Enteral Nutritional Support For Pancreatitis: Practice Gap discussion at...

We already did that one. So here's the next question. I was gonna backtrack a little bit and say I think there's an Otto von Bismarck quote of you don't want to see sausages and laws being made, and I don't know if you want to see the PDC questions being made either. It's kind of a difficult process arguing back and forth, but, uh, we'll go into the next one here. Hey, hey Chuck, before you do, I just want to do this with each one of your points because I want to have this very clear the change in practice. Is that we and this hopefully video will go out to not just pediatric surgeons but anesthesiologists, intensivists, is that we, it is safe to, we don't have to transfuse to a number. Is that what is that the summary or am I missing or is the number 7? The number is lower, I think is in take home point. Yes, that's the that's the message, a restrictive transfusion policy that we, yes. And, and that's well, it's, there's good evidence for that in the PICU. So in fact, using transfusing it for a parameter of 9 doesn't make sense anymore. We're talking about ale and Goldman. That is a bite that is important. I want, let's tweet that out, that the, according to the PDC and that the restrictive transfusion policy of 7, not 9 or 10, is probably going to have no, it will have no difference in mortality. Is that is that the statement? Yeah, I love it. All right. A comment from David Rothstein online is that RBC transfusions may also confer increased risk of DVT, GAMA surgery paper, also in adults and in pediatrics, not the NICU scenario. And so giving transfusions increases, increases DVT risk, yes. This is awesome. All right, let's go. OK, that was number 10. So that was number 10. 9 more. We don't have the cards to hold up, but number 9, a 16-year-old female presents with abdominal pain, and the exam and labs show tachycardia, tachypnea, a distended abdomen, an elevated white count. And an amylase and the ultrasound shows cholelithiasis and edematous pancreatitis. After admission to the ICU, she requires substantial fluid resuscitation and intubation for respiratory failure. So the question in this patient is about the specific aspect of nutrition. What form of nutritional support is most appropriate for this patient with acute pancreatitis? A is additional observation without any nutrition for 48 hours. B is TPN. C is TPN with glutamine. D is nasogastric feeds, and then E is nasogastric feeds with arginine. I love this, uh, question actually. Uh, who wants to make a comment while we're waiting for the poll results? Um, I can make one, but I don't know if anyone else wants to say anything. I mean, what is the point of glutamine and arginine in these? I don't understand why they're even included. I'm just an old guy. What do the young guys to see Chuck's Chuck's, uh, but, well, sometimes so they're distractors, obviously if they're not the right answer. And the reason, so some of these agents were thought to be gut, for instance, glutamine we gave for a while, wrapped in foil, as I recall as a As an amino acid that was a gut nutrient and so it may not be the right answer, but it's a distractor and so, so some of these other just say me and and arginine why did they choose that nitric oxide production? Well, both have, both have been tried as amino acid amino acid nutritional supplements to stabilize gut mucosa or to promote nutrition. I don't think there's a lot of evidence that any of it actually that would just work. So, and you had to get the 5. So Chuck, I'm gonna, I'm gonna play a game with you here. You haven't looked at your iPad, right? You haven't looked at it yet. Don't look. No, it's the battery's dead. Good. The battery's dead. What do you think was the number one answer from the audience? Oh, I would say the number one answer is going to be parenteral nutrition. That was the, the one of the lowest answers. Really wonderful. That's what I would have chosen one of the lowest answers, really. And I will tell you, my guess is that it's nasal gastric feeds. Is that, is that wrong? That's correct. That's correct. OK, now let me tell you, uh, there was the pancreatic Care Center, uh, Cincinnati Children's did a course on, on the, the pancreatic Care Center did a course on pancreatitis, and they put questions up. I got every single one of them wrong, OK, so I am the classic person that was doing every single thing wrong. What's that? That's why I'm not in the pancreatic care center. I was keeping my patients' NPO forever and until they had their 18th birthday. It was every single thing I did wrong, and I was shocked by how many things have changed. That's the point. It's what we've learned. That was what we learned we learned. The wrong lesson. The wrong dog. That's why this is such an important. You got the question right. I learned the first time ever. So, but it was so we made a podcast of it because it was so, it was so practice changing for me. So your screen just that's just the screen here. Is it is the feet OK? It was. All right, OK, we'll keep going. Well, wait, hold on, Dave, we have to, we're gonna pause for a second. There's a Oh, there we go. We're back here at least. There we go. Are we back there? OK, cool. Sorry, so let me get, so my old foggy brain. With acute pancreatitis, NG feeds. Exactly. So why don't we give oral feeds? You can, can, you can. So you just keep feeding. Yeah. So why are they in the hospital? This patient's intubated. Well, this patient's sick as stink, but, but yeah, go ahead. Really, you can just feed a pancreatitic, isn't that? That's what I responded when I first heard it. the light. So this is why we included it as one of the top 10, I guess it's somewhat age dependent, but these are one of those things where if you did this as a resident, they probably would have. Fired you and now it's the wrong answer. And to clarify one thing before Chuck goes, that's the point of this entire course. These are not things that are routine. These are things that are changes that we're all going to be surprised about. OK, go ahead, Chuck. Yeah. So at any rate, just like everyone else, when I first encountered this, I didn't think that was correct, but there's pretty strong evidence, there's very strong evidence in adults, and most of the kids with pancreatitis are probably old enough that they are. At least relatively similar in that regard, that you should feed people with acute pancreatitis. So the evidence in adults strongly recommends early feeding, 24 to 48 hours with interal feedings. The route at which they're given doesn't seem to really make any difference. It doesn't have to be naso jejunal. It doesn't necessarily have to be nasogastric, really, if they're throwing up the feedings and don't tolerate them, then maybe you need a nasal jejunal tube, but generally the route by which it's given isn't that important. And there, there's very good evidence in adults from meta-analyses and multiple studies that that interal feedings reduces the morbidity, the infectious complications, and the mortality, particularly with severe pancreatitis, but even in mild to moderate cases, uh, and the discussion here already talks about one thing I mentioned about the route of the feeding. Uh, there isn't any benefit to supplemental administration of specific. Amino acids or other things in these cases as we've already talked about, uh, and there is some evidence in children. Most of the studies in children are fairly small and retrospective, um, but again you'd have good reason to assume that. Uh, the same beneficial effects would accrue. The myth we grew up in, uh, surgery school, if you will, was that by feeding you would be stimulating the hormones and you're stimulating the pancreas. In fact, uh, that's not the case. There have been c pseudocyst. Do I still feed them? I, I think they're still feeding anybody unless they, unless they clearly have clinically demonstrated they can't tolerate an LPS. So if you have infected, I'm gonna push this infected infected pancreatic phlegm, still feed them. Why not. I got to go back to surgery school. It's, it's, it is interesting how many things we're realizing we're dogma. Without evidence now that we're, so I'm sorry, so they specifically in some of these studies tracked pain and lipase levels and found that they didn't particularly correlate with internal feeding, that they didn't bump, you would have thought when you feed them they're going to bump those things up and they're going to have more pain, but no, this single conversation is totally worth coming to this meeting. Exactly. Awesome. I agree. So are you going to talk more about pancreatitis because if I don't want you to leave this topic I didn't have any. OK, go ahead. Kid comes in with pancreatitis, regular old pancreatitis. Let me ask you a few questions, rapid fire here, OK. Let's take a kid who has a gallstone pancreatitis. Uh, these are all random now. gallstone pancreatitis, uh, amylase and lipase are elevated. Craig, do you do send them for ERCP or do you do a lap coli with an intraoperative changiogram? These are going to be rapid fire questions. First of all, I figure out where that pancreatitis is settling down again, that is whether they passed the stone. So you watched it the next day, lipase and amylase go up again. They're continuing to go up. It's been two days now. Yeah. Then if I get worried, then I would want to intervene. So would you do an ERCP or would you do a lab coli with intraoperative claims agreement? I'd do an ERCP, ERCP, Dave, MRCP. OK, but the, OK, MRCP shows the same thing, obstructed stone, yeah, uh, it depends on my gastroenterologist. OK, so it depends on resources. If you have every resource in the book, they're all there. ERCP, ERCP, same thing, yes. If, if you can get, if you have an ERCP endoscopist at your institution, I think to do a lap foley, and if you can't get the stone out, then take the stone out by ERCP post-optically, which is what's done in adults. OK, let's hold on a second. So what, you go to the operating room, you're going to do an intraoperative cholangangiogram. How do you get the stone out? What are your techniques? Well, you try to, uh, flush it out, or actually you can try to push it back, OK, with what, um. Transcystic like a Fogerty. Yeah, transcystic with a Fogerty catheter. Uh, and then you try to flush it and then you can try to basket it. OK, Rusty, ERCP ERCP, Ron. I do MRCP and then I, if they had dilated ducts, I would take them to the operating room and I would do, um, either basket it, um, uh, over a wire or I would put a koloochoscope in and I would do the same thing. I'd, I'd, I'd explore. We, we had actually a study which we showed that we cut down about, I think it was 2 days of um. Of length of stay because of the, the waiting for the RCP, you know, waking them up, waiting for the RCP, all the other things that have to happen. So if you have a dilated duct, all you have to do is put a wire down, put a, put a koloochoscope over the wire into the duct. It's beautiful, um, great for your fellows, basket the stone, pull it out. But, but the way I answered was if, if you have an endoscopist who can do the ERCP, correct, very few places, very few children's hospitals have that, OK, Craig, because I want to. Questions and number one is that whether it's your decisions all affected by how sick that patient is and how severe that pancreatitis is, and, and to Ron's point, I think it's true when you do the RC 1st, 1st you may settle them down, but yeah, you do prolong, then, then when you're going to do that is a reason not to do it together. A lot of people are a little bit afraid to put that code they're they're, you're not familiar with it. But putting cho choloidochoscope through the cystic duct through a dilated cystic duct, which they usually are if the, if the common duct's dilated, the cystic duct's usually dilated. You can nicely take a, a balloon and just dilate it up and put a, or, or, or it's big enough, you can just put a choleidoscope down and, and it's wonderful to basket that stone. Mark, Mark, comments. No, I, I was gonna say, so I, I, I think that you should take him to the operating room and do an IOC inoperative. Uh, it, you know, either using a choloiddoco scope or basket, basket with fluoro, we're successful basket with fluoro about 90% of the time. Usually we can get it out with a basket with fluoro while they're looking for the choloidochoscope. So, but the other question, the other question I would ask because I think this is something else in the adult literature that we're starting to do now also is, what is the appropriate timing of that cholecystectomy and when do you take him to the operating room, Craig, you, you intimated that you would wait. If their pancreatitis was really bad, should you really? I must say that's again what I learned was that you'd let that interval and settle it down. The experience is that probably you don't gain with that delay. In fact, if you delay sort of intermediate, you may be in a worse spot. So I want to get to, I want to hear everyone's response to that, but I just want to make one comment on the ERCP thing before is the summary that I was trying to get to is that was from last year's update course, 2 years ago when Matt Clifton. They talked about that, and I think SAs is now recommending it's a change in paradigm. Sages is absolutely pushing forth this new paradigm of even if it's a stuck stone, try a lab with IOC first. It does depend on your resources and then send for ERCP that pre-ERCP is falling by the wayside this year, probably change next year, but at least right now, but one of the reasons that is, I think, is that by the time you get the ERCP set. Upstone has passed. There's so many negative ERCPs. Do you know why? When they are obstructed, it's because it's passing. That's, it's not that it's a coincidence. That's usually that means the stone. And then your question is timing. So pancreatic gallstone pancre, that was my second gallstone pancreatitis. The stone passes, they're not jaundiced. When do you time your lap coli? We heard Craig's answer. When would you do your lap coli? Clinically improving. We have to send ours over to another hospital that's close by for the adult people to do the ERCP, and they usually come back that day and generally we operate on them the 24 to 40 hours. What if they're still having evidence? Do you wait for their pancreatitis to completely resolve? Do you wait 6 weeks after their pancreatitis is resolved? No, but I have had one kid that got the ERCP, felt so much better that they went home and never came, refused to come back in even with contact to have their gallbladder. Yeah, no, I think early at that hospitalization within the first few days if possible, even if they still have evidence of persistent, yeah, not, not intubated on pressers, but that's not think it makes the, that's not a typical operation is going to be hard no matter what, but I think that's better than go home and we'll schedule you for a month from now, OK, because there's there's literature that if you wait that long, yeah, it comes back, right? But what about waiting a week till all the symptoms are gone? Doesn't make the operation safer? No, Rusty, do them together. Hm, why not? I've never faced this, but Why can't you do them together? You mean the ERCP and the lap coli, right? But, that's fine. But forget the ERCP. Let's say the stone passed. The kid comes in, he's got gallstone stone passed. They still have pancreatitis. Do you wait to do the gallbladder? OK. Last question. Kid has pancreatitis, and what about amylase and lipase? Do you Do you check them regularly? Do you not check them at all? How do they help your management since we just heard that we're feeding them anyways? Well, I think the literature tells you that they're not good predictors of severity of the pancreatitis. Having said that, human nature is that you check them. Because you'd like to see them come down. That's just human nature, and we were taught to do that, right? And the last question is, is there an advantage of NJ versus NG feeds? No, OK, unless they're vomiting and you can feed them. OK, that's what his slide says. So Mark, were you going to ask one more thing? I said. OK, all right. So your point, did you want, you want to make like one, yeah, the, the point here is don't be afraid to feed your pancreatitis patients, that it's safe and actually it's better to feed patients with pancreatitis. You don't need to wait early enteral feeding, early, and that's better. Early enteral feeding with acute pancreatitis. That's the big game changing thing here. Great. Next, right, yeah. and operate early gallstone for gallstone pancreatitis. Yeah, got it.