This article was downloaded by: [ECU Libraries] On: 23 April 2015, At: 04:58 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of the American College of Nutrition Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uacn20
Total parenteral nutrition in severe acute pancreatitis. a
a
a
a
F E Kalfarentzos , D D Karavias , T M Karatzas , B A Alevizatos & J A Androulakis
a
a
Department of Surgery, Medical School, University of Patras, Greece. Published online: 02 Sep 2013.
To cite this article: F E Kalfarentzos, D D Karavias, T M Karatzas, B A Alevizatos & J A Androulakis (1991) Total parenteral nutrition in severe acute pancreatitis., Journal of the American College of Nutrition, 10:2, 156-162, DOI: 10.1080/07315724.1991.10718140 To link to this article: http://dx.doi.org/10.1080/07315724.1991.10718140
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Total Parenteral Nutrition in Severe Acute Pancreatitis Fotis E. Kalfarentzos, MD, Dionissios D. Karavias, MD, Theodoros M. Karatzas, MD, Bassilios A. Alevizatos, MD, and John A. Androulakis, MD, FACS Department of Surgery, Medical School, University ofPatras, Patras, Greece
Downloaded by [ECU Libraries] at 04:58 23 April 2015
Key words: acute pancreatitis, artificial nutrition, pancreatic complications The influence of total parenteral nutrition (TPN) was studied in 67 patients with severe acute pancreatitis having three or more criteria according to Ranson (mean ± SD = 3.8 ± 0.21). Although TPN has been reported to not be of benefit in the progress and severity of the disease, we have found that the time TPN is started is important in influencing the course of the disease and in the development of local complications, as well as in the mortality rate. Patients whose TPN was started within the first 72 hours of the disease had a 23.6% complication rate and 13% mortality, in comparison with patients whose TPN was started later in the course of the disease, who had a 95.6% complication rate (p < 0.01) and a mortality rate of 38% (p < 0.03). The nutritional status of the patients during TPN administration of 28.4 days was maintained either steady or was improved, as assessed by nitrogen balance, serum levels of transferrin (p < 0.05), and albumin (p < 0.05). The administration of fat solution, either to prevent essential fatty acid deficiency or to provide part of the caloric requirements, was found to cause neither clinical nor laboratory worsening of the disease. All pancreatic fistulae that developed during the course of the disease spontaneously closed in patients receiving TPN without operation in a mean period of 33.3 days, and all pseudocysts subsided in an average of 18.3 days. Those who died (overall mortality rate 24%) had had uncontrollable sepsis, which resulted in hypercatabolism and multiple system organ failure. An increased incidence of catheter-related sepsis was observed (rate = 8.9%), which was significantly higher than the rate occurring (2.9%, p < 0.01) in other patients receiving TPN in our unit, during the same period. Finally, 88% of the patients developed hyperglycemia and required an average of 46 U/day of insulin to keep blood glucose at satisfactory levels. Thus, TPN was demonstrated to be safe, effective, and well tolerated by patients with severe acute pancreatitis. Abbreviations: Ca = calcium, IV = intravenous, K = potassium, Mg = mag nesium, N = nitrogen, P = phosphorus, TGs = triglycérides, TPN = total parenteral nutrition
INTRODUCTION Severe acute pancreatitis is accompanied by increased resting energy requirements and considerable loss of protein mass, resulting from metabolic effects of the in flammatory response following necrosis or inflammation of the retroperitoneal tissues [1,2]. In addition, ab dominal pain, nausea, vomiting, abdominal distension, and malabsorption due to decreased exocrine pancreatic function lead to reduced or absent oral food intake [3]. The combination of the above factors in severe acute
pancreatitis, which is often associated with complica tions such as tissue necrosis, abscesses, pseudocysts, and fistulae, leads to a large loss of skeletal muscle mass. The loss of function and of structural integrity of vital organs which follows contributes to high morbidity and mortality [3,4]. The effect of TPN on the therapeutic management of severe acute pancreatitis has been evaluated in several studies [5-8]. Presented here is a study of 67 patients with severe acute pancreatitis who were treated with TPN in the surgical unit of the Univer sity of Patras over a period of 8 years. The influence of
This manuscript was presented at the Congress of Parenteral and Enterai Nutrition (ESPEN) in Helsinki, Finland, September 1989. Address reprint requests to Dr. T. Karatzas, University ofPatras, Medical School, Department of Surgery, Patras, Greece.
Journal of the American College of Nutrition, Vol. 10, No. 2, 156-162 (1991) © 1991 John Wiley & Sons, Inc.
CCC 0731-5724/91/020156-07$04.00
Parenteral Nutrition and Pancreatitis Table 1. Summary Data from 67 Patients with Severe Acute Pancreatitis: Character!!sties and Etiology Characteristics Age Male/female ratio Average no. of Ranson's criteria [3,9] Etiology Alcohol Cholelithiasis Hypertriglyceridemia
Downloaded by [ECU Libraries] at 04:58 23 April 2015
Trauma Idiopathic
TPN on the nutritional status of the patients, on the dis ease process, and on the development of complications was studied prospectively.
MATERIALS AND METHODS From 1981 to 1989, all patients with severe acute pancreatitis who were treated in our unit (total of 67) were included in this study. The collection of data was based on a previously well-defined protocol [3]. The criterion for diagnosis of severe acute pancreatitis was the presence of three or more criteria from Ranson's classification [9] (Table 1). All patients had severe clini cal symptomatology and required intensive monitoring for more than 48 hours. Patients with less than three criteria were excluded from the study. The confirmation of diagnosis of acute pancreatitis was based on: (a) his tory of cholelithiasis or alcohol intake, (b) typical symptomatology of acute pancreatitis, (c) laboratory findings including serum amylase, Ca, bilirubin, transaminases (SGOT and SGPT), white count, and triglycérides (TGs), (d) radiologie findings with the use of ultrasound, CT scanning, and X-rays of chest and ab domen, and (e) operative or postmortem findings. The diagnosis of severe acute pancreatitis was considered definitive when the CT scan findings agreed with the clinical picture and the laboratory findings. The age, sex, underlying disease process, and severity of the disease (on the basis of Ranson's criteria) are reported in Table 1. All patients received TPN through the subclavian polyurethane catheter. A mean of 1.4 TPN catheters/patient were placed aseptically for an average of 23.4 days in both groups. Patients received TPN
JOURNAL OF THE AMERICAN COLLEGE OF NUTR]
57.8 ± 2 25:42 3.8 ± 0.21
2 (3%) 57 (85%) 2 (3%) 3 (4.5%) 3 (4.5%)
within the first 72 hours (group A = 38) or later (group B = 29) on the basis of clinical criteria. Group A patients achieved hemodynamic stability soon after TPN was in stituted. The average of TPN administration was 28.4 days in both groups. Regular catheter care and change of the dressing were performed by a trained sister twice a week. All patients were initially infused at a rate of 40 ml/hr; in 2-3 days it was increased to the level of caloric and protein requirements, calculated according to the Harris-Benedict equation and the stress factors described by Long et al [10,11]. The administered protein intake ranged from 1.5 to 2.5 g/kg/day according to severity of stress and state of hepatic and renal function. A 10% lipid solution in a 300 ml volume twice a week was given to patients without hypertriglyceridemia to prevent fatty acid deficiency. Patients who had increased levels of hepatic enzymes, respiratory deficiency requiring mechanical ventilatory support, and/or with hyperglyceridemia that was difficult to control received IV lipid daily for a period depending on need, either con tinuously or at intervals, with concomitant reduction of glucose in the TPN solution of 15-20%. Thus, 20 to 30% of the nonprotein calories was provided from fat. Blood glucose levels were closely monitored and insulin was given to maintain glucose levels below 200 mg/dl. Serum electrolytes and liver function tests (bilirubin, alkaline, phosphatase, yGT, SGOT, and SGPT), serum amylase, TGs, and total lipids were measured daily until biochemical stability was achieved, and subsequently twice a week. Abdominal ultrasound, CT scanning, and X-rays were performed at intervals. Blood gases were measured on admission and every 8 hours the first 3 days, and consequently as clinically indicated.
157
Parenteral Nutrition and Pancreatitis Table 2. Complications — Mortality Number of patients
Downloaded by [ECU Libraries] at 04:58 23 April 2015
A. Total parenteral nutrition-related complications 1. Major complications from CVP line catheter (a) Pneumothorax (b) Central vein thrombosis (c) Catheter sepsis 2. Minor complications from CVP line catheter (a) Puncture of subclavian artery (b) Intravascular displacement of central catheter 3. Major metabolic complications (a) Hyperglycemia 4. Minor metabolic complications (a) Liver enzyme disorders B. Complications from acute pancreatitis (a) Respiratory failure required mechanical support (b) Renal failure required hemodialysis (c) Pancreatic or peripancreatic necrosis with positive or negative culture (d) Abscess formation (e) Pseudocysts (f) Pancreatic fistulae C. Mortality (a) Uncontrollable sepsis
The success of nutritional support was determined by weight gain, levels on serum transferrin and albumin, and a positive nitrogen (N) balance. Urine N was calcu lated by the micro-Kjeldahl method in an aliquot of 24hr urine collection. The patients took no food by mouth; N losses from skin and feces were minimal. All patients were routinely treated for acute pancreatitis, which in cluded IV fluids to restore and maintain intravascular volume and meet electrolyte requirements — in par ticular, Ca, Mg, and P. Eight patients required mechani cal support of respiration for an average of 6.2 days. Three patients required hemodialysis. Analgesic drugs were given as required to all patients, and an H2 blocker (ranitidine 150 mg twice/day) was given to reduce pancreatic secretion and to prevent stress ulcers. A nasogastric tube was inserted in 65 patients, as needed, to keep the stomach empty. Antibiotics were used as required to manage proved infection. Surgical interven tion was performed before or during TPN to remove necrotic tissue, whether or not sepsis and abscess forma tion existed. A total of 18 operations were performed in
158
2 1 6 2 3
59 14
3 9 5 6 6 16
14 patients. Cholelithiasis was treated surgically when the acute disease was resolved. The complications occurring during the course of the disease were monitored and classified: (a) those related to central catheter sepsis due to administration of parenteral nutrition and (b) those due to acute pancreatitis (Table 2). The mortality rate and its cause were recorded. Statistical differences between the two groups were estimated by using the χ2 test corrected by Yates [12].
RESULTS
Influence of TPN on Nutritional Status, the Course of the Disease, and the Complications of Acute Pancreatitis TPN did not alter the overall course of the severe acute pancreatitis. Fat administration was used in 65 of
VOL. 10, NO. 2
Parenteral Nutrition and Pancreatitis Table 3. Nutritional Parameters During TPN Start of TPN Weight gain (kg) Albumin (g/dl) Transferrin (mg/dl)
2.4 ± 0.3 145 ± 30
End of TPN 1.2 ±0.2 3.510.5* 208 + 35*
*p < 0.05 (χ2 test).
Table 4. Complications of Acute Pancreatitis and Relationship with the Initial Administration of TPN Group A, TPN started in 1st 72 hours
Downloaded by [ECU Libraries] at 04:58 23 April 2015
Patients (no.)
29
38
Ranson's criteria
Group B, TPN started after 72 hours
3.9
3.2
Complications Respiratory failure Renal failure Tissue necrosis of pancreas and the surrounding tissues Abscesses Pseudocysts Pancreatic fistulae
3 1 2
(7.8) (2.6) (5.3)
5 2 7
(17.2) (6.8) (24.1)
1 2
— (2.6) (5.3)
5 5 4
(17.2) (17.2) (13.8)
Total*
9
(23.6)
28
(96.5)
Mortality**
5
(13)
11
(38)
*p < 0.01, **p < 0.03. χ2 test corrected by Yates.
67 patients; neither clinical symptoms nor laboratory findings suggested an adverse effect upon the course of the disease. The average period of TPN was 28.4 days. During TPN there was a slight increase of body weight, followed by increased serum transferrin and albumin levels (Table 3). N balance became positive 2-3 days after starting TPN. The 37 complications that occurred in 25 patients (a morbidity rate of 37.3%) were directly related to the pancreatitis and its treatment (Table 2). Tissue necrosis and abscesses were treated surgically. All pancreatic fistulae closed spontaneously with TPN in a mean period of 33.3 days. In addition, the six pseudocysts that developed during the course of the acute pancreatitis subsided after an average of 18.3 days of TPN support. The deaths of 16 patients (mortality rate of 24%) were mostly due to uncontrollable sepsis, with
subsequent hypermetabolism and multiple system organ failure. In this study there was a statistically significant lower incidence of morbidity and mortality for patients in whom TPN was started within the first 72 hours (group A), compared with those in whom TPN was started later in the course of the disease (group B) (Table 4). Complications Related to TPN Therapy For complications occurring after central line catheter insertion, see Table 2. The two pneumothoraces required an underwater seal chest drain. The catheter-related sep sis associated with pyrexia and rigors resolved 5—12 hours after removal of the catheter and interruption of TPN. Microorganisms isolated from catheter tips and
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION
159
Downloaded by [ECU Libraries] at 04:58 23 April 2015
Parenteral Nutrition and Pancreatitis blood cultures were: Staphylococcus epidermidis in two patients, Staphylococcus aureus in one, E. cloacae in two, and Candida albicans in one. Septic episodes oc curred during the first 14 days in two patients and after the 14th day of TPN in four. The 8.9% incidence of catheter-related sepsis in the 67 patients with severe acute pancreatitis was statistically higher (p < 0.01) than that developing (2.9%) during the same period in our unit in the other patients on TPN (12 septic episodes of catheter-related sepsis in 412 patients). One patient developed a partial subclavian venous thrombosis, with edema and a collateral venous pattern over the upper arm and the region of the shoulder, demonstrated by venography and treated conservatively with an ticoagulant therapy. Hyperglycemia was the most fre quent metabolic complication during administration of TPN, occurring in 59 patients (88%), and required 46 U/day of crystalline insulin, to maintain a blood glucose level < 200 mg/dl. Increased levels of bilirubin, alkaline phosphatase, 1
Journal of the American College of Nutrition Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uacn20
Total parenteral nutrition in severe acute pancreatitis. a
a
a
a
F E Kalfarentzos , D D Karavias , T M Karatzas , B A Alevizatos & J A Androulakis
a
a
Department of Surgery, Medical School, University of Patras, Greece. Published online: 02 Sep 2013.
To cite this article: F E Kalfarentzos, D D Karavias, T M Karatzas, B A Alevizatos & J A Androulakis (1991) Total parenteral nutrition in severe acute pancreatitis., Journal of the American College of Nutrition, 10:2, 156-162, DOI: 10.1080/07315724.1991.10718140 To link to this article: http://dx.doi.org/10.1080/07315724.1991.10718140
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Total Parenteral Nutrition in Severe Acute Pancreatitis Fotis E. Kalfarentzos, MD, Dionissios D. Karavias, MD, Theodoros M. Karatzas, MD, Bassilios A. Alevizatos, MD, and John A. Androulakis, MD, FACS Department of Surgery, Medical School, University ofPatras, Patras, Greece
Downloaded by [ECU Libraries] at 04:58 23 April 2015
Key words: acute pancreatitis, artificial nutrition, pancreatic complications The influence of total parenteral nutrition (TPN) was studied in 67 patients with severe acute pancreatitis having three or more criteria according to Ranson (mean ± SD = 3.8 ± 0.21). Although TPN has been reported to not be of benefit in the progress and severity of the disease, we have found that the time TPN is started is important in influencing the course of the disease and in the development of local complications, as well as in the mortality rate. Patients whose TPN was started within the first 72 hours of the disease had a 23.6% complication rate and 13% mortality, in comparison with patients whose TPN was started later in the course of the disease, who had a 95.6% complication rate (p < 0.01) and a mortality rate of 38% (p < 0.03). The nutritional status of the patients during TPN administration of 28.4 days was maintained either steady or was improved, as assessed by nitrogen balance, serum levels of transferrin (p < 0.05), and albumin (p < 0.05). The administration of fat solution, either to prevent essential fatty acid deficiency or to provide part of the caloric requirements, was found to cause neither clinical nor laboratory worsening of the disease. All pancreatic fistulae that developed during the course of the disease spontaneously closed in patients receiving TPN without operation in a mean period of 33.3 days, and all pseudocysts subsided in an average of 18.3 days. Those who died (overall mortality rate 24%) had had uncontrollable sepsis, which resulted in hypercatabolism and multiple system organ failure. An increased incidence of catheter-related sepsis was observed (rate = 8.9%), which was significantly higher than the rate occurring (2.9%, p < 0.01) in other patients receiving TPN in our unit, during the same period. Finally, 88% of the patients developed hyperglycemia and required an average of 46 U/day of insulin to keep blood glucose at satisfactory levels. Thus, TPN was demonstrated to be safe, effective, and well tolerated by patients with severe acute pancreatitis. Abbreviations: Ca = calcium, IV = intravenous, K = potassium, Mg = mag nesium, N = nitrogen, P = phosphorus, TGs = triglycérides, TPN = total parenteral nutrition
INTRODUCTION Severe acute pancreatitis is accompanied by increased resting energy requirements and considerable loss of protein mass, resulting from metabolic effects of the in flammatory response following necrosis or inflammation of the retroperitoneal tissues [1,2]. In addition, ab dominal pain, nausea, vomiting, abdominal distension, and malabsorption due to decreased exocrine pancreatic function lead to reduced or absent oral food intake [3]. The combination of the above factors in severe acute
pancreatitis, which is often associated with complica tions such as tissue necrosis, abscesses, pseudocysts, and fistulae, leads to a large loss of skeletal muscle mass. The loss of function and of structural integrity of vital organs which follows contributes to high morbidity and mortality [3,4]. The effect of TPN on the therapeutic management of severe acute pancreatitis has been evaluated in several studies [5-8]. Presented here is a study of 67 patients with severe acute pancreatitis who were treated with TPN in the surgical unit of the Univer sity of Patras over a period of 8 years. The influence of
This manuscript was presented at the Congress of Parenteral and Enterai Nutrition (ESPEN) in Helsinki, Finland, September 1989. Address reprint requests to Dr. T. Karatzas, University ofPatras, Medical School, Department of Surgery, Patras, Greece.
Journal of the American College of Nutrition, Vol. 10, No. 2, 156-162 (1991) © 1991 John Wiley & Sons, Inc.
CCC 0731-5724/91/020156-07$04.00
Parenteral Nutrition and Pancreatitis Table 1. Summary Data from 67 Patients with Severe Acute Pancreatitis: Character!!sties and Etiology Characteristics Age Male/female ratio Average no. of Ranson's criteria [3,9] Etiology Alcohol Cholelithiasis Hypertriglyceridemia
Downloaded by [ECU Libraries] at 04:58 23 April 2015
Trauma Idiopathic
TPN on the nutritional status of the patients, on the dis ease process, and on the development of complications was studied prospectively.
MATERIALS AND METHODS From 1981 to 1989, all patients with severe acute pancreatitis who were treated in our unit (total of 67) were included in this study. The collection of data was based on a previously well-defined protocol [3]. The criterion for diagnosis of severe acute pancreatitis was the presence of three or more criteria from Ranson's classification [9] (Table 1). All patients had severe clini cal symptomatology and required intensive monitoring for more than 48 hours. Patients with less than three criteria were excluded from the study. The confirmation of diagnosis of acute pancreatitis was based on: (a) his tory of cholelithiasis or alcohol intake, (b) typical symptomatology of acute pancreatitis, (c) laboratory findings including serum amylase, Ca, bilirubin, transaminases (SGOT and SGPT), white count, and triglycérides (TGs), (d) radiologie findings with the use of ultrasound, CT scanning, and X-rays of chest and ab domen, and (e) operative or postmortem findings. The diagnosis of severe acute pancreatitis was considered definitive when the CT scan findings agreed with the clinical picture and the laboratory findings. The age, sex, underlying disease process, and severity of the disease (on the basis of Ranson's criteria) are reported in Table 1. All patients received TPN through the subclavian polyurethane catheter. A mean of 1.4 TPN catheters/patient were placed aseptically for an average of 23.4 days in both groups. Patients received TPN
JOURNAL OF THE AMERICAN COLLEGE OF NUTR]
57.8 ± 2 25:42 3.8 ± 0.21
2 (3%) 57 (85%) 2 (3%) 3 (4.5%) 3 (4.5%)
within the first 72 hours (group A = 38) or later (group B = 29) on the basis of clinical criteria. Group A patients achieved hemodynamic stability soon after TPN was in stituted. The average of TPN administration was 28.4 days in both groups. Regular catheter care and change of the dressing were performed by a trained sister twice a week. All patients were initially infused at a rate of 40 ml/hr; in 2-3 days it was increased to the level of caloric and protein requirements, calculated according to the Harris-Benedict equation and the stress factors described by Long et al [10,11]. The administered protein intake ranged from 1.5 to 2.5 g/kg/day according to severity of stress and state of hepatic and renal function. A 10% lipid solution in a 300 ml volume twice a week was given to patients without hypertriglyceridemia to prevent fatty acid deficiency. Patients who had increased levels of hepatic enzymes, respiratory deficiency requiring mechanical ventilatory support, and/or with hyperglyceridemia that was difficult to control received IV lipid daily for a period depending on need, either con tinuously or at intervals, with concomitant reduction of glucose in the TPN solution of 15-20%. Thus, 20 to 30% of the nonprotein calories was provided from fat. Blood glucose levels were closely monitored and insulin was given to maintain glucose levels below 200 mg/dl. Serum electrolytes and liver function tests (bilirubin, alkaline, phosphatase, yGT, SGOT, and SGPT), serum amylase, TGs, and total lipids were measured daily until biochemical stability was achieved, and subsequently twice a week. Abdominal ultrasound, CT scanning, and X-rays were performed at intervals. Blood gases were measured on admission and every 8 hours the first 3 days, and consequently as clinically indicated.
157
Parenteral Nutrition and Pancreatitis Table 2. Complications — Mortality Number of patients
Downloaded by [ECU Libraries] at 04:58 23 April 2015
A. Total parenteral nutrition-related complications 1. Major complications from CVP line catheter (a) Pneumothorax (b) Central vein thrombosis (c) Catheter sepsis 2. Minor complications from CVP line catheter (a) Puncture of subclavian artery (b) Intravascular displacement of central catheter 3. Major metabolic complications (a) Hyperglycemia 4. Minor metabolic complications (a) Liver enzyme disorders B. Complications from acute pancreatitis (a) Respiratory failure required mechanical support (b) Renal failure required hemodialysis (c) Pancreatic or peripancreatic necrosis with positive or negative culture (d) Abscess formation (e) Pseudocysts (f) Pancreatic fistulae C. Mortality (a) Uncontrollable sepsis
The success of nutritional support was determined by weight gain, levels on serum transferrin and albumin, and a positive nitrogen (N) balance. Urine N was calcu lated by the micro-Kjeldahl method in an aliquot of 24hr urine collection. The patients took no food by mouth; N losses from skin and feces were minimal. All patients were routinely treated for acute pancreatitis, which in cluded IV fluids to restore and maintain intravascular volume and meet electrolyte requirements — in par ticular, Ca, Mg, and P. Eight patients required mechani cal support of respiration for an average of 6.2 days. Three patients required hemodialysis. Analgesic drugs were given as required to all patients, and an H2 blocker (ranitidine 150 mg twice/day) was given to reduce pancreatic secretion and to prevent stress ulcers. A nasogastric tube was inserted in 65 patients, as needed, to keep the stomach empty. Antibiotics were used as required to manage proved infection. Surgical interven tion was performed before or during TPN to remove necrotic tissue, whether or not sepsis and abscess forma tion existed. A total of 18 operations were performed in
158
2 1 6 2 3
59 14
3 9 5 6 6 16
14 patients. Cholelithiasis was treated surgically when the acute disease was resolved. The complications occurring during the course of the disease were monitored and classified: (a) those related to central catheter sepsis due to administration of parenteral nutrition and (b) those due to acute pancreatitis (Table 2). The mortality rate and its cause were recorded. Statistical differences between the two groups were estimated by using the χ2 test corrected by Yates [12].
RESULTS
Influence of TPN on Nutritional Status, the Course of the Disease, and the Complications of Acute Pancreatitis TPN did not alter the overall course of the severe acute pancreatitis. Fat administration was used in 65 of
VOL. 10, NO. 2
Parenteral Nutrition and Pancreatitis Table 3. Nutritional Parameters During TPN Start of TPN Weight gain (kg) Albumin (g/dl) Transferrin (mg/dl)
2.4 ± 0.3 145 ± 30
End of TPN 1.2 ±0.2 3.510.5* 208 + 35*
*p < 0.05 (χ2 test).
Table 4. Complications of Acute Pancreatitis and Relationship with the Initial Administration of TPN Group A, TPN started in 1st 72 hours
Downloaded by [ECU Libraries] at 04:58 23 April 2015
Patients (no.)
29
38
Ranson's criteria
Group B, TPN started after 72 hours
3.9
3.2
Complications Respiratory failure Renal failure Tissue necrosis of pancreas and the surrounding tissues Abscesses Pseudocysts Pancreatic fistulae
3 1 2
(7.8) (2.6) (5.3)
5 2 7
(17.2) (6.8) (24.1)
1 2
— (2.6) (5.3)
5 5 4
(17.2) (17.2) (13.8)
Total*
9
(23.6)
28
(96.5)
Mortality**
5
(13)
11
(38)
*p < 0.01, **p < 0.03. χ2 test corrected by Yates.
67 patients; neither clinical symptoms nor laboratory findings suggested an adverse effect upon the course of the disease. The average period of TPN was 28.4 days. During TPN there was a slight increase of body weight, followed by increased serum transferrin and albumin levels (Table 3). N balance became positive 2-3 days after starting TPN. The 37 complications that occurred in 25 patients (a morbidity rate of 37.3%) were directly related to the pancreatitis and its treatment (Table 2). Tissue necrosis and abscesses were treated surgically. All pancreatic fistulae closed spontaneously with TPN in a mean period of 33.3 days. In addition, the six pseudocysts that developed during the course of the acute pancreatitis subsided after an average of 18.3 days of TPN support. The deaths of 16 patients (mortality rate of 24%) were mostly due to uncontrollable sepsis, with
subsequent hypermetabolism and multiple system organ failure. In this study there was a statistically significant lower incidence of morbidity and mortality for patients in whom TPN was started within the first 72 hours (group A), compared with those in whom TPN was started later in the course of the disease (group B) (Table 4). Complications Related to TPN Therapy For complications occurring after central line catheter insertion, see Table 2. The two pneumothoraces required an underwater seal chest drain. The catheter-related sep sis associated with pyrexia and rigors resolved 5—12 hours after removal of the catheter and interruption of TPN. Microorganisms isolated from catheter tips and
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION
159
Downloaded by [ECU Libraries] at 04:58 23 April 2015
Parenteral Nutrition and Pancreatitis blood cultures were: Staphylococcus epidermidis in two patients, Staphylococcus aureus in one, E. cloacae in two, and Candida albicans in one. Septic episodes oc curred during the first 14 days in two patients and after the 14th day of TPN in four. The 8.9% incidence of catheter-related sepsis in the 67 patients with severe acute pancreatitis was statistically higher (p < 0.01) than that developing (2.9%) during the same period in our unit in the other patients on TPN (12 septic episodes of catheter-related sepsis in 412 patients). One patient developed a partial subclavian venous thrombosis, with edema and a collateral venous pattern over the upper arm and the region of the shoulder, demonstrated by venography and treated conservatively with an ticoagulant therapy. Hyperglycemia was the most fre quent metabolic complication during administration of TPN, occurring in 59 patients (88%), and required 46 U/day of crystalline insulin, to maintain a blood glucose level < 200 mg/dl. Increased levels of bilirubin, alkaline phosphatase, 1
