Organization proper nutrition always contributes quick recovery patient. This is due to the fact that the body begins to receive sufficient quantities of substances that are required for the cellular restoration of pathologically altered organs. If necessary, you can use parenteral nutrition. If the functions digestive system preserved, then enteral nutrition of patients is used.
Among patients admitted to hospitals, 20-40% have low nutrition. Importantly, the trend towards worsening malnutrition is clearly evident during the period of hospitalization. Currently, there is no “gold standard” for assessing a person’s nutritional level: all approaches characterize the outcome (“what happened”), and not individual nutritional parameters. Clinicians need a method to help recognize, evaluate, and treat protein malnutrition, as well as other nutritional deficiencies, on a nutritional basis.
Loss of body weight in 1 month. by more than 10%.
Body mass index is less than 20 kg/m2.
Inability to eat for more than 5 days.
Methodology for providing auxiliary nutrition
Enteral tube feeding
Assisted enteral tube feeding in small sips through a tube. For patients with severe fluid loss, enterostomies with copious discharge, and short bowel syndrome, many methods of rehydration therapy have been developed. Special nutritional mixtures include preparations with one nutrient (for example, protein, carbohydrate or fat), elemental (monomeric), polymer, and also intended for the treatment of a specific pathology.
Feeding through a tube or enterostomy. When the gastrointestinal tract remains functional but the patient is unable or will not be able to feed by mouth in the near future, this approach provides significant benefits. There are a number of methods: nasogastric, nasojejunal, gastrostomy, jejunostomy feeding. The choice depends on the doctor’s experience, prognosis, approximate duration of the course and what suits the patient best.
Soft nasogastric tubes may not be removed for several weeks. If nutrition will have to be provided for longer than 4-6 weeks, percutaneous endoscopic gastrostomy surgery is indicated.
Feeding the patient through a tube
Feeding through a nasojejunal tube is sometimes prescribed for patients with gastroparesis or pancreatitis, but this method does not guarantee protection against aspiration, and errors in the insertion of the tube are possible. It is always better to administer the nutritional mixture as a long-term drip rather than as a bolus (a bolus can cause reflux or diarrhea). Feeding the patient through a tube should be carried out under the supervision of nursing staff.
If enterostomy is necessary, preference is usually given to the technique of percutaneous endoscopic gastrostomy, although surgical placement of a gastrostomy or placement under X-ray guidance is often resorted to. A jejunal tube can be inserted over a guidewire through an existing gastrostomy tube or through independent surgical access.
Widespread use endoscopic method The installation of a gastrostomy tube has greatly facilitated the care of patients with disabling diseases, such as progressive neuromuscular pathology, including strokes. The procedure involves relatively frequent complications Therefore, it is necessary that it be performed by an experienced specialist.
Enteral nutrition
A sick person eats more if he is helped during meals and if he has the opportunity to eat what he wants. The patient’s wish that relatives and friends bring him food should not be contradicted.
Preference should be given to enteral nutrition, since drugs containing all nutrients have not yet been created. Moreover, some food components can enter the human body only through the enteral route (for example, short-chain fatty acid for the mucous membrane of the colon are supplied due to the breakdown of fibers and hydrocarbons by bacteria).
Parenteral nutrition is fraught with complications associated with bacterial contamination of systems for administering solutions
Parenteral nutrition
Access through peripheral or central veins. Parenteral nutrition, if performed incorrectly, is fraught with the development of life-threatening complications.
Using modern drugs For parenteral nutrition, catheters installed in peripheral veins can only be used for a short time (up to 2 weeks). The risk of complications can be minimized by carefully performing the catheterization procedure, observing all rules of asepsis and using nitroglycerin patches. If the central catheter must be inserted through a peripheral access, the medial saphenous vein of the arm should be used at the level of the cubital fossa (introduction of the catheter through the lateral saphenous vein should be avoided). saphenous vein arm, as it connects to the axillary vein at an acute angle, which may make it difficult to advance the catheter beyond this point).
Principles of parenteral nutrition
In conditions where there is too short a portion of the intestine left for absorption nutrients(the small intestine is less than 100 cm in length or less than 50 cm with a intact colon), parenteral nutrition is necessary. The following describes the principles of parenteral nutrition for patients.
Indicated for intestinal obstruction, except in cases where endoscopically it is possible to pass an enteral feeding tube through a narrowed section of the esophagus or duodenum.
Shown when severe sepsis if it is accompanied by intestinal obstruction.
External fistula of the small intestine with abundant secretion, which sharply limits the process of digestion of food in the intestine, makes parenteral nutrition necessary.
Patients with chronic intestinal pseudo-obstruction require parenteral nutrition.
Calculating nutritional needs and choosing a diet
When the patient's body temperature increases by 1 degree Celsius, the needs increase by 10%. Should be considered physical activity sick. Changes are made to the calculations accordingly:
- Unconscious - basal metabolism.
- At artificial ventilation lungs: -15%.
- Conscious, activity within bed: +10%.
- Physical activity within the ward: + 30%.
If it is necessary for the patient’s body weight to increase, add another 600 kcal per day.
Protein parenteral nutrition
The average protein requirement is calculated using nitrogen in grams (g N) per day:
- 9 g N per day - for men;
- 7.5 g N per day - for women;
- 8.5 g N per day - for pregnant women.
It is necessary to provide complete protein parenteral nutrition to patients. A person’s energy expenditure often increases during illness. So, in providing nitrogen to the maximum, i.e. 1 g N for every 100 kcal is required for patients with burns, sepsis and other pathologies characterized by increased catabolism. The situation is controlled by monitoring nitrogen excretion with urea.
Carbohydrates
Glucose is almost always the dominant source of energy. It is necessary for blood cells, bone marrow, kidney and other tissues. Glucose is the main energy substrate that powers the brain. The infusion rate of glucose solution is usually maintained at a level of no more than 4 ml/kg per minute.
Fats
Lipid emulsions act as suppliers of energy, as well as fatty acids necessary for the body, including linoleic and lenolenic acids. No one can accurately say the percentage of calories that should enter the body in the form of fats, but they believe that at least 5% of the total calories should be provided by lipids. Otherwise, fatty acid deficiency will develop.
Electrolyte requirements
The number of millimoles of required sodium ions is determined by body weight and this figure is considered as a base figure. You need to add the registered losses to it.
The basic need for potassium is also determined taking into account body weight in kilograms - the number of millimoles/24 hours. Calculated losses are added to it:
- Calcium - 5-10 mmol per day.
- Magnesium - 5-10 mmol per day.
- Phosphates - 10-30 mmol per day.
- Vitamins and microelements.
In the postoperative period, the body's need for proteins, fats, carbohydrates, electrolytes and vitamins is provided enterally, including nutrition through a tube inserted into the stomach or duodenum, gastro- or jejunostomy, and parenterally - mainly intravenously. Enteral nutrition is always more complete, so at the slightest opportunity they switch to oral nutrition, at least partially.
Enteral nutrition in postoperative period should ensure maximum sparing of the affected organs, especially during operations on the gastrointestinal tract, increase its resistance to inflammation and intoxication, promote faster healing surgical wound. After large operations on organs abdominal cavity Fasting is prescribed for 1-2 days (mouth rinsing is allowed). In the future, they gradually begin to give the most gentle food (liquid, semi-liquid, pureed), containing a sufficient amount of liquid, easily digestible proteins, fats, carbohydrates, mineral salts and vitamins.
To prevent flatulence, exclude milk and vegetable fiber.
After gastrectomy, on the 2nd day in the afternoon, you are allowed to drink 250 ml of liquid in sips. On the 3rd day, give 2 glasses of liquid (fruit drink, broth, water) and a raw egg. From the 4th day, table No. lac is prescribed, with the exception of dishes with milk.
After total removal of the stomach, parenteral nutrition is carried out for 3-4 days. If the nipple probe is left, enteral fluid administration is prescribed from the 2-3rd day after the restoration of peristalsis. From 4-5 days the patient is transferred to enteral nutrition. In this case, on the first day they give you 1 teaspoon of 200 ml of boiled water to drink. In the future, nutrition is expanded according to the scheme recommended for patients who have undergone gastrectomy.
After uncomplicated operations on biliary tract You are allowed to drink on the first day. From the 2nd day, table No. 5a is prescribed.
After resection of the colon, the patient is allowed to drink in small sips on the first day after surgery. From the 2nd day, table No. 0 is prescribed without bread (mucous pureed soups, weak broth, jelly, rosehip infusion, tea with milk). On the 5th day, the patient is transferred to surgical table No. 1 with white breadcrumbs. These schemes are sometimes changed depending on the course of the postoperative period.
Tube enteral feeding is carried out according to special indications. It can be used as a method of postoperative preparation of patients, for example, with pyloroduodenal stenosis, after endoscopic passage of the probe beyond the area of narrowing, preferably into the initial part of the jejunum; after total removal of the stomach; after resection of the stomach, complicated by the failure of the sutures of the duodenal stump.
During the period of preoperative preparation, the tube diet can be quite broad: cream, broth, eggs, sour cream, juices, cottage cheese diluted with milk.
After an operation, for example a gastrectomy, on the 2nd day after the nipple probe carried out during the operation, 60 ml is inserted into the jejunum below the anastomosis hypertonic solution sodium chloride and 20 ml Vaseline oil. After 30 minutes, when peristalsis appears, 2 raw eggs, after another 3 hours - 250 ml of broth and 50 g of butter. After 3 hours - two eggs, cream (milk) up to 250 ml. After 3 hours - 250 ml of fruit drink (compote, dried apricot infusion).
Thus, already on the first day of enteral nutrition (2nd day after gastrectomy), the patient receives up to 850 ml of fluid. On the 3-4th day, the amount of simultaneously administered liquid can be increased to 300 - 350 ml. In total, up to 1.5-2 liters are administered per day, including enpits - specially developed food mixtures for enteral nutrition.
Parenteral nutrition is indicated if the patient cannot eat in the usual way or if oral nutrition does not meet the body's metabolic needs. Parenteral nutrition can be complete when it provides the body’s daily energy needs and the need for water, electrolytes, nitrogen, vitamins, and incomplete when it selectively replenishes the body’s deficiency in certain nutritional ingredients. In normal clinical conditions, when it is not possible to quickly and accurately determine the level of actual metabolism based on oxygen consumption, when determining the volume of parenteral nutrition, it is advisable to be guided by the following provisions.
Constant monitoring of the effectiveness of parenteral nutrition is necessary. Its main criteria are: change in body weight, nitrogen balance, amount of total circulating albumin, A/G ratio. The best criterion for the adequacy of parenteral nutrition is the patient's condition.
The procedure for examining patients on parenteral nutrition.
3. Plasma osmolarity is examined during the first 3-4 days, then 2 times a week.
6. General analysis blood and urine every 3 days.
7. Weigh the patient daily: for this purpose, use special electronic scales or bed scales.
TICKET No. 10
1. PPKOVMOLPGK Indications, preparation for surgery, choice of method of surgical treatment for acute gastroduodenal bleeding.
Adequate nutrition forms the basis of the life of the human body and is an important factor in ensuring the resistance of the child’s body to pathological processes of various origins. Stressful conditions (surgery, polytrauma, poisoning, acute infections) lead to a sharp shift in metabolic processes towards increased catabolism. Surgical trauma causes significant metabolic disorders in the body of the person being operated on: disturbances in protein-amino acid, carbohydrate and fat metabolism, water-electrolyte balance, and vitamin metabolism.
Within 24 hours, without nutritional support, the reserves of its own carbohydrates are virtually completely exhausted and the body receives energy from fats and proteins. Not only quantitative, but also qualitative changes in metabolism occur. In patients with initial malnutrition, vital reserves are especially reduced. All this requires additional nutritional support in the overall treatment program for seriously ill patients.
Features of intestinal function in the postoperative period. In the absence of enteritis in newborns and children early age the permeability of the intestinal wall in the postoperative period may remain unchanged. The presence of an inflammatory lesion is most likely accompanied by increased permeability to certain nutrients. This makes the use of products with a potentially allergenic effect undesirable.
During intestinal resection in young children, the secretion of substances into the cavity of the gastrointestinal tract increases. The imbalance between secreted and adsorbed fluid is especially pronounced during resection of the sections responsible for the absorption of salts and water (terminal ileum and colon). Most significant violations secretions are observed in the early postoperative period; in the future, these phenomena can be compensated.
With isolated resection of the jejunum, adaptation is usually successful, with only a slight decrease in the absorption of carbohydrates and lipids. Isolated resection of the ileum, especially its terminal section, is characterized by a decrease in the absorption of bile salts, an increase in secretion and a simultaneous decrease in the absorption of lipids, an increase in sodium and water losses, a decrease in the absorption of fat-soluble vitamins, and a decrease in bacterial fermentation of carbohydrates.
With combined resection of the jejunum and ileum, the changes characteristic of resection of the ileum are aggravated; there is also a decrease in the absorption of carbohydrates, an increase in the loss of fatty acids, and an increased risk of lactic acidosis.
Changes in digestion and absorption are closely related to changes in intestinal motility. As is known, intestinal paresis is observed in the early postoperative period, as well as in the presence of local inflammation. Subsequently, in the most difficult cases - during resection of the terminal ileum and colon, an acceleration of the passage of nutrients through the intestine is observed. Post-resection acceleration of passage does not mean the activation of normal motor activity, but only reflects a shortening of the length of the intestine and activation of peristalsis in response to increased secretion
Nutritional support belongs to the category of highly effective intensive care methods and is aimed at preventing, in patients in serious (or extremely serious) condition, weight loss and decreased protein synthesis, the development of immunodeficiency, electrolyte and microelement imbalance, deficiency of vitamins and other nutrients.
Nutritional support is the process of providing adequate nutrition through a number of methods other than regular eating.
In accordance with the order of the Ministry of Health of the Russian Federation No. 330 dated 05.08.2003. “On measures to improve therapeutic nutrition in medical institutions of the Russian Federation” the types of nutritional support used include:
enteral nutrition;
parenteral nutrition;
standard diet system;
therapeutic nutrition using enteral nutrition mixtures.
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Interest in nutritional issues for surgical patients has been stimulated over the past two decades by advances in enteral and parenteral nutrition. The most significant milestone along this path was undoubtedly the introduction of parenteral nutrition into clinical practice, which forced doctors to pay attention to the peculiarities of the course of the disease, reduced by nutrition. Issues of nutritional needs continue to be constantly redefined to this day as treatment problems develop. various types pathology.
In the United States, the highest incidence of malnutrition occurs among inpatients, which undoubtedly has a negative impact on their recovery. Particularly severe nutritional changes, particularly protein malnutrition, often occur after injury and major surgery.
Nutrition issues for children, compared to adults, present a complex problem, which is associated with the special specific needs of a growing body, most pronounced in infants. Therefore, it is for younger children age group will be the subject of this chapter.
Physiological needs
Water is absolutely necessary for the existence of the body and is second in importance only to oxygen. Lack of water leads to death within a few days. Its content in the body of infants is higher than in adults (75% of body weight, in adults - 65%) (Fig. 2-l).
Rice. 2-1. The total amount of water (OBT - total body sex) and extracellular fluid (ECF) in the body decreases as the child grows, the amount of extracellular fluid (ECF) increases.
The main reserves of water are contained in organ fluids, but part of it is provided through the oxidation processes of food and tissues. An infant needs significantly more water per unit of body weight than an adult. If you count water per 100 kilocalories received, then the required amount will be the same for children and adults (Table 2-1).
Table 2-1. Daily fluid requirements 
Daily consumption liquids healthy child equals 10-15% of body weight, while in an adult it is only 2-4% of BW. In addition, the food consumed by children contains much more water than the poverty of adults. The fruits and vegetables that are usually included in a child’s diet consist of almost 90% water. However, only 0.5-3% of the fluid children receive is retained in the body, while about 50% is excreted by the kidneys, 3-10% by the gastrointestinal tract, and 40-50% is part of intangible losses.
Kilocalories. The energy needs of children vary significantly depending on age and a number of other circumstances (Table 2-2). Fine balanced diet should include 15% protein, 35% fat and 50% carbohydrates. An adult needs 150 non-protein kilocalories for every gram of nitrogen received.
Table 2-2. Energy and protein requirements 
Protein requirements increase in states of stress and injury, but it is not yet known what the ratio of non-protein kilocalories to nitrogen should be in this case. The studies have shown one thing for certain - in young children after major operations this ratio should be at least 230:1.
Squirrels. The protein requirements of infants are determined by the need not only to maintain the body, but also to grow. Proteins make up 20% of an adult’s body weight, nitrogen makes up 2% of an adult’s body weight. small child and 3% in adults.
The greatest increase in nitrogen content in the body occurs during the first year of life. The nutritional value of protein is determined by its content not only of nitrogen, but also of amino acids. Of the 20 known amino acids, 9 are essential, i.e. necessary infant(Table 2-3).
Table 2-3. Essential amino acids 
New tissue cannot be formed in the body unless all essential amino acids are supplied at the same time. The absence of even one of them leads to a negative nitrogen and protein balance. The total level of plasma proteins varies in healthy children from 60 to 75 g/l, with slightly more low performance in newborns and premature infants.
Carbohydrates. The largest portion of energy needs is provided by carbohydrates, the reserves of which consist mainly of glycogen in the liver and muscles. However, since infant The relative mass of the liver and muscles is significantly less than in an adult, and glycogen reserves are significantly reduced compared to adults. Glycogen is converted to glucose in the liver and then converted in tissues, either anaerobically into lactic acid or aerobically into carbon dioxide and water. Aerobic metabolism produces significantly more energy in the form of adenosine triphosphate (ATP).
Fats are another significant source of non-protein calories. Fats, both in the body and from food, consist mainly of simple lipids, mainly glycerides. Natural fats contain fatty acids, saturated and unsaturated.
The human body does not synthesize linoleic acid, so it is considered essential and, accordingly, should be contained in food. Its deficiency is manifested by dryness and thickening of the skin with typical rashes and peeling. If a child receives 1-2% of kilocalories in the form of linoleic acid, linoleic acid deficiency does not occur.
The question of the need for linolenic acid for the body continues to remain controversial, although children on long-term parenteral nutrition with fat emulsions containing 78% linoleic acid and only 0.5% linolenic acid may develop neurological disorders that can be stopped by the administration of emulsions containing 54% linoleic acid. acid and 8% linolenic.
Minerals and vitamins. A rapidly growing child needs more minerals than an adult, especially phosphorus and calcium. The mineral content in the fetal body is low, at the time of birth they make up only 3% of body weight, gradually increasing throughout childhood. At the same time, both the absolute and relative amount of minerals increases, as a result, in an adult there are 40 times more of them than in a newborn, while the body weight of an adult is only 23 times higher than the BW of a newborn. For every gram of protein, about 0.3 grams of minerals are deposited in the body.
The most important electrolytes required for the body are calcium, magnesium, potassium, sodium, phosphorus, sulfur, chlorine (Table 2-4). Iron, iodine and cobalt are present in the body as part of various organic complexes. As for microelements, the nature of participation in the metabolism of some of them is known, for example fluorine, copper, zinc, manganese. At the same time, selenium, silicon, boron, nickel, aluminum, arsenic, molybdenum and strontium are required for the body, but their specific metabolic effects have not been sufficiently studied (Table 2-5).
Vitamins for normal cellular metabolism are required in minimal quantities. They must be supplied wholly or partly from outside. B vitamins act as coenzymes in various biochemical reactions, but the specific type of action of other vitamins is not yet well known. Fat-soluble vitamins include A, D, K and E, and water-soluble vitamins include thiamine, riboflavin, folic acid, vit. AT 12. pyridoxine, nicotinic acid, biotin, pantothenic acid and vit. C. Since a person has reserves fat-soluble vitamins, their excessive administration can cause various disorders. In addition, impaired fat absorption leads to a deficiency of fat-soluble vitamins (Table 2-6).
K.U. Ashcraft, T.M. Holder
Artificial nutrition is today one of the basic types of treatment for patients in a hospital setting. There is practically no area of medicine in which it is not used. The most relevant use of artificial nutrition (or artificial nutritional support) is for surgical, gastroenterological, oncological, nephrological and geriatric patients.
Nutritional support– a set of therapeutic measures aimed at identifying and correcting disturbances in the nutritional status of the body using nutritional therapy methods (enteral and parenteral nutrition). This is the process of providing the body nutrients(nutrients) through methods other than regular food intake.
“The failure of a doctor to provide food to a patient should be regarded as a decision to starve him to death. A decision for which in most cases it would be difficult to justify,” wrote Arvid Vretlind.
Timely and adequate nutritional support can significantly reduce the frequency infectious complications and mortality of patients, improve the quality of life of patients and speed up their rehabilitation.
Artificial nutritional support can be complete, when all (or the main part) of the patient’s nutritional needs are provided artificially, or partial, if the introduction of nutrients by enteral and parenteral routes is additional to normal (oral) nutrition.
Indications for artificial nutritional support are varied. 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 that 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 “7 days or 7% reduction in body weight” rule is widely known. It means that artificial nutrition must be carried out in cases where the patient has been unable to eat naturally for 7 days or more, or if the patient has lost more than 7% of the recommended body weight.
Assessing the effectiveness of nutritional support includes the following indicators: dynamics of nutritional status parameters; state of nitrogen balance; course of the underlying disease, condition 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 body's primary reaction in response to the cessation of the supply of nutrients from the outside is the use of glycogen and glycogen stores as an energy source (glycogenolysis). However, the glycogen reserve in the body is usually not large and is depleted within the first two to three days. In the future, the body's structural proteins (gluconeogenesis) become the easiest and most accessible source of energy. During gluconeogenesis, glucose-dependent tissues produce ketone bodies, which by reaction feedback slow down the basal metabolism and oxidation of lipid reserves as an energy source begins. Gradually, the body switches to a protein-saving mode of functioning, and gluconeogenesis resumes only when fat reserves are completely depleted. So, if in the first days of fasting protein loss is 10–12 g per day, then in the fourth week it is only 3-4 g in the absence of pronounced external stress.
In patients in critical condition, 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 hormones with an anabolic effect such as growth hormone and insulin is blocked. As often happens in critical conditions, the adaptive reaction aimed at destroying proteins and providing the body with substrates for building new tissues and healing 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 per day can be burned. This condition was called autocaniballism. Energy consumption increases by 50-150%. For some time, the body can maintain its needs for amino acids and energy, but 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 and adaptive reactions in terminal conditions is that in the first case there is an adaptive decrease in energy requirements, and in the second, energy consumption increases significantly. Therefore, in post-aggression states, a negative nitrogen balance should be avoided, since protein depletion ultimately leads to death, which occurs when more than 30% of the total body nitrogen is lost.
- Gastrointestinal tract during fasting and critical illness
In critical illnesses, conditions often arise in which adequate perfusion and oxygenation of the gastrointestinal tract are disrupted. This leads to damage to intestinal epithelial cells with disruption of barrier function. The disorders 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 to a large extent directly from the chyme.
An important factor damaging the digestive tract is any centralization of blood circulation. With centralization of blood circulation, intestinal perfusion decreases 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 vital perfusion important organs. The absence of chyme in the intestinal lumen disrupts the supply of antioxidants and their precursors to enterocytes and aggravates reperfusion injuries. The liver, due to autoregulatory mechanisms, suffers somewhat less from a decrease in blood flow, but its perfusion still 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. Escherihia coli, Enterococcus and bacteria of the genus Candida are mainly involved in translocation. Microbial translocation is always present in certain quantities. Bacteria penetrating into the submucosal layer are captured by macrophages and transported to the systemic lymph nodes. When they enter the bloodstream, they are captured and destroyed by Kupffer cells of the liver. Stable balance is disrupted by uncontrolled growth of intestinal microflora and changes in it normal composition(i.e. with the development of dysbiosis), impaired mucosal permeability, impaired local intestinal immunity. It has been proven that microbial translocation occurs in critically ill patients. It intensifies in the presence of risk factors (burns and severe trauma, systemic antibiotics wide range, pancreatitis, hemorrhagic shock, reperfusion injuries, exclusion of solid foods, etc.) and is often the cause of infectious lesions in critically ill patients. In the United States, 10% of hospitalized patients develop a nosocomital infection. This is 2 million people, 580 thousand deaths and treatment costs of about 4.5 billion dollars.
Disorders of the intestinal barrier function, expressed in mucosal atrophy and impaired permeability, develop quite early in critically ill patients and are expressed already 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, epithelial and basement membrane lymphocytes. Maintaining normal nutrition through the intestines helps maintain the immune system of the whole body in a normal state.
- Gastrointestinal tract during fasting and critical illness
- Principles of nutritional support
One of the founders of the doctrine of artificial nutrition, Arvid Wretlind (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 treat.
- Optimality.
Artificial nutrition must be carried out until the nutritional status stabilizes.
- Adequacy.
Nutrition must cover the body's energy needs and be balanced in the composition of nutrients and meet the patient's needs for them.
- Timeliness.
- Enteral nutrition
Enteral nutrition (EN) is a type of nutritional therapy in which nutrients are given orally or through a gastric (intestinal) tube.
Enteral nutrition is a type of artificial nutrition and, therefore, is not carried out through natural routes. To carry out enteral nutrition, one or another access is required, as well as special devices for administering nutritional mixtures.
Some authors classify only methods that bypass the oral cavity as enteral nutrition. Others include oral feeding 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 administration of a special mixture for enteral nutrition in small sips (usually through a tube).
- Benefits of Enteral Nutrition
Enteral nutrition has a number of advantages over parenteral nutrition:
- Enteral nutrition is more physiological.
- Enteral nutrition is more economical.
- Enteral nutrition practically does not cause life-threatening complications and does not require strict sterility.
- Enteral nutrition allows you 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 EN 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 to use enteral nutrition in all cases where this is possible, if only because its cost is significantly lower than parenteral nutrition, and its effectiveness is higher.
For the first time, 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, swallowing disorders, etc.).
- Enteral nutrition is indicated when the patient should not eat food (acute pancreatitis, gastrointestinal bleeding and etc.).
- Enteral nutrition is indicated when the patient does not want to eat food ( anorexia nervosa, infections, etc.).
- Enteral nutrition is indicated when normal nutrition is not adequate to the needs (injuries, burns, catabolism).
According to the "Instructions for organizing enteral nutrition..." the Ministry of Health of the Russian Federation identifies the following nosological indications for the use of enteral nutrition:
- Protein-energy deficiency when it is impossible to ensure adequate intake of nutrients through the natural oral route.
- Neoplasms, especially localized in the head, neck and stomach.
- Disorders of the central nervous system: comatose states, cerebrovascular strokes or Parkinson's disease, as a result of which nutritional disorders develop.
- Radiation and chemotherapy for cancer.
- Gastrointestinal diseases: Crohn's disease, malabsorption syndrome, short bowel syndrome, chronic pancreatitis, ulcerative colitis, diseases of the liver and biliary tract.
- Nutrition in the pre- and early postoperative periods.
- Trauma, burns, acute poisoning.
- Complications of the postoperative period (gastrointestinal fistulas, sepsis, leakage of anastomotic 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 studied and used in an increasingly diverse group of patients. Stereotypes are being broken about mandatory fasting in patients undergoing operations on the gastrointestinal tract, in patients immediately after recovery from shock, and even in patients with pancreatitis. As a result, there is no consensus on absolute contraindications for enteral nutrition.
Absolute contraindications to enteral nutrition:
- Clinically pronounced shock.
- Intestinal ischemia.
- Full intestinal obstruction(ileus).
- Refusal of the patient or his guardian to provide enteral nutrition.
- Continued gastrointestinal bleeding.
Relative contraindications to enteral nutrition:
- Partial intestinal obstruction.
- Severe intractable diarrhea.
- External small intestinal fistulas with discharge 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 a 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 intestines (essentially intestinal paresis).
- General recommendations for enteral nutrition
- Enteral nutrition should be given as early as possible. Provide nutrition through a nasogastric tube if there are no contraindications to this.
- Enteral nutrition 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 value is reached (25-35 kcal/kg/day).
- In cases where the residual volume exceeds 3 ml/kg, then treatment with prokinetics should be prescribed.
- If after 24-48 hours, due to high residual volumes, it is still not possible to feed the patient adequately, then the probe should be inserted into ileum blind method (endoscopically or under X-ray control).
- It should be conveyed to the nurse providing enteral nutrition that if she cannot provide it properly, this means that she cannot provide proper care to the patient at all.
- When to start enteral nutrition
The literature mentions the benefits of “early” parenteral nutrition. Data is provided that in patients with multiple injuries, enteral nutrition was started immediately after stabilization of the condition, in the first 6 hours from admission. Compared to the control group, when nutrition began after 24 hours from admission, a less pronounced disturbance 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 nutrition should begin as early as possible - not only in order to immediately replenish the patient’s energy costs, but in order to prevent changes in the intestines, which can be achieved by enteral nutrition with relatively small volumes of administered food .
Theoretical basis for early enteral nutrition.
Lack of enteral nutrition
leads to:Atrophy of the mucous membrane. Proven in animal experiments. Excessive colonization of the small intestine. Enteral nutrition prevents this in the experiment. Translocation of bacteria and endotoxins into the portal bloodstream. People have impaired mucosal permeability due to burns, trauma and critical conditions.
- Enteral nutrition regimens
The choice of diet is determined by the patient’s condition, underlying and concomitant pathology and capabilities medical institution. The choice of method, volume and speed of EN are determined individually for each patient.
The following modes of enteral nutrition are available:
- Power supply at constant speed.
Feeding through a gastric tube begins with isotonic mixtures at a rate of 40–60 ml/hour. If well tolerated, the feeding rate can be increased by 25 ml/hour every 8–12 hours until the desired rate is achieved. 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, cramps or diarrhea, it is necessary to reduce the rate of administration or the concentration of the solution. In this case, simultaneous changes in the feeding rate and concentration of the nutrient mixture should be avoided.
- Cyclical nutrition.
The continuous drip is gradually “compressed” to a 10–12 hour overnight period. Such nutrition, convenient for the patient, can be provided through a gastrostomy tube.
- Periodic or session nutrition.
Nutrition 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 nutrition.
It imitates a normal meal, therefore ensuring a more natural functioning of the gastrointestinal tract. It is performed only with transgastric access. The mixture is administered dropwise or by syringe at a rate of no more than 240 ml in 30 minutes 3-5 times a day. The initial bolus should not exceed 100 ml. If well tolerated, the injected volume is increased daily by 50 ml. Diarrhea develops more often during bolus feeding.
- Usually, if the patient has not received nutrition for several days, continuous drip administration of mixtures is preferable to periodic administration. Continuous 24-hour nutrition is best used in cases where there are doubts about the preservation of the functions of digestion and absorption.
- Power supply at constant speed.
- Enteral nutrition mixtures
The choice of formula for enteral nutrition depends on many factors: disease and general condition patient, presence of disorders digestive tract patient, the required enteral nutrition regimen.
- General requirements requirements for enteral formulas.
- The enteral mixture must have sufficient energy density (at least 1 kcal/ml).
- Enteral formula should be lactose and gluten free.
- The enteral mixture should have low osmolarity (no more than 300–340 mOsm/L).
- The enteral mixture should have a low viscosity.
- Enteral formula should not cause excessive stimulation of intestinal motility.
- The enteral formula must 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 mixtures for complete EN contain sufficient free water to meet the patient's daily fluid requirements. The daily fluid requirement is usually estimated as 1 ml per 1 kcal. Most mixtures with energy value 1 kcal/ml contains 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 due to their imbalance and inadequacy to the needs of adult patients.
- General requirements requirements for enteral formulas.
- 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 for 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 severe 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 intolerance to natural nutrition for various reasons.
- Enteral nutrition is not natural nutrition, and artificial, with specially prepared mixtures.
- Classification of complications of enteral nutrition
The following types of complications of enteral nutrition are distinguished:
- Infectious complications (aspiration pneumonia, sinusitis, otitis, wound infection during gastoenterostomies).
- Gastrointestinal complications (diarrhea, constipation, bloating, regurgitation).
- Metabolic complications (hyperglycemia, metabolic alkalosis, hypokalemia, hypophosphatemia).
This classification does not include complications associated with enteral nutrition techniques - self-extraction, migration and blockage of feeding tubes and feeding tubes. In addition, a gastrointestinal complication such as regurgitation may coincide with an infectious complication such as aspiration pneumonia. starting with the most frequent and significant.
The literature indicates the frequency of various complications. The wide scatter of data is explained by the fact that no uniform diagnostic criteria have been developed for determining a particular complication and there is no uniform protocol for the management of complications.
- High residual volumes - 25%-39%.
- Constipation - 15.7%. With long-term enteral nutrition, the incidence of constipation can increase 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 different authors, frequency aspiration pneumonia indicated from 1 to 70 percent.
- About sterility during 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 environment for the proliferation of microorganisms and, on the other hand, in the departments intensive care there are all conditions for bacterial aggression. The danger is represented by both the possibility of infection of the patient with microorganisms from the nutritional mixture, and poisoning by the resulting endotoxin. It must 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 processed gastric juice, which has pronounced bactericidal properties. Other factors accompanying the development of infection include: antibacterial therapy, immunosuppression, concomitant infectious complications, etc.
Common recommendations to prevent bacterial contamination are to use no more than 500 ml of locally prepared mixture. And use them for no more than 8 hours (for sterile factory solutions - 24 hours). In practice, there are no experimentally substantiated recommendations in the literature on the frequency of replacement of probes, bags, and droppers. It seems reasonable that for IVs and bags this should be at least once every 24 hours.
- Benefits of Enteral Nutrition
- Parenteral nutrition
Parenteral nutrition (PN) is a special type replacement therapy, in which nutrients to replenish energy, plastic costs and maintain normal level metabolic processes are introduced into the body, bypassing the gastrointestinal tract directly into internal environments body (usually into the vascular bed).
The essence of parenteral nutrition is to provide the body with all the substrates necessary for normal functioning that are involved in the regulation of protein, carbohydrate, fat, water-electrolyte, vitamin metabolism and acid-base balance.
- Classification of parenteral nutrition
- Complete (total) parenteral nutrition.
Complete (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 supply or absorption of which is not ensured by the enteral route. Incomplete parenteral nutrition is considered as additional nutrition if 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.
- Complete (total) parenteral nutrition.
- Main objectives 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 necessary vitamins, macro- and microelements.
- Parenteral Nutrition Concepts
Two main concepts of PP have been developed.
- The “American concept” - the hyperalimentation system according to S. Dudrick (1966) - involves the separate introduction of solutions of carbohydrates with electrolytes and nitrogen sources.
- The “European concept”, created by A. Wretlind (1957), involves the separate introduction of plastic, carbohydrate and fatty substrates. Its later version is the “three in one” concept (Solasson C, Joyeux H.; 1974), according to which everything necessary components nutrition (amino acids, monosaccharides, fat emulsions, electrolytes and vitamins) are mixed before administration in a single container under aseptic conditions.
IN last years Many countries have begun to use the all-in-one parenteral nutrition technique, using 3-liter containers to mix all the ingredients in one plastic bag. If it is impossible to mix three-in-one solutions, infusion of plastic and energetic 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 contamination is reduced, and the risk of hypoglycemia and hyperosmolar non-ketone coma is reduced. Disadvantages: sticking of fatty particles and the formation of large globules that can be dangerous for the patient, the problem of catheter occlusion has not been solved, it is not known how long this mixture can be safely stored in the refrigerator.
- Basic principles of parenteral nutrition
- Timely initiation of parenteral nutrition.
- Optimal timing of parenteral nutrition (until restoration of normal trophic status).
- Adequacy (balance) of parenteral nutrition in terms of the amount of nutrients introduced and the degree of their absorption.
- Rules for parenteral nutrition
- Nutrients must be administered in a form adequate to the metabolic needs of the cells, that is, similar to the entry of nutrients into the bloodstream after passing the enteric 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 energy substrates must be introduced simultaneously. Be sure to use all essential nutrients.
- Infusion of high-osmolar solutions (especially those exceeding 900 mOsmol/L) should be carried out only in the central veins.
- PN infusion sets are changed every 24 hours.
- When conducting a complete PN, the inclusion of glucose concentrates in the mixture is mandatory.
- The fluid requirement for a stable patient is 1 ml/kcal or 30 ml/kg 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 cessation or limitation of the supply of nutrients by exogenous routes, the most important adaptive mechanism comes into play: the consumption of mobile reserves of carbohydrates, body fats and the 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 body’s needs not through the breakdown of its own tissues, but through the exogenous supply 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 loss of nitrogen in intensive care patients ranges from 15 to 32 g, which corresponds to a loss of 94-200 g of tissue protein or 375-800 g of muscle tissue.
The main indications for PN can be divided into several groups:
- Inability to receive oral or enteral nutrition for at least 7 days in a stable patient, or more short time in a debilitated patient (this group of indications is usually associated with dysfunction of the gastrointestinal tract).
- Severe hypermetabolism or significant protein loss when enteral nutrition alone does not cope with nutrient deficiency ( classic example is a burn disease).
- The need to temporarily exclude intestinal digestion “intestinal rest mode” (for example, with ulcerative colitis).
- Indications for total parenteral nutrition
Total parenteral nutrition is indicated in all cases when it is impossible to take food naturally or through a tube, which is accompanied by increased 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 fasting in diseases of the gastrointestinal tract in cases of functional or organic damage it with impaired digestion and resorption.
- In the postoperative period after extensive operations on the abdominal organs or its complicated course (anastomotic leakage, fistulas, peritonitis, sepsis).
- In the post-traumatic period (severe burns, multiple injuries).
- With increased protein breakdown or disruption of its synthesis (hyperthermia, failure of liver, kidney, etc.).
- In intensive care patients, when the patient does not regain consciousness for a long time or the activity of the gastrointestinal tract is sharply disrupted (damage to the central nervous system, tetanus, acute poisoning, comatose states, etc.).
- For infectious diseases (cholera, dysentery).
- For neuropsychiatric diseases in cases of anorexia, vomiting, food refusal.
- Contraindications to parenteral nutrition
- Absolute contraindications to PN
- 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 PN does not improve the prognosis of the disease.
In some of the listed situations, elements of PN can be used during 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 are determined 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.
- With hyperlipidemia, lipoid nephrosis, signs of post-traumatic fat embolism, acute heart attack myocardium, cerebral edema, diabetes mellitus, in the first 5-6 days of the post-resuscitation period and in case of violation of the coagulating properties of blood, fat emulsions are contraindicated.
- Caution must be exercised in patients with allergic diseases.
- Absolute contraindications to PN
- Providing parenteral nutrition
- Infusion technology
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-arterially.
When carrying out parenteral nutrition, infusion pumps and electronic drop regulators are used. The infusion should be carried out over 24 hours at a certain speed, but not more than 30-40 drops per minute. At this rate of administration, there is no overload of enzyme systems with nitrogen-containing substances.
- Access
The following access options are currently used:
- Via a peripheral vein (using a cannula or catheter) it is usually used when initializing parenteral nutrition for up to 1 day or with additional PN.
- Through central vein using temporary central catheters. Among the central veins, preference is given to subclavian vein. Less commonly used are the internal jugular and femoral veins.
- Through the central vein using indwelling central catheters.
- Through alternative vascular access and extravascular approaches (eg, peritoneal cavity).
- Infusion technology
- Parenteral nutrition regimens
- 24-hour administration of nutrient media.
- Extended infusion (over 18–20 hours).
- Cyclic mode (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:
- Have a nutritional effect, that is, contain all the substances necessary for the body in sufficient quantities and in proper proportions to each other.
- Replenish the body with fluid, as many conditions are accompanied by dehydration.
- It is highly desirable that the products used have a detoxifying and stimulating effect.
- It is desirable to have a substitutive and anti-shock effect of the drugs used.
- It is necessary to ensure that the products used are harmless.
- An important component is ease of use.
- Characteristics of parenteral nutrition products
To correctly use nutrient solutions for parenteral nutrition, it is necessary to evaluate some of their characteristics:
- Osmolarity of solutions for parenteral nutrition.
- Energy value of solutions.
- The limits of maximum infusions are the rate or rate of infusion.
- When planning parenteral nutrition, the required doses of energy substrates, minerals and vitamins are calculated based on their daily needs and level of energy consumption.
- Parenteral nutrition components
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 during parenteral nutrition.
- Sorbitol (20%) and xylitol are used as additional energy sources with glucose and fat emulsions.
- Fats are the most effective energy substrate. They are administered in the form of fat emulsions.
- Proteins are the most important integral part for the construction of tissues, blood, synthesis of proteohormones, enzymes.
- Saline solutions: simple and complex, are introduced to normalize water-electrolyte and acid-base balance.
- Vitamins, microelements, and anabolic hormones are also included in the parenteral nutrition complex.
- Basic requirements for parenteral nutrition products
- Assessing the patient's condition if parenteral nutrition is necessary
When conducting 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.
- Nutrition assessment and monitoring of parenteral nutrition adequacy.
The goal is to determine the type and severity of malnutrition and the need for nutritional support.
Nutritional status in recent years is assessed based on the determination of trophic or trophological status, which is considered as an indicator physical development and health. Trophic insufficiency is established on the basis of anamnesis, somatometric, laboratory and clinical-functional indicators.
- Somatometric indicators are the most accessible and include measurement of body weight, shoulder circumference, skin-fat fold thickness and calculation of body mass index.
- Laboratory tests.
Serum albumin. When it decreases below 35 g/l, the number of complications increases 4 times, mortality increases 6 times.
Serum transferrin. A decrease in it indicates depletion of visceral protein (the norm is 2 g/l or more).
Excretion of creatinine, urea, 3-methylhistidine (3-MG) in urine. A decrease in creatinine and 3-MG excreted in urine indicates a deficiency muscle protein. 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 (urinary excretion 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 urine: the appearance of sugar in the urine and an increase in the concentration of glucose in the blood more than 2 g/l requires not so much an increase in the dose of insulin as a decrease in the amount of administered glucose.
- Clinical and functional indicators: decreased tissue turgor, presence of cracks, edema, etc.
- Nutrition assessment and monitoring of parenteral nutrition adequacy.
- Monitoring of parenteral nutrition
Parameters for monitoring homeostasis during complete PN were defined 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, arterial pressure and respiratory rate are determined in patients daily. Definition of main laboratory parameters in unstable patients it is usually carried out 1–3 times a day, with nutrition in the pre- and postoperative period 1–3 times a week, with long-term PN – 1 time a 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 when 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 speed of introduction of ingredients is required, which is associated with certain technical difficulties. Parenteral nutrition produces a fair number of complications. There are indications that parenteral nutrition may suppress one's own immunity.
In any case, with total parenteral nutrition, intestinal atrophy occurs - atrophy from inactivity. Atrophy of the mucosa leads to its ulceration, atrophy of the secreting glands leads to the subsequent appearance enzyme deficiency, there is stagnation of bile, uncontrolled growth and changes in the composition of intestinal microflora, atrophy of intestinal-associated lymphoid tissue.
Enteral nutrition is more physiological. It does not require sterility. Enteral nutrition mixtures contain all the necessary components. Calculation of the need for enteral nutrition and the methodology for its implementation are much simpler than for parenteral nutrition. Enteral nutrition allows you to maintain the gastrointestinal tract in a normal physiological state and prevent many complications that arise in patients in critical condition. Enteral nutrition leads to improved blood circulation in the intestine and promotes normal healing of anastomoses after intestinal surgery. Thus, whenever possible, the choice of nutritional support should favor enteral nutrition.
- Classification of parenteral nutrition
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