When to start tricot (possibly a medication) in pancreatitis?

When to Start Nutritional Support in Pancreatitis

In acute pancreatitis, enteral nutrition should be started early (within 24-72 hours) in severe cases, while mild cases can resume oral feeding once pain subsides and pancreatic enzyme levels begin decreasing. 1

Assessment of Severity

Before determining when to initiate nutritional support, severity assessment is crucial:

• Mild Pancreatitis: 80% of cases, self-limiting with <5% mortality 1
• Severe Pancreatitis: Characterized by organ failure, systemic complications, and higher mortality rates 2

Severity assessment should be completed within 48 hours of admission using:

• Clinical impression
• APACHE II score in first 24 hours
• C-reactive protein >150 mg/L
• Glasgow score ≥3
• Persistent organ failure after 48 hours 2

Nutritional Support in Mild Pancreatitis

• No nutritional support needed within the first 5-7 days as it has no positive impact on disease course 2
• Resume oral feeding when:
  • Pain has ceased
  • Amylase and lipase values are decreasing 2
• Initial diet should be rich in carbohydrates and protein but low in fat (<30% of total energy intake) 2
• If oral feeding not possible due to persistent pain for >5 days, consider tube feeding 2

Nutritional Support in Severe Pancreatitis

• Start enteral nutrition early (within 24-72 hours of admission) 1
• Benefits of early enteral nutrition:
  • Decreases incidence of nosocomial infections
  • Reduces duration of systemic inflammatory response syndrome (SIRS)
  • Decreases overall disease severity 2
• Route of administration:
  • Jejunal feeding is traditionally preferred 2
  • Nasogastric route can be effective in approximately 80% of cases 2
• Formula selection:
  • Peptide-based formulas are safe and recommended 2
  • Standard formulas can be tried if tolerated 2

Parenteral Nutrition Considerations

• Only use parenteral nutrition when:
  • Enteral nutrition is not tolerated
  • Enteral route is contraindicated (e.g., prolonged ileus, complex pancreatic fistulae, abdominal compartment syndrome) 2
• Start parenteral nutrition after adequate fluid resuscitation and hemodynamic stabilization (usually 24-48 hours from admission) 2
• Energy requirements:
  • 25-35 kcal/kg body weight/day
  • Protein: 1.2-1.5 g/kg body weight/day 2
  • Carbohydrates: 3-6 g/kg body weight/day (maintain blood glucose <10 mmol/L)
  • Lipids: up to 2 g/kg body weight/day (maintain triglycerides <12 mmol/L) 2

Special Considerations

• Combined approach: When caloric goals cannot be achieved with enteral nutrition alone, combine with parenteral nutrition 2
• Monitoring: Regular assessment of tolerance and nutritional parameters is essential
• Weaning: Transition from tube feeding to oral nutrition should be gradual based on clinical improvement 2
• Micronutrients: Daily multivitamins and trace elements are recommended, with special attention to selenium, thiamine (especially in alcoholic patients), and calcium 2

Common Pitfalls to Avoid

• Delaying nutritional support in severe pancreatitis
• Overfeeding patients, which can worsen outcomes
• Prolonged NPO status without nutritional support
• Ignoring hypertriglyceridemia when administering lipids (maintain levels <12 mmol/L)
• Failing to transition from parenteral to enteral nutrition when possible

By following these evidence-based guidelines for timing nutritional support in pancreatitis, you can optimize patient outcomes while minimizing complications related to both the disease and nutritional deficiencies.