Enteral and parenteral nutrition. Physiological needs. Routes of administration of drugs into the body Enteral and parenteral nutrition of patients

Enteral nutrition is a type of nutritional support in which all nutrients are supplied through a tube when adequate oral nutrition is not possible.

Parenteral nutrition is a special type replacement therapy, in which nutrients to replenish energy, plastic costs and maintain normal level metabolic processes are introduced into the body, bypassing gastrointestinal tract.

The essence of parenteral nutrition is to provide the body with everything necessary for normal life substrates involved in the regulation of protein, carbohydrate, fat, water-electrolyte, vitamin metabolism and acid-base balance.

In newborns with RDS acute period In case of illness, feeding from a nipple is impossible, therefore partial or complete parenteral nutrition is required, especially for children with extremely low body weight.

When choosing a method of nutrition (enteral or parenteral), it is necessary to take into account not only the newborn’s tolerance to enteral nutritional loads, but also factors limiting the use of parenteral nutrition: frequent absence of sufficient quantity necessary medications for parenteral nutrition, circulatory disorders, renal function, CBS and blood gas composition, which impede the normal absorption of parenterally administered proteins and fats, the need for central venous catheterization and the associated risk of complications, as a rule, limited opportunities adequate laboratory monitoring of parenteral nutrition, and therefore high frequency metabolic disorders.

Therefore, in most departments and intensive care units and intensive care newborns, the problem of feeding patients with RDS has to be solved mainly with the help in various ways enteral nutrition.

As the child’s condition stabilizes (usually on the 2nd-3rd day of life), after a trial administration sterile water or 5% glucose solution through a tube, enteral nutrition is started. More early start nutrition in children born with asphyxia and who have developed RDS can lead to the development of ulcerative necrotizing enterocolitis (especially in very premature infants), and later to severe intestinal dysbacteriosis, up to the development of enterocolitis of bacterial etiology.

The presence of a significant amount of stagnant contents in the stomach, persistent regurgitation or vomiting mixed with bile, sluggish or increased peristalsis intestines, blood in the stool, and symptoms of peritoneal irritation are contraindications for starting enteral nutrition.

In these cases, the child needs parenteral nutrition. For this purpose, from the first days of life, solutions of amino acids and glucose are used, to which, if complete parenteral nutrition is necessary, fat emulsions are added from the 3rd to 7th days of life. An important condition To carry out total parenteral nutrition is the normalization of CBS indicators, levels of bilirubin, creatinine and urea.

The question of the possibility and time to start feeding children with mild RDS is decided individually, taking into account functional state gastrointestinal tract and central hemodynamics.

Usually intravenous administration A 10% glucose solution at the rate of 60-70 ml/kg/day provides the minimum physiological (at the level of basal metabolism) need for water and calories in the first 2-3 days of life. For children with RDS who are on mechanical ventilation, taking into account the reduction in insensible fluid losses due to perspiration due to humidification of the gas mixture, the volume of fluid should be reduced by 20-30 ml/kg/day compared to the data presented in table. 3.

Table 3

Estimated fluid requirements for children

in the first week of life

For children weighing 800-1000 g, it is advisable to start infusion therapy with the introduction of a 7.5% glucose solution, for children weighing 500-800 g - with the introduction of a 5% glucose solution. In the event of hypoglycemia, the concentration of administered glucose is increased. The main goal of the therapy is to maintain biochemical homeostasis. When conducting infusion therapy it is necessary to monitor the main biochemical constants of the child’s blood (concentration of glucose, urea, creatinine, total protein, K, Na, Ca and CBS).

In the absence of laboratory monitoring, maintenance therapy should be aimed at ensuring the body's minimum physiological needs for fluid, nutrients and electrolytes. In this case, the neonatologist is forced to focus on the average values of the physiological needs of the newborn.

In the absence of control over blood electrolytes, parenteral calcium administration is carried out starting from the end of the first day of life, in order to prevent early hypocalcemia. For this purpose, 10% solutions of calcium gluconate or calcium chloride are used, which contain 0.45 meq and 0.136 meq of elemental calcium in 1 ml, respectively. Parenteral administration of sodium begins from the moment adequate diuresis is established, administration of potassium begins on the 2nd-3rd day of life.

To ensure the physiological need for sodium, an isotonic (“physiological”) solution of sodium chloride can be added to a 10% glucose solution (1 ml contains 0.15 mEq of sodium).

To ensure the physiological need for potassium, 4 are used; 7.5 or 10% solutions of potassium chloride containing 0.6 in 1 ml; 1.0 and 1.5 mEq of potassium, respectively.

In the first 2-3 days of life, the need for magnesium is usually satisfied by parenteral administration of 0.2 ml/kg of a 25% solution of magnesium sulfate (if the drug is administered intravenously, it is necessary to dissolve it in 10-20 ml of a 10% glucose solution and slow rate of administration).

The physiological need for sodium is 2--3 mEq/kg/day (in children weighing less than 1000 g up to 4 mEq/kg/day), the physiological need for potassium is 1--2 mEq/kg/day (in children with a body weight of less than 1000 g 2--3 meq/kg/day), the need for calcium in most children is 0.45--0.9 meq/kg/day.

So, enteral nutrition in newborns with RDS is preferable.

In addition to meeting the child's needs for energy, fluid and basic nutritional ingredients, enteral nutrition, even in very small quantities, contributes to the normal functioning and maturation of the gastrointestinal tract, prevents atrophy of the intestinal mucosa, cholestasis, liver and pancreatic dysfunction, which can be observed during parenteral nutrition .

Content

There are several ways to deliver it to the body. medicines. Parenteral administration is a route in which the drug is delivered to tissues and organs, bypassing digestive tract(the literal translation of the term “parenteral” means “past the intestines”). These methods include all types of injections, including large-volume injections called infusions and inhalations.

Advantages of the parenteral route of administration

Parenteral administration medicines has a number of obvious advantages over oral administration similar drugs. These include the following factors:

It becomes possible to treat unconscious patients.
Ability to assist patients with severe vomiting and other dysfunctions digestive system when there is a risk of rejection of a drug taken orally.
Improved bioavailability active ingredients medications (increasing their absorption).
Advance speed therapeutic effect with parenteral administration it increases, which is especially important in critical conditions.
The ability to easily achieve constant therapeutic concentrations of drug components in the blood.
The use of drugs is available that are poorly absorbed when passing through the gastrointestinal tract or have an effect on it irritant effect; compounds that are destroyed by acids and enzymes gastric juice(for example, adrenaline or insulin).
Due to the large pores in the endothelial cell membrane, the rate of diffusion for some types of parenteral administration is independent of the lipid solubility of the drug.
The digestibility of the drug components does not depend on the meal schedule, exposure to gastric juice, bile, or digestive enzymes.
Parenteral nutrition of the body is an integral part of therapy for serious illnesses liver and kidneys.

Flaws

The main physiological complications after the procedures are necrosis, abscesses, individual allergic reactions. The parenteral route of drug administration is carried out medical personnel. The quality and safety of injections depends on compliance with the standards of instrument sterilization and hand disinfection, the qualifications of the specialist, and compliance with the rules and techniques for administering drugs. If these requirements are violated during the day after the administration procedure, the formation of an infiltrate with accompanying inflammation may be observed.

Another common complication of improper injection technique is an air or oil embolism—a small amount of air or oil entering a blood vessel. This condition can cause necrosis and provoke vein thrombosis. Regular insulin injections for diabetes mellitus contribute to the development of insulin lipodystrophy - atrophy or hypertrophy of the skin base at the sites of constant drug administration.

An unsterile or poorly processed instrument used during procedures can cause severe infection of the patient. viral disease(hepatitis, HIV (human immunodeficiency virus), etc.). Side effect parenteral infusion is endophlebitis - a form of inflammation venous wall, which develops due to damage to the inner lining of the vein or injury to the vessel after catheterization or prolonged stay of the needle in the cavity.

According to statistics, severe allergic reactions to a drug, for example, anaphylactic shock, with parenteral injections develop more often than after oral administration. Therefore, it is a strict contraindication to this method administration of a drug is intolerance by the patient to any component of its composition.

Kinds

Parenteral route of administration medications differentiated by the places through which the drug enters the systemic circulation. Injections into tissues are carried out intradermally (diagnostic), subcutaneously (the solution enters the subcutaneous blood vessels), intramuscularly (the drug enters the lymphatic and blood vessels in the muscle), intraosseously (the injection is carried out if intravenous or intramuscular administration is not possible).

Another method of parenteral administration is directly into the vessels (intravenous, intraarterial and lymphatic vessels). The latter type of injection is indicated in situations where it is necessary to avoid the passage of the drug through the liver and kidneys. In some clinical cases Direct administration of the drug into the cavities (abdominal, pleural, articular) is necessary. Individual special types parenteral administration are:

Intrathecal (subarachnoid or epidural) route: through cerebrospinal fluid.
Subconjunctival route: with local therapy eye diseases, through the conjunctiva of the eye.
Intranasal route: through the nasal cavity.
Intratracheal (inhalation): the method of inhaling vapors saturated with medicinal components through an inhaler.
Transdermal: penetration of the drug components occurs through the skin.

Algorithm for parenteral administration of drugs

Parenteral injections different types are carried out according to certain algorithms that ensure the safety and effectiveness of the procedures performed. These rules include the preparation of the patient, the doctor and the necessary equipment, the method of administering the injection, and a number of final measures after the end of the injection. For different drugs, the speed and technique of their administration differ.

Intravenous administration

Preparing for intravenous injection includes actions to comply with sanitary rules - washing and disinfecting the doctor’s hands, sterilizing gloves (if necessary), examining the drug ampoule, collecting the syringe, drawing the medicinal solution into it and placing the prepared instrument in a sterile tray. Then the patient is prepared for the injection, which consists of the following steps:

The patient's hand is placed on a hard, stationary surface.
Through examination, the doctor selects a vein for the injection.
A tourniquet is applied to the middle third of the shoulder, after which the patient needs to clench and unclench his fist three or four times so that the vein becomes clearly visible and can be easily felt with his fingers.

An intravenous injection is given according to a clear algorithm; only the speed of drug administration changes. The sequence of actions performed for this type of parenteral injection is as follows:

A cotton swab moistened with alcohol is used to treat the intended injection area and the areas of skin adjacent to it.
The cap is removed from the syringe needle, the syringe itself is taken in the right hand, index finger the cannula is fixed. The left hand clasps the patient's forearm, thumb The skin is stretched and the vein adheres. The patient must make a fist before inserting the needle.
The skin and vessel are punctured at an angle of 15°, then the needle is advanced 15 mm forward. With your left hand, pull the piston slightly, and blood should appear in the syringe (this means that the needle is inside the vein).
Then the tourniquet is removed with the left hand, the patient unclenches his palm, and after once again checking that the needle is in the vein, the doctor slowly presses the piston until the injection solution is completely administered.

When giving an injection medical worker should carefully monitor changes in the patient’s condition (pallor of the skin, dizziness, etc.). After the injection, the needle is quickly removed from the vein, and the puncture site is pressed with an alcohol-soaked cotton ball. The patient needs to sit for 7-10 minutes with his arm bent at the elbow. After this, no blood should appear at the injection site.

Subcutaneous

Algorithm for preparing for subcutaneous type parenteral administration is no different from intravenous administration. Hands and instruments are sterilized (if necessary), the ampoule is inspected, medicinal solution drawn into the syringe. The injection site and surrounding area are treated with alcohol. skin covering. The injection is carried out as follows:

With your left hand, the skin is gathered into a fold.
The needle is inserted at an angle of 45°, at the base of the fold, under the skin, to a depth of 15 mm.
Using the fingers of the hand that fixed the skin fold, the syringe plunger is slowly pressed.
After completing the administration of the drug, the needle is removed and an alcohol-soaked cotton ball is applied to the injection site.

Intramuscular

Preparing for intramuscular parenteral administration is carried out according to a similar algorithm. The patient lies face down on the couch, and a site is selected for the injection on the upper part of the gluteal muscle. It is treated with alcohol. The injection is carried out according to the following rules:

The syringe holds right hand, use your left fingers to slightly stretch the skin at the site of the future puncture.
With a sharp movement the needle is inserted into gluteal muscle approximately 2/3 of its length, at an angle of 90°.
With your left hand, check whether it has hit the muscle - slightly pull the piston towards you, there should be no blood.
The drug is administered, the puncture site is sterilized with an alcohol-soaked cotton swab.

Intra-arterial

To perform an intra-arterial injection, arteries located close to the surface of the skin are selected - cervical, elbow, axillary, radial or femoral. Preparation for injection is carried out according to general rules. The injection point is determined by the doctor in the area of greatest pulsation. The skin and artery are punctured according to the same rules as with an intravenous injection, in the direction of the arterial flow. After the procedure is completed, a pressure bandage is applied to the puncture site for several minutes.

Intrathecal

Parenteral administration medical supplies into the cerebrospinal fluid is complex and painful procedure, in which the patient lies on his side with his legs tucked to his stomach and his head to his chest. The injection site is selected between the vertebrae lumbar region, it is not only treated with an antiseptic, but also anesthetized using local analgesics method subcutaneous injection. The needle is inserted directly into the spinal canal; after the procedure, the patient must remain motionless for 20-30 minutes.

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Interest in nutritional issues for surgical patients has been stimulated over the past two decades by advances in enteral and parenteral nutrition. The most significant milestone along this path was undoubtedly the introduction of parenteral nutrition into clinical practice, which forced doctors to pay attention to the peculiarities of the course of the disease, reduced by nutrition. Issues of nutritional needs continue to be constantly redefined to this day as treatment problems develop. various types pathology.

In the United States, the highest incidence of malnutrition occurs among inpatients, which undoubtedly has a negative impact on their recovery. Particularly severe nutritional changes, particularly protein malnutrition, often occur after injury and major surgery.

Nutrition issues for children, compared to adults, present a complex problem, which is associated with the special specific needs of a growing body, most pronounced in infants. Therefore, it is for younger children age group will be the subject of this chapter.

Physiological needs

Water is absolutely necessary for the existence of the body and is second in importance only to oxygen. Lack of water leads to death within a few days. Its content in the body of infants is higher than in adults (75% of body weight, in adults - 65%) (Fig. 2-l).

Rice. 2-1. Total water (OBT - total body sex) and extracellular fluid (ECF) in the body decreases; as the child grows, the amount of extracellular fluid (ECF) increases.

The main reserves of water are contained in organ fluids, but part of it is provided through the oxidation processes of food and tissues. An infant needs significantly more water per unit of body weight than an adult. If you count water per 100 kilocalories received, then the required amount will be the same for children and adults (Table 2-1).

Table 2-1. Daily fluid requirements

Daily fluid intake healthy child equals 10-15% of body weight, while in an adult it is only 2-4% of BW. In addition, the food consumed by children contains much more water than the poverty of adults. The fruits and vegetables that are usually included in a child’s diet consist of almost 90% water. However, only 0.5-3% of the fluid children receive is retained in the body, while about 50% is excreted by the kidneys, 3-10% by the gastrointestinal tract, and 40-50% is part of intangible losses.

Kilocalories. The energy needs of children vary significantly depending on age and a number of other circumstances (Table 2-2). Fine balanced diet should include 15% protein, 35% fat and 50% carbohydrates. An adult needs 150 non-protein kilocalories for every gram of nitrogen received.

Table 2-2. Energy and protein requirements

Protein requirements increase in states of stress and injury, but it is not yet known what the ratio of non-protein kilocalories to nitrogen should be in this case. The studies carried out showed one thing for sure - in young children after large operations this ratio should be at least 230:1.

Squirrels. The protein requirements of infants are determined by the need not only to maintain the body, but also to grow. Proteins make up 20% of an adult’s body weight, nitrogen makes up 2% of an adult’s body weight. small child and 3% in adults.

The greatest increase in nitrogen content in the body occurs during the first year of life. Nutritional value Protein is determined by its content not only of nitrogen, but also of amino acids. Of the 20 known amino acids, 9 are essential, i.e. necessary infant(Table 2-3).

Table 2-3. Essential amino acids

New tissue cannot be formed in the body unless all essential amino acids are supplied at the same time. The absence of even one of them leads to a negative nitrogen and protein balance. The total level of plasma proteins varies in healthy children from 60 to 75 g/l, with slightly more low performance in newborns and premature infants.

Carbohydrates. The largest portion of energy needs is provided by carbohydrates, the reserves of which consist mainly of glycogen in the liver and muscles. However, since infant The relative mass of the liver and muscles is significantly less than in an adult, and glycogen reserves are significantly reduced compared to adults. Glycogen is converted to glucose in the liver and then converted in tissues, either anaerobically into lactic acid or aerobically into carbon dioxide and water. Aerobic metabolism produces significantly more energy in the form of adenosine triphosphate (ATP).

Fats are another significant source of non-protein calories. Fats, both in the body and from food, consist mainly of simple lipids, mainly glycerides. Natural fats contain fatty acids, saturated and unsaturated.

The human body does not synthesize linoleic acid, so it is considered essential and, accordingly, should be contained in food. Its deficiency is manifested by dryness and thickening of the skin with typical rashes and peeling. If a child receives 1-2% of kilocalories in the form of linoleic acid, linoleic acid deficiency does not occur.

The question of the need for linolenic acid for the body continues to remain controversial, although children on long-term parenteral nutrition with fat emulsions containing 78% linoleic acid and only 0.5% linolenic acid may develop neurological disorders that can be stopped by the administration of emulsions containing 54% linoleic acid. acid and 8% linolenic.

Minerals and vitamins. A rapidly growing child needs more minerals than an adult, especially phosphorus and calcium. The mineral content in the fetal body is low, at the time of birth they make up only 3% of body weight, gradually increasing throughout childhood. At the same time, both the absolute and relative amount of minerals increases, as a result, in an adult there are 40 times more of them than in a newborn, while the body weight of an adult is only 23 times higher than the BW of a newborn. For every gram of protein, about 0.3 grams of minerals are deposited in the body.

The most important electrolytes required for the body are calcium, magnesium, potassium, sodium, phosphorus, sulfur, chlorine (Table 2-4). Iron, iodine and cobalt are present in the body as part of various organic complexes. As for microelements, the nature of participation in the metabolism of some of them is known, for example fluorine, copper, zinc, manganese. At the same time, selenium, silicon, boron, nickel, aluminum, arsenic, molybdenum and strontium are required for the body, but their specific metabolic effects have not been sufficiently studied (Table 2-5).

Vitamins for normal cellular metabolism are required in minimal quantities. They must be supplied wholly or partly from outside. B vitamins act as coenzymes in various biochemical reactions, but the specific type of action of other vitamins is not yet well known. Fat-soluble vitamins include A, D, K and E; water-soluble vitamins include thiamine, riboflavin, folic acid, vit. AT 12. pyridoxine, a nicotinic acid, biotin, pantothenic acid and vit. C. Since a person has reserves fat-soluble vitamins, their excessive administration can cause various disorders. In addition, impaired fat absorption leads to a deficiency of fat-soluble vitamins (Table 2-6).

K.U. Ashcraft, T.M. Holder

In the postoperative period, the body's need for proteins, fats, carbohydrates, electrolytes and vitamins is provided enterally, including nutrition through a tube inserted into the stomach or duodenum, gastro- or jejunostomy, and parenterally - mainly intravenously. Enteral nutrition is always more complete, so at the slightest opportunity they switch to oral nutrition, at least partially.

Enteral nutrition in the postoperative period should ensure maximum sparing of the affected organs, especially during operations on the gastrointestinal tract, increase its resistance to inflammation and intoxication, and promote faster healing surgical wound. After major organ surgeries abdominal cavity Fasting is prescribed for 1-2 days (mouth rinsing is allowed). In the future, they gradually begin to give the most gentle food (liquid, semi-liquid, pureed), containing a sufficient amount of liquid, easily digestible proteins, fats, carbohydrates, mineral salts and vitamins.

To prevent flatulence, exclude milk and vegetable fiber.

After gastrectomy, on the 2nd day in the afternoon, you are allowed to drink 250 ml of liquid in sips. On the 3rd day, give 2 glasses of liquid (fruit drink, broth, water) and a raw egg. From the 4th day, table No. lac is prescribed, with the exception of dishes with milk.

After total removal of the stomach parenteral nutrition carried out for 3-4 days. If the nipple probe is left, enteral fluid administration is prescribed from the 2-3rd day after the restoration of peristalsis. From 4-5 days the patient is transferred to enteral nutrition. In this case, on the first day they give you 1 teaspoon of 200 ml of boiled water to drink. In the future, nutrition is expanded according to the scheme recommended for patients who have undergone gastrectomy.

After uncomplicated operations on biliary tract You are allowed to drink on the first day. From the 2nd day, table No. 5a is prescribed.

After resection of the colon, the patient is allowed to drink in small sips on the first day after surgery. From the 2nd day, table No. 0 is prescribed without bread (mucous pureed soups, weak broth, jelly, rosehip infusion, tea with milk). On the 5th day, the patient is transferred to surgical table No. 1 with white breadcrumbs. These schemes are sometimes changed depending on the course of the postoperative period.

Tube enteral feeding is carried out according to special indications. It can be used as a method postoperative preparation patients, for example, with pyloroduodenal stenosis, after endoscopic passage of the probe beyond the area of narrowing, preferably into the initial part of the jejunum; after total removal of the stomach; after gastric resection, complicated by failure of the stump sutures duodenum.

During the period of preoperative preparation, the tube diet can be quite broad: cream, broth, eggs, sour cream, juices, cottage cheese diluted with milk.

After an operation, for example a gastrectomy, on the 2nd day after the nipple probe carried out during the operation, 60 ml is inserted into the jejunum below the anastomosis hypertonic solution sodium chloride and 20 ml Vaseline oil. After 30 minutes, when peristalsis appears, 2 raw eggs, after another 3 hours - 250 ml of broth and 50 g butter. After 3 hours - two eggs, cream (milk) up to 250 ml. After 3 hours - 250 ml of fruit drink (compote, dried apricot infusion).

Thus, already on the first day of enteral nutrition (2nd day after gastrectomy), the patient receives up to 850 ml of fluid. On the 3-4th day, the amount of simultaneously administered liquid can be increased to 300 - 350 ml. In total, up to 1.5-2 liters are administered per day, including enpits - specially developed food mixtures for enteral nutrition.

Parenteral nutrition is indicated if the patient cannot eat normally or if oral nutrition does not meet the metabolic needs of the body. Parenteral nutrition can be complete when it provides the body’s daily energy needs and the need for water, electrolytes, nitrogen, vitamins, and incomplete when it selectively replenishes the body’s deficiency in certain nutritional ingredients. In normal clinical conditions, when it is not possible to quickly and accurately determine the level of actual metabolism based on oxygen consumption, when determining the volume of parenteral nutrition, it is advisable to be guided by the following provisions.

Constant monitoring of the effectiveness of parenteral nutrition is necessary. Its main criteria are: change in body weight, nitrogen balance, amount of total circulating albumin, A/G ratio. The best criterion for the adequacy of parenteral nutrition is the patient's condition.

The procedure for examining patients on parenteral nutrition.

3. Plasma osmolarity is examined during the first 3-4 days, then 2 times a week.

6. General analysis blood and urine every 3 days.

7. Weigh the patient daily: for this purpose, use special electronic scales or bed scales.

TICKET No. 10

1. PPKOVMOLPGK Indications, preparation for surgery, choice of method surgical treatment for acute gastroduodenal bleeding.

Organization proper nutrition always contributes quick recovery patient. This is due to the fact that the body begins to receive sufficient quantities of substances that are required for the cellular restoration of pathologically altered organs. If necessary, parenteral nutrition can be used. If the functions of the digestive system are preserved, then enteral nutrition of patients is used.

Among patients admitted to hospitals, 20-40% have low nutrition. Importantly, the trend towards worsening malnutrition is clearly evident during the period of hospitalization. Currently, there is no “gold standard” for assessing a person’s nutritional level: all approaches characterize the outcome (“what happened”), and not individual nutritional parameters. Clinicians need a method to help recognize, evaluate, and treat protein malnutrition, as well as other nutritional deficiencies, on a nutritional basis.

Loss of body weight in 1 month. by more than 10%.

Body mass index is less than 20 kg/m2.

Inability to eat for more than 5 days.

Methodology for providing auxiliary nutrition

Enteral tube feeding

Assisted enteral tube feeding in small sips through a tube. For patients with severe fluid loss, enterostomies with copious discharge and short bowel syndrome, many methods of rehydration therapy have been developed. Special nutritional mixtures include preparations with one nutrient (for example, protein, carbohydrate or fat), elemental (monomeric), polymer, and also intended for the treatment of a specific pathology.

Feeding through a tube or enterostomy. When the gastrointestinal tract remains functional but the patient is unable or will not be able to feed by mouth in the near future, this approach provides significant benefits. There are a number of methods: nasogastric, nasojejunal, gastrostomy, jejunostomy feeding. The choice depends on the doctor’s experience, prognosis, approximate duration of the course and what suits the patient best.

Soft nasogastric tubes may not be removed for several weeks. If nutrition will have to be provided for longer than 4-6 weeks, percutaneous endoscopic gastrostomy surgery is indicated.

Feeding the patient through a tube

Feeding through a nasojejunal tube is sometimes prescribed for patients with gastroparesis or pancreatitis, but this method does not guarantee protection against aspiration, and errors in the insertion of the tube are possible. Nutrient mixture It is always better to administer as a long-term drip rather than as a bolus (boluses can cause reflux or diarrhea). Feeding the patient through a tube should be carried out under the supervision of nursing staff.

If enterostomy is necessary, preference is usually given to the technique of percutaneous endoscopic gastrostomy, although surgical placement of a gastrostomy or placement under X-ray guidance is often resorted to. A jejunal tube can be inserted over a guidewire through an existing gastrostomy tube or through independent surgical access.

Widespread use endoscopic method The installation of a gastrostomy tube has greatly facilitated the care of patients with disabling diseases, such as progressive neuromuscular pathology, including strokes. The procedure involves relatively frequent complications Therefore, it is necessary that it be performed by an experienced specialist.

Enteral nutrition

A sick person eats more if he is helped during meals and if he has the opportunity to eat what he wants. The patient’s wish that relatives and friends bring him food should not be contradicted.

Preference should be given to enteral nutrition, since drugs containing all nutrients have not yet been created. Moreover, some food components can enter the human body only through the enteral route (for example, short-chain fatty acids for the mucous membrane colon supplied by the breakdown of fibers and hydrocarbons by bacteria).

Parenteral nutrition is fraught with complications associated with bacterial contamination of systems for administering solutions

Parenteral nutrition

Access via peripheral or central veins. Parenteral nutrition, if carried out incorrectly, is fraught with the development life-threatening complications.

Using modern drugs For parenteral nutrition, catheters installed in peripheral veins can only be used a short time(up to 2 weeks). The risk of complications can be minimized by carefully performing the catheterization procedure, observing all rules of asepsis and using nitroglycerin patches. If the central catheter must be inserted through a peripheral access, the medial saphenous vein of the arm should be used at the level of the cubital fossa (introduction of the catheter through the lateral saphenous vein should be avoided). saphenous vein arm, as it connects to the axillary vein at an acute angle, which may make it difficult to advance the catheter beyond this point).

Principles of parenteral nutrition

In conditions where there remains too short a section of the intestine capable of absorbing nutrients (the small intestine is less than 100 cm in length or less than 50 cm with a intact colon), parenteral nutrition is necessary. The following describes the principles of parenteral nutrition for patients.

Shown when intestinal obstruction unless it is possible to endoscopically pass an enteral feeding tube through a narrowed portion of the esophagus or duodenum.

Shown when severe sepsis if it is accompanied by intestinal obstruction.

External fistula small intestine with abundant secretion, which sharply limits the process of food absorption in the intestines, making parenteral nutrition necessary.

Patients with chronic intestinal pseudo-obstruction require parenteral nutrition.

Calculating nutritional needs and choosing a diet

When the patient's body temperature increases by 1 degree Celsius, the needs increase by 10%. Should be considered physical activity sick. Changes are made to the calculations accordingly:

Unconscious - basal metabolism.
At artificial ventilation lungs: -15%.
Conscious, activity within bed: +10%.
Physical activity within the ward: + 30%.

If it is necessary for the patient’s body weight to increase, add another 600 kcal per day.

Protein parenteral nutrition

The average protein requirement is calculated using nitrogen in grams (g N) per day:

9 g N per day - for men;
7.5 g N per day - for women;
8.5 g N per day - for pregnant women.

It is necessary to provide complete protein parenteral nutrition to patients. A person’s energy expenditure often increases during illness. So, in providing nitrogen to the maximum, i.e. 1 g N for every 100 kcal is required for patients with burns, sepsis and other pathologies characterized by increased catabolism. The situation is controlled by monitoring nitrogen excretion with urea.

Carbohydrates

Glucose is almost always the dominant source of energy. It is necessary for blood cells bone marrow, kidney and other tissues. Glucose is the main energy substrate that powers the brain. The infusion rate of glucose solution is usually maintained at a level of no more than 4 ml/kg per minute.

Fats

Lipid emulsions act as energy suppliers as well as necessary for the body fatty acids, including linoleic and lenolenic. No one can accurately say the percentage of calories that should enter the body in the form of fats, but they believe that at least 5% of the total calories should be provided by lipids. Otherwise, fatty acid deficiency will develop.

Electrolyte requirements

The number of millimoles of required sodium ions is determined by body weight and this figure is considered as a base figure. You need to add the registered losses to it.

The basic need for potassium is also determined taking into account body weight in kilograms - the number of millimoles/24 hours. Calculated losses are added to it:

Calcium - 5-10 mmol per day.
Magnesium - 5-10 mmol per day.
Phosphates - 10-30 mmol per day.
Vitamins and microelements.