Hang Time for Enteral Formula

Lyman B, Gebhards S, Hensley C, Roberts C, San Pablo W. Safety of decanted enteral formula hung for 12 hours in a pediatric setting. Nutr Clin Prac. 2011;26:451-456.

Pancreatitis is often mild and self-limiting. However, in 20–30% of cases, it can cause systemic inflammatory distress syndrome (SIRS), multi-organ failure, and a mortality rate of 15–40%. In this “severe group,” pancreatitis is a very catabolic condition; therefore, nutrition support has been a cornerstone of therapy. The question always asked is how to “feed” the patient while “resting” the pancreas. Previous trials have demonstrated that enteral nutrition (EN) is superior to parenteral nutrition (PN) in the setting of acute pancreatitis because of reduced associated infectious complications and cost. This current study wanted to determine if the time to initiation of EN and the time to reach target nutrition goals impacted clinical outcomes in patients with severe acute pancreatitis (SAP).

A retrospective chart review was performed on 17 patients in an ICU with a diagnosis of SAP who were referred to a nutrition support team. These patients had at least one system in organ failure and an APACHE II score of >8. Patients were divided into 3 groups: A — never reached goal nutrition needs; B — reached goal nutrition needs after >3 days; and C— reached goal nutrition needs in <3 days. APACHE II scores were similar among the 3 groups. Nasojejunal (NJ) feeding tubes were placed endoscopically. Patients were fed using a semi-elemental tube feeding. ICU stay was significantly higher in group A (45.3 days) as compared to group B (19 days) and C (13 days) (p=.035). The percentage of patients with overall complications (e.g., sepsis, pancreatic necrosis, multiple organ failure) was similar among the 3 groups. The overall mortality rate was similar in the 3 groups (24%). There was a significant difference in the time to EN initiation between the survivors (8+/-3 days)(n=13) and non-survivors (17+/-13 days)(n=4) (p<.05) The average BMI in survivors was 34.2 and in non-survivors 44.8. Overall, it appears that patients with SAP benefit from early EN use by NJ feeding. Significantly obese patients appear to have reduced survival.

This study underscores the importance of early EN use in patients with SAP. These patients were able to get a NJ tube placed endoscopically in a time-efficient manner in order to begin EN therapy. In this patient group, severe obesity was associated with a decrease in survival. More work on obese patients is required to understand why this group has an increased incidence of death.

Glutamine as a Supplement to Parenteral Nutrition

Vaneck VW, Matarese LE, Robinson M, Sacks GS, Young LS, Kochevar M. A.S.P.E.N. position paper: parenteral nutrition glutamine supplementation. Nutr Clin Pract. 2011;26:479-494.

The A.S.P.E.N. Novel Nutrient Task Force examined the utility of glutamine in addition to parenteral nutrition (PN) for the hospitalized patient. Glutamine is the most common amino acid in the blood. During critical illness, the body becomes unable to produce enough glutamine to meet required needs.

Glutamine can be compounded into a PN solution as a free amino acid. However, because of its relative instability in this form, it must be added daily to the PN formulation. This requires a PN compounding center that has the resources and processes to complete this compounding with a physician’s order. Alternatively, glutamine dipeptides (L-alanyl L-glutamine and glycyl L-glutamine) are available in many locations outside of the U.S. These dipeptides are water- and heat-stable and have a shelf life of up to two years. When injected parenterally, these dipeptides are hydrolyzed to L-glutamine rapidly by peptidase, which is present in the vascular endothelium.

Using a PubMed search, the Task Force identified papers addressing parenteral glutamine. The recommendations of the Task Force were based on meta-analysis papers, published clinical guidelines, review articles, and a review of selected original articles when there was a discrepancy. Seventeen meta-analysis papers were found; seven were excluded for various reasons.

The Task Force determined that parenteral glutamine administration is associated with a decrease in infectious complications, a decrease in hospital length of stay, and possibly a decrease in mortality in critically ill, post-operative, or ventilator-dependent patients requiring PN. The heterogeneity of the populations in the studies, however, called for additional research to confirm the recommendations. The Task Force additionally pointed out that there may be a utility in positive blood culture reduction in bone marrow transplant patients with the use of parenteral glutamine. (There is not enough data to make recommendations in pediatric patients.) A dose of >.2 g/kg/day is suggested. There is no data to suggest that parenteral glutamine is harmful.