Prognostic Tests for Early Enteral Nutrition Feeding Intolerance during Early Acute Pancreatitis with Severe Illness Predictors

The objective: to assess the acetaminophen absorption test and gastric emptying rate as predictive criteria of enteral nutrition feeding intolerance during the early acute pancreatitis with severe illness predictors.

Subjects and Methods. An open prospective cohort study was carried out in ICU of AO Neftyanik Hospital, in Tyumen from November 2012 to October 2018. The inclusion criteria were as follows: the diagnosed acute pancreatitis and presence of a severe illness predictor. The gastric emptying rate was estimated using an original technique wherein sonography was performed after administration of 200 ml of water into the gaster and subsequent assessment of the volume in 30 min. and 60 min. Acetaminophen absorption was assessed based on drug concentration in the blood 15-30 min. after its administration into the gaster.

Results. The gastric liquid volume on minute 30 (OR 1.061, 95% CI 1.033-1.089, p < 0.001 with AUC 0.835, 95% CI 0.752-0.918 with a cut-off value of 136) and minute 60 (OR 1.131, 95% CI 1.02-1.043, p < 0.001 with AUC 0.826, 95% CI 0.728-0.924 with a cut-off value of 60.5) after liquid administration allows a statistically significant prediction of the residual gastric volume ≥500 ml/day and enteral nutrition feeding intolerance: OR 1.032, 95% CI 1.013-1.051, p = 0.001 with AUC 0.727, 95% CI 0.628-0,827 with a cut-off value of 133 and OR 1.032, 95% CI 1.018-1.047, p < 0.001 with AUC 0.762, 95% CI 0.667-0.857 with a cut-off value of 56, respectively. The acetaminophen absorption test statistically significantly predicts the residual gastric volume ≥ 500 ml/day (OR 0.686, 95% CI 0.583-0.806, p < 0.001 with AUC 0.854, 95% CI 0.777-0.931 with a cut-off value of 6.96) and enteral nutrition feeding intolerance (OR 0.626, 95% CI 0.522-0.749, p < 0.001 with AUC 0.893, 95% CI 0.828-0.958 with a cut-off value of 7.6).

Conclusions. The gastric water emptying rate and acetaminophen absorption test allow predicting gavage feeding intolerance during early acute pancreatitis with severe illness predictors.

The acetaminophen absorption test has a higher predictive power.

1. Revishvili A.Sh., Kubyshkin V.A., Zatevakhin I.I. Ostryy pankreatit: Klinicheskiye rekomendatsii. [Acute pancreatitis. Guidelines]. Moscow, Ministerstvo Zdravookhraneniya Publ., 66 p.

2. Sivkov O.G. Predicting the feasibility of small bowel feeding in patients with generalized secondary peritonitis. Obschaya Reanimatologiya, 2021, vol. 17, no. 1, pp. 27-33. (In Russ.) doi: 10.15360/1813-9779-2021-1-27-33.

3. Sivkov O.G., Leyderman I.N., Lutsyuk M.I. Predicting of enteral nutrition intolerance in critically ill patients. Vestnik Intensivnoy Terapii Im. А.I. Saltanova, 2020, no. 4, pp. 120-126. (In Russ.) doi: 10.21320/1818-474X-2020-4-120-126.

4. Agarwala R., Rana S.S., Sharma R. et al. gastrointestinal failure is a predictor of poor outcome in patients with acute pancreatitis. Dig. Dis. Sci., 2020, vol. 65, no. 8, pp. 2419‒2426. doi: 10.1007/s10620-019-05952-5. Epub 2019 Nov 13. PMID: 31722056.

5. Banks P.A., Bollen T.L., Dervenis C. et al. Acute Pancreatitis Classification Working Group. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut., 2013, vol. 62, no. 1, pp. 102‒111. doi: 10.1136/gutjnl-2012-302779. Epub 2012 Oct 25. PMID: 23100216.

6. Blaser A.R., Starkopf J., Kirsimägi Ü. et al. Definition, prevalence, and outcome of feeding intolerance in intensive care: a systematic review and meta-analysis. Acta Anaesthesiol. Scand., 2014, vol. 58, no. 8, pp. 914‒922. doi: 10.1111/aas.12302. Epub 2014 Mar 11. PMID: 24611520.

7. Dutta A.K., Goel A., Kirubakaran R. et al. Nasogastric versus nasojejunal tube feeding for severe acute pancreatitis. Cochrane Database Syst Rev., 2020, vol. 26, no. 3, CD010582. doi: 10.1002/14651858.CD010582.pub2.

8. Fan H., Yang C., Duan Z. et al. Risk factors of enteral feeding intolerance in severe acute pancreatitis patients: A protocol for systematic review and meta-analysis. Medicine (Baltimore), 2021, vol. 7, no. 100, pp. e25614. doi: 10.1097/MD.0000000000025614.

9. Gao T., Cheng M.H., Xi F.C. et al. Predictive value of transabdominal intestinal sonography in critically ill patients: a prospective observational study. Crit. Care, 2019, vol. 27, no. 23 (1), pp. 378. doi: 10.1186/s13054-019-2645-9. PMID: 31775838; PMCID: PMC6880579.

10. Hamada S.R., Garcon P., Ronot M. et al. Ultrasound assessment of gastric volume in critically ill patients. Int. Care Med., 2014, vol. 40, no. 7, pp. 965‒972. doi: 10.1007/s00134-014-3320-x.

11. Heyland D., Cook D.J., Winder B. et al. Enteral nutrition in the critically ill patient: a prospective survey. Crit. Care Med., 1995, vol. 23, no. 6, pp. 1055‒1060. doi: 10.1097/00003246-199506000-00010.

12. Hu B., Sun R., Wu A. et al. Severity of acute gastrointestinal injury grade is a predictor of all-cause mortality in critically ill patients: a multicenter, prospective, observational study. Crit. Care, 2017, vol. 14, no. 21 (1), pp. 188. doi: 10.1186/s13054-017-1780-4.

13. Hurt R.T., McClave S.A. Gastric residual volumes in critical illness: what do they really mean? Crit. Care Clin., 2010, vol. 26, no. 3, pp. 481‒490. doi: 10.1016/j.ccc.2010.04.010. PMID: 20643301.

14. Liu Y., Gao Y.K., Yao L. et al. Modified B-ultrasound method for measurement of antral section only to assess gastric function and guide enteral nutrition in critically ill patients. World J. Gastroenterol., 2017, vol. 28, no. 23, pp. 5229‒5236. doi: 10.3748/wjg.v23.i28.5229.

15. Marzio L., Giacobbe A., Conoscitore P. et al. Evaluation of the use of ultrasonography in the study of liquid gastric emptying. Am. J. Gastroenterol., 1989, vol. 84, no. 5, pp. 496‒500. PMID: 2655434.

16. McClave S.A., Gualdoni J., Nagengast A. et al. Gastrointestinal dysfunction and feeding intolerance in critical illness: do we need an objective scoring system? Curr. Gastroenterol. Rep., 2020, vol. 7, no. 22. doi: 10.1007/s11894-019-0736-z. PMID: 31912312.

17. McClave S.A., Taylor B.E., Martindale R.G. et al. Society of Critical Care Medicine; American Society for 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.). J. Parenter. Enteral. Nutr., 2016, vol. 40, no. 2, pp. 159‒211. doi: 10.1177/0148607115621863.

18. Miyauchi T., Ishikawa M., Tashiro S. et al. Acetaminophen absorption test as a marker of small bowel transplant rejection. Transplantation, 1997, vol. 27, no. 8, pp. 1179‒1182. doi: 10.1097/00007890-199704270-00020.

19. Nguyen T., Frenette A.J., Johanson C. et al. Impaired gastrointestinal transit and its associated morbidity in the intensive care unit. J. Crit. Care, 2013, vol. 28, no. 4, pp. 537, e11-7. doi: 10.1016/j.jcrc.2012.12.003.

20. Pan L.L., Li J., Shamoon M. et al. Recent Advances on nutrition in treatment of acute pancreatitis. Front Immunol., 2017, vol. 30, no. 8, pp. 762. doi: 10.3389/fimmu.2017.00762.

21. Perez-Calatayud A.A., Carrillo-Esper R., Anica-Malagon E.D. et al. Point-of-care gastrointestinal and urinary tract sonography in daily evaluation of gastrointestinal dysfunction in critically ill patients (GUTS Protocol). Anaesthesiol. Int. Ther., 2018, vol. 50, no. 1, pp. 40‒48. doi: 10.5603/AIT.a2017.0073.

22. Puleo F., Arvanitakis M., Van Gossum A. et al. Gut failure in the ICU. Semin. Respir. Crit. Care Med., 2011, vol. 32, no. 5, pp. 626‒638. doi: 10.1055/s-0031-1287871.

23. Reignier J., Mercier E., Le Gouge A. et al. Clinical Research in Intensive Care and Sepsis (CRICS) Group. Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. JAMA, 2013, vol. 16, no. 3, pp. 249–256. doi: 10.1001/jama.2012.196377. PMID: 23321763.

24. Reintam A., Jakob S.M., Starkopf J. Gastrointestinal failure in the ICU. Curr. Opin. Crit. Care, 2016, vol. 22, no. 2, pp. 128–141. doi: 10.1097/MCC.0000000000000286.

25. Reintam A., Malbrain M.L., Starkopf J. et al. Gastrointestinal function in intensive care patients: terminology, definitions and management. Recommendations of the ESICM Working Group on Abdominal Problems. Int. Care Med., 2012, vol. 38, no. 3, pp. 384–394. doi: 10.1007/s00134-011-2459-y.

26. Reintam A., Parm P., Kitus R. et al. Gastrointestinal failure score in critically ill patients: a prospective observational study. Crit. Care, 2008, vol. 12, no. 4, R90. doi: 10.1186/cc6958.

27. Singer P., Blaser A.R., Berger M.M. et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin. Nutr., 2019, vol. 38, no. 1, pp. 48–79. doi: 10.1016/j.clnu.2018.08.037.

28. Southren D.L., Nardone A.D., Haastrup A.A. et al. An examination of gastrointestinal absorption using the acetaminophen absorption test in critically ill patients with COVID-19: A retrospective cohort study. Nutr. Clin. Pract., – 2021. vol. 36, no. 4, pp. 853–862. doi: 10.1002/ncp.10687.

29. Sun J.K., Li W.Q., Ni H.B. et al. Modified gastrointestinal failure score for patients with severe acute pancreatitis. Surg. Today, 2013, vol. 43, no. 5, pp. 506–513. doi: 10.1007/s00595-013-0496-6.

30. Tenner S., Baillie J., DeWitt J. et al. American College of Gastroenterology. American College of Gastroenterology guideline: management of acute pancreatitis. Am. J. Gastroenterol., 2013, vol. 108, no. 9, pp. 1400–1416. doi: 10.1038/ajg.2013.218.

31. Tenner S., Steinberg W.M. Acute Pancreatitis. 10th ed. Feldman M., Friedman L.S., Brandt L.J., editors. In: Sleisenger and Fordtran’s gastrointestinal and liver disease. Philadelphia: Elsevier, Inc. 2016, pp. 969-993.