antibody types immunoglobulin G and M.Results:Seventy-eight patients were randomized to feeding by either the NG or the NJ route.During the hospital stay,the presence of any infectious complication in the NG an

32、d NJ groups was 23.1%and 35.9%(significantly different),respectively.The effect size of the difference of infectious complications was j12.8(95%confidence interval,j29.6 to 4.0).The upper limit of the 95%confidence interval was 4.0 and was within the 5%limit set for noninferiority.The value of 8.0 f

33、or the number needed to treat implies that 8 patients should be treated with NG compared with the NJ group to prevent 1 patient from any of the infectious complications.Conclusions:Early enteral feeding through NG was not inferior to NJ in patients with SAP.Infectious complications were within the noninferiority limit.Pain in refeeding,intestinal permeability,and endotoxemia were comparable in both groups.