Calculation of parenteral nutrition. Parenteral nutrition. Parenteral nutrition for cancer patients

Artificial nutrition is today one of the basic types of treatment for patients in a hospital. There is practically no field of medicine in which it would not be applied. The most important is the use of artificial nutrition (or artificial nutritional support) for surgical, gastroenterological, oncological, nephrological and geriatric patient populations.

Nutritional support- a set of therapeutic measures aimed at identifying and correcting violations of the nutritional status of the body using methods of nutritional therapy (enteral and parenteral nutrition). It is the process of providing the body with food substances (nutrients) using methods other than normal food intake.

“The doctor's failure to provide food for the patient should be seen as a decision to starve him to death. A solution for which in most cases it would be difficult to find an excuse "- wrote Arvid Vretlind.

Timely and adequate nutritional support can significantly reduce the incidence of infectious complications and mortality in patients, improve the quality of life of patients and accelerate their rehabilitation.

Artificial nutritional support can be complete, when all (or most) of the patient's nutritional needs are provided artificially, or partial, if the introduction of nutrients by enteral and parenteral routes is additional to the usual (oral) nutrition.

There are many indications for artificial nutritional support. In general, they can be described as any disease in which the patient's need for nutrients cannot be met naturally. Usually these are diseases of the gastrointestinal tract, which do not allow the patient to eat adequately. Also, artificial nutrition may be necessary for patients with metabolic problems - severe hypermetabolism and catabolism, high loss of nutrients.

The rule of thumb is "7 days or weight loss by 7%" is widely known. It means that artificial nutrition should be carried out in cases when the patient cannot eat naturally for 7 days or more, or if the patient has lost more than 7% of the recommended body weight.

Evaluation of the effectiveness of nutritional support includes the following indicators: dynamics of parameters of nutritional status; state of nitrogen balance; the course of the underlying disease, the state of the surgical wound; the general dynamics of the patient's condition, the severity and course of organ dysfunction.

There are two main forms of artificial nutritional support: enteral (tube) and parenteral (intravascular) nutrition.

• Features of human metabolism during fasting

  The primary reaction of the body in response to the cessation of the supply of nutrients from the outside is to use glycogen and glycogen stores as an energy source (glycogenolysis). However, the storage of glycogen in the body is usually not large and is depleted within the first two to three days. In the future, the structural proteins of the body (gluconeogenesis) become the easiest and most accessible source of energy. In the process of gluconeogenesis, glucose-dependent tissues produce ketone bodies, which, according to a feedback reaction, slow down the basal metabolism and begin the oxidation of lipid stores as an energy source. Gradually, the body goes into a protein-saving mode of functioning, and gluconeogenesis is resumed only when fat reserves are completely depleted. So, if in the first days of fasting the loss of protein is 10-12 g per day, then in the fourth week - only 3-4 g in the absence of pronounced external stress.

  In critically ill patients, there is a powerful release of stress hormones - catecholamines, glucagon, which have a pronounced catabolic effect. In this case, the production is disrupted or the response to such hormones with an anabolic effect as growth hormone and insulin is blocked. As is often the case in critical conditions, the adaptive response to break down proteins and provide the body with substrates to build new tissue and heal wounds gets out of control and becomes purely destructive. Catecholaminemia slows down the body's transition to using fat as an energy source. In this case (with severe fever, polytrauma, burns), up to 300 g of structural protein can be burned per day. This condition was called autocaniballism. Energy costs increase by 50-150%. For a while, the body can maintain its needs for amino acids and energy, however, protein reserves are limited and the loss of 3-4 kg of structural protein is considered irreversible.

  The fundamental difference between physiological adaptation to starvation from adaptive reactions in terminal states is that in the first case, an adaptive decrease in energy demand is noted, and in the second, energy consumption increases significantly. Therefore, in post-aggressive states, a negative nitrogen balance should be avoided, since protein depletion ultimately leads to death, which occurs when more than 30% of the total nitrogen of the body is lost.

  • Gastrointestinal tract during fasting and in critical condition

    In critical conditions of the body, conditions often arise under which adequate perfusion and oxygenation of the gastrointestinal tract is impaired. This leads to damage to the cells of the intestinal epithelium with impaired barrier function. Disturbances are aggravated if there are no nutrients in the lumen of the gastrointestinal tract for a long time (during fasting), since the cells of the mucous membrane receive nutrition largely directly from the chyme.

    Any centralization of blood circulation is an important factor damaging the digestive tract. With the centralization of blood circulation, there is a decrease in the perfusion of the intestine and parenchymal organs. In critical conditions, this is further aggravated by the frequent use of adrenomimetic drugs to maintain systemic hemodynamics. In terms of time, the restoration of normal intestinal perfusion lags behind the restoration of normal perfusion of vital organs. The absence of chyme in the intestinal lumen disrupts the entry of antioxidants and their precursors into enterocytes and aggravates reperfusion lesions. The liver, due to autoregulatory mechanisms, suffers somewhat less from a decrease in blood flow, but its perfusion also decreases.

    During fasting, microbial translocation develops, that is, the penetration of microorganisms from the lumen of the gastrointestinal tract through the mucous barrier into the blood or lymph flow. Basically, Escherihia coli, Enterococcus and bacteria of the genus Candida are involved in translocation. In certain quantities, microbial translocation is always present. Bacteria penetrating into the submucosa are captured by macrophages and transported to the systemic lymph nodes. When they enter the bloodstream, they are captured and destroyed by the Kupffer's cells in the liver. A stable balance is disturbed with uncontrolled growth of the intestinal microflora and changes in its normal composition (i.e., with the development of dysbiosis), impaired mucosal permeability, and impaired local intestinal immunity. It has been proven that microbial translocation occurs in critically ill patients. It is exacerbated by risk factors (burns and severe trauma, systemic broad-spectrum antibiotics, pancreatitis, hemorrhagic shock, reperfusion injury, exclusion of solid foods, etc.) and is often the cause of infectious disease in critically ill patients. In the United States, 10% of those hospitalized develop nosocomital infection. This is 2 million people, 580 thousand deaths and the cost of treatment is about 4.5 billion dollars.

    Disorders of the intestinal barrier function, expressed in mucosal atrophy and impaired permeability, develop early enough in critically ill patients and are already expressed on the 4th day of fasting. Many studies have shown the beneficial effect of early enteral nutrition (the first 6 hours from admission) to prevent mucosal atrophy.

    In the absence of enteral nutrition, not only atrophy of the intestinal mucosa occurs, but also atrophy of the so-called gut-associated lymphoid tissue (GALT). These are Peyer's patches, mesenteric lymph nodes, lymphocytes of the epithelium and basement membrane. Maintaining normal gut nutrition helps to maintain a healthy immune system throughout the body.

• Nutritional support principles

  One of the founders of the theory of artificial nutrition, A. Wretlind, formulated the principles of nutritional support:

  • Timeliness.

    Artificial nutrition should be started as early as possible, even before the development of nutritional disorders. You cannot wait for the development of protein-energy malnutrition, since cachexia is much easier to prevent than to cure.

  • Optimality.

    Artificial nutrition should be carried out until the nutritional status is stabilized.

  • Adequacy.

    Nutrition should cover the energy needs of the body and be balanced in terms of the composition of nutrients and meet the needs of the patient in them.

• Enteral nutrition

  Enteral nutrition (EN) is a type of nutritional therapy in which nutrients are administered orally or through a gastric (intraintestinal) tube.

  Enteral nutrition is a form of artificial nutrition and, therefore, is not carried out through natural routes. Enteral feeding requires one or another access, as well as special devices for the introduction of nutritional mixtures.

  Some authors refer to enteral nutrition only methods that bypass the oral cavity. Others include oral nutrition with mixtures other than regular food. In this case, there are two main options: tube feeding - the introduction of enteral mixtures into a tube or stoma, and sipping (sip feeding) - oral intake of a special mixture for enteral feeding in small sips (usually through a tube).

  • Benefits of enteral nutrition

    Enteral nutrition has several advantages over parenteral nutrition:

    • Enteral nutrition is more physiological.
    • Enteral nutrition is more economical.
    • Enteral nutrition practically does not cause life-threatening complications, does not require compliance with strict sterility conditions.
    • Enteral nutrition makes it possible to provide the body with the necessary substrates to a greater extent.
    • Enteral nutrition prevents the development of atrophic processes in the gastrointestinal tract.
  • Indications for enteral nutrition

    Indications for EP are almost all situations when it is impossible for a patient with a functioning gastrointestinal tract to meet the protein and energy needs in the usual, oral way.

    The global trend is the use of enteral nutrition in all cases when it is possible, if only because its cost is much lower than that of parenteral nutrition, and the effectiveness is higher.

    For the first time, the indications for enteral nutrition were clearly formulated by A. Wretlind, A. Shenkin (1980):

    • Enteral nutrition is indicated when the patient cannot eat food (lack of consciousness, impaired swallowing, etc.).
    • Enteral nutrition is indicated when the patient should not eat food (acute pancreatitis, gastrointestinal bleeding, etc.).
    • Enteral nutrition is indicated when the patient does not want to eat food (anorexia nervosa, infections, etc.).
    • Enteral nutrition is indicated when the usual nutrition is not adequate to the needs (trauma, burns, catabolism).

    According to the "Instructions for the organization of enteral nutrition ..." of the Ministry of Health of the Russian Federation, the following nosological indications for the use of enteral nutrition are distinguished:

    • Protein-energy malnutrition when it is impossible to provide an adequate intake of nutrients by the natural oral route.
    • Neoplasms, especially those localized in the head, neck and stomach.
    • Disorders of the central nervous system: coma, cerebrovascular stroke or Parkinson's disease, as a result of which nutritional disorders develop.
    • Radiation and chemotherapy for cancer.
    • Diseases of the gastrointestinal tract: Crohn's disease, malabsorption syndrome, short bowel syndrome, chronic pancreatitis, ulcerative colitis, liver and biliary tract diseases.
    • Nutrition in the pre- and early postoperative periods.
    • Trauma, burns, acute poisoning.
    • Complications of the postoperative period (fistulas of the gastrointestinal tract, sepsis, incompetence of the anastomoses sutures).
    • Infectious diseases.
    • Mental disorders: anorexia nervosa, severe depression.
    • Acute and chronic radiation injuries.
  • Contraindications to enteral nutrition

    Enteral nutrition is a technique that is being intensively researched and used in an increasingly diverse group of patients. There is a breaking of stereotypes about compulsory fasting in patients with operations on the gastrointestinal tract, in patients immediately after recovery from a state of shock, and even in patients with pancreatitis. As a result, there is no consensus on the absolute contraindications for enteral nutrition.

    Absolute contraindications to enteral nutrition:

    • Clinically pronounced shock.
    • Intestinal ischemia.
    • Complete intestinal obstruction (ileus).
    • Refusal of the patient or his guardian from enteral nutrition.
    • Continued gastrointestinal bleeding.

    Relative contraindications to enteral nutrition:

    • Partial bowel obstruction.
    • Severe, indomitable diarrhea.
    • External small bowel fistulas with discharge of more than 500 ml / day.
    • Acute pancreatitis and pancreatic cyst. However, there are indications that enteral nutrition is possible even in patients with acute pancreatitis with the distal position of the probe and the use of elemental diets, although there is no consensus on this issue.
    • A relative contraindication is also the presence of large residual volumes of food (feces) in the intestine (in fact, intestinal paresis).
  • General recommendations for enteral nutrition
    • Enteral nutrition should be given as early as possible. Conduct food through a nasogastric tube, if there are no contraindications to this.
    • Enteral feeding should be started at a rate of 30 ml / hour.
    • It is necessary to determine the residual volume as 3 ml / kg.
    • It is necessary to aspirate the contents of the probe every 4 hours and if the residual volume does not exceed 3 ml / hour, then gradually increase the feeding rate until the calculated one is reached (25-35 kcal / kg / day).
    • In cases where the residual volume exceeds 3 ml / kg, then prokinetic treatment should be prescribed.
    • If after 24-48 hours, due to high residual volumes, it is not yet possible to adequately feed the patient, then a probe should be inserted into the ileum by a blind method (endoscopically or under X-ray control).
    • It should be suggested to the enteral feeding nurse that if she is unable to administer it properly, it means that she cannot provide the patient with proper care at all.
  • When to start enteral feeding

    The literature mentions the benefits of “early” parenteral nutrition. The data are given that in patients with multiple injuries, enteral nutrition was started immediately after stabilization of the condition, in the first 6 hours from admission. In comparison with the control group, when feeding began after 24 hours from admission, a less pronounced violation of the permeability of the intestinal wall and less pronounced multiple organ disorders were noted.

    In many resuscitation centers, the following tactics have been adopted: enteral feeding should begin as early as possible - not only with the aim of immediately replenishing the patient's energy consumption, but in order to prevent changes in the intestine, which can be achieved by enteral nutrition with relatively small amounts of food introduced. ...

    Theoretical substantiation of early enteral nutrition.

    Lack of enteral nutrition leads to:
    Mucosal atrophy.	Proven in animal experiments.
    Excessive colonization of the small intestine.	Enteral nutrition prevents this experimentally.
    Translocation of bacteria and endotoxins into the portal circulation.	In humans, there is a violation of the permeability of the mucous membrane during burns, trauma and in critical conditions.

  • Enteral feeding regimens

    The choice of diet is determined by the patient's condition, underlying and concomitant pathology and the capabilities of the medical institution. The choice of the method, volume and speed of EP are determined individually for each patient.

    There are the following modes of enteral nutrition:

    • Food at a constant rate.

      Feeding through a gastric tube begins with isotonic mixtures at a rate of 40-60 ml / h. If tolerated, the feed rate can be increased by 25 ml / h every 8–12 hours until the desired rate is reached. When feeding through a jejunostomy tube, the initial rate of administration of the mixture should be 20-30 ml / h, especially in the immediate postoperative period.

      In case of nausea, vomiting, convulsions or diarrhea, it is necessary to reduce the rate of administration or the concentration of the solution. At the same time, a simultaneous change in the rate of feeding and the concentration of the nutrient mixture should be avoided.

    • Cyclic food.

      Continuous drip is gradually "squeezed" until a 10-12 hour night period. Such food, convenient for the patient, can be carried out through a gastrostomy tube.

    • Periodic, or session meals.

      Meals in sessions of 4-6 hours are carried out only in the absence of a history of diarrhea, malabsorption syndrome and operations on the gastrointestinal tract.

    • Bolus feeding.

      Mimics normal food intake, so it allows the gastrointestinal tract to function more naturally. It is performed only with transgastric approaches. The mixture is injected drip or syringe at a rate of no more than 240 ml for 30 minutes 3-5 times a day. The initial bolus should not exceed 100 ml. With good tolerance, the injected volume is increased daily by 50 ml. Diarrhea is more common with bolus feeding.

    • Usually, if the patient has not received food for several days, continuous drip infusion of mixtures is preferable to periodic. Continuous 24-hour nutrition is best used in cases where there are doubts about the safety of the functions of digestion and absorption.
  • Enteral formula

    The choice of a mixture for enteral nutrition depends on many factors: the disease and the general condition of the patient, the presence of disorders of the patient's digestive tract, the necessary enteral nutrition regimen.

    • General requirements for enteral mixtures.
      • The enteral mixture must have a sufficient energy density (at least 1 kcal / ml).
      • The enteral mixture should be free of lactose and gluten.
      • The enteral mixture should have a low osmolarity (no more than 300-340 mosm / l).
      • The enteral mixture should have a low viscosity.
      • The enteral mixture should not overstimulate intestinal motility.
      • Enteral formula should contain sufficient information about the composition and manufacturer of the nutritional formula, as well as indications of the presence of genetic modification of nutrients (proteins).

    None of the TPS mixtures contains enough free water to meet the patient's daily fluid requirement. The daily fluid requirement is usually estimated as 1 ml per kcal. Most formulas with an energy value of 1 kcal / ml contain approximately 75% of the required water. Therefore, in the absence of indications for fluid restriction, the amount of additional water consumed by the patient should be approximately 25% of the total nutrition.

    Currently, mixtures prepared from natural products or recommended for baby food are not used for enteral nutrition due to their imbalance and inadequacy to the needs of adult patients.

  • Complications of enteral nutrition

    Prevention of complications is strict adherence to the rules of enteral nutrition.

    The high incidence of complications of enteral nutrition is one of the main limiting factors of its widespread use in critically ill patients. The presence of complications leads to frequent cessation of enteral nutrition. There are quite objective reasons for such a high incidence of complications of enteral nutrition.

    • Enteral nutrition is carried out in a severe category of patients, with damage to all organs and systems of the body, including the gastrointestinal tract.
    • Enteral nutrition is necessary only for those patients who already have an intolerance to natural nutrition for various reasons.
    • Enteral nutrition is not natural nutrition, but artificial, specially prepared mixtures.
    • Classification of complications of enteral nutrition

      There are the following types of complications of enteral nutrition:

      • Infectious complications (aspiration pneumonia, sinusitis, otitis media, wound infection during gastroenterostomy).
      • Gastrointestinal complications (diarrhea, constipation, bloating, regurgitation).
      • Metabolic complications (hyperglycemia, metabolic alkalosis, hypokalemia, hypophosphatemia).

      This classification does not include complications associated with the technique of enteral feeding - self-extraction, migration, and blockage of feeding tubes and tubes. In addition, such a gastrointestinal complication as regurgitation may coincide with such an infectious complication as aspiration pneumonia. starting with the most frequent and significant ones.

      The literature indicates the incidence of various complications. The wide scatter of data is explained by the fact that unified diagnostic criteria have not been developed to determine a particular complication and there is no single protocol for managing complications.

      • High residual volumes - 25% -39%.
      • Constipation - 15.7% With prolonged enteral feeding, the frequency of constipation can increase up to 59%.
      • Diarrhea - 14.7% -21% (from 2 to 68%).
      • Bloating - 13.2% -18.6%.
      • Vomiting - 12.2% -17.8%.
      • Regurgitation - 5.5%.
      • Aspiration pneumonia - 2%. According to various authors, the frequency of aspiration pneumonia is indicated from 1 to 70 percent.
  • About sterility with enteral nutrition

    One of the advantages of enteral nutrition over parenteral nutrition is that it is not necessarily sterile. However, it must be remembered that, on the one hand, enteral nutrition mixtures are an ideal breeding ground for microorganisms and, on the other hand, there are all conditions for bacterial aggression in intensive care units. The danger is both the possibility of infection of the patient with microorganisms from the nutrient mixture, and poisoning with the resulting endotoxin. It should be taken into account that enteral nutrition is always carried out bypassing the bactericidal barrier of the oropharynx and, as a rule, enteral mixtures are not treated with gastric juice, which has pronounced bactericidal properties. As other factors accompanying the development of infection, antibiotic therapy, suppression of immunity, concomitant infectious complications, etc. are called.

    The usual recommendations for preventing bacterial contamination are to use a volume of prepared on-site mixture of no more than 500 ml. And their use for no more than 8 hours (for sterile factory solutions - 24 hours). Practically in the literature there are no experimentally substantiated recommendations on the frequency of replacement of probes, bags, droppers. It seems reasonable that for droppers and bags this should be at least once every 24 hours.

• Parenteral nutrition

  Parenteral nutrition (PN) is a special type of substitution therapy, in which nutrients are introduced into the body to replenish energy, plastic costs and maintain a normal level of metabolic processes, bypassing the gastrointestinal tract directly into the internal environment of the body (as a rule, into the vascular bed) ...

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

  • Classification of parenteral nutrition
    • Complete (total) parenteral nutrition.

      Full (total) parenteral nutrition provides the entire volume of the body's daily need for plastic and energy substrates, as well as maintaining the required level of metabolic processes.

    • Incomplete (partial) parenteral nutrition.

      Incomplete (partial) parenteral nutrition is auxiliary and is aimed at selectively replenishing the deficiency of those ingredients, the intake or assimilation of which is not provided by the enteral route. Incomplete parenteral nutrition is considered a complementary nutrition when it is used in combination with tube or oral administration of nutrients.

    • Mixed artificial nutrition.

      Mixed artificial nutrition is a combination of enteral and parenteral nutrition in cases where none of them is predominant.

  • The main tasks of parenteral nutrition
    • Restoration and maintenance of water-electrolyte and acid-base balance.
    • Providing the body with energy and plastic substrates.
    • Providing the body with all the necessary vitamins, macro- and microelements.
  • Parenteral nutrition concepts

    There are two main concepts of PP have been developed.

    1. The "American concept" - the system of hyperalimation according to S. Dudrick (1966) - implies the separate introduction of solutions of carbohydrates with electrolytes and nitrogen sources.
    2. The "European concept", created by A. Wretlind (1957), implies the separate introduction of plastic, carbohydrate and fatty substrates. A more recent version is the "three in one" concept (Solasson C, Joyeux H .; 1974), according to which all the necessary nutritional components (amino acids, monosaccharides, fat emulsions, electrolytes and vitamins) are mixed before administration in a single container under aseptic conditions.

       In recent years, all-in-one parenteral nutrition has been introduced in many countries using 3 liter containers to mix all the ingredients in one plastic bag. If it is impossible to mix solutions "three in one", the infusion of plastic and energy substrates should be carried out in parallel (preferably through a V-shaped adapter).

       In recent years, ready-made mixtures of amino acids and fat emulsions have been produced. The advantages of this method are minimized manipulation of containers containing nutrients, their infection decreases, and the risk of hyglycemia and hyperosmolar non-ketogenic coma decreases. Disadvantages: adhesion of fat particles and the formation of large globules that can be dangerous for the patient, the problem of catheter occlusion is not solved, it is not known how long this mixture can be safely kept in the refrigerator.

  • Basic principles of parenteral nutrition
    • Timely start of parenteral nutrition.
    • Optimal timing of parenteral nutrition (until the restoration of normal trophic status).
    • Adequacy (balance) of parenteral nutrition in terms of the amount of nutrients introduced and the degree of their assimilation.
  • Parenteral nutrition rules
    • Nutrients should be administered in a form that is adequate to the metabolic needs of the cells, that is, similar to the entry of nutrients into the bloodstream after passing the enteral barrier. Accordingly: proteins in the form of amino acids, fats - fat emulsions, carbohydrates - monosaccharides.
    • Strict adherence to the appropriate rate of introduction of nutrient substrates is necessary.
    • Plastic and energetic substrates must be introduced at the same time. It is imperative to use all essential nutrients.
    • Infusion of highly osmolar solutions (especially those exceeding 900 mOsm / L) should be carried out only in the central veins.
    • Infusion sets for PN are changed every 24 hours.
    • When performing a complete PP, the inclusion of glucose concentrates in the mixture is mandatory.
    • The need for fluid for a stable patient is 1 ml / kcal or 30 ml / kg of body weight. In pathological conditions, the need for water increases.
  • Indications for parenteral nutrition

    When carrying out parenteral nutrition, it is important to take into account that in conditions of termination or restriction of the supply of nutrients by exogenous means, the most important adaptive mechanism comes into play: the expenditure of mobile reserves of carbohydrates, body fats and intensive breakdown of protein into amino acids with their subsequent conversion into carbohydrates. Such metabolic activity, being at first expedient, designed to ensure vital activity, subsequently has a very negative effect on the course of all life processes. Therefore, it is advisable to cover the needs of the body not due to the breakdown of its own tissues, but due to the exogenous intake of nutrients.

    The main objective criterion for the use of parenteral nutrition is a pronounced negative nitrogen balance, which cannot be corrected by the enteral route. The average daily nitrogen loss in resuscitation patients is from 15 to 32 g, which corresponds to the loss of 94-200 g of tissue protein or 375-800 g of muscle tissue.

    The main indications for PP can be divided into several groups:

    • The impossibility of oral or enteral food intake for at least 7 days in a stable patient, or in a shorter time in an emaciated patient (this group of indications is usually associated with dysfunction of the gastrointestinal tract).
    • Severe hypermetabolism or significant loss of protein, when only enteral nutrition does not allow coping with nutritional deficiencies (a classic example is burn disease).
    • The need to temporarily exclude intestinal digestion "bowel rest mode" (for example, in ulcerative colitis).
    • Indications for Complete Parenteral Nutrition

      Total parenteral nutrition is indicated in all cases when it is impossible to eat naturally or through a tube, which is accompanied by an increase in catabolic and inhibition of anabolic processes, as well as a negative nitrogen balance:

      • In the preoperative period, in patients with symptoms of complete or partial starvation in diseases of the gastrointestinal tract in cases of functional or organic damage to it with impaired digestion and resorption.
      • In the postoperative period after extensive operations on the abdominal organs or its complicated course (anastomoses failure, fistulas, peritonitis, sepsis).
      • In the post-traumatic period (severe burns, multiple injuries).
      • With increased breakdown of protein or a violation of its synthesis (hyperthermia, failure of the liver, kidneys, etc.).
      • Resuscitation patients, when the patient does not regain consciousness for a long time or the activity of the gastrointestinal tract is sharply disrupted (lesions of the central nervous system, tetanus, acute poisoning, coma, etc.).
      • With infectious diseases (cholera, dysentery).
      • With neuropsychiatric diseases in cases of anorexia, vomiting, refusal to eat.
  • Contraindications to parenteral nutrition
    • Absolute contraindications for PP
      • Period of shock, hypovolemia, electrolyte disturbances.
      • Possibility of adequate enteral and oral nutrition.
      • Allergic reactions to components of parenteral nutrition.
      • Refusal of the patient (or his guardian).
      • Cases in which PP does not improve the prognosis of the disease.

      In some of these situations, the elements of the PP can be used in the course of complex intensive care of patients.

    • Contraindications to the use of certain drugs for parenteral nutrition

      Contraindications to the use of certain drugs for parenteral nutrition determine pathological changes in the body caused by the underlying and concomitant diseases.

      • With hepatic or renal failure, amino acid mixtures and fat emulsions are contraindicated.
      • In case of hyperlipidemia, lipoid nephrosis, signs of post-traumatic fat embolism, acute myocardial infarction, cerebral edema, diabetes mellitus, in the first 5-6 days of the postresuscitation period and in violation of the coagulating properties of blood, fat emulsions are contraindicated.
      • Care must be taken in patients with allergic diseases.
  • Providing parenteral nutrition
    • Infusion technique

      The main method of parenteral nutrition is the introduction of energy, plastic substrates and other ingredients into the vascular bed: into the peripheral veins; into the central veins; into the recanalized umbilical vein; through shunts; intra-arterial.

      When carrying out parenteral nutrition, infusion pumps, electronic droplet regulators are used. The infusion should be carried out within 24 hours at a certain rate, but not more than 30-40 drops per minute. At such a rate of introduction, there is no overload of enzyme systems with nitrogen-containing substances.

    • Access

      Currently, the following access options are used:

      • Through a peripheral vein (using a cannula or catheter), it is usually used when initiating parenteral nutrition within a period of up to 1 day or with additional PN.
      • Through the central vein with temporary central catheters. Among the central veins, the subclavian vein is preferred. The internal jugular and femoral veins are less commonly used.
      • Through the central vein using indwelling central catheters.
      • Through alternative vascular and extravascular approaches (eg, peritoneal cavity).
  • Parenteral nutrition regimes
    • Round-the-clock introduction of culture media.
    • Extended infusion (within 18–20 hours).
    • Cyclic regimen (infusion over 8-12 hours).
  • Preparations for parenteral nutrition
    • Basic requirements for parenteral nutrition products

      Based on the principles of parenteral nutrition, parenteral nutrition products must meet several basic requirements:

      • To have a nutritious effect, that is, to have in its composition all the substances necessary for the body in sufficient quantities and proper ratios with each other.
      • Replenish the body with fluid, since many conditions are accompanied by dehydration of the body.
      • It is highly desirable to have a detoxifying and stimulating effect in the means used.
      • A substitutional and anti-shock effect of the agents used is desirable.
      • It is necessary to make sure that the means used are harmless.
      • An important component is ease of use.
    • Characteristics of parenteral nutrition products

      For the correct use of nutrient solutions for parenteral nutrition, it is necessary to evaluate some of their characteristics:

      • Osmolarity of solutions for parenteral nutrition.
      • Energy value of solutions.
      • Limits of maximum infusions - rate or rate of infusion.
      • When planning parenteral nutrition, the required doses of energy substrates, minerals and vitamins are calculated based on their daily requirement and the level of energy consumption.
    • Components of parenteral nutrition

      The main components of parenteral nutrition are usually divided into two groups: energy donors (carbohydrate solutions - monosaccharides and alcohols and fat emulsions) and plastic material donors (amino acid solutions). Parenteral nutrition products consist of the following components:

      • Carbohydrates and alcohols are the main sources of energy for parenteral nutrition.
      • Sorbitol (20%) and xylitol are used as additional energy sources with glucose and fat emulsions.
      • Fat is the most efficient energy substrate. They are introduced in the form of fat emulsions.
      • Proteins - are the most important component for building tissues, blood, synthesis of proteohormones, enzymes.
      • Saline solutions: simple and complex, are introduced to normalize the water-electrolyte and acid-base balance.
      • Vitamins, trace elements, anabolic hormones are also included in the parenteral nutrition complex.
    More details: Pharmacological group - Means for parenteral nutrition.
  • Assessment of the patient's condition if it is necessary to carry out parenteral nutrition

    When carrying out parenteral nutrition, it is necessary to take into account the individual characteristics of the patient, the nature of the disease, metabolism, as well as the energy needs of the body.

    • Evaluation of nutrition and monitoring the adequacy of parenteral nutrition.

      The goal is to determine the type and extent of the malnutrition and the need for nutritional support.

      Nutritional status in recent years is assessed on the basis of determining the trophic or trophological status, which is considered as an indicator of physical development and health. Trophic insufficiency is established on the basis of anamnesis, somatometric, laboratory and clinical and functional indicators.

      • Somatometric indicators are the most readily available and include measurements of body weight, shoulder circumference, skinfold thickness, and body mass index calculation.
      • Laboratory tests.

        Serum albumin. With a decrease in it below 35 g / l, the number of complications increases by 4 times, mortality by 6 times.

        Serum transferrin. Its decrease indicates the depletion of visceral protein (the norm is 2 g / l or more).

        Excretion of creatinine, urea, 3-methylhistidine (3-MG) in the urine. A decrease in creatinine and 3-MG excreted in the urine indicates a muscle protein deficiency. The 3-MG / creatinine ratio reflects the direction of metabolic processes towards anabolism or catabolism and the effectiveness of parenteral nutrition in correcting protein deficiency (excretion in the urine of 4.2 μM 3-MG corresponds to the breakdown of 1 g of muscle protein).

        Controlling the concentration of glucose in the blood and in the urine: the appearance of sugar in the urine and an increase in the concentration of glucose in the blood of more than 2 g / l requires not so much an increase in the dose of insulin as a decrease in the amount of glucose administered.

      • Clinical and functional indicators: decreased tissue turgor, the presence of cracks, edema, etc.
  • Control over the conduct of parenteral nutrition

    The parameters for monitoring homeostasis indicators during complete PN were determined in Amsterdam in 1981.

    Monitoring is carried out over the state of metabolism, the presence of infectious complications and nutritional efficiency. Indicators such as body temperature, pulse rate, blood pressure and respiratory rate are measured daily in patients. Determination of the main laboratory parameters in unstable patients is mainly carried out 1-3 times a day, with nutrition in the pre- and postoperative period 1-3 times a week, with prolonged PP - 1 time per week.

    Particular importance is attached to indicators characterizing the adequacy of nutrition - protein (urea nitrogen, serum albumin and prothrombin time), carbohydrate (

    Alternative - parenteral nutrition is used only if enteral nutrition is impossible (intestinal fistulas with significant discharge, short bowel syndrome or malabsorption, intestinal obstruction, etc.).

    Parenteral nutrition is several times more expensive than enteral nutrition. When carrying out it, strict adherence to sterility and the rate of introduction of ingredients is required, which is associated with certain technical difficulties. Parenteral nutrition is associated with a sufficient number of complications. There are indications that parenteral nutrition can suppress their own immunity.

    In any case, during full parenteral nutrition, intestinal atrophy occurs - atrophy from inactivity. Atrophy of the mucosa leads to its ulceration, atrophy of the secreting glands leads to subsequent enzymatic deficiency, stagnation of bile, uncontrolled growth and changes in the composition of the intestinal microflora, atrophy of intestinal-associated lymphoid tissue.

    Enteral nutrition is more physiological. It does not require sterility. Enteral formula contains all the necessary ingredients. Calculation of the need for enteral nutrition and the method of its implementation are much simpler than with parenteral nutrition. Enteral nutrition helps to maintain the gastrointestinal tract in a normal physiological state and prevent many complications that arise in critically ill patients. Enteral nutrition improves blood circulation in the intestines and promotes normal healing of anastomoses after bowel surgery. Thus, whenever possible, the choice of nutritional support method should lean towards enteral nutrition.

Medicines for parenteral nutrition are divided into preparations for protein nutrition (alvezin "new", amikin, aminocrovin, aminoplasmal LS, aminotroph, hydrolysin, casein hydrolyzate, nephramine, polyamine, fibrinosol) and fat emulsions (intralipid, lipovenosis, lipofundin).

ALVESIN "NEW" (Alvesin "Neu")

Infusion solution containing a mixture of amino acids, sorbitol, sodium, potassium and magnesium ions.

Pharmachologic effect.

Indications for use. Diseases accompanied by protein deficiency, severe burns, dystrophy (delayed growth and development, decreased body resistance) in children, pre- and postoperative periods.

Method of administration and dosage. The drug is administered intravenously in the form of slow drip infusions in doses corresponding to the amount of protein loss, daily 1000-2000 ml for adults and 25-50 ml / kg for children. During prolonged drip infusion, add ascorbic acid, rutin, B vitamins according to indications.

Contraindications Hyperkalemia (high potassium in the blood), severe liver and kidney damage.

Release form. 500 ml bottles.

Storage conditions. In a cool, dark place.

AMIKIN (Amikinum)

Pharmachologic effect. A drug obtained by deep acid hydrolysis (decomposition with the participation of water in an acidic medium) of protein (casein, keratin), containing L-amino acids in optimal ratios for parenteral (bypassing the digestive tract) nutrition.

Indications for use.

Method of administration and dosage. Injected into a vein only by drip (30-40 drops per minute). The contents of one bottle (400 ml) are injected over 3-4 hours; a faster introduction is impractical, since the absorption of amino acids decreases and they are excreted from the body in the urine.

The daily dose (it is one-time) is 2 liters.

Simultaneously with amikin, you can enter a glucose solution, vitamins.

Release form. In hermetically sealed bottles of 400 ml. The total nitrogen content is 0.65-0.8%; amine nitrogen - not less than 80% of the total amount of nitrogen; tryptophan - 40-50 mg per 100 ml of the drug.

Storage conditions. At temperatures from +5 to +25 "C.

AMINOCROVIN (Aminocrovinum)

A drug obtained by acid hydrolysis (decomposition with the participation of water in an acidic medium) of human blood proteins with the addition of glucose.

Pharmachologic effect. Applied for parenteral (bypassing the digestive tract) nutrition.

Indications for use. The same as for hydrolysin.

Method of administration and dosage. Aminocrovin is administered intravenously. The daily dose for adults is 20-30 ml per 1 kg of body weight.

Side effect. With the rapid introduction of the drug, discomfort may appear in the form of nausea, headache, fever, pain along the vein. If these sensations occur, the introduction of aminoc-rovin should be slowed down or temporarily stopped.

Contraindications Same as for aminotroph.

Release form. In bottles of 250; 450 and 500 ml. Contains free amino acids (40 g per 1000 ml) and low molecular weight peptides.

Storage conditions.

During storage, a slight sediment may form at the bottom of the bottle, which is easily dispersed when shaken.

Aminoplasmal LS (Aminoplasmal LS)

Pharmachologic effect. Solution for parenteral (bypassing the digestive tract) nutrition. Contains 21 amino acids, including tryptophan, as well as sorbitol and sodium, potassium and magnesium salts.

Indications for use. As a remedy for parenteral protein nutrition in case of hypoproteinemia (low protein content in the blood) of various origins, in case of impossibility or severe restriction of intake, write in the usual way in the pre- and postoperative period, with extensive burns, especially with burn exhaustion, trauma, fractures, suppurative processes , functional liver failure, etc.

Method of administration and dosage. Introduced intravenously. The initial rate of infusion (during the first 30 minutes) is 10-20 drops per minute, then the rate of infusion is increased to 25-35 drops per minute. For the introduction of every 100 ml of the drug, at least 1 hour is required. A faster introduction is impractical, since the excess of amino acids is not absorbed by the body and is excreted in the urine. The daily dose is from 400 to 1200 ml daily for 5 days or more. At the same time, solutions of glucose (up to 0.5 g / kg of body weight per hour) and vitamins should be administered.

Side effects and contraindications are the same as for aminotroph.

Release form. Solution in vials of 400 ml for infusion.

Storage conditions. At temperatures from +10 to +20 "C.

AMINOTROPH (Aminotrophum)

Compositionally improved casein hydrolyzate. Pharmachologic effect. Protein solution for parenteral (bypassing the digestive tract) nutrition.

Indications for use. The same as for hydrolysin.

Method of administration and dosage. It is administered intravenously as an infusion, starting at 10-20 drops per minute (in the first 30 minutes), then at 25-35 drops per minute. With complete parenteral nutrition, up to 1500-2000 ml per day are administered, with incomplete (auxiliary) parenteral nutrition - 400-500 ml per day.

Simultaneously with the aminotroph, you can enter a solution of glucose with insulin (1 U for every 4 g of glucose), vitamins.

Side effect. When using aminotroph, a feeling of heat, flushing (redness) of the face, headache, nausea, vomiting are possible. In these cases, the administration is stopped and desensitizing (preventing or inhibiting allergic reactions) therapy is carried out.

Contraindications The drug is contraindicated in case of decompensation of cardiac activity (a sharp decrease in the pumping function of the heart), cerebral edema, cerebral hemorrhage, acute renal and hepatic failure.

Release form. Available in 400 ml bottles. 1000 ml contains 50 g of amino acids, including L-tryptophan (0.5 g), as well as potassium, calcium, magnesium ions.

Storage conditions. At temperatures from +10 to +25 ° C. During storage, a slight suspension may appear, which easily breaks down when shaken.

HYDROLIZIN L-103 (Well-drolizin L-103)

A product obtained by acid hydrolysis (decomposition with the participation of water in an acidic medium) of cattle blood proteins with the addition of glucose.

Pharmachologic effect. Protein preparation for parenteral (bypassing the digestive tract) nutrition; also has a detoxifying effect (removes harmful substances from the body). _

Indications for use. Diseases accompanied by protein deficiency (hypoproteinemia - low protein content in the blood), exhaustion of the body, intoxication (poisoning), radiation and burn disease, sluggish granulating (poorly healing) wounds, operations on the esophagus and stomach.

Method of administration and dosage. Intravenous and subcutaneous (in both cases, drip); through a gastric tube (special tube). Intravenous and subcutaneous, starting at 20 drops per minute. With good tolerance up to 40-60 drops per minute. The daily dose is up to 1.5-2 liters per day.

Side effects and contraindications. The same as when using aminotroph.

Release form. In bottles of 450 ml.

Storage conditions. At temperatures from +4 to +20 "C.

INTRALIPID (Intralipid)

Pharmachologic effect. Means for parenteral (bypassing the gastrointestinal tract) nutrition. It is a source of energy and essential fatty acids.

Indications for use. Parenteral nutrition, essential fatty acid deficiency.

Method of administration and dosage. Adults are injected intravenously with 10% and 20% intralipid at a rate of no more than 500 ml per 5 hours, 30% - 333 ml per 5 hours; the maximum daily dose is 3 g of triglycerides per kg of body weight. Newborns and young children are injected intravenously at a rate of no more than 0.17 g / kg of body weight per hour; For premature babies, it is advisable to infuse continuously throughout the day. The initial dose is 0.5-1.0 g / kg of body weight per day; the dose can be increased to 2.0 r / kg / day; further increase

doses up to the maximum (4.0 g / kg / day) is possible only under the condition of constant monitoring of the concentration of triglycerides in the blood serum, liver function tests and hemoglobin oxygen saturation.

Intralipid should be used with caution in patients with renal failure, decompensated diabetes mellitus, pancreatitis (inflammation of the pancreas), impaired liver function, hypothyroidism (thyroid disease) in the case of hypertriglyceridemia (increased triglyceride content in the blood), sepsis (infection of the blood by microbes from focus of purulent inflammation); the use of intralipid in these patients is possible only if the level of triglycerides in the blood serum is carefully monitored. Intralipid is used with caution in patients with soy protein allergy; the use of the drug is possible only after carrying out allergic tests. When preterm infants with hyperbilirubinemia (elevated levels of bilirubin / bile pigment / in the blood) and newborns are prescribed, as well as in suspected pulmonary hypertension (increased pressure in the vessels of the lungs), it is necessary to control the number of platelets, liver function tests and the concentration of triglycerides in serum. Laboratory tests such as determination of bilirubin (bile pigment) in the blood, activity of lactate dehydrogenase (oxidative enzyme), saturation of hemoglobin with oxygen, should preferably be carried out 5-6 hours after the end of the drug infusion. In the case of long-term use of the drug (more than 1 week), before the administration of the next dose of the drug, a blood sample should be taken to assess the rate of elimination (excretion from the body) of fat: if the plasma obtained by centrifugation of blood opalescent (scatters light), the next infusion of the drug is desirable postpone.

Side effect. Fever, chills, nausea, vomiting.

Contraindications Shock (initial stage); severe disorders of lipid (fat) metabolism.

Release form. Emulsion for infusion 10% in bottles of 500 ml in a package of 12 pieces; emulsion for infusion 20% in bottles of 100 ml and 500 ml in a package of 12 pieces; emulsion for infusion 30% in vials of 330 ml in a package of 12 pieces. 1 liter of 10% emulsion contains fractionated soybean oil - 100 g, fractionated egg phospholipids - 12 g, glycerol - 22.0 g and water for injection - up to 1 liter. 1 liter of 20% emulsion contains fractionated soybean oil - 200 g, fractionated egg phospholipids - 12 g, glycerol - 22.0 g and water for injection - up to 1 liter. 1 liter of 30% emulsion contains fractionated soybean oil - 300 g, fractionated egg phospholipids - 12 g, glycerol - 16.7 g and water for injection - up to 1 liter.

Storage conditions. At a temperature of + 2- + S "C.

CASEINA HYDROLYSIS (Hydrolysatum caseini)

The product obtained by acid hydrolysis (decomposition with the participation of water in an acidic medium) of casein protein.

Pharmachologic effect. Protein preparation for parenteral (bypassing the digestive tract) nutrition.

Indications for use. Diseases accompanied by protein deficiency: hypoproteinemia (low content of proteins / proteins / in the blood), exhaustion of the body, intoxication (poisoning), radiation and burn sickness, sluggish (poorly healing) wounds; operations on the esophagus and stomach.

Method of administration and dosage. Intravenous drip at a rate of no more than 60 drops per 1 min or through a tube in

stomach and small intestine. The daily dose of the drug, depending on the patient's condition, is 250-1500 ml.

Side effect. Possible malaise, nausea, headache, fever, pain along the vein.

Contraindications Acute and subacute renal and hepatic insufficiency, cerebrovascular accident, cardiovascular and cardiopulmonary insufficiency, thromboembolic (associated with vascular blockage by a blood clot) diseases.

Release form. Available in 250 ml and 400 ml bottles.

Storage conditions. At a temperature of + 10- + 23 ° C.

LIPOVENOS (Upovenos)

Pharmachologic effect. Combined preparation for parenteral (bypassing the gastrointestinal tract) nutrition, containing essential fatty acids: linoleic and linoleic acids; choline. Does not affect kidney function, has a high calorie content. The caloric content of a 10% solution is 4600 kJ (1100 kcal), 20% -8400 kJ (2000 kcal). pH (acid-base state) of 10% solution - 7-8.5, 20% - 7-8.7. Osmolarity of 10% solution - 280 mOsm, 20% solution - 330 mOsm.

Indications for use. For parenteral nutrition and / or providing the body with essential fatty acids in the preoperative and postoperative periods, during surgical interventions and diseases of the gastrointestinal tract, with severe burns, with impaired renal function; with cachexia (extreme exhaustion).

Method of administration and dosage. The drug is administered by intravenous drip. The daily dose is determined at the rate of 2 g of fat / kg of body weight or 20 ml of 10% or 10 ml of 20% of the drug per 1 kg of body weight. The initial rate of administration is 0.05 g / kg per hour, the maximum rate of administration is 0.1 g / kg per hour (approximately 10 drops of 10% or 5 drops of 20% of the drug per minute during the first 30 minutes with a gradual increase to 30 drops 10% per minute and up to 15 drops per minute 20% lipovenosis).

Lipovenosis is prescribed in conjunction with solutions of carbohydrates and amino acids, but through separate transfusion systems. Before use, the contents of the bottle must be shaken, the lipovenosis must have a homogeneous (uniform) appearance. The emulsion must not be mixed with other infusion solutions, electrolytes, drugs, or alcohol. Before using fat emulsions, it is necessary to carry out the following tests: sugar curve during the day, the level of potassium, sodium, cholesterol, triglycerides, complete blood count. When using the drug for more than a week, it is necessary to monitor blood serum.

Side effect. A significant increase in temperature, feeling hot or cold, chills, abnormal feeling of warmth or blue color, nausea, vomiting, shortness of breath, headache, back pain, bones, chest or lower back. When these symptoms appear, the administration of the drug must be stopped immediately.

Contraindications Pronounced violation of the metabolism of fats in the body (with severe liver damage, shock, decompensated diabetes mellitus, severe renal failure). It is used with caution in acute pancreatitis (inflammation of the pancreas) and pancreatic necrosis (necrosis of pancreatic tissue).

Release form. 10% and 20% emulsion for infusion in bottles of 100 ml and 500 ml. 1 liter of 10% lipovenose contains: soybean oil - 100 g; lecithin - 12 g, glycerol - 25 g; 1 liter of 20% lipovenose contains: soybean oil - 200 g; lecithin - 12 g, glycerol - 25 g.

Storage conditions. In a cool place.

LIPOFUNDIN (Lipofundin)

Pharmachologic effect. Fat emulsion (visually homogeneous tiny suspension of fats in a liquid that does not dissolve them) for parenteral nutrition (bypassing the digestive tract).

Indications for use. Diseases of the digestive tract, unconsciousness, fasting in the preoperative and postoperative period, lasting more than 3 days, etc.

Method of administration and dosage. Enter warmed up to the patient's body temperature or not lower than room temperature. To do this, the drug is kept at room temperature for 12 hours before administration. The infusion rate of a 10% lipofundin solution in the first 15 minutes should not exceed 0.5-1 ml / kg / hour. In the absence of adverse reactions, the infusion rate can be increased to 2 ml / kg / hour. The infusion rate of a 20% lipofundin solution in the first 15 minutes should not exceed 0.25-0.5 ml / kg / hour. In the absence of adverse reactions, the infusion rate can be increased to 1 ml / kg / hour. On the first day of therapy, the dose of lipofundin 10% - 500 ml and lipofundin 20% - 250 ml should not be exceeded. In the absence of adverse reactions in the following days, the dose can be increased. Do not add other drugs to the emulsion. Too fast transfusion of fat emulsions can cause fluid and fat overload, followed by a decrease in the concentration of serum electrolytes, overhydration (increased fluid content in the body), pulmonary edema, and impaired diffusion capacity of the lungs.

Too rapid infusion of lipofundin can also cause hyperketonemia (increased levels of ketone bodies in the blood) and / or metabolic acidosis (acidification of the blood due to metabolic disorders). The infusion of the drug must be accompanied by a simultaneous transfusion of carbohydrate solutions, the calorie content of which should be at least 40% of the total calorie content. When infusing lipofundin, the body's ability to eliminate (remove) fat from the bloodstream should be monitored. It should not be forgotten that there should be no lipidemia (increased blood fat) between daily infusions. With long-term treatment with the drug, you should carefully monitor the picture of peripheral blood (including platelet count), indicators of the blood coagulation system, liver function. Lipofundin can only be used with other parenteral nutritional medicines in the same infusion container if the mixture is compatible and stable. Unused solution in a bottle is not subject to storage and further use.

Filters are not used for infusion of fat emulsions. Do not use vials in which separation (fat settling) of emulsions appears. The vials with the drug must not be frozen.

Side effect. Acute reactions: shortness of breath, cyanosis (blue skin and mucous membranes), allergic reactions, hyperlipidemia (high lipids / fats / in the blood), hypercoagulability (increased blood clotting), nausea, vomiting, headache, hyperemia (redness) of the face, hyperthermia ( fever), sweating, chills, drowsiness, chest pain and lower back pain. Late reactions: hepatomegaly (enlarged liver), cholestatic (associated with stagnation of bile in the bile ducts) jaundice, transient (temporary) increase in liver function tests; thrombocytopenia (a decrease in the number of platelets in the blood), leukopenia (a decrease in the level of leukocytes in the blood), splenomegaly (an increase in the spleen); overhydration syndrome (increased fluid content in the body). Accumulation of brown pigment (called "intravenous fatty pigment") in tissues.

Contraindications Lipid metabolism disorders in the form of pathological hyperlipidemia (increased lipids / fats / in the blood) or fat nephrosis (non-inflammatory kidney disease, accompanied by the accumulation of fat in its tissue); acute pancreatitis (inflammation of the pancreas), accompanied by hyperlipidemia; thromboembolism (blockage of the vessel by a blood clot), accompanied by hypoxia (insufficient supply of oxygen to the tissue or impaired absorption); ketoacidosis (acidification due to excess ketone bodies in the blood; shock; hypersensitivity to the components of the drug.

Care should be taken when the intravenous administration of fat emulsions to patients with metabolic acidosis (blood acidification due to metabolic disorders), severe liver damage, lung diseases, sepsis (blood poisoning by microbes from the focus of purulent inflammation), diseases of the reticuloendothelial system, anemia (decreased hemoglobin level in the blood ), blood clotting disorders, as well as with an increased risk of fatty embolism (blockage of the vessel with droplets of fat).

Lipofundin should not be used during pregnancy and lactation, as well as in children, since there is no data on the safety of the drug in these categories of patients.

Release form. Fat emulsion for intravenous administration in bottles of 100, 200 and 500 ml. Composition of 10% emulsion (per 1 liter): soybean oil - 50 g, medium-chain triglycerides - 50 g, egg yolk phosphatides - 12 g, glycerol - 25 g, water for injection - 1000 ml; calorie content - 1058 kcal; osmolarity - 354 my. Composition of 20% emulsion (per 1 liter): soybean oil - 100 g, medium-chain triglycerides - 100 g, egg yolk phosphatides - 12 g, glycerol - 25 g, water for injection - 1000 ml; calorie content - 1908 kcal; osmolarity - 380 my.

Storage conditions. At a temperature of + 2- + S "C. Avoid freezing.

Nephramin

Pharmachologic effect. Promotes a decrease in the content of urea in the blood, equalization of the concentration of electrolytes (ions) and the establishment of a positive nitrogen metabolism.

Indications for use. Amino acid solution for parenteral (bypassing the digestive tract) nutrition, used mainly for the treatment of patients with chronic renal failure and postoperative azotemia (excess content of nitrogen-containing products in the blood). Contains ions of potassium, phosphorus, magnesium.

Method of administration and dosage. Adults: daily dose - 500 ml. Children: the starting daily dose should be low and increase gradually. It is not recommended to exceed 1 g of essential amino acids per kg of body weight per day. The initial rate of administration is 20-30 ml / hour. An increase of 10 ml / hour is allowed every day. The maximum speed is 60-100 ml / hour.

Contraindications The drug is contraindicated in violation of the acid-base state, with hypovolemia (decrease in the volume of circulating blood), hyperammonemia (increased content of free ammonium ions in the blood).

Do not use simultaneously with other solutions for parenteral nutrition.

Release form. In bottles of 500 ml.

Storage conditions. At a temperature of + 10- + 20 ° С

POLYAMINE (Polyaminum)

An aqueous solution containing 13 L-amino acids (alanine, arginine, valine, histidine, glycine, isoleucine, lysine, tryptophan, etc.) and D-sorbitol.

Pharmachologic effect. Being a balanced mixture of amino acids, the drug is easily absorbed by the body and contributes to a positive nitrogen balance, elimination or reduction of protein deficiency.

Indications for use. As a means for parenteral (bypassing the digestive tract) protein nutrition in case of hypoproteinemia (low protein content in the blood) of various origins, if it is impossible or severely limited in intake, write in the usual way in the pre- and postoperative period, with extensive burns, especially with burn exhaustion, trauma , fractures, suppurative processes, functional liver failure, etc.

Method of administration and dosage. Introduced intravenously. The initial rate of infusion (during the first 30 minutes) is 10-20 drops per minute, then the rate of infusion is increased to 25-35 drops per minute. For the introduction of every 100 ml of the drug, at least 1 hour is required. A faster introduction is impractical, since the excess of amino acids is not absorbed by the body and is excreted in the urine. The daily dose is from 400 to 1200 ml daily for 5 days or more. Simultaneously with the polyamine, solutions of glucose (up to 0.5 g / kg of body weight per hour) and vitamins should be administered.

Side effect. If the speed of polyamine injection is exceeded, hyperemia (redness) of the face, a feeling of heat, headache, nausea, and vomiting are possible.

Release form. Aqueous solution in 400 ml vials for injection.

Storage conditions. At temperatures from +10 to +20 ° C.

FIBRINOSOL (Fibrinosolum)

A drug obtained by incomplete hydrolysis (decomposition with the participation of water) of blood fibrin of cattle and pigs. Contains free amino acids and selected peptides.

Indications for use. Designed for parenteral (bypassing the digestive tract) protein nutrition.

Method of administration and dosage. Introduced intravenously, starting at 20 drops per minute; with good tolerance, the number of drops is increased to 60 per minute. The total amount for one infusion is up to 20 ml per 1 kg of the patient's weight. Before administration, the drug is warmed up to body temperature.

Side effect. With intravenous administration of fibrinosol, a sensation of heat in the body, heaviness in the head is possible. In these cases, the rate of administration is reduced, and, if necessary, the administration of the drug is stopped.

Contraindications Same as for aminotroph.

Release form. In bottles of 250; 450 and 500 ml. Transparent liquid of light brown color with a specific odor (pH 6.4-7.4); contains total nitrogen 0.6-0.8 g in 100 ml of the preparation, amine nitrogen not less than 40% of the total amount of nitrogen, tryptophan not less than 50 mg in 100 ml.

Storage conditions. In a dark place at temperatures from +4 to +20 ° С.x

DISINTHOXIC SOLUTIONS AND MEDICINES FOR PARENTERAL (MINUTE DIGESTIVE TRACT) FOOD USED IN PEDIATRICS See also intralipid.

AMINOVENOSUM N-CHILD (Aminovenozum N pro infantibus)

Pharmachologic effect. Amino acid solutions based on an amino acid sample of mother's milk, carbohydrate-free and electrolyte-free (salt-free).

Indications for use. Partial parenteral nutrition (partial nutrition bypassing the digestive tract) of premature babies, infants and children under three years of age.

Method of administration and dosage. Aminovenosis N-children 6%. Unless otherwise prescribed, infants receive 1.5-2.5 g of amino acids / kg bw / day (25 ml - 41.5 ml / kg bw / day), small children 1.5-2, 0 g amino acids / kg body weight / day (25 ml - 33 ml / kg body weight / day). Aminovenosis N-children 10%. Unless otherwise prescribed, infants receive 1.5-2.5 g of amino acids / kg of body weight / day (15 ml - 25 ml / kg of body weight / day), small children - 1.5-2.0 g amino acids / kg body weight / day (15 ml - 20 ml / kg body weight / day).

Electrolytes and carbohydrates add balance or enter at the same time, but through a different system.

When amino acids are administered for parenteral nutrition of premature babies, infants and young children, the following laboratory parameters should be regularly monitored: urea nitrogen, acid-base status, serum ionogram, liver enzymes, lipid levels, water balance and, if possible, serum amino acid levels.

Aminovenosis N-pediatric is used as long as parenteral nutrition is needed.

Side effect. Thrombosis (formation of a blood clot in a vessel) in the area of ​​infusion, metabolic acidosis (acidification of the blood due to metabolic disorders), hyperammonemia (increased content of free ammonium ions in the blood).

Contraindications Impaired amino acid metabolism, shock, unexplained or unsatisfactory renal function, renal failure, damage to liver function, overhydration (increased fluid content in the body), metabolic acidosis, septic (associated with the presence of microbes in the blood) phenomena.

Release form. Vials of 100 ml (glass). Pack of 10 bottles. Bottles of 250 ml (glass). Pack of 10 bottles.

1 liter of N-children's aminovenose solution 6% contains: L-isoleucine - 3.84 g, L-leucine - 6.45 g, L-lysine-mono-acetate - 5.994 g (= L-lysine -4.25 g) , L-methionine - 2.58 g, N-aueTRH-L-UHcreHH - 0.5178 g (= E-cysteine ​​- 0.38 g), L-phenylalanine - 2.74 g, L-threonine - 3.09 g, L-tryptophan - 1.10 g, L-valine 402 - 4.25 g, arginine - 3.84 g, L-histidine - 2.48 g, aminoacetic acid - 2.48 g, L-alanine -4 , 30 g, L-proline -9.71 g, L-serine - 5.42 g, N-acetyl-L-tyrosine - 4.05 g (= L-tyrosine - 3.29 g), L-malic acid - 0.75 g, total amino acids - 60 g / l, total nitrogen - 8.6 g / l. Theoretical osmolarity - 520 mosm / l.

1 liter of N-children's aminovenose solution 10% contains: L-isoleucine ^ -6.40 g, L-leucine - 10.75 g, L-lysine-mono-acetate - 10.00 g (= L-lysine - 7, 09 g), L-methionine - 4.62 g, N-auemn-L-UHCTeHH- 0.5178 g (= L-cysteine ​​- 0.38 g), L-phenylalanine -4.57 g, L-threonine - 5.15 g, L-tryptophan - 1.83 g, L-valine 402 - 7.09 g, arginine - 6.40 g, L-histidine - 4.14 g, aminoacetic acid - 4.14 g, L- alanine - 7.16 g, L-proline - 16.19 g, L-serine - 9.03 g, N-aiethyl-L-tyrosine 6.76 g (= L-thyro-

zine - 5.49 g), L-malic acid - 1.50 g, total amino acids - 100 g / l, total nitrogen - 14.4 g / l. Theoretical osmolarity - 869 mosm / l Storage conditions. In a cool place.

Aminoped

Pharmachologic effect. Aminoped solutions 5% and 10% contain 18 essential and non-essential amino acids in combination with taurine, a sulfamic acid necessary for the normal functioning of the retina and other tissues. The spectrum of amino acids of the aminoped solution corresponds to that of the blood of the umbilical cord (the vascular bundle connecting the body of the mother and the child). Taurine, which is part of the drug, is an essential ingredient for children.

Indications for use. Parenteral (bypassing the gastrointestinal tract) nutrition (partial) in children with protein deficiency. When carrying out total parenteral nutrition, aminoped should be combined with carbohydrates, fats and electrolyte solutions.

Method of administration and dosage. Doses of solutions are selected individually in accordance with the need for amino acids and the age of the child. The average daily dose of aminopeda 5% for rapidly growing premature babies with a birth weight of about 1500 g is 30-40-50 ml / kg of body weight. The daily dose for newborns is 20-30 ml / kg; for infants - 20 ml / kg; for children over 1 year old - 10-20 ml / kg of body weight. The maximum infusion rate is 2 ml / kg body weight per hour. The average daily dose of 10% aminoped for rapidly growing premature babies with a birth weight of about 1500 g is 15-20-25 ml / kg of body weight. The daily dose for newborns is 10-15 ml / kg; for infants - 10 ml / kg; for children older

1 year - 5-10 ml / kg of body weight. The maximum infusion rate is 1 ml / kg of body weight per hour.

When carrying out infusion therapy, it is necessary to control the concentration of electrolytes (ions) in the blood plasma and indicators of water balance. Caution is needed if there is concomitant hyponatremia (low sodium in the blood). The recommended infusion rate should not be exceeded, as too rapid an infusion can lead to increased excretion of ingredients through the kidneys and be accompanied by nausea. In such cases, the administration of the drug should be discontinued. Aminoped solutions do not contain electrolytes, therefore, the doses of electrolyte solutions should be selected taking into account the individual needs of the patient. In order to achieve optimal utilization of the amino acids administered, parenteral nutrition should also include carbohydrates and fats, which serve as a source of energy.

Contraindications Congenital disorders of the metabolism (metabolism) of amino acids, hyperhydration (increased fluid content in the tissues of the body), hypokalemia (a decrease in the level of potassium in the blood), acute metabolic disorders due to hypoxia (insufficient supply of oxygen to the tissue or a violation of its assimilation) and acidosis (acidification).

Release form. Solution for infusion 10% and 20% in bottles of 100 ml and 250 ml in a package of 10 pieces. Composition of 1 liter of aminopeda: alanine - 7.95 g and 15.9 g (respectively, in 5% solution and 10% solution); glycine - 1 g and

2 g; arginine - 4.55 g and 9.1 g; aspartic acid - 3.3 g and 6.6 g; valine - 3.05 g and 6.1 g; histidine 2.3 g and 4.6 g; glutamic acid - 0.225 g and 0.45 g; isoleucine - 2.55 g and 5.1 g; leucine - 3.8 g and 7.6 g; lysine salt of glutamic acid - 9.91 g and 19.82 g; methionine - 1 g and 2 g; proline - 3.05 g and 6.1 g; series - 1 g and 2 g; taurine -0.15 g and 0.3 g; tyrosine (in the form of acetyl) - 0.53 g and 1.06 g; threonine -2.55 g and 5.1 g; tryptophan -2 g and 4 g; phenylalanine - 1.55 g and 3.1 g; cysteine ​​(in the form

acetyl) - 0.52 g and 0.52 g. The total amount of amino acids is 50 g / l and 100 g / l, respectively in 5% and 10% solutions; the total amount of nitrogen is 7.6 g / l and 15.2 g / l; energy value - 200 kcal / l and 400 kcal / l. Storage conditions. In a cool place.

VAMINOLACT (Vaminolact)

Pharmachologic effect. Solution for parenteral (bypassing the gastrointestinal tract) nutrition of newborns. Contains 18 amino acids required for protein synthesis. Amino acids are selected in a proportion corresponding to the ratio of amino acids in breast milk. The drug also contains the sulfamic acid taurine, which is necessary for the normal functioning of the retina and other tissues. The drug meets the need of newborns, infants and older children in amino acids. The nitrogen content in 1 liter of the preparation is 9.3 g, which corresponds to 60 g of protein. Energy value (per 1 liter) - 240 kcal.

Simultaneously with the infusion of vamolact, an infusion of a glucose solution or intralipid (as energy sources) is carried out, which contributes to the optimal utilization of amino acids. With the simultaneous administration of vamolact and intralipid, the risk of thrombophlebitis (inflammation of the vein wall with its blockage) at the injection site decreases due to a decrease in the total osmolarity of the solution, since intralipid is isotonic to blood plasma.

Method of administration and dosage. Newborns and infants are injected intravenously at the rate of 30-35 ml / kg of body weight during the day. Children over 1 year old with a body weight of 10-20 kg are administered in a daily dose of 24.0-18.5 ml / kg; with a body weight of 20-30 kg - 18.5-16.0 ml / kg; with a body weight of 30-40 kg - 16.0-14.5 ml / kg per day.

Side effect. Rarely - nausea, thrombophlebitis at the injection site.

Contraindications Severe liver dysfunction; uremia (kidney disease characterized by the accumulation of nitrogenous toxins in the blood) in the absence of the possibility of dialysis (a method of blood purification).

Release form. Solution in bottles of 100, 250 and 500 ml in a package of 12 pieces. 1 liter of the solution contains levorotatory isomers of amino acids: alanine - 6.3 g, arginine - 4.1 g, aspartic acid - 4.1 g, cystine - 1.0 g, glycine - 2.1 g, glutamic acid - 7.1 g, histidine - 2.1 g, isoleucine - 3.1 g, leucine - 7.0 g, lysine - 5.6 g, methionine - 1.3 g, phenylalanine - 2.7 g, proline - 5.6 g , serine - 3.8 g, taurine - 0.3 g, threonine - 3.6 g, tryptophan - 1.4 g, tyrosine - 0.5 g, valima - 3.6 g, water for injection - up to 1000 ml ...

Storage conditions. In a cool place.

CHILDREN'S GLUCOVENOSIS 12.5% ​​(Glucovenozum pro infantibus 12.5%)

Pharmachologic effect. Solution for parenteral (bypassing the digestive tract) nutrition.

Indications for use. For the introduction of fluid, electrolytes (ions) and calories (in pediatrics), as well as for parenteral (bypassing the digestive tract) nutrition with the simultaneous introduction of amino acids.

Isotonic dehydration (dehydration) of various origins, especially conditions requiring a large expenditure of energy.

Method of administration and dosage. For intravenous infusion: if the solution is administered to premature infants, newborns and infants through the temporal vein, then the puncture site should be changed every 2-3 days.

If not prescribed otherwise, then depending on the age of the child - 80-130 ml / kg of body weight / day. Due to the relatively high osmolarity (high osmotic pressure) of the solution, the infusion should be continued for 12, preferably 24 hours.

Side effect. Due to the relatively high osmotic pressure at high infusion rates, there is a risk of irritation of the veins and hyperosmolar coma (unconsciousness due to a sharp increase in osmotic pressure).

Contraindications Conditions of excess water in the body (overhydration), heart weakness (heart failure), renal failure, diabetes mellitus, excess serum potassium (hyperkalemia).

Release form. Vials of 100 ml and 250 ml (glass). Pack of 10 bottles.

1 liter of solution contains: Na + 25.00 mmol (0.574 g); K + 20.00 mmol (0.782 g); Ca ++ 8.00 mmol (0.320 g); Mg ++ 2.00 mmol (0.048 g); C1 "40.00 mmol (1.418 g); glycerol - 12.00 mmol (2.037 g); malate - 8.00 mmol (1.064 g); glucose monohydrate for injection 137.5 g (= glucose without water for injection 125 , 0 g) Total caloric content - 2100 kJ / l (500 kcal / l) Theoretical osmolarity = 810 mosm / l.

Storage conditions. In a cool place.

IONOSTERIL CHILD I (lonosterllum pro infantibus I)

Pharmachologic effect. This balanced solution is primarily used in pediatrics, since the child's body should not be burdened with an excessive amount of electrolytes (ions). Potassium deficiency should be compensated for in a targeted manner.

Indications for use. For the regulation of water-electrolyte (water-salt) metabolism with normal renal function. With extrarenal (not associated with renal excretory function: with sweat, vomiting, etc.) loss of water due to increased temperature, before and after surgery. Renal (associated with impaired renal function) water loss in infants.

Method of administration and dosage. As a continuous intravenous drip infusion: premature babies - 80-120 ml / kg body weight / day; infants - 180-200 ml / kg of body weight / day. The injection rate is 6-20 drops / min.

Contraindications

Release form. Vials of 100 ml (glass). Pack of 10 bottles. Bottles of 250 ml (glass). Pack of 10 bottles. 500 ml bottles (glass). Pack of 10 bottles.

1 liter of solution contains: Na + 29.44 mmol (0.676 g); K + 0.80 mmol (0.031 g); Ca ++ 0.45 mmol (0.018 g); C1 ~ 31.14 mmol (1.104 g); glucose monohydrate for injection 44.0 g (= 40.0 g glucose without water of crystallization). Caloric content - 164 kcal / l (686 kJ / l).

Storage conditions. In a cool place.

IONOSTERIL CHILD II (lonosterilum pro infantibus II)

Pharmachologic effect. The drug is a balanced solution with a variety of applications in pediatrics. The concentration of electrolytes (ions) is sufficient to meet the daily needs of the body.

Indications for use. For the regulation of water-electrolyte (water-salt) metabolism with normal renal function. With extrarenal (not associated with renal excretory function: with sweat, vomiting, etc.) loss of water due to increased temperature, before and after surgery. Renal loss (associated with impaired renal function) of water, exsicosis (dehydration) in infants.

Method of administration and dosage. As a continuous intravenous drip infusion: 20-40 drops / min or 60-20 ml / hour, depending on the child's age. In case of potassium deficiency, targeted substitution.

Contraindications State of overhydration (increased fluid content in the body), heart and kidney failure.

Release form. Bottles of 250 ml (glass). Pack of 10 bottles. 500 ml bottles (glass). Pack of 10 bottles. 1 liter of solution contains: Na + 49.10 mmol (1.129 g); K + 1.33 mmol (0.052 g); Ca ++ 0.75 mmol (0.030 g); C1 "51.90 mmol (1.840 g); glucose monohydrate for injection 36.6 g (= 33.3 g glucose without crystallization water). Caloric content - 136 kcal / l (570 kJ / l). Theoretical osmolarity = 288 mosm / l.

Storage conditions. In a cool place.

IONOSTERIL CHILDREN III (lonosterilum pro infantibus III)

Pharmachologic effect. This solution consists of half of 5% glucose solution and Ringer's solution, therefore it contains only half the electrolytes (ions) of Ringer's solution and enough metabolically free water. It is optimal as a basic solution in pediatrics.

Indications for use. For the regulation of water-electrolyte (water-salt) metabolism with normal renal function. With extrarenal (not related to renal excretory function: with sweat, vomiting, etc.) loss of water due to increased temperature, before and after surgery. Renal (associated with impaired renal function) water loss, basic solution.

Method of administration and dosage. As a continuous intravenous drip infusion: 20-40 drops / min or 60-120 ml / hour, depending on the child's age. In case of potassium deficiency, targeted substitution.

Contraindications State of overhydration (increased fluid content in the body), heart and kidney failure.

Release form. Bottles of 250 ml (glass). Pack of 10 bottles. 500 ml bottles (glass and plastic). Pack of 10 bottles. 1 liter of solution contains: Na + 73.60 mmol (1.690 g); K + 2.00 mmol (0.079 g); Ca ++ 1.12 mmol (0.045 g); C1 ~ 77.85 mmol (2.760 g); glucose monohydrate for injection 27.50 g (= 25.0 g glucose without water of crystallization). Caloric content: 100 kcal / l (420 kJ / l).

Storage conditions. In a cool place.

TROPHAMIN (Trophamine)

Pharmachologic effect. Amino acid solution for parenteral (bypassing the gastrointestinal tract) nutrition. Osmolarity 5.25 mOsm / L.

Indications for use. Adequate nutrition of newborns with low body weight, a state of increased need for proteins (proteins).

Method of administration and dosage. Slow intravenous infusion. The dose of the drug is set by the doctor individually in each case.

Side effect. Nausea, vomiting, phlebitis (inflammation of the vein) at the injection site, allergic reactions such as skin rash, urticaria, angioedema.

Contraindications Hypersensitivity to any of the components of the drug.

Release form. Solution for infusion in special bottles of 500 ml. 100 ml of the preparation contains: isoleucine - 0.49 g, leucine - 0.84 g, lysine - 0.49 g, methionine - 0.2 g, phenylalanine - 0.29 g, threonine - 0.25 g, tryptophan -0 , 12 g, valine -0.47 g, c isteine ​​-0.02 g, tyrosine -0.14 g, alanine -0.32 g, arginine -0.73 g, proline - 0.41 g, serine - 0 , 23 g, glycine - 0.22 g, aspartic acid - 0.19 g, glutamic acid - 0.3 g. The concentration of electrolytes (ions) in mEQ / L: sodium - 5, chlorides - less than 3, acetate - 56.

Storage conditions. In a cool place.

The drugs used in parenteral nutrition include glucose and fat emulsions. Solutions of crystalline amino acids used in parenteral nutrition also serve as an energy substrate, but their main purpose is plastic, since various proteins of the body are synthesized from amino acids. For amino acids to fulfill this goal, it is necessary to supply the body with adequate energy from glucose and fat, non-protein energy substrates. With a lack of so-called non-protein calories, amino acids are included in the process of neoglucogenesis and become only an energy substrate.

Carbohydrates for parenteral nutrition

The most common nutrient for parenteral nutrition is glucose. Its energy value is about 4 kcal / g. The proportion of glucose in parenteral nutrition should be 50-55% of the actual energy expenditure.

The rational rate of glucose delivery during parenteral nutrition without the risk of glucosuria is considered to be 5 mg / (kg x min), the maximum rate is 0.5 g / kg x h). The dose of insulin, the addition of which is necessary for glucose infusion, is indicated in table. 14-6.

The daily amount of injected glucose should not exceed 5-6 g / kg x day). For example, with a body weight of 70 kg, it is recommended to introduce 350 g of glucose per day, which corresponds to 1750 ml of a 20% solution. In this case, 350 g of glucose provides 1400 kcal delivery.

Fat emulsions for parenteral nutrition

Fat emulsions for parenteral nutrition contain the most energy-intensive nutrient - fats (energy density 9.3 kcal / g). Fat emulsions in a 10% solution contain about 1 kcal / ml, in a 20% solution - about 2 kcal / ml. Dose of fat emulsions - up to 2 g / kg x day). The rate of administration is up to 100 ml / h for a 10% solution and 50 ml / h for a 20% solution.

Example: an adult weighing 70 kg is prescribed 140 g, or 1400 ml of a 10% fat emulsion solution per day, which should provide 1260 kcal. Such a volume is poured at the recommended speed in 14 hours. In the case of using a 20% solution, the volume is halved.

Historically, there are three generations of fat emulsions.

• First generation. Fat emulsions based on long-chain triglycerides (intralipid, lipofundin 5, etc.). The first of these, Intralipid, was created by Arvid Vretlind in 1957.
• Second generation. Fat emulsions based on a mixture of long and medium chain triglycerides (MCH and LCT). MCT / LCT ratio = 1/1.
• Third generation. Structured lipids.

In recent years, among lipids, preparations containing co-3-fatty acids - eicosopentoic (EPA) and decosopentoene (DPA), contained in fish oil (omegaven), have become widespread. The pharmacological action of co-3-fatty acids is determined by the substitution of EPA / DPA in the phospholipid structure of the cell membrane of arachidonic acid, resulting in a decrease in the formation of pro-inflammatory metabolites of arachidonic acid - thromboxanes, leukotrienes, prostaglandins. Omega-3-fatty acids stimulate the formation of eicosanoids with anti-inflammatory effects, reduce the release of cytokines (IL-1, IL-2, IL-2, IL-6, TNF) and prostaglandins (PGE2) by mononuclear cells, reduce the frequency of wound infections and the length of hospital stay.

Amino acids for parenteral nutrition

The main purpose of amino acids for parenteral nutrition is to provide the body with nitrogen for plastic processes, but when there is a shortage of energy, they also become an energy substrate. Therefore, it is necessary to maintain a rational ratio of non-protein calories to nitrogen - 150/1.

WHO requirements for solutions of amino acids for parenteral nutrition:

• absolute transparency of solutions;
• the content of all 20 amino acids;
• the ratio of essential amino acids to nonessential 1: 1;
• the ratio of essential amino acids (g) to nitrogen (g) is closer to 3;
• the leucine / isoleucine ratio is about 1.6.

Branched Chain Amino Acids for Parenteral Nutrition

The inclusion in the solution of crystalline amino acids, essential branched-chain amino acids (valine, leucine, isoleucine-VLI) creates distinct therapeutic effects, especially manifested in liver failure. Unlike aromatics, branched-chain amino acids inhibit the formation of ammonia. The VLI group serves as a source of ketone bodies - an important energy resource for critically ill patients (sepsis, multiple organ failure). The increase in the concentration of branched-chain amino acids in modern solutions of crystalline amino acids is justified by their ability to oxidize directly in muscle tissue. They serve as an additional and effective energy substrate in conditions when the absorption of glucose and fatty acids is slowed down.

Arginine becomes an essential amino acid under stress. It also serves as a substrate for the formation of nitric oxide, has a positive effect on the secretion of polypeptide hormones (insulin, glucagon, growth hormone, prolactin). The additional inclusion of arginine in food reduces thymic hypotrophy, increases the level of T-lymphocytes, and improves wound healing. In addition, arginine dilates peripheral vessels, reduces systemic pressure, promotes sodium excretion and enhances myocardial perfusion.

Pharmaconutrients (nutraceuticals) are nutrients with therapeutic effects.

Glutamine is an essential substrate for cells of the small intestine, pancreas, alveolar epithelium of the lungs and leukocytes. As part of glutamine, about V3 of total nitrogen is transported in the blood; glutamine is used directly for the synthesis of other amino acids and protein; also serves as a nitrogen donor for the synthesis of urea (liver) and ammoniogenesis (kidney), the antioxidant glutathione, purines and pyrimidines involved in the synthesis of DNA and RNA. The small intestine is the main organ that consumes glutamine; under stress, the use of glutamine by the gut increases, which increases its deficiency. Glutamine, being the main source of energy for the cells of the digestive organs (enterocytes, colonocytes), is deposited in skeletal muscles. A decrease in the level of free muscle glutamine to 20-50% of the norm is considered a sign of damage. After surgical interventions and in other critical conditions, the intramuscular concentration of glutamine decreases by 2 times and its deficiency persists for up to 20-30 days.

The introduction of glutamine protects the mucous membrane from the development of gastric stress ulcers. The inclusion of glutamine in nutritional support significantly reduces bacterial translocation by preventing mucosal atrophy and stimulating immune function.

The most widely used dipeptide is alanine-glutamine (dipeptive). 20 g of dipeptiven contains 13.5 g of glutamine. The drug is administered intravenously together with commercial solutions of crystalline amino acids for parenteral nutrition. The average daily dose is 1.5-2.0 ml / kg, which corresponds to 100-150 ml of dipeptiven per day for a patient weighing 70 kg. The drug is recommended to be administered for at least 5 days.

According to modern research, the infusion of alanine-glutamine in patients receiving parenteral nutrition allows:

• improve nitrogen balance and protein metabolism;
• support the intracellular pool of glutamine;
• correct the catabolic reaction;
• improve immune function;
• protect the liver. Multicenter studies noted:
• restoration of bowel function;
• a decrease in the incidence of infectious complications;
• decrease in mortality;
• reduced length of hospital stay;
• reduction of treatment costs with parenteral administration of glutamine dipeptides.

Parenteral nutrition technique

The modern technique of parenteral nutrition is based on two principles: infusion from different containers ("bottle") and technology "all in one" ("all in one"), developed in 1974 by K. Solassol. All-in-one technology is presented in two options: “two in one - two in one” and “three in one - three in one”.

Infusion technique from various containers

The technique involves the intravenous administration of glucose, solutions of crystalline amino acids and fat emulsions separately. At the same time, the technique of simultaneous transfusion of solutions of crystalline amino acids and fat emulsions in the mode of synchronous infusion (drop by drop) from different vials into one vein through a Y-shaped adapter is used.

Two-in-one technique

For parenteral nutrition, drugs are used containing a solution of glucose with electrolytes and a solution of crystalline amino acids, usually produced in the form of two-chamber bags (nutriflex). The contents of the package are mixed before use. This technique allows observing the conditions of sterility during infusion and makes it possible to simultaneously introduce the components of parenteral nutrition, pre-balanced in terms of the content of the components.

Three-in-one technique

When using the technique, all three components (carbohydrates, fats, amino acids) are introduced from one bag (kabiven). Three-in-one bags are designed with an additional port for the introduction of vitamins and minerals. This technique provides for the introduction of a fully balanced composition of nutrients, reducing the risk of bacterial contamination.

Parenteral nutrition in children

In newborns, the metabolic rate in terms of MT is 3 times higher than that of adults, while approximately 25% of energy is spent on growth. At the same time, in children, compared to adults, energy reserves are significantly limited. For example, in a premature baby with a body weight of 1 kg at birth, fat reserves are only 10 g and therefore are quickly utilized in the metabolic process with a lack of nutritional elements. The store of glycogen in young children is utilized in 12-16 hours, for older children - in 24 hours.

Under stress, up to 80% of energy comes from fat. The reserve is the formation of glucose from amino acids - glyconeogenesis, in which carbohydrates come from the proteins of the child's body, primarily from muscle protein. Protein breakdown is provided by stress hormones: GCS, catecholamines, glucose-gon, growth hormone and thyroid-stimulating hormones, cAMP, as well as hunger. The same hormones have counterinsular properties, therefore, in the acute phase of stress, glucose utilization deteriorates by 50-70%.

With pathological conditions and hunger, children rapidly develop MT loss, dystrophy; to prevent them, timely use of parenteral nutrition is necessary. It should also be remembered that in the first months of life, the child's brain develops intensively, nerve cells continue to divide. Malnutrition can lead to a decrease not only in the growth rate, but also in the level of mental development of the child, which is not compensated in the future.

For parenteral nutrition, 3 main groups of ingredients are used, including proteins, fats and carbohydrates.

Protein (amino acid) mixtures: protein hydrolysates - Aminosol (Sweden, USA), Amigen (USA, Italy), Izovac (France), Aminon (Germany), hydrolysin-2 (Russia), and amino acid solutions - "Polyamine" (Russia), "Levamin-70" (Finland), "Vamin" (USA, Italy), "Moriamin" (Japan), "Freeamin" (USA), etc.

Fat emulsions: Intralipid-20% (Sweden), Lipofundin-C 20% (Finland), Lipofundin-S (Germany), Liposin (USA), etc.

Carbohydrates: glucose is usually used - solutions of various concentrations (from 5 to 50%); fructose in the form of 10 and 20% solutions (less irritating to the intima of the veins than glucose); invertose, galactose (maltose is rarely used); alcohols (sorbitol, xylitol) are added to fat emulsions to create osmolarity and as an additional energy substrate.

It is generally believed that parenteral nutrition should be continued until normal gastrointestinal function is restored. Most often, parenteral nutrition is necessary for a very short period (from 2-3 weeks to 3 months), but in case of chronic intestinal diseases, chronic diarrhea, malabsorption syndrome, short loop syndrome and other diseases, it can be longer.

Parenteral nutrition in children can cover the basic needs of the body (with a stable phase of intestinal inflammation, in the preoperative period, with prolonged parenteral nutrition, with the patient's unconscious state), moderately increased needs (with sepsis, cachexia, gastrointestinal diseases, pancreatitis, in cancer patients), as well as increased needs (with severe diarrhea after stabilization of VEO, burns of II-III degree - more than 40%, sepsis, severe injuries, especially of the skull and brain).

Parenteral nutrition is usually done by catheterizing the patient's veins. Catheterization (venipuncture) in the peripheral veins is performed only if the expected duration of parenteral nutrition is less than 2 weeks.

Calculation of parenteral nutrition

The energy requirement of children aged 6 months and older is calculated by the formula: 95 - (3 x age, years) and is measured in kcal / kg * day).

In children of the first 6 months of life, the daily requirement is 100 kcal / kg or (according to other formulas): up to 6 months - 100-125 kcal / kg * day), in children over 6 months and up to 16 years, it is determined from the calculation: 1000 + (100 p), where l is the number of years.

When calculating energy needs, you can focus on average indicators with a minimum (basic) and optimal metabolism.

In the case of an increase in body temperature on HS, the specified minimum need should be increased by 10-12%, with moderate physical activity - by 15-25%, with pronounced physical activity or convulsions - by 25-75%.

The need for water is determined based on the amount of energy required: in infants - from a ratio of 1.5 ml / kcal, in older children - 1.0-1.25 ml / kcal.

In relation to MT, the daily water requirement in newborns older than 7 days and in infants is 100-150 ml / kg, with MT from 10 to 20 kg -50 ml / kg + 500 ml, more than 20 kg -20 ml / kg + 1000 ml. In newborns at the age of the first 7 days of life, the volume of fluid can be calculated using the formula: 10-20 ml / kg x l, where n is age, days.

For premature and low birth weight babies born with MT less than 1000 g, this figure is 80 ml / kg or more.

You can also calculate the water requirement from the Aber-Dean nomogram, adding the volume of pathological losses. With MT deficiency, we develop as a result of acute fluid loss (vomiting, diarrhea, perspiration), one should first of all eliminate this deficiency according to the standard scheme and only then proceed to parenteral nutrition.

Fat emulsions (intralipid, lipofundin) in most children, except for premature babies, are administered intravenously, starting from 1-2 g / kg-day) and increasing the dose in the next 2-5 days to 4 g / kg day) (with appropriate tolerance). In premature babies, the 1st dose is 0.5 g / kg-day), in full-term newborns and in infants - 1 g / kg-day). When withdrawing from the state of intestinal toxicosis in children of the 1st half of life with severe hypotrophy, the initial dose of lipids is determined at the rate of 0.5 g / kg-day), and in the next 2-3 weeks it does not exceed 2 g / kg-day). The rate of lipid administration is 0.1 g / kg-h), or 0.5 ml / (kg-h).

With the help of fats, 40-60% of energy is supplied to the child's body, and when fat is utilized, 9 kcal are released per 1 g of lipids. In emulsions, this value is 10 kcal due to the utilization of xylitol, sorbitol, added to the mixture as an emulsion stabilizer, and substances that ensure the osmolarity of the mixture. 1 ml of 20% lipofundin contains 200 mg of fat and 2 kcal (1 liter of 20% mixture contains 2000 kcal).

Lipid solutions when injected into a vein should not be mixed with anything; they do not add heparin either, although it is desirable to administer it (intravenously, in a stream in parallel with the introduction of fat emulsions) in usual therapeutic doses.

According to Rosenfeld's figurative expression, “fats burn in the flame of carbohydrates,” therefore, when carrying out parenteral nutrition according to the Scandinavian scheme, it is necessary to combine the introduction of fats with the transfusion of carbohydrate solutions. Carbohydrates (glucose solution, less often fructose) according to this system should provide the same amount of energy as fats (50:50%). Utilization of 1 g of glucose gives 4.1 kcal of heat. Insulin can be injected into glucose solutions at the rate of 1 U per 4-5 g of glucose, but this is not required with prolonged parenteral nutrition. With a rapid increase in glucose concentration in intravenous solutions, hyperglycemia with coma may develop; to avoid this, you need to increase it gradually by 2.5-5.0% every 6-12 hours of infusion.

The Dadrick scheme requires continuity with the administration of glucose solutions: even an hour break can cause hypoglycemia or hypoglycemic coma. The concentration of glucose is also slowly reduced - in parallel with a decrease in the volume of parenteral nutrition, that is, in 5-7 days.

Thus, the use of high-concentration glucose solutions poses a certain danger, which is why it is so important to observe safety rules and monitor the patient's condition using clinical and laboratory analysis.

Glucose solutions can be administered in a mixture with amino acid solutions, while the final glucose content in the solution will decrease and the likelihood of developing phlebitis will decrease. With the Scandinavian scheme of parenteral nutrition, these solutions are injected continuously for 16-22 hours daily, with the Dadrick scheme - around the clock without interruptions by drip or using syringe pumps. The required amount of electrolytes is added to glucose solutions (calcium and magnesium are not mixed), vitamin mixtures (vitafusin, multivitamin, intravit).

Amino acid solutions (levamine, moriprom, aminone, etc.) are administered intravenously at the rate of protein: 2-2.5 g / kg-day) in young children and 1-1.5 g / kg-day) in older children ... With partial parenteral nutrition, the total amount of protein can reach 4 g / kg-day).

An accurate accounting of the protein required to stop catabolism is best done by the volume of its losses in the urine, i.e., by the amino nitrogen of urea:

The amount of residual nitrogen in daily urine, g / l x 6.25.

1 ml of 7% mixture of amino acids (levamine, etc.) contains 70 mg of protein, 10% of the mixture (polyamine) - 100 mg. The injection rate is maintained at the level of 1-1.5 ml / (kg-h).

The optimal ratio of proteins, fats and carbohydrates for children is 1: 1: 4.

The parenteral nutrition program for a day is calculated by the formula:

Amount of amino acid solution, ml = Required amount of protein (1 -4 g / kg) x MT, kg x K, where the coefficient K is 10 at 10% concentration of the solution and 15 at 7% concentration.

The need for a fat emulsion is determined taking into account the energy value: 1 ml of a 20% emulsion gives 2 kcal, 1 ml of a 10% solution - 1 kcal.

The concentration of the glucose solution is selected taking into account the amount of kilocalories released during its utilization: for example, 1 ml of 5% glucose solution contains 0.2 kcal, 10% solution -0.4 kcal, 15% -0.6 kcal, 20% - 0, 8 kcal, 25% - 1D) kcal, 30% - 1.2 kcal, 40% - 1.6 kcal and 50% - 2.0 kcal.

In this case, the formula for determining the percentage concentration of a glucose solution will take the following form:

Concentration of glucose solution,% = Number of kilocalories / Volume of water, ml x 25

Example of calculating a total parenteral nutrition program

• Child's MT - 10 kg,
• energy volume (60 kcal x 10 kg) - 600 kcal,
• volume of water (600 kcal x 1.5 ml) - 90 0 ml,
• protein volume (2g x 10 kg x 15) - 300 ml,
• fat volume (300 kcal: 2 kcal / ml) - 150 ml of 20% lipofundin.

The remaining volume of water for diluting glucose (900 - 450) is 550 ml. The percentage of glucose solution (300 kcal: 550 ml x 25) is 13.5%. Sodium (3 mmol / kg) and potassium (2 mmol / kg) are also added, or at the rate of 3 and 2 mmol, respectively, for every 115 ml of liquid. Electrolytes are usually diluted in the entire volume of the glucose solution (except for calcium and magnesium, which cannot be mixed in the same solution).

With partial parenteral nutrition, the volume of the injected solutions is determined minus the total amount of calories and ingredients supplied with food.

Calculation example of a partial parenteral nutrition program

The problem conditions are the same. The child's MT is 10 kg, but he receives 300 g of milk formula per day.

• Food volume - 300 ml,
• the remaining amount of energy (1/3 of 600 kcal) - 400 kcal,
• the remaining volume of water (2/9 of 900 ml) - 600 ml,
• protein volume (2/3 from 300 ml) - 200 ml of 7% levamine,
• fat volume (1/3 of 150 ml) - 100 ml of 20% lipofundin (200 kcal),
• the volume of water for diluting glucose (600 ml - 300 ml) - 300 ml.

The percentage of glucose solution (200 kcal: 300 ml x 25) is 15%, that is, this child needs to inject 300 ml of a 15% glucose solution, 100 ml of 20% lipofundin and 200 ml of 7% levamine.

In the absence of fat emulsions, parenteral nutrition can be carried out according to the method of hyperalimation (according to Dadrick).

An example of calculating a partial parenteral nutrition program according to the Dadrick method

• Food volume - 300 ml, water volume - 600 ml,
• protein volume (1/3 of 300 ml) - 200 ml of 7% levamine solution,
• glucose volume: 400 kcal: 400 ml (600-200 ml) x 25, which corresponds to a 25% glucose solution, which must be applied in an amount of 400 ml.

At the same time, the development of a deficiency syndrome of essential fatty acids (linoleic and linolenic) in a child should not be allowed, their required amount with this option of parenteral nutrition can be provided by plasma transfusion at a dose of 5-10 ml / kg (1 time in 7-10 days). However, it should be remembered that the administration of plasma to patients is not used for the purpose of replenishing energy and protein.

Enteral nutrition is a type of medical or additional nutrition with special mixtures, in which the absorption of food (when it enters through the mouth, through a tube in the stomach or intestines) is carried out in a physiologically adequate way, that is, through the intestinal mucosa. In contrast, parenteral nutrition is distinguished, in which mixtures are introduced through a vein into the blood.

Liquid or tube feeding (enteral feeding) is also called elemental or astronaut nutrition. These are liquid mixtures of various compositions that have been developed for space flights. Then these technologies began to be used in the development of special preparations for therapeutic nutrition.

The basis of such a meal is a mixture of products freed from toxins (fiber, cell membranes, connective tissue), crushed to a powdery state, balanced in chemical composition.

They contain various products in the form of monomers, dimers and partially polymers. In terms of their physicochemical state, these are partly true and partly colloidal solutions. The daily portion usually contains all the nutrients necessary for vital activity: proteins, fats, carbohydrates, mineral salts, trace elements and vitamins within the physiological norm.

With this type of nutrition, the principle of mechanical sparing of the intestines is fully implemented. Some elemental diets exclude foods to which an intolerance has been established (cereals, dairy products, yeast).

Nowadays there are mixtures with different tastes and with the presence or absence of ballast substances (fiber). The presence of fiber in mixtures should be paid attention to in case of stenosis (narrowing) of the small intestine, since it can clog the narrow lumen of the intestine.

The so-called elemental (low molecular weight) diets are also prescribed. These are easily digestible mixtures that are absorbed already in the upper part of the small intestine. They are used for severe intestinal inflammation, because the stronger the inflammation, the more the absorption process in it is disturbed.

In elemental mixtures, substances are presented in an already "digested" form. For example, protein is in the form of amino acids. This state of the elements makes them unpleasant to the taste.

In addition, there are formulas with limited fat content. They provide a decrease in their absorption.

When is enteral nutrition used?

This therapy is prescribed during a period of severe exacerbation in inflammatory bowel diseases and in diseases of impaired absorption.

With an exacerbation of Crohn's disease in children, it has been proven that the use of enteral nutrition (elemental diet) for 6-8 weeks is more effective than treatment with corticosteroids (cortisone). Therefore, when treating children, preference is given to diets. No differences in efficacy were found between low molecular weight and high molecular weight diets.

Studies of adults have failed to establish the superiority of diet over cortisone therapy. In addition, adults are less disciplined and do not follow a strict diet.

The Ministry of Health of the Russian Federation has developed "Instructions for the organization of enteral nutrition ...", which indicates the following indications for its use:

1. Protein-energy malnutrition when it is impossible to provide an adequate intake of nutrients by the natural oral route.
2. Neoplasms, especially those localized in the head, neck and stomach.
3. Disorders of the central nervous system: coma, cerebrovascular stroke or Parkinson's disease, as a result of which nutritional disorders develop.
4. Radiation and chemotherapy for cancer.
5. Diseases of the gastrointestinal tract: Crohn's disease, malabsorption syndrome, short bowel syndrome, chronic pancreatitis, ulcerative colitis, liver and biliary tract diseases.
6. Nutrition in the pre- and early postoperative periods.
7. Trauma, burns, acute poisoning.
8. Complications of the postoperative period (fistulas of the gastrointestinal tract, sepsis, incompetence of the anastomoses sutures).
9. Infectious diseases.
10. Mental disorders: anorexia nervosa, severe depression.
11. Acute and chronic radiation injuries.

Contraindications for use

Contraindications are indicated in the same instructions:

• intestinal obstruction;
• acute pancreatitis;
• severe malabsorption.

The principle of the choice of mixtures

The data are given from the instructions of the Ministry of Health of the Russian Federation.

The choice of mixtures for adequate enteral nutrition should be based on the data of clinical, instrumental and laboratory examination of patients, associated with the nature and severity of the course of the disease and the degree of preservation of the functions of the gastrointestinal tract (GIT).

• With normal needs and the preservation of gastrointestinal tract functions, standard nutritional mixtures are prescribed.
• For increased protein and energy requirements or fluid restriction, high-calorie nutritional formulas are prescribed.
• Pregnant and breastfeeding women should be given formula for this group.
• In critical and immunodeficient conditions, nutritional mixtures are prescribed with a high content of biologically active protein, enriched with trace elements, glutamine, arginine, omega-3 fatty acids.
• Patients with type I and II diabetes mellitus are prescribed nutritional mixtures with a low content of fats and carbohydrates, containing dietary fiber.
• If your lung function is impaired, a high-fat, low-carbohydrate nutritional formula is prescribed.
• In case of impaired renal function, nutritional mixtures containing highly biologically valuable protein and amino acids are prescribed.
• For liver dysfunctions, nutritional mixes are prescribed that are low in aromatic amino acids and high in branched chain amino acids.
• In case of partially impaired gastrointestinal tract functions, nutritional mixtures based on oligopeptides are prescribed.

Nutrition rules

When using such a power system, a number of rules should be followed in order to avoid complications.

• Start taking the mixture with a small daily portion (250-500 ml per day). With good tolerance, slowly increase it.
• Food should be taken slowly, in small sips through the tube.
• In case of food intolerance, attention should be paid to the presence of these types of elements in the mixture (for example, lactose, gluten).
• With a restrictive diet, pay attention to a balanced diet.
• Additional fluid intake is required.
• The prepared mixture should not be stored for more than 24 hours. Store in the refrigerator, then reheat before use.
• In case of impaired absorption of fats, fat-free mixtures or mixtures with easily digestible fats should be taken.
• For severe malabsorption, a low molecular weight diet is recommended.
• If, nevertheless, intolerance manifests itself (increased diarrhea, nausea and vomiting), then the amount of food intake should be reduced and the intervals between meals should be increased. It may be useful to replace the high-molecular-weight mixture with a low-molecular one.

How are the mixtures used?

The mixture is diluted with boiled water and used for feeding internally as the only source of nutrition (seriously ill during a sharp exacerbation, more often with Crohn's disease) or as an additional source of nutrition along with consumption or 4c, depending on the functional state of the intestine, for patients with underweight, anemia, hypoproteinemia.

Depending on the duration of the course of enteral nutrition and the safety of the functional state of various parts of the gastrointestinal tract, the following routes of administration of nutritional mixtures are distinguished:

• Drinking nutritional mixtures in the form of drinks through a tube in small sips;
• Tube feeding using nasogastric, nasoduodenal, nasojejunal and two-channel probes (for aspiration of gastrointestinal contents and intraintestinal administration of nutrient mixtures, mainly for surgical patients).
• By imposing a stoma: gastro-, duodeno-, jejuno-, ileostomy. Stomas can be placed surgically or endoscopically.

When some mixtures are ingested (kozylate, terapin), diarrhea may worsen due to the occurrence of hyperosmolarity of the intestinal contents after consuming the mixture. The introduction through the tube is usually well tolerated, since the mixture enters the intestine evenly, in small portions. The following mixtures are most commonly used: isocal, kozylate, terapin, enshur, alfarek, etc.

When is parenteral nutrition prescribed?

In especially severe cases, for example, with extensive stenosis, fistulas, it is necessary to completely exclude the intestines from the digestion process. In these cases, the mixture is administered by infusion into a vein. In this case, inflammation in the gastrointestinal tract quickly subside, since it is not loaded.

In addition, this therapy is prescribed to maintain the balance of nutrients in patients with severe malabsorption (for example, after extensive resection of the small intestine) and inflammatory diseases in cases of very poor general condition, anorexia, and repeated vomiting.

However, with prolonged parenteral (intravenous) nutrition, the mucous membrane of the small intestine always changes (villi atrophy). Therefore, before resorting to parenteral nutrition, the possibility of eneteral nutrition should be investigated.

After withdrawal from parenteral nutrition, the patient should begin to take small amounts of liquid formulas in order to begin to repair the intestinal mucosa.

Types of parenteral nutrition

• Incomplete (partial) parenteral nutrition.
• Full (total) parenteral nutrition provides the entire volume of the body's daily need for plastic and energy substrates, as well as maintaining the required level of metabolic processes.

Incomplete (partial) parenteral nutrition

This treatment is auxiliary and is aimed at replenishing those ingredients, the intake or assimilation of which is not provided by the enteral route. In addition, it is used as an adjunct if it is used in combination with the introduction of nutrients through a tube or orally.

Preparations for parenteral nutrition

There is a fairly wide range of drugs for parenteral nutrition.
For the introduction of nitrogen into the body, the following amino acid solutions are available:

Amino acid solutions without essential additives:

• aminosteril II (the concentration of amino acids in it is high, but it is a hypertonic solution, therefore, it can cause thrombophlebitis);
• aminosteril III (the concentration of amino acids in it is much lower, but it does not lead to thrombophlebitis, since it is an isotonic solution);
• Vamin-9, Vamin-14, Vamin-18, Intrafusil, Polyamine.

Combined amino acid solutions:

• solutions of amino acids and ions: vamin-N, infesol-40, aminosteril KE 10%;
• solutions of amino acids, carbohydrates and ions: aminoplasmal 10%, vamin-glucose;
• solutions of amino acids with ions and vitamins: aminosteril L 600, L 800, aminosteril KE forte.

For the introduction of fats and ensuring the energy balance, there are fat emulsions: intralipid 10%, 20%, 30%, lipovenosis 10%, 20%, lipofundin MCT / LST.

Supplements for parenteral nutrition preparations are also produced:

• micronutrient supplements: addamel;
• supplements with vitamins: vitalipid adult, soluvit.

The composition of diets for parenteral nutrition also includes a 5% glucose solution as a source of carbohydrates, vitamins, potassium, calcium, magnesium and sodium salts. The need for nutrients is calculated depending on body weight using a balanced diet formula.

Enteral and parenteral nutrition - which is better?

Advantages of enteral nutrition over parenteral:

• natural form of nutrition;
• cheaper;
• fewer complications;
• it is easier to return to regular products, as there is no villous atrophy.

Parenteral nutrition is the introduction of nutrients directly into the venous system. The mixture can be injected both into the peripheral veins of the arm and into the central veins - the subclavian, internal jugular or hollow veins. Whether to administer the mixture to the peripheral or central veins depends on the calories required and the duration of parenteral nutrition. Concentrated high-calorie solutions of carbohydrates and amino acids are hypertonic, and they cannot be injected through peripheral veins, since, due to the small diameter of the vessels and the relatively low blood flow velocity, they can cause inflammation of the vascular walls and thrombophlebitis. In large veins, hypertonic solutions are rapidly diluted due to the high blood flow velocity, which reduces the risk of inflammation and thrombosis. Parenteral nutrition of both types can be combined with enteral nutrition.

Indications

Parenteral nutrition is indicated for patients with severe disorders of digestion and absorption.

Total parenteral nutrition through central veins

Introduction

Parenteral nutrition is a complex procedure that should only be performed by an experienced medical team - resuscitator, therapist, nutritionist, pharmacist, nurse - according to the established protocol.

Placement of a central venous catheter

For short-term parenteral nutrition, the catheter is inserted into the subclavian or internal jugular vein. The installation should be performed by an experienced physician according to standard protocol.

For long-term parenteral nutrition (> 1 month), soft Hickman, Groshong and Broviak catheters are used. These are tunnel-type silicone one- or two-lumen catheters equipped with screw caps and subcutaneously anchored with a dacron cuff. They should be installed by an experienced doctor under the control of fluoroscopy.

Mechanical complications of central venous catheterization

Be prepared for the following complications and deal with them appropriately.

1. Pneumothorax.
2. Hemo-, hydro- and chylothorax.
3. Pericardial effusion with cardiac tamponade.
4. Accidental puncture of the artery.
5. Brachial plexus injury.
6. Embolism with fragments of the catheter.
7. Air embolism.
8. Vein thrombosis or thrombophlebitis.

Catheter care

With parenteral nutrition, the risk of infectious complications is increased. Predisposing factors are exhaustion, immunodeficiency, glucocorticoid treatment or chemotherapy, concomitant infections, broad-spectrum antibiotics, and the very presence of a foreign body (catheter) in the vascular system. Infections can occur when skin microflora enters the catheter, contamination of nutrient mixtures or probes, and also due to the penetration of bacteria into the bloodstream from other foci of infection. In most cases, catheter infections are caused by pathogens from superficial foci, such as tracheostomies or abdominal injuries.

When installing and caring for a catheter, you must carefully follow the rules of asepsis.

Energy needs

Artificial feeding regimens are usually calculated based on an assessment of energy requirements. It was assumed that in patients with severe trauma or sepsis, these requirements are significantly higher, since their basal metabolic rate is increased. However, direct measurement of energy expenditures did not reveal a significant increase in the level of metabolism in such patients. At the same time, excessive caloric content of food can cause complications such as hepatomegaly and fatty liver infiltration with impaired liver function; respiratory failure caused by excess production of carbon dioxide during lipogenesis; hyperglycemia and osmotic diuresis due to impaired glucose tolerance.

1. A patient's energy needs depend on a number of factors, including age, gender, height, and the degree of increased catabolism. Basal metabolic rate is determined using indirect calorimetry, measuring the level of carbon dioxide production and oxygen uptake. If indirect calorimetry is not possible, the basal metabolic rate can be calculated using the Harris-Benedict equations.
2. The Harris-Benedict equation allows you to fairly accurately estimate the basal metabolic rate, although with a small height and weight or with low energy costs, the results are usually somewhat overestimated (B - weight in kg, P - height in cm). Husbands. Basal metabolic rate = 66 + (13.7 x B) + (5 x P) - (6.8 x x age). Women. Basal metabolic rate = 655 + (9.6 x B) + (1.8 x P) - - (4.7 x age).
3. According to most studies, the basal metabolic rate in sepsis, trauma, or in critically ill patients who require mechanical ventilation should be increased by 12-40%. With parenteral nutrition, this value must be increased by another 15% in order to take into account the energy required to assimilate incoming nutrients.
4. Thus, when calculating the energy needs of a patient without sepsis and injuries, the basal metabolic rate should be increased by 15%. If the patient is on mechanical ventilation. the basal metabolic rate should be increased by 20-25%, and if the patient's basal metabolic rate is increased due to sepsis or trauma, then by 30-40%.

The need for proteins and nitrogen

A healthy person needs 0.8 g / day of protein per 1 kg of ideal weight. In case of illness, the need for protein can increase up to 2.5 g / kg. To compensate for the loss of protein during illness or to increase anabolism, the intake of protein is usually increased to 1.2-1.5 g / kg.

The relationship between non-protein calories and protein nitrogen levels can also be used to estimate protein requirements. The following ratios are often used: 250-300 kcal per 1 g of protein nitrogen, and in case of diseases, in order to increase anabolism - 100-150 kcal per 1 g of nitrogen. At the same time, it is assumed that the caloric content of food must be sufficient so that protein can be used to maintain and restore tissues, in other words, 100-150 kcal is needed to assimilate 1 g of protein nitrogen.

Amino acids for parenteral nutrition are mainly a building material for anabolic processes, and not a source of energy; the exception is patients with burns or septic syndrome, who poorly absorb fats and glucose, therefore they are forced to use amino acids both as a building material and as a source of energy. Amino acid solutions with an increased concentration of branched-chain amino acids (leucine, isoleucine and valine) are better absorbed with increased catabolism, such as sepsis and trauma. According to some studies, when using such solutions, the nitrogen balance improved faster, lymphocyte counts returned to normal faster, and delayed-type allergic reactions were less common. Since the positive effect of branched-chain amino acids is manifested with increased catabolism, they should not be used in all cases in a row.

Sources of nutrients

A balanced daily intake of all 7 food components (carbohydrates, fats, proteins, electrolytes, vitamins, trace elements and water) is required, which the doctor must monitor daily. In addition to increasing the production of carbon dioxide, as a result of which the respiratory coefficient rises to a value exceeding 1, oxygen consumption also increases, since the synthesis of fats requires energy. Therefore, in respiratory distress, the intake of large amounts of glucose can become an excessive metabolic load and lead to carbon dioxide retention. The use of glucose and fat instead of an equal amount of glucose alone reduces the risk of respiratory overload in patients with impaired lung function. In sepsis, glucose utilization due to insulin resistance is impaired, therefore, fats are preferable as an energy source, and carbohydrates should be no more than half of the basal metabolic rate.

Additives

The stock solution for parenteral nutrition does not contain electrolytes, trace elements and vitamins. Electrolytes are added to the mixture, taking into account the individual needs of the patient, in order to avoid water-electrolyte disturbances.

Electrolytes

Sodium- the main cation of the extracellular fluid, it must be supplied in quantities sufficient to maintain its concentration and replenish the observed losses. The amount of sodium required is based on extracellular fluid volume and serum sodium concentration. In hyponatremia, sodium intake should be increased against the background of fluid restriction (for example, 75-120 mEq / L of the nutritional formula), and in case of hypernatremia or an increase in the volume of extracellular fluid, the amount of sodium should be reduced (for example, 30 mmol / L). Sodium is administered in the form of chloride, phosphate, acetate, or bicarbonate.

Chloride- the main extracellular anion, is introduced in the form of sodium and potassium salts. Excess chlorides can cause hyperchloremic metabolic acidosis.

Acetate turns into bicarbonate in the body; it is included in solutions for parenteral nutrition in an amount of 50-120 meq per day to prevent the development of acidosis.

Potassium- the main intracellular cation. When anabolism is activated, the need for potassium increases. Hypokalemia is common with parenteral nutrition. Potassium is lost during osmotic diuresis against the background of hyperglycemia caused by parenteral nutrition. An increase in the concentration of insulin in plasma during parenteral nutrition leads to the activation of Na +, K + -ATPase and leads to the movement of K ions from the extracellular fluid into the cells. The use of β-adrenostimulants, vasopressor and inotropic agents also increases the activity of Na +, K + -ATPase and can lead to severe hypokalemia.

Magnesium deficiency can be observed with alcoholism, malabsorption syndrome, exhaustion, diseases of the parathyroid glands, as well as with increased excretion of magnesium in the urine while taking aminoglycosides. Magnesium from parenteral nutrition is used to synthesize new muscle tissue and is stored in the bones. Since magnesium is excreted in the urine, when calculating its amount in the nutritional formula, special attention should be paid to the condition of the kidneys. With moderate hypomagnesemia (1.2-1.3 meq / l), the amount of magnesium should be 2.5-5 meq (1-2 ml of 50% magnesium sulfate solution for each liter of parenteral nutrition). With a pronounced magnesium deficiency, it is necessary to additionally enter it intravenously.

Phosphates are part of nucleic acids, phosphoproteins, lipids, are necessary for the synthesis of high-energy compounds and 2,3-DPG in erythrocytes, as well as for maintaining bone metabolism. Depletion in severe illness and resumption of nutrition after fasting can be accompanied by hypophosphatemia and a general decrease in phosphate reserves in the body. Increased catabolism in sepsis and trauma leads to muscle breakdown and depletion of intracellular phosphate stores. Parenteral nutrition can aggravate hypophosphatemia, since the administration of glucose leads to the transfer of phosphates from the extracellular space into the cells, as in the case of potassium.

Phosphates must be included in the parenteral formula daily. The initial dose for sepsis and trauma should be 15-30 mmol / day. Phosphates are administered as sodium or potassium salts, depending on the serum potassium concentration.

Calcium like magnesium, you need to include it daily. Increased catabolism (for example, with sepsis or trauma) may be accompanied by an increase in calcium excretion. The mobilization of calcium from the bones leads to a decrease in its total amount in the body. Calcium deficiency also occurs with vitamin D deficiency. Since magnesium is required for the secretion and action of PTH, hypomagnesemia can lead to hypocalcemia. Approximately 50-60% of serum calcium is associated with albumin, therefore, with hypoalbuminemia, plasma calcium levels may be underestimated. To correctly assess serum calcium levels in hypoalbuminemia, the following formula can be used:

Serum calcium + (4.0 - serum albumin, g%) x 0.8 = = adjusted calcium level. If, after correction, the calcium level is too low, calcium is prescribed at a dose of 5 meq per 1 liter of parenteral mixture in the form of gluconate or glucoheptanate.

Buffers... Oxidation of positively charged and sulfur-containing amino acids is accompanied by the formation of hydrogen ions. If the serum bicarbonate level or the total ability to bind carbon dioxide falls below 20 meq / l, sodium acetate is added to the nutrient mixture at a dose of 25-30 meq / l. Acetate is broken down in the liver to bicarbonate. In case of impaired liver function, sodium bicarbonate (25-50 meq / l) is used to correct metabolic acidosis.

Vitamins

The mixture for parenteral nutrition should include daily water-soluble forms of vitamins A, D and E, vitamin C, B vitamins (including B 12), biotin and folic acid in doses exceeding the recommended daily requirement for them. Vitamin K is administered separately, once a week, intramuscularly at a dose of 10-25 mg (except for patients receiving anticoagulants). For patients on dialysis, folic acid (1 mg / 100 ml) is added to the mixture, since it is washed out during dialysis.

Trace elements

Chromium, manganese, copper, selenium and zinc should also be included in the daily diet (3-5 ml). Some authors propose to inject 1 dose of freshly frozen plasma every 3-4 weeks in order to provide the patient's body with cofactors unknown for today.

Heparin

It has been shown that heparin at a dose of 1000 units per 1 liter of nutritional formula improves the patency of veins and catheters.

Albumen

In severe protein deficiency (serum albumin< 2,0 г%) вводят бессолевой раствор альбумина.

Insulin

Short-acting insulin in crystalline form is usually added to the formula only for persistent hyperglycemia or glucosuria. Under normal conditions, it is not necessary.

Initiation, modification and discontinuation of parenteral nutrition

• Nutrition should be started gradually, taking into account the patient's tolerance to glucose and his individual needs. On the first day, 1000 ml of the mixture is injected, on the second - 2000 ml, and on the third - 3000 ml or more.
• It is recommended to stop parenteral nutrition gradually, reducing the volume of the injected mixture within 48 hours. You can also reduce the rate of administration to 50 ml / h and stop the administration of the mixture completely after 30-60 minutes. In rare cases, hypoglycemia is possible.
• Nutrient mixtures are usually administered continuously at the same rate. If, for some reason, the rate of administration has been reduced, it should not be increased too much, as this can cause glucosuria and osmotic diuresis. Usually, the rate of administration is increased by 10-20%.

Monitoring a patient on parenteral nutrition

• Estimation of the amount of injected and released fluid
• Measurement of original weight and height. Weigh the patient at the same time every day.
• Determination of basic physiological parameters is carried out every 4 hours. At temperatures above 38 ° C, notify the doctor.
• Laboratory research. Determine the initial daily excretion of creatinine and urea nitrogen, blood biochemical parameters, serum levels of electrolytes, transferrin, triglycerides, and also conduct a general blood test with determination of the leukocyte formula and platelet count. After the start of parenteral nutrition, the concentrate of electrolytes and serum phosphorus should be determined 2 times a day until levels corresponding to the daily requirements for them are reached. Plasma glucose levels are measured every 4-6 hours, and the levels of calcium, magnesium, serum creatinine and AMA are measured once a day. After stabilization on the background of parenteral nutrition, the levels of electrolytes, creatinine and AMA can be measured every other day, and calcium and magnesium levels - 2 times a week. Once a week, the activity of ALT, AST and ALP is determined, as well as the level of bilirubin for early detection of possible fatty degeneration of the liver. To assess the quality of parenteral nutrition, the total lymphocyte count, serum albumin and transferrin levels are determined weekly. The best criterion that parenteral nutrition meets the patient's needs is the indicator of nitrogen balance, which is determined by the level of daily excretion of urea and creatinine. With the additional daily introduction of fats, it is necessary to measure the level of serum triglycerides once a day for several days in order to avoid overloading the patient's body with fats. With a continuous parenteral nutrition regimen, triglyceride levels can be measured once a week.

Complications of parenteral nutrition

Hyperglycemia... The risk of hyperglycemia and glucosuria is increased in patients with overt or latent diabetes mellitus, liver disease, acute or chronic pancreatitis. Such patients may develop dehydration and hyperosmolar coma. Slow administration of the formula in the early stages of parenteral nutrition and frequent measurement of serum glucose levels can reduce the risk of this complication.

Hypoglycemia... May occur with rapid cessation of parenteral nutrition. A 10% glucose solution is injected intravenously.

Hypo- and hyperkalemia, hypo- and hypercalcemia, hypo- and hypermagnesemia. hypo- and hyperphosphatemia. Adequate administration of electrolytes and regular measurement of serum concentrations can prevent these complications.

Azotemia... Mixtures with a high nitrogen content may cause a slight increase in AMK. It is important to avoid dehydration and prerenal ARF.

Acute thiamine deficiency can occur with alcoholism, sepsis or trauma, if vitamins are not included in the solution for parenteral nutrition. Acute thiamine deficiency is manifested by severe lactic acidosis, not eliminated by the administration of bicarbonate, heart failure with high cardiac output, confusion, and arterial hypotension. It is possible to eliminate lactic acidosis only by intravenous administration of thiamine.

Side effects of fat emulsions... Delayed side effects of fat emulsions, especially if their dose exceeds 2.5 g / kg / day, include the accumulation of fats in the lungs, leading to a decrease in their diffusion capacity, and in the liver, leading to impaired bile production. The introduction of more than 4 g / kg of fat per day can cause bleeding (fat overload syndrome). With a decrease in the amount of injected fats, thrombocytopenia, platelet aggregation disorders and bleeding disappear.

Mixtures high in carbohydrates can cause the development of fatty liver disease... Glucose contained in such mixtures is converted into fats in hepatocytes and deposited in the liver parenchyma. Fatty degeneration of the liver is accompanied by cholestatic jaundice, increased alkaline phosphatase activity and serum bilirubin levels. Mixtures containing predominantly fat or mixed carbohydrate-fat mixtures rarely cause such complications.

Calculous and non-calculous cholecystitis develop in about 45% of patients who are on parenteral nutrition for a long time. Their development is facilitated by impaired motility of the biliary tract, stagnation of bile, the formation of bile putty and stones. These complications are more common in patients with hemoblastosis.

Taurine deficiency... Taurine is not included in parenteral formulas. It does not belong to essential amino acids, but with prolonged parenteral nutrition, its level in children and adults may decrease. Taurine deficiency causes retinal dysfunction. To avoid this, add taurine to the formula.

Carnitine deficiency... The need for carnitine increases with injury. It is essential for the oxidation of fatty acids in skeletal muscle and myocardium. With carnitine deficiency, hyperbilirubinemia, generalized muscle weakness, and reactive hypoglycemia develop. It is necessary to monitor the level of carnitine in erythrocytes and serum.

Biotin deficiency can develop with prolonged parenteral nutrition; hair loss, itchy dermatitis, waxy pallor of the skin, drowsiness, depression, and anemia are common.

Selenium deficiency leads to dilated cardiomyopathy with diffuse focal myocardial necrosis and impaired conduction. Selenium deficiency is exacerbated by fluid loss through the gastrointestinal tract.

Respiratory complications... Protein-energy deficiency can cause respiratory muscle weakness. It is better to stop mechanical ventilation after completing the nutritional deficiency. Amino acid solutions may increase sensitivity to hypercapnia. High glucose nutritional formulas increase respiratory rate and carbon dioxide production. Fat has a lower respiratory quotient than glucose, so increasing the proportion of fat in the formula can reduce the production of carbon dioxide.

Protein-energy imbalance... For most nutritional mixes, the ratio of non-protein calories to protein nitrogen is 80-200 kcal / g nitrogen or 13-32 kcal / g protein. If not enough carbohydrates and fats are introduced, the body begins to use amino acids as an energy source. The breakdown of amino acids leads to a steady increase in AMK, which does not correspond to the level of creatinine. Protein-energy imbalance observed with burns, pronounced. Increased catabolism or renal failure. To eliminate it, you need to increase the ratio of non-protein calories and protein nitrogen, for which either reduce the amount of amino acids introduced, or increase the intake of non-protein energy sources.

Catheter infection. Sepsis occurs in less than 5% of patients receiving parenteral nutrition. This is most often caused by contamination of the catheter, dressing, or solutions. Catheter infection should be ruled out in all cases of fever and leukocytosis if no other foci of infection are found. Sow blood, urine, sputum and wound contents. Each time the temperature rises, the container for the nutrient mixture and the system for administration are changed and given for sowing. A blood culture from the catheter should also be done. If culture is positive, the catheter is removed and the tip sent for culture. To clear the bloodstream, a new catheter is installed no earlier than 24-48 hours. Treatment consists in the introduction of intravenous antibacterial drugs that are active against the identified pathogen.

Parenteral nutrition through peripheral veins

Indications. Parenteral nutrition through peripheral veins is used in the following cases.

1. If parenteral nutrition through the central vein is not possible.
2. If short-term artificial nutrition is required (for example, in some patients before and after surgery).
3. If patients eat on their own, but in insufficient quantities.

Benefits of Parenteral Peripheral Vein Nutrition

1. Inserting a catheter into a peripheral vein is safer than a central one.
2. It is easier to control possible infection at the infusion site.
3. Catheter care is easier.
4. There are no complications associated with the use of hyperosmolar glucose solutions.

Disadvantages of parenteral nutrition through peripheral veins

1. Hyperosmolar solutions should not be used, as they irritate the walls of blood vessels and thrombophlebitis.
2. The volume of solution required to provide the required number of calories may be too large, which limits the total caloric content of the mixture to be administered.
3. The calorie content of the introduced mixture may be insufficient for long-term support of anabolic processes.

Administration modes. A solution of amino acids and carbohydrates can be administered simultaneously with the fat emulsion. A Y-piece is used for this. This In most clinics, ready-made mixtures of fats, carbohydrates and proteins are used, which makes the use of a Y-piece unnecessary. Monitoring of patients with parenteral nutrition through peripheral veins is carried out in the same way as when using a central catheter, and the same careful care and well-coordinated work of all personnel are required.