Can feeding influence outcome

A recent prospective study designed specifically to evaluate the therapeutic use of Lexipafant, a platelet-activating antagonist, again from the Scottish group, examined the relationship between SIRS and mortality in the subgroup of Scottish patients with severe disease (n = 121) and found that the incidence of SIRS on admission, at 24 h and 48 h, as well as the persistence of SIRS, was correlated with survival as shown in Table 5.1 and Fig. 5.7 [69]. The authors also examined the relationship between multiple organ failure (MOF) and death risk, and showed that transient MOF, i.e., MOF that resolved with the 1st week, was associated with no mortality, but 'permanent" or progressive MOF was associated with a mortality rate of 55%. More recently,

Table 5.1

Association Between Systemic Inflammatory Response Syndrome and Overall Survival in Patients with Severe Acute Pancreatitis

SIRS present SIRS absent

Table 5.1

Association Between Systemic Inflammatory Response Syndrome and Overall Survival in Patients with Severe Acute Pancreatitis

SIRS present SIRS absent

n

Survivors

n

Survivors

p*

Admission

87

74 (85)

34

34 (100)

0 ■ 019

24 h

45

35 (78)

76

73 (96)

0 ■ 002

48 h

32

21 (66)

89

87 (98)

<0 ■ 001

Persistent

27

17 (63)

94

91 (97)

<0 ■ 001

Values in parentheses are percentages. SIRS, systemic inflammatory response syndrome. V test [69].

Values in parentheses are percentages. SIRS, systemic inflammatory response syndrome. V test [69].

a full evaluation of all the patients with severe disease enrolled in the UK Lexipafant study (n = 290) was reported, confirming the predictive value of permanent MOF on mortality [70]. In addition, they examined the relationship between MOF and local complications, such as pancreatic necrosis and infection. They found that there was a significant association, such that 52% of patients with permanent MOF developed local complications, as opposed to none with no organ failure and 26% with transient MOF (p < 0.001). These studies suggest that there is a 'window of opportunity' in the 1st week of hospitalization to reduce mortality if we can apply measures to suppress the development of SIRS, and thus MOF. The reverse is also true, that exacerbation of SIRS may prevent the reversal of early MOF, and therefore lead to an increase in mortality. From what we have discussed above, it is likely that enteral feeding will reduce the risk of MOF as it reverses ileus, and jejunal feeding bypasses the obstructed upper GI

Fig. 5.7. Kaplan-Meier survival plot illustrating that all the mortality associated with acute pancreatitis is associated with progressive multiple organ failure [70].

tract, thus preventing intestinal failure. Secondly, the maintenance of mucosal health and prevention of bacterial overgrowth will suppress the systemic cytokine-generated inflammatory response, also reducing the risk of MOF and mortality. On the other hand, proximal feeding may exacerbate the pancreatic injury and increase the risk of aspiration pneumonia, thereby increasing the risk of MOF and mortality.

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