Costos, días estancia y complicaciones según tipo de soporte nutricional en pacientes con pancreatitis aguda grave
Palabras clave:
pancreatitis, terapia nutricional, costos y análisis de costosResumen
Introducción: El soporte nutricional en pancreatitis aguda grave ha sido controversial según los resultados. Nuestro objetivo es describir los resultados en días de hospitalización, costos y complicaciones según el tipo de soporte nutricional (enteral, parenteral y mixto) en pacientes con pancreatitis aguda grave.
Materiales y métodos: Se realizó un estudio observacional descriptivo (serie de casos) en 45 pacientes con diagnóstico de pancreatitis aguda y criterios de cuadro grave, que ingresaron al Hospital Pablo Tobón Uribe durante 1999-2004. Para el análisis estadístico se utilizaron las siguientes pruebas: Chi cuadrado para comparación de proporciones, Kuskall Wallis y U de Mann Whitney para la comparación de promedios entre los diferentes grupos.
Resultados: La principal causa de pancreatitis fue la de origen biliar (49%). La NE fue la más utilizada (48,8%). Al comparar la NE y NPT se presentaron diferencias estadísticamente significativas en hiperglicemia (p=0.0001) y días de hospitalización (p=0.047). No se presentaron diferencias en las complicaciones generales (p=0.053), ni en las infecciosas (p=0.136). La nutrición mixta tuvo resultados similares a la NPT en hiperglicemia, días de estancia hospitalaria y costos. No hubo mortalidad en esta serie.
Conclusión: La NE se puede usar con seguridad en pacientes con pancreatitis aguda grave; con ella se logra mejor control de la glicemia y menos días de hospitalización. Se observó además la necesidad de implementar nutrición mixta en algunos pacientes en quienes no se logra siempre llenar los requerimientos sólo con NE.
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Referencias bibliográficas
1. ABOU-ASSI S, O’KEEFE SJD. Nutrition in acute pancreatitis. Am J Clin Gastroenterol 2001; 32: 203-209.
2. KINGSNORTH A. role of cytokines and their inhibitors in acute pancreatitis. Gut 1997; 4: 1-4.
3. TOOULI J, BROOKE-SMITH M, BASSI C, et al. Guidelines for the management of acute pancreatitis. J Gastroenterol Hepatol 2002; 17(Suppl): S15-S39. Referencias
4. SEKIMOTO M, TAKADA T, KAWARADA Y, et al. JPN Guidelines for the management of acute pancreatitis: epidemiology, etiology, natural history, and outcome predictors in acute pancreatitis. J Hepatobiliary Pancreat Surg 2006; 13: 10-24.
5. MANN DV, HERSHMAN MJ, HITTINGER R, et al. Multicentre audit of death from acute pancreatitis. Br J Surg 1994; 81: 890-893.
6. YOUSAF M, MCCALLION K, DIAMOND T. Management of severe acute pancreatitis. Br J Surg, 2003; 90: 407-420.
7. LOBO D, MEMON M, ALLISON S, et al. Evolution of nutritional support in acute pancreatitis. Br J Surg, 2000; 87: 695-707.
8. WHITCOMB DC. Acute pancreatitis. N Engl J Med 2006; 354: 2142-2150.
9. HOYOS S, HENAO K, GIRALDO N, et al. Evaluación del soporte nutricional en la pancreatitis aguda severa. Lecturas sobre nutrición 2001; 8 (3): 65-70.
10. GONZÁLEZ MA, RESTREPO B. Soporte nutricional y metabólico en el paciente críticamente enfermo. En: González M, Restrepo G, Sanín A. Fundamentos de Medicina, paciente en estado crítico, 3a. ed., CIB. 2003; 56-73.
11. MCCLAVE S, GREENE L, SNIDER HL, et al. Comparison of the safety of early enteral vs. parenteral nutrition in mild acute pancreatitis. JPEN 1997; 21: 14-20.
12. KALFARENTZOS F, KEHAGIAS J, MEAD N, et al. Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial. Br J Surg 1997; 84: 1665- 1669.
13. WINDSOR A, KANWAR S, LI AG, et al. Compared with parenteral nutrition, enteral feeding attenuates the acute phase response and improves disease severity in acute pancreatitis. Gut 1998; 42: 431-435.
14. ABOU-ASSI S, CRAIG K, O’KEEFE S. Hipocaloric jejunal feeding is better than total parenteral nutrition in acute pancreatitis: results of a randomized comparative study. Am J Grastoenterol 2002; 97: 2255-2262.
15. RANSON JHC, RIFKIND KM, ROSES DF, et al. Prognostic signs an the role of operative management in acute pancreatitis. Surg Gynecol Obstet 1974; 139: 69-81.
16. RANSON JH. Etiological and prognostic factors in human acute pancreatitis: a review. Am J Gastroenterol 1982; 77: 633-638.
17. BALTHAZAR E, ROBINSON D, MEGIBOW A, et al. Acute pancreatitis value of CT in establishing prognosis. Radiology 1990; 174: 331-336.
18. TRAN D, CUESTA M. Evaluation of severity in patients with acute pancreatitis. Am J Gastroenterol 1992; 87: 604-608.
19. ANDERSSON R, ANDERSSON B, HARALDSEN P, et al. Incidence, management, and recurrence rate of acute pancreatitis. Scand J Gastroenterol 2004; 39 (9): 891-894.
20. GISLASON H, HORN A, HOEM D, et al. Acute pancreatitis in Bergen, Norway: a study on incidence, etiology, and severity. Scand J Surg 2004; 93 (1): 29-33.
21. GULLO L, MIGLIORI M, OLAH A, et al. Acute pancreatitis in five European countries: etiology and mortality. Pancreas 2002; 24 (3): 223-227.
22. CAVALLINI G, FRULLONI L, BASSI C, et al. ProInf-AISP Study Group prospective multicentre survey on acute pancreatitis in Italy (ProInf-AISP): results on 1005 patients. Dig Liver Dis 2004; 36 (3): 205-211.
23. SUAZO-BARAHONA J, CARMONA-SÁNCHEZ R, ROBLES-DÍAZ G, et al. Obesity: a risk factor for severe acute biliary and alcoholic pancreatitis. Am J Gastroenterol 1998; 93 (8): 1324-1328.
24. HIROTA M, TAKADA T, KAWARADA Y, et al. JPN Guidelines for the management of acute pancreatitis: severity assessment of acute pancreatitis. J Hepatobiliary Pancreat Sur 2006; 13: 33-41.
25. MARTÍNEZ J, SÁNCHEZ PJ, PALEZON JM, et al. Obesity: a prognostic factor of severity in acute pancreatitis. Pancreas 1999; 19: 15-20.
26. PITCHUMONI CS, PATEL NM, SHAH P. Factors influencing mortality in acute pancreatitis. J Clin Gastroenterol 2005; 39: 798-814.
27. MARIK PE ZALOGA GP. Early enteral nutrition in acutely ill patients: a systemic review. Crit Care Med 2001; 29: 2264-2270.
28. MCCLAVE S, RITCHIE C. Artificial nutrition in pancreatic disease: ¿what lessons have we learned from the literature? Clin Nutrit 2000; 19: 1-6.
29. BODOKY G. HARSANYI L. PAP A, TIHANYI T, et al Effect of enteral nutrition on exocrine pancreatic function. AM J SURG JAN 1991; 161 (1): 144-1448.
30. PISTERS PW, Ranson JHC. Nutritional support for acute pancreatitis. Surg Gynecol Obstet 1992; 175: 275-284.
31. BUCHMAN AL, MOUKARZEL AA, et al. Parenteral nutrition is associated with intestinal morphologic and functional changes in humans. J Parenter Enteral Nutr 1995; 19: 453-460.
32. KALFARENTZOS FE, KARAVIAS DD, KARATZAS TM, et al. Total parenteral nutrition in severe acute pancreatitis. J Am Coll Nutr 1991; 10: 156-162.
33. MIURA S, TANAKA S, YOSHIOKA M, et al. Changes in intestinal absorption of nutrients and brush border glycoproteins after total parenteral nutrition in rats. Gut 1992; 33: 484-489.
34. TAKEDA K, TAKADA T, KAWARADA Y, et al. JPN Guidelines for the management of acute pancreatitis: medical management of acute pancreatitis. J Hepatobiliary Pancreat Sur 2006; 13: 42-47.
35. LOUIE BE, NOSEWORTHY T, HAILEY D, et al. 2004 McLean Mueller Prize. Enteral or parenteral nutrition for severe pancreatitis; a randomized controlled trial and health technology assessment. Can J Surg 2005; 48 (4): 298-306.
36. MARIK P, ZALOGA G. Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis. BMJ 2004; 328: 1407-1413.
37. OLA’H A, PARDAVI G, BELA’GYI T, et al. Mohamed GA. Early nasojejunal feeding in acute pancreatitis is associated with a lower complication rate. Nutrition 2002; 18: 259-262.
38. MARIK PE, PINSKY M. Death by parenteral nutrition. Intensive Care Med 2003; 29: 867-869.
39. MCCLAVE SA, CHANG WK, DHALIWAL R, et al. Nutrition support in acute pancreatitis: a systematic review of the literature. J Parenter Enteral Nutr 2006; 30 (2): 143-156.
40. SWAROOP VS, CHARI ST, CLAIN JE. Severe acute pancreatitis. JAMA 2004; 23: 2865-2868.
41. UK Working party on acute pancreatitis. UK guidelines for the management of acute pancreatitis. Gut 2005; 54 (Suppl III) III1-III9.
42. MITCHELL RM, BYRNE MF, BAILLIE J. Pancreatitis. Lancet 2003; 361: 1447-1455.
43. MONTERO JG, GARCÍA A, ORDÓÑEZ FJ. Soporte nutricional en la pancreatitis aguda. Nutr Hosp 2005; 20: 25-27.
44. NATHENS A, CURTIS JR, BEALE RJ, et al. Management of the critically ill patient with severe acute pancreatitis.Crit Care Med 2004; 32: 2524-2536.
45. BARREDA L, TARGARONA J, RODRÍGUEZ C. Protocolo para el manejo de la pancreatitis aguda grave con necrosis. Rev. Gastroenterol. Perú 2005; 25: 168-175.
46. ALAEDEEN DI, WALSH MC, CHWALS WJ. Total parenteral nutritionassociated hyperglycemia correlates with prolonged mechanical ventilation and hospital stay in septic infants. J Pediatr Surg 2006; 41: 239-244.
47. BRISTIAN BR. Update on total parenteral nutrition. Am J Clin Nutr 2001; 74: 153-154.
48. VARGA P, GRIFFITHS R, CHIOLERO R, et al. Is parenteral nutrition guilty? Intensive Care Med 2003; 29: 1861-1864.
49. VAN DEN BG, WOUTERS P, WEEKERS F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001; 345: 1359-1367.
50. THORELL A, ROOYACKERS O, MYRENFORS P, et al Intensive insulin treatment in critically ill trauma patients normalizes glucose by reducing endogenous glucose production. J Clin Endocrinol Metab 2004; 89: 5382-5386.
51. CHEUNG NW, NAPIER B, ZACCARIA C, et al. Hyperglycemia is associated with adverse outcomes in patients receiving total parenteral nutrition. Diabetes Care 2005; 28: 2367-2371.
2. KINGSNORTH A. role of cytokines and their inhibitors in acute pancreatitis. Gut 1997; 4: 1-4.
3. TOOULI J, BROOKE-SMITH M, BASSI C, et al. Guidelines for the management of acute pancreatitis. J Gastroenterol Hepatol 2002; 17(Suppl): S15-S39. Referencias
4. SEKIMOTO M, TAKADA T, KAWARADA Y, et al. JPN Guidelines for the management of acute pancreatitis: epidemiology, etiology, natural history, and outcome predictors in acute pancreatitis. J Hepatobiliary Pancreat Surg 2006; 13: 10-24.
5. MANN DV, HERSHMAN MJ, HITTINGER R, et al. Multicentre audit of death from acute pancreatitis. Br J Surg 1994; 81: 890-893.
6. YOUSAF M, MCCALLION K, DIAMOND T. Management of severe acute pancreatitis. Br J Surg, 2003; 90: 407-420.
7. LOBO D, MEMON M, ALLISON S, et al. Evolution of nutritional support in acute pancreatitis. Br J Surg, 2000; 87: 695-707.
8. WHITCOMB DC. Acute pancreatitis. N Engl J Med 2006; 354: 2142-2150.
9. HOYOS S, HENAO K, GIRALDO N, et al. Evaluación del soporte nutricional en la pancreatitis aguda severa. Lecturas sobre nutrición 2001; 8 (3): 65-70.
10. GONZÁLEZ MA, RESTREPO B. Soporte nutricional y metabólico en el paciente críticamente enfermo. En: González M, Restrepo G, Sanín A. Fundamentos de Medicina, paciente en estado crítico, 3a. ed., CIB. 2003; 56-73.
11. MCCLAVE S, GREENE L, SNIDER HL, et al. Comparison of the safety of early enteral vs. parenteral nutrition in mild acute pancreatitis. JPEN 1997; 21: 14-20.
12. KALFARENTZOS F, KEHAGIAS J, MEAD N, et al. Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial. Br J Surg 1997; 84: 1665- 1669.
13. WINDSOR A, KANWAR S, LI AG, et al. Compared with parenteral nutrition, enteral feeding attenuates the acute phase response and improves disease severity in acute pancreatitis. Gut 1998; 42: 431-435.
14. ABOU-ASSI S, CRAIG K, O’KEEFE S. Hipocaloric jejunal feeding is better than total parenteral nutrition in acute pancreatitis: results of a randomized comparative study. Am J Grastoenterol 2002; 97: 2255-2262.
15. RANSON JHC, RIFKIND KM, ROSES DF, et al. Prognostic signs an the role of operative management in acute pancreatitis. Surg Gynecol Obstet 1974; 139: 69-81.
16. RANSON JH. Etiological and prognostic factors in human acute pancreatitis: a review. Am J Gastroenterol 1982; 77: 633-638.
17. BALTHAZAR E, ROBINSON D, MEGIBOW A, et al. Acute pancreatitis value of CT in establishing prognosis. Radiology 1990; 174: 331-336.
18. TRAN D, CUESTA M. Evaluation of severity in patients with acute pancreatitis. Am J Gastroenterol 1992; 87: 604-608.
19. ANDERSSON R, ANDERSSON B, HARALDSEN P, et al. Incidence, management, and recurrence rate of acute pancreatitis. Scand J Gastroenterol 2004; 39 (9): 891-894.
20. GISLASON H, HORN A, HOEM D, et al. Acute pancreatitis in Bergen, Norway: a study on incidence, etiology, and severity. Scand J Surg 2004; 93 (1): 29-33.
21. GULLO L, MIGLIORI M, OLAH A, et al. Acute pancreatitis in five European countries: etiology and mortality. Pancreas 2002; 24 (3): 223-227.
22. CAVALLINI G, FRULLONI L, BASSI C, et al. ProInf-AISP Study Group prospective multicentre survey on acute pancreatitis in Italy (ProInf-AISP): results on 1005 patients. Dig Liver Dis 2004; 36 (3): 205-211.
23. SUAZO-BARAHONA J, CARMONA-SÁNCHEZ R, ROBLES-DÍAZ G, et al. Obesity: a risk factor for severe acute biliary and alcoholic pancreatitis. Am J Gastroenterol 1998; 93 (8): 1324-1328.
24. HIROTA M, TAKADA T, KAWARADA Y, et al. JPN Guidelines for the management of acute pancreatitis: severity assessment of acute pancreatitis. J Hepatobiliary Pancreat Sur 2006; 13: 33-41.
25. MARTÍNEZ J, SÁNCHEZ PJ, PALEZON JM, et al. Obesity: a prognostic factor of severity in acute pancreatitis. Pancreas 1999; 19: 15-20.
26. PITCHUMONI CS, PATEL NM, SHAH P. Factors influencing mortality in acute pancreatitis. J Clin Gastroenterol 2005; 39: 798-814.
27. MARIK PE ZALOGA GP. Early enteral nutrition in acutely ill patients: a systemic review. Crit Care Med 2001; 29: 2264-2270.
28. MCCLAVE S, RITCHIE C. Artificial nutrition in pancreatic disease: ¿what lessons have we learned from the literature? Clin Nutrit 2000; 19: 1-6.
29. BODOKY G. HARSANYI L. PAP A, TIHANYI T, et al Effect of enteral nutrition on exocrine pancreatic function. AM J SURG JAN 1991; 161 (1): 144-1448.
30. PISTERS PW, Ranson JHC. Nutritional support for acute pancreatitis. Surg Gynecol Obstet 1992; 175: 275-284.
31. BUCHMAN AL, MOUKARZEL AA, et al. Parenteral nutrition is associated with intestinal morphologic and functional changes in humans. J Parenter Enteral Nutr 1995; 19: 453-460.
32. KALFARENTZOS FE, KARAVIAS DD, KARATZAS TM, et al. Total parenteral nutrition in severe acute pancreatitis. J Am Coll Nutr 1991; 10: 156-162.
33. MIURA S, TANAKA S, YOSHIOKA M, et al. Changes in intestinal absorption of nutrients and brush border glycoproteins after total parenteral nutrition in rats. Gut 1992; 33: 484-489.
34. TAKEDA K, TAKADA T, KAWARADA Y, et al. JPN Guidelines for the management of acute pancreatitis: medical management of acute pancreatitis. J Hepatobiliary Pancreat Sur 2006; 13: 42-47.
35. LOUIE BE, NOSEWORTHY T, HAILEY D, et al. 2004 McLean Mueller Prize. Enteral or parenteral nutrition for severe pancreatitis; a randomized controlled trial and health technology assessment. Can J Surg 2005; 48 (4): 298-306.
36. MARIK P, ZALOGA G. Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis. BMJ 2004; 328: 1407-1413.
37. OLA’H A, PARDAVI G, BELA’GYI T, et al. Mohamed GA. Early nasojejunal feeding in acute pancreatitis is associated with a lower complication rate. Nutrition 2002; 18: 259-262.
38. MARIK PE, PINSKY M. Death by parenteral nutrition. Intensive Care Med 2003; 29: 867-869.
39. MCCLAVE SA, CHANG WK, DHALIWAL R, et al. Nutrition support in acute pancreatitis: a systematic review of the literature. J Parenter Enteral Nutr 2006; 30 (2): 143-156.
40. SWAROOP VS, CHARI ST, CLAIN JE. Severe acute pancreatitis. JAMA 2004; 23: 2865-2868.
41. UK Working party on acute pancreatitis. UK guidelines for the management of acute pancreatitis. Gut 2005; 54 (Suppl III) III1-III9.
42. MITCHELL RM, BYRNE MF, BAILLIE J. Pancreatitis. Lancet 2003; 361: 1447-1455.
43. MONTERO JG, GARCÍA A, ORDÓÑEZ FJ. Soporte nutricional en la pancreatitis aguda. Nutr Hosp 2005; 20: 25-27.
44. NATHENS A, CURTIS JR, BEALE RJ, et al. Management of the critically ill patient with severe acute pancreatitis.Crit Care Med 2004; 32: 2524-2536.
45. BARREDA L, TARGARONA J, RODRÍGUEZ C. Protocolo para el manejo de la pancreatitis aguda grave con necrosis. Rev. Gastroenterol. Perú 2005; 25: 168-175.
46. ALAEDEEN DI, WALSH MC, CHWALS WJ. Total parenteral nutritionassociated hyperglycemia correlates with prolonged mechanical ventilation and hospital stay in septic infants. J Pediatr Surg 2006; 41: 239-244.
47. BRISTIAN BR. Update on total parenteral nutrition. Am J Clin Nutr 2001; 74: 153-154.
48. VARGA P, GRIFFITHS R, CHIOLERO R, et al. Is parenteral nutrition guilty? Intensive Care Med 2003; 29: 1861-1864.
49. VAN DEN BG, WOUTERS P, WEEKERS F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001; 345: 1359-1367.
50. THORELL A, ROOYACKERS O, MYRENFORS P, et al Intensive insulin treatment in critically ill trauma patients normalizes glucose by reducing endogenous glucose production. J Clin Endocrinol Metab 2004; 89: 5382-5386.
51. CHEUNG NW, NAPIER B, ZACCARIA C, et al. Hyperglycemia is associated with adverse outcomes in patients receiving total parenteral nutrition. Diabetes Care 2005; 28: 2367-2371.
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Publicado
2007-09-20
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Hoyos Duque, S. I.; Giraldo, N.; Donado, J.; Henao, K.; Peláez Hernández, M. Costos, días Estancia Y Complicaciones Según Tipo De Soporte Nutricional En Pacientes Con Pancreatitis Aguda Grave. Rev Colomb Cir 2007, 22, 157-165.
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