Artificial nutrition is administered with liquid food. Patient's nutrition. Artificial nutrition of the patient. Test questions for students' independent work

Depending on the method of eating, the following forms of nutrition for patients are distinguished.

Active nutrition - the patient eats independently.

Passive nutrition - the patient eats with the help of a nurse. (Cha-

The sick are fed by a nurse with the help of junior medical staff.)

Artificial nutrition – feeding the patient with special nutritional mixtures

through the mouth or tube (gastric or intestinal) or by intravenous drip

drugs.

Passive nutrition

With strict bed rest, the weakened and seriously ill, and if necessary,

Feeding assistance for elderly and elderly patients is provided by medical

sister. When passive feeding, you should lift the patient's head with one hand along with the

darling, the other is to bring a sippy cup with liquid food or a spoon with food to his mouth. Feed the pain-

This is necessary in small portions, always leaving the patient time to chew and swallow.

nie; You should drink it using a sippy cup or from a glass using a special tube.

The order of the procedure (Fig. 4-1).

1. Ventilate the room.

2. Treat the patient’s hands (wash or wipe with a damp, warm towel).

3. Place a clean napkin on the patient’s neck and chest.

4. Place warm dishes on the bedside table (table).

6. Give the patient a comfortable position (sitting or half-sitting).

6. Choose a position that is comfortable for both the patient and the nurse (at least

example, if the patient has a fracture or acute cerebrovascular accident). 7. Feed small portions of food, be sure to leave the patient time to chew

vomiting and swallowing.

8. Give the patient water using a sippy cup or from a glass using a special

tubes.

9. Remove the dishes, napkin (apron), help the patient rinse his mouth, wash (prote-

rub) his hands.

10. Place the patient in the starting position.

Artificial nutrition

Artificial nutrition refers to the introduction of food (nutrient) into the patient’s body.

nal substances) enterally (Greek entera - intestines), i.e. through the gastrointestinal tract, and parenterally (Greek para - row-

house, entera – intestines) – bypassing the gastrointestinal tract.

Main indications for artificial nutrition.

Damage to the tongue, pharynx, larynx, esophagus: swelling, traumatic injury, wound

pain, tumor, burns, scar changes, etc.

Swallowing disorder: after appropriate surgery, in case of brain damage -

disruption of cerebral circulation, botulism, traumatic brain injury, etc.

Diseases of the stomach with its obstruction.

Coma.

Mental illness (food refusal).

Terminal stage of cachexia.

Enteral nutrition is a type of nutritional therapy (Latin nutricium - nutrition), using

mine when it is impossible to adequately provide energy and plastic needs

body naturally. In this case, nutrients are administered orally or through

through a gastric tube or through an intraintestinal tube. Previously, the rectal route was also used

administration of nutrients - rectal nutrition (introduction of food through the rectum), one-

However, it is not used in modern medicine, since it has been proven that it is not absorbed in the large intestine.

fats and amino acids are contained. However, in a number of cases (for example, with severe dehydration,

life due to uncontrollable vomiting) rectal administration of the so-called physio-

logical solution (0.9% sodium chloride solution), glucose solution, etc. A similar method

called a nutritional enema.

The organization of enteral nutrition in medical institutions is carried out

There is a team of nutritional support, including anesthesiologists and resuscitators, gastrointestinal

roenterologists, therapists and surgeons who have undergone special training in enteral nutrition

Main indications:

Neoplasms, especially in the head, neck and stomach;

CNS disorders – coma, cerebrovascular accidents;

Radiation and chemotherapy;

Gastrointestinal diseases - chronic pancreatitis, nonspecific ulcerative colitis, etc.;

Diseases of the liver and biliary tract;

Nutrition in the pre- and postoperative periods;

Trauma, burns, acute poisoning;

Infectious diseases – botulism, tetanus, etc.;

Mental disorders – neuropsychic anorexia (persistent, conditioned

mental illness, refusal to eat), severe depression.

Main contraindications: intestinal obstruction, acute pancreatitis, severe

forms of malabsorption (Latin talus - bad, absorptio - absorption; malabsorption in thin-

intestine of one or more nutrients), ongoing gastrointestinal

bleeding; shock; anuria (in the absence of acute renal function replacement); presence of pi-

food allergy to the components of the prescribed nutritional mixture; uncontrollable vomiting.

Depending on the duration of the course of enteral nutrition and the preservation of function

tional state of various parts of the gastrointestinal tract, the following routes of administration of nutrients are distinguished:

ny mixtures.

1. Drinking nutritional mixtures in the form of drinks through a tube in small sips.

2. Tube feeding using nasogastric, nasoduodenal, nasojejunal and

two-channel probes (the latter for aspiration of gastrointestinal contents and intra-

intestinal administration of nutritional mixtures, mainly for surgical patients). 3. By applying a stoma (Greek stoma - hole: created surgically by external

fistula of a hollow organ): gastrostomy (opening in the stomach), duodenostomy (opening in the duodenum)

duodenum), jejunostomy (opening in the jejunum). Ostomies can be created chi-

surgical laparotomy or surgical endoscopic methods.

There are several ways to administer nutrients enterally:

In separate portions (fractions) according to the prescribed diet (for example, 8 times a day)

50 ml per day; 4 times a day, 300 ml);

Drip, slow, long;

Automatically regulating food supply using a special dispenser.

For enteral feeding, liquid food (broth, fruit drink, formula) is used.

mineral water; homogeneous dietary canned foods (meat,

vegetable) and mixtures balanced in the content of proteins, fats, carbohydrates, minerals

lei and vitamins. The following nutritional mixtures are used for enteral nutrition.

1. Mixtures that promote early restoration of the supporting function in the small intestine

homeostasis and maintaining the body’s water-electrolyte balance: “Glucosolan”, “Gast-

Rolit", "Regidron".

2. Elemental, chemically precise nutritional mixtures - for feeding patients with severe

significant disorders of digestive function and obvious metabolic disorders (ne-

liver and kidney failure, diabetes mellitus, etc.): “Vivonex”, “Travasorb”, “Hepatic”

Aid" (with a high content of branched amino acids - valine, leucine, isoleucine), etc.

3. Semi-element balanced nutritional mixtures (as a rule, they include

diet and a complete set of vitamins, macro- and microelements) for nutrition of patients with disorders

digestive functions: “Nutrilon Pepti”, “Reabilan”, “Peptamen”, etc.

4. Polymer, well-balanced nutritional mixtures (artificially created

nutritional mixtures containing all essential nutrients in optimal proportions

va): dry nutritional mixtures “Ovolakt”, “Unipit”, “Nutrison”, etc.; liquid, ready-to-use

nutritional mixtures (“Nutrison Standard”, “Nutrison Energy”, etc.).

5. Modular nutritional mixtures (a concentrate of one or more macro- or micro-

elements) are used as an additional source of nutrition to enrich daily

human diet: “Protein ENPIT”, “Fortogen”, “Diet-15”, “AtlanTEN”, “Pepta-

min”, etc. There are protein, energy and vitamin-mineral modular mixtures. These

mixtures are not used as isolated enteral nutrition for patients, since they do not

are balanced.

The choice of mixtures for adequate enteral nutrition depends on the nature and severity of the current

disease, as well as the degree of preservation of gastrointestinal tract functions. So, with normal needs

problems and preservation of gastrointestinal functions, standard nutritional mixtures are prescribed, in case of critical and

immunodeficiency states - nutritional mixtures with a high content of easily digestible

protein, enriched with microelements, glutamine, arginine and omega-3 fatty acids,

in case of impaired renal function - nutritional mixtures containing highly biologically valuable

protein and amino acids. With a non-functioning intestine (intestinal obstruction, severe

forms of malabsorption) the patient is prescribed parenteral nutrition.

Parenteral nutrition (feeding) is carried out by intravenous drip

administration of drugs. The administration technique is similar to intravenous administration of drugs.

Main indications.

Mechanical obstacle to the passage of food in various parts of the gastrointestinal tract: tumor-

formations, burns or postoperative narrowing of the esophagus, inlet or outlet

section of the stomach.

Preoperative preparation of patients with extensive abdominal operations, isto-

pregnant patients.

Postoperative management of patients after gastrointestinal surgery.

Burn disease, sepsis.

Major blood loss.

Violation of the processes of digestion and absorption in the gastrointestinal tract (cholera, dysentery, entero-

colitis, disease of the operated stomach, etc.), uncontrollable vomiting.

Anorexia and food refusal. The following types of nutrient solutions are used for parenteral feeding. "

Proteins – protein hydrolysates, solutions of amino acids: “Vamin”, “Aminosol”, polyamine, etc.

Fats are fat emulsions.

Carbohydrates - 10% glucose solution, usually with the addition of trace elements and vitamins

Blood products, plasma, plasma substitutes. There are three main types of parente-

ral nutrition.

1. Complete - all nutrients are introduced into the vascular bed, the patient does not drink

even water.

2. Partial (incomplete) - only basic nutrients are used (for example,

proteins and carbohydrates).

3. Auxiliary – oral nutrition is not enough and additional supplementation is necessary.

deduction of a number of nutrients.

Large doses of hypertonic glucose solution (10% solution) prescribed for pa-

enteral nutrition, irritate peripheral veins and can cause phlebitis, so they

injected only into the central veins (subclavian) through a permanent catheter, which is placed

by puncture method with careful adherence to the rules of asepsis and antisepsis.

In therapeutic nutrition for many diseases, especially gastric diseases, fractional nutrition in small portions is used. In response to a small irritation, a diseased stomach secretes more digestive juices than in response to a large load. Sometimes, for example, during fever, it becomes necessary to introduce food not at the usual time, but when the patient feels better and is able to eat, even at night. In this case, meals are carried out in fractions, mainly with liquid and semi-liquid food that does not contain coarse plant fiber, so as to spend as little energy as possible on digestion and not disturb his rest. Ready-made food, prepared no more than 1 hour before shipment, is delivered to distribution and buffets in thermoses, pre-washed well with boiling water, as well as containers with tight-fitting lids. Sauces, fats, prepared foods, bread and semi-finished products are transported in special containers. The terms and conditions of storage and sale of prepared food must be strictly observed.

20. Types of nutrition. Artificial nutrition

Artificial nutrition refers to the introduction of food into the patient’s body.

enterally

Main indications for artificial nutrition.

Damage to the tongue, pharynx, larynx, esophagus: swelling, traumatic injury, wound, tumor, burns, scar changes, etc.

Swallowing disorder: after appropriate surgery, in case of brain damage -

disruption of cerebral circulation, botulism, traumatic brain injury, etc.

Diseases of the stomach with its obstruction.

Coma.

Mental illness (food refusal).

Terminal stage of cachexia.

Enteral nutrition– a type of intravital therapy used when it is impossible to adequately provide the energy and plastic needs of the body in a natural way. In this case, nutrients are administered orally either through a gastric tube or through an intraintestinal tube.

Parenteral nutrition(feeding) is carried out by intravenous drip

administration of drugs. The administration technique is similar to intravenous administration of drugs.

Depending on the method of eating, the following forms of nutrition for patients are distinguished.

Active nutrition - the patient eats independently.

Passive nutrition - the patient eats with the help of a nurse. (Cha-

The sick are fed by a nurse with the help of junior medical staff.)

Artificial nutrition – feeding the patient with special nutritional mixtures

through the mouth or tube (gastric or intestinal) or by intravenous drip

drugs.

21.Feeding the patient through a gastrostomy tube.

If a patient has an obstruction of the esophagus (tumors, scars, wounds), then, to save his life, a gastrostomy tube is placed on his stomach, through which the patient is fed. necessary:

prepare dishes with warm liquid and semi-liquid food;

seat the patient;

remove the napkin covering the inlet hole from the rubber tube and the clamp from the tube;

insert a glass funnel into the hole in the tube, lift it up, tilt it slightly to prevent the possibility of food leaking out of the stomach;

pour the nutritional composition or food chewed by the patient into the funnel;

after the food mixture leaves the funnel, pour tea or rosehip infusion into it to rinse the tube and prevent rotting of food debris in it;

remove the funnel and place it in a special container with a disinfectant solution;

Place a sterile napkin and a clamp on the end of the rubber tube, which should be secured with a bandage loop so that the tube does not come out of the stoma. Any crushed food substances diluted with liquid can be poured through the funnel. You can add finely pureed meat, deboned fish, milk, bread, crackers. Patients can chew food themselves, collect it in a mug and give it to the sister for subsequent insertion through a gastrostomy tube. In this case, the food chewed by the patient should be diluted with the required amount of liquid.

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. It is the process of providing the body with food substances (nutrients) through methods other than regular food intake.

There are several methods of artificial nutrition : through a tube inserted into the stomach; using a gastrostomy or jejunostomy (a hole surgically placed in the stomach and jejunum), as well as through the parenteral administration of various drugs, bypassing the gastrointestinal tract. Since a tube is also often used for artificial nutrition when applying a gastrostomy or jejunostomy, the first two methods are often combined into the concept of tube, or enteral, nutrition.

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, 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).

For short-term enteral nutrition up to 3 weeks, nasogastric or nasojejunal approaches are usually used. When providing nutritional support of medium duration (from 3 weeks to 1 year) or long-term (more than 1 year), it is customary to use percutaneous endoscopic gastro-, duodenostomy or surgical gastro- or jejunostomy.

Indications for enteral nutrition:

Insertion of a tube into the stomach through the nose or through the mouth for artificial nutrition is usually used after trauma to the oral cavity (for example, with jaw fractures), in case of swallowing disorders after severe traumatic brain injury or cerebrovascular accidents, in comatose (long-term unconscious) states, in some mental illnesses accompanied by refusal to eat.

The use of artificial nutrition using a gastrostomy tube is necessary after injuries to the larynx, pharynx and esophagus or severe burns, after operations on the esophagus, in case of inoperable (unremovable) tumors of the esophagus and pharynx.

Contraindications to enteral nutrition :

Absolute:

Intestinal ischemia.

Complete intestinal obstruction (ileus).

Refusal of the patient or his guardian to provide enteral nutrition.

Continued gastrointestinal bleeding.

Relative:

Partial intestinal obstruction, intestinal paresis)

Severe intractable diarrhea.

External small intestinal fistulas.

Acute pancreatitis and pancreatic cyst.

As artificial feeding tubes soft plastic, rubber or silicone tubes with a diameter of 3-5 mm are used, as well as special probes with olives at the end, facilitating subsequent monitoring of the position of the probe.

Various mixtures can be used for enteral (tube) feeding , containing broth, milk, butter, raw eggs, juices, homogenized canned meat and vegetable diet, as well as infant formula. In addition, special preparations (protein, fat, oat, rice and other enpits) are currently produced for enteral nutrition, in which proteins, fats, carbohydrates, mineral salts and vitamins are selected in strictly defined proportions.

The introduction of nutrients through a tube or gastrostomy can be done fractionally, i.e. in separate portions, for example 5-6 times a day; by drip slowly, over a long period of time, and also with the help of special dispensers that allow you to automatically regulate the flow of food mixtures.

One of the methods of artificial enteral nutrition is a nutritional enema. , with the help of which it was recommended, in particular, the introduction of meat broths, cream and amino acids, has now lost its significance. It has been established that in the large intestine there are no conditions for the digestion and absorption of fats and amino acids. As for the introduction of water, saline, etc. (such a need may, for example, arise with uncontrollable vomiting and severe dehydration of the body), then it is more appropriate to call this method not a nutritional enema, but a medicinal enema.

Indications for parenteral nutrition

In cases where enteral nutrition cannot provide the body with the required amount of nutrients, parenteral nutrition is used. The need for its use often arises in patients with extensive abdominal operations, both during preoperative preparation and in the postoperative period, as well as with sepsis, extensive burns, and severe blood loss. Parenteral nutrition is also indicated for patients with severe disturbances in the processes of digestion and absorption in the gastrointestinal tract (for example, with cholera, severe dysentery, severe forms of enteritis and enterocolitis, diseases of the operated stomach, etc.), anorexia (complete lack of appetite), uncontrollable vomiting, refusal to eat.

Contraindications to parenteral nutrition :

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.

Used as drugs for parenteral nutrition donor blood, protein hydrolysates, saline solutions and glucose solutions with microelements and vitamin supplements. Well-balanced solutions of amino acids (for example, vamine, containing 14 or 18 amino acids, aminosol, aminosteril), as well as fat emulsions containing triglycerides of polyunsaturated fatty acids (intralipid) are now widely used in clinical practice.

Parenteral nutrition drugs are most often administered intravenously. If frequent and long-term use is necessary, venous catheterization is performed.

Already starting from 3-4 days of fasting, tissue proteins become sources of energy. The labile proteins of the gastrointestinal tract and circulating blood are the first to be mobilized, then the proteins of the internal organs and muscles disintegrate, and the last are the proteins of the nervous system. Artificial nutrition (AI) can be enteral (tube) or parenteral.

Indications for andartificial (enteral and parenteral) nutrition

• If the patient is unable to start eating independently within 2-3 days;
• If there is a protein-calorie deficiency, and it cannot be eliminated by oral food intake.
• Hypoproteinemia< 60 г/л или гипоальбуминемия < 30 г/л;
• Body mass index< 19 кг/м²;
• < 50 мм рт. ст., SpO2 <90%;
• Acidosis pH< 7,2;
• Blood lactate level > 3-4 mmol/l;
• PaСO2 > 80 mm Hg. st;
• Dying patients.

Signs of protein-calorie malnutrition

• Rapid and progressive loss of body weight due to an existing disease, amounting to 10% or more in 1 month or 20% or more in 3 months;
• Hypoproteinemia< 60 г/л или гипоальбуминемии < 30 г/л;
• Body mass index< 19 кг/м²;
• Body mass index (BMI) is calculated using the formula: BMI kg/m²= m/h²
• where: m - body weight in kilograms; h - height in meters;
• Contraindications to artificial (enteral and parenteral) nutrition
• Hypoxia that cannot be compensated by mechanical ventilation: PaO2< 50 мм рт. ст., SpO2 <90%;
• Acidosis pH< 7,2;
• Blood lactate level > 3-4 mmol/l;
• PaСO2 > 80 mm Hg. st;
• The first 24-48 hours after severe injury, major operations;
• Dying patients.

Calculation of the patient's need for energy and nutrients during IP

Nutritional requirements can be predicted using formulas or measured using indirect calorimetry. When calculating energy requirements, it is not the patient’s actual body weight that is used, but the ideal one.

This is proposed formula for calculating daily energy needs regardless of the patient's gender:

Daily energy requirement in kcal/kg = 25 × (Height (cm) - 100);

The daily protein requirement of an adult is 1-1.5 g/kg body weight. To minimize the breakdown of proteins, the body's energy needs are provided with sufficient amounts of carbohydrates and fats. For most patients, a diet is suitable that contains 1 g of protein nitrogen for every 100-150 non-protein kilocalories. The ratio of protein, fat and glucose should be approximately 20:30:50%.

If there is no pronounced initial body weight deficit, the specified level of energy and protein intake should be reached gradually, over 3-5 days. When catabolic processes are activated (for example, with), energy needs may exceed the calculated value of the basal metabolism by 40-100%. With hypercatabolism, higher amounts of energy substrates and amino acids should be administered, the proportion of lipids in energy should be increased and the proportion of glucose reduced, and glutamine should be additionally administered.

Laboratory control during artificial nutrition

• General analysis of blood, urine;
• Blood electrolytes (Na, K, Mg, phosphates);
• Blood glucose;
• Blood protein level;
• Blood albumin;
• Blood lipid levels.

The level of albumin in the blood is far from the most reliable indicator of nutritional adequacy. It can decrease with blood loss, acute inflammatory diseases, and not just with protein deficiency. More sensitive methods (but also less accessible) are the determination of the level of short-lived serum proteins: prealbumin, retinol-binding protein and transferrin.

During parenteral nutrition, it is especially important to monitor electrolyte levels and lipid profiles. First, studies are carried out daily, if necessary, adjusting the rate and volume of administration of the nutrient mixture. The INR can also change; with long-term parenteral nutrition, vitamin K deficiency often develops.

Nitrogen balance is determined in some cases (for example, if depletion hidden by fluid retention is suspected). Let us remember that 6.25 g of protein contains 1 g of nitrogen.

Daily urine is collected, daily excretion of urea nitrogen is determined and the nitrogen balance is calculated using the formula. Nitrogen balance = administered protein (g)/ 6.25 - urine nitrogen (g) + (correction factor g/day).

A negative nitrogen balance indicates the need to increase protein intake. The nitrogen balance, which reflects the balance between protein requirements and protein supply, is the difference between the amount of nitrogen in and the amount of nitrogen released. A positive balance (i.e., when more is gained than lost) means adequate income.

Enteral (tube) nutrition

Enteral nutrition is the preferred method of artificial nutrition for patients with preserved gastrointestinal function. Food is administered using a nasogastric tube, jejunostomy, gastrostomy, cervical esophagostomy, nasoduodenal tube. Early tube feeding prevents degenerative changes in the intestine and ensures the preservation of the protective function of the gastrointestinal tract. Compared to parenteral nutrition, it costs less and causes fewer complications.

Attention. Typically, for patients who are not expected to establish oral nutrition in the next 3-5 days, enteral nutrition is prescribed in the first 1-2 days.

Contraindications to the use of enteral nutrition:

• Intolerance to the components of the nutritional formula;
• Digestion and absorption disorders.

Currently, the use of natural products and baby food for enteral nutrition is not recommended. Formulas (including homogenized and commercial lactose-free or milk-based formulas) are commercially available and provide a complete, balanced diet. They can be used for regular oral or tube feeding.

Nutrient formulas vary in composition, calorie content, osmolarity and electrolyte content. Compared to natural liquid products, they more fully satisfy the patient’s body’s needs for nutrients, are better absorbed, and are less likely to cause intestinal disorders.

The mixtures differ in their purpose:

• Universal (standard) mixtures contain a balanced set of essential nutrients and are used as a basic nutrition;
• Modular mixtures contain only one nutrient and are used as a supplement to the main diet;
• Specialized mixtures are prescribed for certain conditions and diseases: pulmonary pathology, diabetes, pregnancy, renal, liver failure;
• Immunomodulatory mixtures containing increased concentrations of arginine, modern fat emulsions (reduced ratio of omega-6 to omega-3 fatty acids) are prescribed for septic conditions.

To reduce personnel labor costs, preference should be given to liquid, ready-to-use mixtures. Standard mixtures are almost isosmolar and contain all the necessary elements, their calorie content is approximately 1 kcal per 1 ml. If it is necessary to limit the volume of injected fluid, use low-volume mixtures with a calorie content of 1.5-2 kcal/ml; they are hyperosmolar.

Selecting and installing an enteral feeding tube

A small caliber, soft nasogastric or nasoenteric (eg nasoduodenal) tube made of silicone or polyurethane is used. If damage to the nose or its deformation makes it difficult to place the probe, then orogastric or oroenteric probes are placed. Tube feeding for more than six weeks in most cases requires a gastrostomy or jejunostomy to place the tube. This probe is usually placed endoscopically, surgically, or radiographically. Jejunostomy tubes are suitable for patients with contraindications to gastrostomy (eg, gastrectomy, intestinal obstruction above the jejunum).

The thinner the gastric tube, the less discomfort it causes the patient, and the less often complications (bleeding, bedsores, sinusitis) occur during prolonged standing. At the same time, the insertion of very thin probes can be difficult, and it is impossible to evacuate gastric contents through them; they are often obstructed by food debris. The optimal diameter seems to be 3-4 mm (10-12 Fr).

The most authoritative organizations on clinical nutrition (American Association of Clinical Nutrition, European Association of Clinical Nutrition, etc.) require that the position of the tube be confirmed radiographically before starting enteral nutrition. An X-ray of the chest or abdomen is performed.

Accordingly, the generally accepted method of determining the position of the tip of the probe by listening to gurgling sounds during auscultation of the epigastric region during the introduction of air into the probe is not considered a reliable method. A similar sound picture can be obtained when the probe enters the lower parts of the lung.

Attention. You cannot administer the nutritional mixture without breaks during the day, as this leads to disruption of the absorption process and diarrhea.

Tube feeding is carried out as a bolus or by continuous infusion of the mixture over 12-18 hours. You cannot bolus the nutritional mixture if the end of the probe is installed in the small intestine. For bolus administration, the total daily volume is divided into 6 parts, which are administered through a tube with a syringe or by gravity from a hanging bag. After each insertion, the probe should be rinsed with water. During enteral feeding, and then for another 2 hours after completing the meal, patients should be in a sitting or semi-sitting position.

Continuous infusion is carried out using dosing devices or drips. With a continuous method of administering the nutritional mixture, the likelihood of nausea and diarrhea is reduced. The probe is washed, alternating the introduction of a nutrient mixture with water 4-6 times a day.

Enteral nutrition technique

The introduction of a nutrient mixture into the stomach in patients with unchanged intestines can begin with the introduction of the full (calculated) volume, covering the daily energy requirement. In this case, the stomach itself does a good job of diluting the nutritional mixture.

When introducing a nutrient mixture into the small (duodenal, jejunum) intestine, or into the stomach, when significant disturbances in the structure of the small intestinal mucosa are suspected (sepsis, operations on the gastrointestinal tract, a long period of fasting, etc.), the starting mode is used. In this case, the introduction of the nutrient mixture begins at low speeds - 15-25 ml/hour. Then, daily the rate of administration is increased by 25 ml/hour until it reaches the calculated value, i.e. in 3-5 days. Standard nutritional mixtures (1 kcal per 1 ml) do not contain enough water to cover the daily requirement.

The amount of water missing to the daily requirement is administered as a bolus through a tube or intravenously - in the form of saline solutions and (or) 5% glucose solutions. For example, if the daily energy requirement is fully satisfied by the introduction of a nutritional mixture, to maintain water balance the patient should add a volume of water equal to 20-25% of the total daily volume of the mixture.

In the following days, the rate of administration of the nutrient mixture is increased daily by 25 ml/hour until it reaches the calculated value of approximately 100 ml/hour. With this step-by-step method of administration, the likelihood of diarrhea, bloating, and vomiting is reduced. It is not advisable to increase the rate of administration of the nutritional mixture to more than 125 ml/hour.

With a bolus feeding regimen, the full daily volume is divided into 6 parts and introduced into the tube at regular intervals. Before each administration, the residual volume of the mixture in the stomach is determined: if it exceeds half the volume of the previous administration, the administration is postponed for 1 hour.

Feeding through a tube during jejunostomy requires an even greater dilution of the drug. Feeding usually begins with concentration< 0,5 ккал/мл и скорости 25 мл/ч. Зондовое питание отменяют, когда обычное питание обеспечивает не менее 75% суточных энергетических потребностей. Если зондовое питание не обеспечивает достаточный калораж, дополнительно назначается лечащим врачом парентеральное питание.

Monitoring residual gastric contents

The reasons for the increase in residual volume of gastric contents (RGV) may be paresis of the stomach, intestines, pyloric stenosis or obstruction of the small intestine, taking drugs that weaken gastrointestinal motility (opioids, M-anticholinergics, catecholamines, etc.). It is clear that the accumulation of fluid and food in the stomach increases the likelihood of vomiting, regurgitation, and significantly increases the risk of developing aspiration complications. Dynamic monitoring of the residual volume of gastric contents is an essential component of properly administered enteral nutrition.

Here's how to correctly implement this provision:

To determine the residual volume of gastric contents in real time, an accessible method is to aspirate gastric contents with a large-volume syringe (minimum 60 ml), or lower the end of an open probe into a container located below bed level;

Check OSJ every 4 hours for the first 2 days when intragastric feeding the patient. After the goal of enteral nutrition is achieved (it is possible to ensure that the patient is given 70-100% of the mixture per day), monitoring of OSJ in patients not in critical conditions can be carried out less frequently - every 6-8 hours. However, in critically ill patients it should be performed every 4 hours;

If OSJ is >250 mL after the second measurement, a motor stimulant drug should be prescribed in adult patients;

If TFL is greater than 500 mL, stop enteral nutrition and reassess tolerance using an established algorithm that includes physical assessment, GI assessment, glycemic control dynamics, minimizing pain relief, and consider prescribing a motility drug if not already prescribed;

The decision to pass the probe below the ligament of Treitz should be made if the OSJ remained > 500 ml during successive measurements;

Attention. Of particular relevance is the implementation of measures to monitor OSJ in case of non-isolated upper respiratory tract of the patient.

For treatment, prokinetics are used: 10 mg per tube 3-4 times a day, if necessary, the dose is increased to 60 mg/day, or metoclopramide 10 mg per tube or IV 4 times a day. They also try to minimize the use or eliminate drugs that weaken intestinal motility.

Complications of enteral nutrition

The success and safety of the EN procedure is directly related to the integrity and qualifications, first of all, of nursing staff. Violation of EN technology is most often associated with a discrepancy between the prescribed and administered volume of fluid.

The use of dispensers, including syringe ones, allows you to normalize the water balance and better control the procedure. Diarrhea is common in patients receiving enteral nutrition. It can be caused by poor tolerance of nutritional components, or be a consequence of other reasons: taking antibiotics, laxatives, chemotherapy drugs, infection (Clostridium difficile, etc.). Diarrhea is not an indication for stopping enteral feeding of the patient.

They are trying to establish and eliminate the cause - they reduce the rate of administration of the nutritional mixture, and stop its bolus administration. If these measures are ineffective, the nutritional mixture should be replaced, for example, use a mixture with fiber and less fat.

Antidiarrheals are used only when other measures are ineffective and after infectious diseases have been excluded. The following drugs are prescribed: loperamide (2-4 mg after each loose stool, but not more than 16 mg/day). Sandostatin 0.1 mg three times a day subcutaneously is sometimes more effective.

When aspiration occurs, food enters the lungs, causing pneumonia. Aspiration is usually caused by malposition of the probe or reflux. Aspiration in controversial cases is confirmed by a change in the color of the sputum after adding a dye (methylene blue) to the nutritional mixture.

The method of prevention is the patient's sitting or semi-sitting position during feeding and regular monitoring of the correct placement of the tube and the residual volume of gastric contents. Probes, especially large ones, can contribute to tissue erosion in the nose, pharynx, or esophagus. Sometimes sinusitis develops. Soft (collapsed) probes minimize these complications.

Disturbances in electrolyte balance, blood glucose levels, and osmolarity, if they occur, are corrected according to existing rules.

Parenteral nutrition

With parenteral nutrition (PN), nutrients are administered intravenously. If parenteral nutrition fully meets the body's nutritional needs, it is called complete. If partially - incomplete. Auxiliary - when PN is prescribed simultaneously with enteral or oral.

In order to properly carry out artificial nutrition in general, and parenteral nutrition in particular, a special nutritional support service must function in a medical institution, with staff, special equipment (monitoring of basal metabolism, dispensers), provided with a variety of nutritional mixtures and nutrients.

Most hospitals, including the department where I work, don’t have all this. There are also no prerequisites that the situation will change for the better in the near foreseeable future. But the sick need to be fed; without this they recover very poorly. Below we will talk about how to conduct PP in poorly equipped departments. I’ll say right away that this is the author’s subjective point of view on this problem.

Dear colleagues, you should remember that there are official recommendations from the Ministry of Health of the Russian Federation on parenteral nutrition in surgery. If, after reading the recommendations mentioned, you understand how to carry out PN and have the appropriate drugs and equipment, you don’t have to read the text below.

Indications and initiation of parenteral nutrition

Parenteral nutrition is indicated when oral or enteral nutrition is not possible or does not provide sufficient nutrients and energy to the patient. Among the leading experts in this field, there is no consensus on when to start parenteral nutrition (Table 1):

Since Russian recommendations do not say anything definite in this regard, you can be guided by any of the recommendations proposed above, or choose some average, most optimal option for your institution.

If the patient already has protein-calorie deficiency, and oral or enteral nutrition does not eliminate it, then we prescribe incomplete PN immediately, unless there are contraindications for this. If it is presumably impossible for the patient to provide adequate EN within 3-5 days, in the absence of contraindications, incomplete PN should be started after 2-3 days. In this context, incomplete parenteral nutrition should provide approximately 50% of energy and protein requirements.

If after 5 days it is not possible to provide adequate EN, full PN should be prescribed. Parenteral nutrition is carried out until the patient is able to take food orally or enterally in quantities sufficient to cover his metabolic needs.

Determination of metabolic needs

Having made sure that parenteral nutrition is indicated for the patient and there are no contraindications, we determine:

• We will provide complete or incomplete parenteral nutrition;
• We determine the need for energy and proteins.
• We determine which nutrients we will use for parenteral nutrition.

Parenteral nutrition mixtures

We determined what volume of glucose solution, amino acid mixtures and fat emulsions should be transfused to the patient. But in order for the administered amino acid mixtures to be absorbed to the maximum extent, all components of parenteral nutrition must be administered simultaneously throughout the day.

However, the implementation of this simple and long-known position turned out to be almost impossible in the conditions of the average anesthesiology-reanimation department. Not to mention specialized departments of hospitals. The reason is simple - there are no dosing devices. And without them, it turned out to be impossible to ensure uniform intravenous administration of nutritional components.

About ten years ago, ready-made All-in-One mixtures appeared on our market, and this changed the situation radically.

The use of these drugs has significantly simplified the feeding process, increased its safety and made it possible to introduce all the necessary nutritional components continuously and at a constant speed without the use of special dosing devices. Another very big plus is that some of the drugs on the market can be injected into peripheral veins, which allows effective PN to be carried out outside the intensive care unit.

Attention. For those hospitals where there is no nutritional support service, All-in-One PN drugs are the drugs of choice for complete and incomplete parenteral nutrition.

How to administer All-in-One parenteral nutrition products

The Russian market offers drugs from various manufacturers. We will not discuss their advantages and disadvantages - there are company representatives for that. One thing is clear - all the presented mixtures are quite suitable for carrying out PP. Let us recall that the system for parenteral nutrition consists of three sections: the first contains a fat emulsion, the second contains a solution of amino acids and electrolytes, vitamins, and the third contains a glucose solution. Their mixing is carried out immediately before administration by destroying the partitions separating the container.

Solutions with an osmolarity less than 900 mOsm/L can be injected into peripheral veins. If PN is required for more than a week, or the osmolarity of solutions is higher than the specified value, a central venous catheter should be used for their administration.

Attention. When introducing nutritional mixtures, you must follow the manufacturer's recommendations.

In any case, the slower the nutritional mixture is introduced, the better it is absorbed and the less often side effects develop. Therefore, the usual practice is to administer it continuously over 24 hours at the same rate, regardless of the intended volume.

Some contraindications and restrictions for prescribing “All in one” drugs

It is not very often that there are situations where it is not recommended to use All-in-One nutritional formulas for a certain person. More often this is due to an insufficient range of drugs. For example, 32 types of OliClinomel are registered in European countries, which makes it possible to use it in almost all clinical situations. In our country, OliKlinomel N 4 is for administration into a peripheral vein and OliKlinomel N 7 is for administration into a central vein.

Let's consider some situations when it is better to refrain from administering standard All-in-One drugs, or the infusion program should be modified in accordance with clinical requirements:

1. For obese patients, amino acid mixtures and glucose are used for PN. Refusal of lipids allows you to mobilize endogenous fat reserves, thereby increasing their sensitivity to insulin;

2. For patients with respiratory failure (severe, ARDS), the lipid emulsion should provide the majority of non-protein calories to minimize CO2 production during carbohydrate metabolism. By preferentially using fat as an energy source, a decrease in the respiratory quotient can be achieved. The proportion of non-protein calories provided by fat should be at least 35% (and probably no more than 65%);

3. For patients suffering from heart failure, it is necessary to limit the amount of fluid administered. Which makes it more appropriate to carry out PN using solutions with increased concentrations of nutrients. Sometimes these patients need to limit the amount of sodium administered;

4. Patients with chronic renal failure and oliguria often need to limit the amount of sodium and potassium administered and fluid volume. In general, protein/nitrogen restriction is not recommended because it may contribute to the malnutrition that often accompanies chronic renal failure. The possibilities of renal replacement therapy have increased to such an extent that excess nitrogen can be effectively removed even if the amount of amino acids in the diet is not limited, etc.

Complications with parenteral nutrition

• Increased glucose levels, especially with complete PN, are quite common. In the first days of PN, glucose levels should be measured three to four times a day. If it increases, 8-10 units of insulin are injected into the solution for PN, and the rate of administration of the solution is reduced. If these measures are ineffective, subcutaneous insulin is used;
• Metabolic complications (water and electrolyte disturbances, hypertriglyceridemia, increased blood urea nitrogen levels, increased aminotransferase levels, etc.);
• Intolerance to the components of the nutritional mixture (skin reactions, anaphylaxis);
• Complications associated with the installation and use of a venous catheter (infectious, thrombosis and thromboembolism, etc.).

Artificial nutrition refers to the introduction of food (nutrients) into the patient’s body enterally, that is, through the gastrointestinal tract, and parenterally, bypassing the gastrointestinal tract.

Patients who cannot swallow independently or refuse food must be fed through a gastric tube, using nutritional enemas, or parenterally. The main indications for artificial nutrition of patients can be identified: extensive traumatic injuries and swelling of the tongue, pharynx, larynx, esophagus; unconscious state; obstruction of the upper gastrointestinal tract (tumors of the esophagus, pharynx, etc.); refusal of food in mental illness, end-stage cachexia.

There are several ways to administer nutrients enterally:

In separate portions (fractional

Drip, slow, long;

Automatically regulating food supply using a special dispenser.

For enteral feeding, liquid food (broth, fruit drink, formula), mineral water are used; Homogeneous dietary canned foods (meat, vegetables) and mixtures balanced in the content of proteins, fats, carbohydrates, mineral salts and vitamins can also be used. The following nutritional mixtures are used for enteral nutrition.

Mixtures that promote early restoration of the function of maintaining homeostasis in the small intestine and maintaining the water-electrolyte balance of the body: “Glucosolan”, “Gastrolit”, “Regidron”.

Elemental, chemically precise nutritional mixtures - for feeding patients with severe digestive disorders and obvious metabolic disorders (liver and kidney failure, diabetes mellitus, etc.): “Vivonex”, “Travasorb”, “Hepatic Aid” (with a high content of branched amino acids - felted milk, leucine, isoleucine), etc.

Semi-element balanced nutritional mixtures (as a rule, they also include a full set of vitamins, macro- and microelements) for feeding patients with digestive disorders: “Nutrilon Pepti”, “Reabilan”, “Pcptamen”, etc.

Polymer, well-balanced nutritional mixtures (artificially created nutritional mixtures containing all essential nutrients in optimal proportions): dry nutritional mixtures “Ovolakt”, “Unipit”, “Nutrison”, etc.; liquid, ready-to-use nutritional mixtures (“Nutrison Standart”, “Nutrison Energy”, etc.).

Modular nutritional mixtures (a concentrate of one or more macro- or microelements) are used as an additional source of nutrition to enrich the daily human diet: “Protein EN-PIT”, “Fortogen”, “Diet-15”, “AtlanTEN”, “Peptamine” etc. There are protein, energy and vitamin-mineral modular mixtures. These mixtures are not used as isolated enteral nutrition for patients, since they are not balanced.

The choice of mixtures for adequate enteral nutrition depends on the nature and severity of the disease, as well as on the degree of preservation of gastrointestinal tract functions. Thus, with normal needs and preservation of the functions of the digestive complex, standard nutritional mixtures are prescribed, in critical and immunodeficient conditions - nutritional mixtures with a high content of easily digestible protein, enriched with microelements, glutamine, arginine and omega-3 fatty acids, in case of impaired night function - nutritional mixtures containing highly biologically valuable protein and amino acids.In case of non-functioning intestines (intestinal obstruction, severe forms of malabsorption), parenteral nutrition is indicated for the patient.

When feeding a patient through a tube, any food (and medicine) can be administered in liquid or semi-liquid form. Vitamins must be added to food. Usually cream, eggs, broth, slimy vegetable soup, jelly, tea, etc. are introduced.

For feeding you need: 1) a sterile gastric tube with a diameter of 8-10 mm; 2) a funnel with a capacity of 200 ml or a Janet syringe; 3) Vaseline or glycerin.

Before feeding, the instruments are boiled and cooled in boiled water, and the food is heated.

Before insertion, the end of the gastric tube is lubricated with glycerin. The probe is inserted through the nose, moving it slowly along the inner wall, while throwing back the patient's head. When 15-17 cm of the probe passes into the nasopharynx, the patient’s head is slightly tilted forward, the index finger is inserted into the mouth, the end of the probe is felt and, lightly pressing it against the back wall of the pharynx, it is advanced further with the other hand. If the probe enters the larynx instead of the esophagus, the patient begins to have a sharp cough. If the patient is unconscious and cannot be seated, the probe is inserted in the supine position, if possible under the control of a finger inserted into the mouth. After insertion, check whether the probe has entered the trachea; to do this, bring a fluff of cotton wool to the outer edge of the probe and see if it sways when breathing. If necessary, the probe is advanced further into the stomach. A funnel is attached to the outer end of the probe, and food is poured into it in small portions. After feeding, the tube, if necessary, can be left until the next artificial feeding. The outer end of the probe is folded and secured on the patient’s head so that it does not interfere with him.

Sometimes patients are fed using drip enemas. Nutrient enemas are given only after the rectum has been emptied of its contents. For better absorption, solutions heated to 36-40°C are usually injected into the rectum - 5% glucose solution, 0.85% sodium chloride solution. In modern medicine, this method is rarely used, since it has been proven that fats and amino acids are not absorbed in thick skin. Nevertheless, in some cases, for example, with severe dehydration due to uncontrollable vomiting, the technique is used. 100-200 ml of solution is administered dropwise at a time 2-3 times a day. Small amounts of liquid can be administered using a rubber bulb.

Parenteral nutrition (feeding) is carried out by intravenous drip administration of drugs. The administration technique is similar to intravenous administration of drugs.

Main indications:

Mechanical obstacle to the passage of food in various parts of the gastrointestinal tract: tumor formations, burns or postoperative narrowing of the esophagus, inlet or outlet of the stomach.

Preoperative preparation of patients with extensive abdominal operations, exhausted patients.

Postoperative management of patients after gastrointestinal surgery.

Burn disease, sepsis.

Major blood loss.

Violation of the processes of digestion and absorption in the gastrointestinal tract (cholera, dysentery, enterocolitis, disease of the operated stomach, etc.), uncontrollable vomiting.

Anorexia and food refusal.

The following types of nutrient solutions are used for parenteral feeding:

Proteins - protein hydrolysates, solutions of amino acids: “Vamin”, “Aminosol”, polyamine, etc.

Fats - fat emulsions (lipofundin).

Carbohydrates - 10% glucose solution, usually with the addition of trace elements and vitamins.

Blood products, plasma, plasma substitutes.

There are three main types of parenteral nutrition.

Complete - all nutrients are introduced into the vascular bed, the patient does not even drink water.

Partial (incomplete) - only essential nutrients are used (for example, proteins, carbohydrates).

Auxiliary - oral nutrition is not enough and additional administration of a number of nutrients is necessary.

About 2 liters of solutions are administered per day.

Before administration, the following medications should be heated in a water bath to a temperature of 37-38°C: hydrolysine, casein hydrolysate, aminopeptide. When administering intravenous drips of these drugs, a certain rate of administration should be observed: in the first 30 minutes, solutions are administered at a rate of 10-20 drops per minute, then, if the patient tolerates the drug administered well, the rate of administration is increased to 30-40 drops per minute. On average, the administration of 500 ml of the drug lasts about 3-4 hours. With faster administration of protein drugs, the patient may experience a feeling of heat, facial flushing, and difficulty breathing.

If food is obstructed through the esophagus, the patient is fed through a fistula (gastrostomy) created surgically. A tube is inserted into the stomach through the fistula, through which food is poured into the stomach. A funnel is attached to the free end of the inserted probe and heated food is introduced into the stomach in small portions (50 ml) 6 times a day. Gradually, the volume of administered fluid is increased to 250-500 ml, and the number of feedings is reduced! up to 4 times. In this case, it is necessary to ensure that the edges and gastrostomy tubes are not contaminated with food, for which the inserted probe is strengthened with an adhesive plaster, and after each feeding, the skin around the fistula is cleaned, lubricated with 96% ethyl alcohol and a sterile dry bandage is applied.

In order to comply with the therapeutic nutrition regimen, each department must organize control over the food products brought by visitors. Each department in the wards must have refrigerators for storing food. The doctor and nursing staff systematically check the quality of the products in refrigerators and bedside tables.