Artificial nutrition can be carried out with the help of. Artificial nutrition: support for the body in critical situations

artificial nutrition used in cases where feeding the patient through the mouth is difficult or impossible. The causes may be diseases of the esophagus (stenosis of the esophagus with burns or compression by a tumor), diseases of the stomach (gastric cancer), intestinal diseases (tumors, Crohn's disease, etc.). Artificial nutrition is used in preparation for surgery in debilitated, emaciated patients in order to increase vitality and the possibility of a better transfer. surgical intervention. Artificial nutrition can be carried out using a probe inserted into the stomach through the mouth or nose, or a gastrostomy.

You can drive nutrient solutions with an enema, as well as parenterally, bypassing the digestive tract.

I. Probe feeding

The nurse should be well versed in the method of feeding the patient through a tube, causing the patient minimal discomfort.

For this procedure, you need to prepare:

Sterile thin rubber probe with a diameter of 0.5-0.8 cm;

Vaseline or glycerin;

Funnel or syringe Janet;

liquid food.

Sequencing.

1. Treat the probe with petroleum jelly or glycerin.

2. Through the lower nasal passage, insert the probe to a depth of 15-18 cm.

3. With the fingers of the left hand, determine its position in the nasopharynx and press it against the back wall of the pharynx. Without such finger control, the probe may enter the trachea.

4. Tilt the patient's head slightly forward and right hand advance the probe to the middle third of the esophagus; if the air does not come out during exhalation, and the patient's voice is preserved, then the probe is in the esophagus.

5. Connect the free end of the probe to the funnel.

6. Slowly pour the prepared food into the funnel.

7. Then pour into the funnel clean water to rinse the probe and remove the funnel.

8. Attach the outer end of the probe to the patient's head so that it does not interfere with him.

Do not remove the probe during the entire feeding period, which usually lasts 2-3 weeks.

Sweet tea can be used as food for tube feeding, raw eggs, mors, mineral water without gas, broth, cream. Once through the probe, you can enter no more than 600-800 ml. For this purpose, there is a special preparation ENPIT, which is a homogenized emulsion balanced in proteins, fats, carbohydrates, vitamins and mineral salts.

II. Feeding the patient through a gastrostomy

This operation (applying a gastrostomy) is performed with obstruction of the esophagus and stenosis (narrowing) of the pylorus. Gastrostomy in Greek (gaster - "stomach", stoma - "mouth, hole") - "stomach fistula".

The gastrostomy tube is a rubber tube that usually exits at the left rectus abdominis. The method of feeding through the gastrostomy is simple: a funnel is attached to the free end of the probe, through which heated liquid food is introduced into the stomach in small portions (50 ml) 6 times a day. Gradually, the volume of food introduced is increased to 25-500 ml, and the number of feedings is reduced to four times. Sometimes the patient is allowed to chew food on his own, then it is diluted in a glass of liquid and poured into a funnel already diluted. With this feeding option, reflex excitation is preserved gastric secretion.

III. Eating with an enema

Drip (nutritional) enemas are designed for resorptive effects on the body. Used to introduce nutritional medicines into the intestines of a patient. Use 0.85% sodium chloride solution, 5% glucose solution, 15% amino acid solution. This method of nutrition is used when it is impossible to implement either natural nutrition or parenteral nutrition. A drip enema is placed 20-30 minutes after cleansing. For a drip enema, you should prepare:

Esmarch's mug (rubber, enameled or glass);

Two rubber tubes connected to a dropper;

Thick stomach tube. The rubber tubes and the probe are connected by a glass tube. A screw clamp must be fixed on the rubber tube above the dropper;

medicinal solution heated to 38-40°C. It is poured into Esmarch's mug, suspended on a tripod. So that the solution does not cool down, the mug is wrapped with a cotton cover or heating pad;

Petrolatum.

Sequencing:

1. Put the patient in a position that is comfortable for him (possibly on his back).

2. After opening the clamp, fill the system with a solution (solution should appear from the gastric tube) and close the clamp.

3. Insert a Vaseline-lubricated probe into the rectum to a depth of 20-30 cm.

4. Use a clamp to adjust the rate of drops, not faster than 60-100 per minute. During this procedure, the nurse must ensure that a constant speed is maintained and the solution remains warm.

IV. parenteral nutrition

It is prescribed to patients with symptoms of obstruction digestive tract, when normal nutrition is impossible, after operations on the esophagus, stomach, intestines, etc., malnourished patients in their preparation for surgery.

When carrying out the infusion of nutrients through the subclavian vein, complications such as infection of the catheter, cholestasis (stagnation of bile), bone damage, and microelement deficiency are possible. Therefore, parenteral nutrition should be resorted to in exceptional cases and according to strict indications. For this purpose, preparations containing protein hydrolysis products, amino acids are used: hydrolysin, casein protein hydrolyzate, fibrinosol, as well as artificial mixtures of amino acids - alvezin, levamine, polyamine; fat emulsions - lipofundin, indralipid, 10% glucose solution up to 1 - 1.5 liters per day. In addition, up to 1 liter of electrolyte solutions, B vitamins, ascorbic acid must be injected. Means for parenteral administration are administered intravenously. Before the introduction, they are heated in a water bath to a body temperature of 37 ° C. It is necessary to strictly observe the rate of administration of drugs: hydrolysin, protein hydrolyzate of casein, fibrinosol, polyamine in the first 30 minutes are administered at a rate of 10-20 drops per minute, and with good tolerance, the rate of administration is increased to 40-60 drops per minute. Polyamine in the first 30 minutes is administered at a rate of 10-20 drops per minute, and then 25-30 drops per minute. A more rapid administration is impractical, since the excess of amino acids is not absorbed and is excreted in the urine. Lipofundin S (10% solution) is injected in the first 10-15 minutes at a rate of 15-20 drops per minute, and then gradually over 30 minutes increase the rate of administration to 60 drops per minute. All preparations are administered within 3-5 hours in the amount of 500 ml. With the rapid introduction of protein preparations, the patient may experience a feeling of heat, flushing of the face, difficulty breathing.

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

Active nutrition - the patient eats independently.

Passive nutrition - the patient takes food with the help of a nurse. (Tya-

the coveted patients are fed by a nurse with the help of junior medical staff.)

Artificial nutrition - feeding the patient with special nutrient mixtures

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

drugs.

Passive power

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

sti and patients in the elderly and old age assistance in feeding is provided by medical

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

darling, the other is to bring a bowl of liquid food or a spoonful of food to his mouth. Feed the pain

much is needed in small portions, always leaving the patient time to chew and swallow;

nie; it should be watered with a drinking bowl or from a glass using a special tubular

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. Put a clean napkin on the neck and chest of the patient.

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

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

6. Choose a position that is comfortable for both the patient and nurse(on the-

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

gagging and swallowing.

8. Give the patient water with a drinker or from a glass using a special

tubules.

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

tho) his hands.

10. Place the patient in the starting position.

artificial nutrition

Artificial nutrition is understood as the introduction of sick food into the body (nutrient-

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

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

The main indications for artificial nutrition.

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

ion, swelling, burns, cicatricial changes, etc.

Swallowing disorder: after an appropriate operation, with brain damage - on-

rupture of cerebral circulation, botulism, with traumatic brain injury, etc.

Diseases of the stomach with its obstruction.

Coma.

Mental illness (refusal of food).

Terminal stage of cachexia.

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

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

body in a natural way. In this case, nutrients are administered through the mouth or through

through a gastric tube, or through an intra-intestinal tube. Previously used and rectal route

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

ko in modern medicine it is not used, since it has been proven that there is no absorption in the large intestine

fats and amino acids. However, in some cases (for example, with severe dehydration)

living due to indomitable vomiting), rectal administration of the so-called physio-

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

called a nutrient enema.

The organization of enteral nutrition in medical institutions is carried out

a team of nutritional support, including anesthesiologists-resuscitators, gastro-

roenterologists, internists and surgeons who have passed special training by enteral pi-

Main indications:

Neoplasms, especially in the head, neck and stomach;

CNS disorders - coma, cerebrovascular accident;

Radiation and chemotherapy;

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

Diseases of the liver and biliary tract;

Meals in pre- and postoperative periods;

injury, burns, acute poisoning;

Infectious diseases - botulism, tetanus, etc.;

Mental disorders- psychiatric anorexia (persistent, due to

mental illness refusal to eat), severe depression.

Main contraindications: intestinal obstruction, acute pancreatitis, heavy

forms of malabsorption (lat. talus - bad, absorptio - absorption; malabsorption in tone

colon of one or more nutrients), ongoing gastrointestinal

bleeding; shock; anuria (in the absence of acute substitution of renal functions); the presence of pi

joint allergy to the components of the prescribed nutritional formula; uncontrollable vomiting.

Depending on the duration of the course of enteral nutrition and the safety of the

the rational state of various parts of the gastrointestinal tract, the following ways of introducing nutritional

mixtures.

1. The use of 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 nutrient mixtures, mainly for surgical patients). 3. By imposing a stoma (Greek stoma - hole: created by an operative method of external

fistula of a hollow organ): gastrostomy (hole in the stomach), duodenostoma (hole in the

duodenum), jejunostomy (hole in the jejunum). Stomas can be imposed by chi-

surgical laparotomy or surgical endoscopic methods.

There are several ways to enterally administer nutrients:

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

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

Drip, slowly, for a long time;

Automatically adjusting the intake of food using a special dispenser.

For enteral feeding, liquid food is used (broth, fruit drink, milk mixture),

mineral water; homogeneous dietary canned food (meat,

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

lei and vitamins. Use the following nutrient mixtures for enteral nutrition.

1. Mixtures that promote early recovery in the small intestine of the support function

homeostasis and maintaining the body's water and electrolyte balance: Glucosolan, Gast-

roll", "Regidron".

2. Elemental, chemically accurate nutrient mixtures - for the nutrition of patients with severe

digestive disorders and overt metabolic disorders (pe-

hepatic and renal insufficiency, diabetes etc.): Vivonex, Travasorb, Hepatic

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

3. Semi-elemental balanced nutrient mixtures (as a rule, they include

dit and full set vitamins, macro- and microelements) for the nutrition of patients with impaired

digestive functions: "Nutrilon Pepti", "Reabilan", "Peptamen", etc.

4. Polymeric, well-balanced nutritional formulas (artificially created

nutrient mixtures containing in optimal ratios all the main nutrients

va): dry nutrient mixtures "Ovolakt", "Unipit", "Nutrison", etc.; liquid, ready to use

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

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

elements) are used as an additional source of nutrition to enrich the 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 an isolated enteral nutrition of patients, since they do not

are balanced.

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

disease, as well as the degree of preservation of the functions of the gastrointestinal tract. Thus, under normal

ties and preservation of the functions of the gastrointestinal tract, standard nutrient mixtures are prescribed, with critical and

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

proteins enriched with trace elements, glutamine, arginine and omega-3 fatty acids,

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

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

forms of malabsorption) the patient is shown parenteral nutrition.

Parenteral nutrition (feeding) is carried out by intravenous drip

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

Main indications.

Mechanical obstruction to the passage of food into various departments Gastrointestinal tract: tumor

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

section of the stomach.

Preoperative preparation patients with extensive abdominal operations, historical

pregnant patients.

Postoperative management of patients after operations on the gastrointestinal tract.

Burn disease, sepsis.

Big blood loss.

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

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

Anorexia and food refusal. Used for parenteral feeding the following types nutrient solutions. "

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 parent

ral nutrition.

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

even water.

2. Partial (incomplete) - use only the main nutrients (for example,

proteins and carbohydrates).

3. Auxiliary - nutrition through the mouth is not enough and additional

supply of a number of nutrients.

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

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

injected only into the central veins (subclavian) through an indwelling catheter, which is placed

puncture method with careful observance of the rules of asepsis and antisepsis.

Numerous studies have established that malnutrition can be accompanied by various structural and functional changes in the body, as well as metabolic disorders, homeostasis and its adaptive reserves. There is a direct correlation between the trophic supply of seriously ill (affected) patients and their mortality - the higher the energy and protein deficiency, the more often they have severe multiple organ failure and death. It is known that trophic homeostasis, together with oxygen supply, is the basis of the life of the human body and the cardinal condition for overcoming many pathological conditions. The maintenance of trophic homeostasis, along with its internal factors, is determined primarily by the possibility and reality of obtaining the nutrient substrates necessary for life support by the body. At the same time, situations often arise in clinical practice in which patients (victims) due to various reasons do not want, should not, or cannot eat. The same category of persons should also include patients with sharply increased substrate needs (peritonitis, sepsis, polytrauma, burns, etc.), when the usual natural nutrition does not adequately meet the body's nutritional needs.

Back in 1936, H. O. Studley noted that if patients lost more than 20% of their body weight before surgery, their postoperative mortality reached 33%, while with adequate nutrition it was only 3.5%.

According to G. P. Buzby, J. L. Mullen (1980), malnutrition in surgical patients leads to an increase postoperative complications 6, and lethality 11 times. At the same time, the timely administration of optimal nutritional support to malnourished patients reduced the number of postoperative complications by 2-3, and mortality by 7 times.

It should be noted that trophic insufficiency in one form or another is quite often observed in clinical practice among patients with both surgical and therapeutic profile, amounting, according to various authors, from 18 to 86%. At the same time, its severity significantly depends on the type and characteristics clinical course existing pathology, as well as the duration of the disease.

The ideological basis of the vital need for early prescription of differentiated nutritional support to seriously ill and injured patients who are deprived of the possibility of optimal natural oral nutrition is due, on the one hand, to the need for adequate substrate supply of the body in order to optimize intracellular metabolism, which requires 75 nutrients, 45-50 of which are indispensable, and on the other hand, the need to quickly stop the often developing pathological conditions hypermetabolic hypercatabolism syndrome and associated autocannibalism.

It has been established that it is stress, which is based on glucocorticoid and cytokine crises, sympathetic hypertonicity with subsequent catecholamine depletion, deenergization and dystrophy of cells, circulatory disorders with the development of hypoxic hypoergosis, that leads to pronounced metabolic changes. This is manifested by increased protein breakdown, active gluconeogenesis, depletion of the somatic and visceral protein pools, decreased glucose tolerance with a transition often to diabetogenic metabolism, active lipolysis and excessive formation of free fatty acids, as well as ketone bodies.

Presented far from complete list metabolic disorganization that occurs in the body due to post-aggressive effects (illness, injury, surgery) can significantly reduce the effectiveness of therapeutic measures, and often, in the absence of appropriate correction of emerging metabolic disorders, generally lead to their complete neutralization with all the ensuing consequences.

Consequences of metabolic disorders

IN normal conditions in the absence of any significant metabolic disorders, the energy and protein requirements of patients, as a rule, average 25-30 kcal / kg and 1 g / kg per day. At radical operations for cancer, severe combined injuries, extensive burns, destructive pancreatitis and sepsis, they can reach 40-50 kcal / kg, and sometimes more per day. At the same time, daily nitrogen losses increase significantly, reaching, for example, 20–30 g/day in case of traumatic brain injury and sepsis, and 35–40 g/day in severe burns, which is equivalent to a loss of 125–250 g of protein. This is 2-4 times higher than the average daily loss of nitrogen in healthy person. At the same time, it should be noted that for a deficiency of 1 g of nitrogen (6.25 g of protein), the body of patients pays 25 g of its own muscle mass.

In fact, under such conditions, an active process of autocannibalism develops. In this regard, rapid exhaustion of the patient can occur, accompanied by a decrease in the body's resistance to infection, delayed healing of wounds and postoperative scars, poor consolidation of fractures, anemia, hypoproteinemia and hypoalbuminemia, impaired blood transport function and digestive processes, as well as multiple organ failure.

Today we can state that malnutrition of patients is a slower recovery, the threat of developing various complications, a longer stay in the hospital, higher costs for their treatment and rehabilitation, as well as higher mortality of patients.

Nutritional support in a broad sense is a set of measures aimed at proper substrate provision of patients, elimination of metabolic disorders and correction of trophic chain dysfunction in order to optimize trophic homeostasis, structural-functional and metabolic processes of the body, as well as its adaptive reserves.

In a narrower sense, nutritional support refers to the process of providing the body of patients with all the necessary nutrients with the help of special methods and modern artificially created nutrient mixtures of various directions.

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These methods include:

• sipping - oral consumption of special artificially created nutritional mixtures in liquid form (partial as an addition to the main diet or complete - consumption of only nutritional mixtures);
• enrichment of ready-made meals with powdered specialized mixtures, which increases their biological value;
• tube feeding, carried out through a nasogastric or nasointestinal tube, and if necessary, long-term artificial nutrition of patients (more than 4-6 weeks) - through a gastro- or enterostomy;
• parenteral nutrition, which can be administered through a peripheral or central vein.

Basic principles of active nutritional support:

• Timeliness of appointment - any exhaustion is easier to prevent than to treat.
• The adequacy of the implementation is the substrate provision of patients, focused not only on the estimated needs, but also on real opportunity absorption of incoming nutrients by the body (a lot does not mean good).
• Optimal timing - until the stabilization of the main indicators of the trophological status and the restoration of the possibility of optimal nutrition of patients in a natural way.

It seems quite obvious that the implementation of nutritional support should be focused on certain standards (protocols), which are some guaranteed (at least minimal) list of necessary diagnostic, therapeutic and preventive measures. In our opinion, it is necessary to highlight the standards of action, content and support, each of which includes a sequential list of specific activities.

A. Action standard

Includes at least two components:

• early diagnosis of malnutrition in order to identify patients requiring the appointment of active nutritional support;
• selection of the most best method nutritional support, in accordance with a certain algorithm.

Absolute indications for the appointment of patients with active nutritional support are:

1. The presence of a relatively rapidly progressive loss of body weight in patients due to an existing disease, comprising more than:

• 2% per week,
• 5% per month,
• 10% per quarter,
• 20% for 6 months.

2. Initial signs of malnutrition in patients:

• body mass index< 19 кг/ м2 роста;
• shoulder circumference< 90 % от стандарта (м — < 26 см, ж — < 25 см);
• hypoproteinemia< 60 г/л и/ или гипоальбуминемия < 30 г/л;
• absolute lymphopenia< 1200.

3. The threat of developing rapidly progressive trophic insufficiency:

• lack of the possibility of adequate natural oral nutrition (cannot, do not want, should not take food naturally);
• the presence of pronounced phenomena of hypermetabolism and hypercatabolism.

The algorithm for choosing the tactics of nutritional support for the patient is shown in Scheme 1.

Priority method

When choosing one or another method of artificial therapeutic nutrition of patients, in all cases, preference should be given to more physiological enteral nutrition, since parenteral nutrition, even completely balanced and meeting the needs of the body, cannot prevent certain undesirable consequences from the gastrointestinal tract. It should be taken into account that the regenerative trophism of the mucous membrane small intestine by 50%, and the thick one by 80% is provided by the intraluminal substrate, which is a powerful stimulus for the growth and regeneration of its cellular elements (the intestinal epithelium is completely renewed every three days).

Prolonged absence of food chyme in the intestine leads to dystrophy and atrophy of the mucous membrane, decrease enzymatic activity, violation of the production of intestinal mucus and secretory immunoglobulin A, as well as active contamination of opportunistic microflora from the distal to the proximal intestines.

The developing dystrophy of the glycocalyx membrane of the intestinal mucosa leads to a violation of its barrier function, which is accompanied by active transportal and translymphatic translocation of microbes and their toxins into the blood. This is accompanied, on the one hand, by excessive production of pro-inflammatory cytokines and induction of systemic inflammatory response organism, and on the other hand, the depletion of the monocyte-macrophage system, which significantly increases the risk of developing septic complications.

It should be remembered that under the conditions of a post-aggressive reaction of the body, it is the intestine that becomes the main undrained endogenous focus of infection and the source of uncontrolled translocation of microbes and their toxins into the blood, which is accompanied by the formation of a systemic inflammatory reaction and often developing against this background of multiple organ failure.

In this regard, the appointment of patients with early enteral support (therapy), the mandatory component of which is minimal enteral nutrition (200-300 ml/day of the nutrient mixture), can significantly minimize the consequences of the aggressive impact of various factors on gastrointestinal tract, to preserve its structural integrity and polyfunctional activity, which is a necessary condition for a faster recovery of patients.

Along with this, enteral nutrition does not require strict sterile conditions, does not cause life-threatening complications for the patient, and is significantly (2-3 times) cheaper.

Thus, when choosing a method of nutritional support for any category of seriously ill (injured) patients, one should adhere to the currently generally accepted tactics, the essence of which is summary can be presented as follows: if the gastrointestinal tract works, use it, and if not, make it work!

B. Content standard

Has three components:

1. determination of the needs of patients in the required volume of substrate provision;
2. selection of nutrient mixtures and formation daily ration artificial medical nutrition;
3. drawing up a protocol (program) of the planned nutritional support.

The energy needs of patients (victims) can be determined by indirect calorimetry, which, of course, will more accurately reflect their actual energy expenditure. However, such opportunities are currently practically absent in the vast majority of hospitals due to the lack of appropriate equipment. In this regard, the actual energy consumption of patients can be determined by the calculation method according to the formula:

DRE \u003d OO × ILC, where:

• DRE — actual energy consumption, kcal/day;
• OO is the main (basal) energy exchange at rest, kcal/day;
• CMF is the average metabolic correction factor depending on the condition of the patients (unstable - 1; stable condition with moderate hypercatabolism - 1.3; stable condition with severe hypercatabolism - 1.5).

To determine the basal metabolic rate, the well-known Harris-Benedict formulas can be used:

GS (men) \u003d 66.5 + (13.7 × × MT) + (5 × R) - (6.8 × B),

GS (women) \u003d 655 + (9.5 × MT) + + (1.8 × P) - (4.7 × B), where:

• BW — body weight, kg;
• Р — body length, cm;
• B - age, years.

In a more simplified version, you can focus on the average indicators of OO, which are 20 kcal/kg for women and 25 kcal/kg for men per day. At the same time, it should be taken into account that for each subsequent decade of a person's life after 30 years, the TO decreases by 5%. The recommended amount of substrate provision for patients is given in Table. 1.

Scheme 1. Algorithm for choosing nutritional support tactics

B. Security standard

Nutrient mixtures for enteral nutrition of patients

Contraindications for enteral nutrition are

Subtleties of parenteral nutrition

Table 4. Containers "three in one"

Micronutrients

Basic principles of effective parenteral nutrition

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Purpose of the lecture: to study the types of artificial nutrition, the features of feeding seriously ill patients, the algorithms for performing various methods of nutrition.

Lecture plan

1. Types of artificial nutrition

2. Basic principles of artificial nutrition, features of feeding a seriously ill patient

3. Indications for artificial nutrition

4. Algorithm of feeding through a gastric tube

5. Algorithm for performing feeding through a gastrostomy

6. Algorithm for performing feeding through a drip enema

7. Parenteral nutrition - the main components, solutions used for this type of feeding.
In conditions critical conditions the natural intake of nutrient substrates is either impossible due to a violation of the patient's nutritional activity, or does not satisfy the energy and plastic needs of the body. This puts before medical worker the task of meeting the needs of the patient's body for nutrients with partial or complete replacement of the natural way of their receipt. But anyway enteral nutrition preferable parenteral, since it is more physiological, cheaper than parenteral, does not require strictly sterile conditions and practically does not cause life-threatening complications.

If the patient cannot take food naturally, then, as prescribed by the doctor, the nurse performs artificial nutrition:

* through a gastric tube;

* through the surgical fistula of the stomach (gastrostomy) or duodenal ulcer (duodenostomy);

* parenterally (intravenous drip).

Basic principles of artificial nutrition:

1. 
   Timeliness of artificial nutrition. Don't wait to develop severe symptoms exhaustion.
2. 
   Optimality. Nutrition should be carried out until the metabolic, anthropometric and immunological parameters are restored.
3. 
   Nutritional adequacy: quantitative and qualitative ratio of nutrients.

FEATURES OF FEEDING A SERIOUSLY ILL
Often seriously ill patient refuses to eat. Helping him eat, the nurse must follow the rules.

• 
  do not leave the patient alone when he eats;
• 
  eliminate any distractions, for example, turn off the TV, radio, etc .;
• 
  keep the patient's head in an elevated position during meals and for half an hour after meals.
• 
  feed the patient food into the mouth from the side, from the uninjured side, since he will not be able to feel the food from the damaged side and it will accumulate behind his cheek;
• 
  make sure that the patient tilts his head down when chewing, encourage the patient to chew carefully and slowly.

Bedside table- bedside table Designed for use in hospitals, nursing homes and at home for reading and eating in bed. Provides comfort to the patient and greatly facilitates the work of medical staff. Made from materials resistant to cleaning and disinfectants, equipped with rollers with individual brakes.

FEEDING A SERIOUSLY ILL


Feeding the patient is carried out by a barmaid or ward nurse. Before you start feeding, you must:

1. 
   Wash the hands.
2. 
   Check the table setting and create conditions for the patient to eat.
3. 
   To make it easier for the patient to chew food, it must be divided into small pieces before giving a new portion, wait for him to chew.

artificial nutrition- this is the nutrition of the patient when natural feeding is impossible, i.e. the introduction of nutrients into the body in an unnatural way, bypassing the oral cavity. Artificial nutrition is sometimes an addition to the normal one. The quantity and quality of food, the method and frequency of feeding is determined by the doctor. Nutrients must be administered in such a form that the body can absorb, transfer, utilize and contain all the necessary ingredients: fats, proteins, carbohydrates, etc.

Types of artificial nutrition:
enteral nutrition;
parenteral nutrition.

Enteral nutrition- a type of artificial nutrition, in which nutrients enter the stomach or intestines, absorption occurs through the intestines, i.e. in a natural way.

parenteral nutrition- a type of artificial nutrition, in which nutrients are introduced into the body, bypassing the gastrointestinal tract, directly into the blood.
Indications for artificial nutrition:
obstruction of the esophagus as a result of burns, tumors, injuries;
pyloric stenosis (narrowing of the exit from the stomach);
external enteric fistulas;
the period after operations on the esophagus, stomach, intestines, etc.;
difficulty swallowing in severe traumatic brain injury;
swelling of the tongue, pharynx, larynx, esophagus;
unconscious state of the patient;
psychosis with food refusal.
Contraindications to artificial nutrition:
clinically pronounced shock;
ischemia (impaired blood supply) of the intestine;
intestinal obstruction;
intolerance to the components of mixtures for artificial nutrition.
Complications of artificial nutrition:
aspiration pneumonia;
nausea, vomiting, diarrhea;
phlebitis and thrombosis;
water overload;
hyperglycemia;
hypoglycemia, etc.

ENTERAL NUTRITION
Enteral nutrition can be carried out:

1) through a tube or catheter through which nutrients are delivered to the stomach or intestines, bypassing the oral cavity (tube feeding);
2) through a gastrostomy;
3) through the rectum.
If enteral nutrition is carried out for up to 3 weeks (the period is set by the doctor), then nutrition is applied through a probe inserted through the mouth or nose; if more than 3 weeks and up to a year, then after gastrostomy.
Advantages enteral nutrition before parenteral:
– cheaper, safer and more convenient;
- physiological;
- reduces the risk of developing sepsis;
- prevents atrophy of the mucosa of the gastrointestinal tract;
- reduces the severity of the stress reaction;
- significantly increases mesenteric and hepatic blood flow;
- reduces the frequency gastrointestinal bleeding from acute ulcers;
- reduces the risk of infectious complications and the development of multiple organ failure syndrome.
Nutrient mixtures prepared from high quality ground hard food products diluted with boiled water: finely grated meat, fish, bread, crackers, also used: milk, cream, raw eggs, broth, jelly, pureed vegetables, liquid cereals.

Ready-to-use enteral mixtures:
dry powder mixes(diluted with boiled water) - Nutricomp-Standard, Nutrizon, Berlamin, Nutrien-Standard, infant formula.
liquid mixtures- Nutrizon-Standard, Nutrizon-Energy, Nutricomp-Liquid-Standard, Nutricomp-Liquid-Energy.

Algorithms for types of artificial nutrition.

1. 
   Through gastric tube - a sterile thin probe, lubricated with glycerin or petroleum jelly, is inserted into the stomach. A funnel is put on the free end, into which it is slowly poured by gravity or a syringe is attached to Janet and injected under slight pressure liquid food: porridge, cream, raw eggs, juices, 6 soups several times a day. After the introduction of food, boiled water is poured into the probe to rinse it. The probe is fixed to the skin of the cheek with adhesive tape.
2. 
   Feeding through operational fistulas (gastrostomy). Food is injected

1. 
   With help nutrient enema(an hour before it, a cleansing enema is nutritiously placed). Liquid temperature 37-38 0 , volume 1 liter. After an enema, a thorough toilet anus. Enter a solution of 5% glucose and 0.9% sodium chloride solution.
2. 
   Parenterally(iv): albumins, hydrolysates, caseins, a mixture of amino acids, plasma, blood components.

Feeding through a stomach tube

Tube feeding is carried out through a nasogastric tube.
Probes are made of plastic, silicone or rubber; their length varies depending on the injection site: stomach or intestines. The probe is marked along the length, which helps to determine its correct position in the stomach.

A nasogastric tube is inserted through the nose into the stomach to introduce liquid food or other liquid substances through the stomach.

Usually, a nasogastric tube is inserted by a specially trained nurse only at the direction of a doctor.
The procedure for inserting a nasogastric tube consists of several steps.

PROBE POWER MODES
This type of food is prescribed for patients with normal function of the gastrointestinal tract (GIT) when it is impossible to feed by mouth due to unconscious state, paralysis of swallowing, aversion to food, refusal to eat in psychoses.
There are two modes of tube feeding:
intermittent (fractional) mode;
continuous (drip) mode.
Intermittent (fractional) mode
Liquid food (volume 500-600 ml per feeding) in a heated form is introduced into the nasogastric tube in small portions (fractionally). The nutrient mixture is usually administered 3-4 times a day. The consistency of the nutrient mixture should not be dense. This mode simulates normal process food.
Continuous (drip) mode
Liquid food or sterile nutrient solutions are introduced through a nasogastric tube into the stomach continuously by drip for 16 hours daily.

Equipment:

Sterile: tweezers, thin gastric tube (0.5-0.8 cm in diameter), gauze pads, spatula, funnel or Janet syringe;

Non-sterile: Liquid food at a temperature of 37-40 degrees, in the amount of 600-800 ml (ground vegetables, meat, fish, raw eggs, broth or ready-made nutritional mixture) and drinks (sweet tea, juice cream or boiled water), a diaper, a container for waste material, couch.

Execution algorithm.

1. 
   
2. 
   
3. 
   Give the patient's head a comfortable, elevated position.
4. 
   Cover the patient's chest with a diaper.
5. 
   Inspect the nasal passages, make sure they are patency, if necessary, perform a nose toilet.
6. 
   Moisten the blind end of the probe with water for 5-7 cm.
7. 
   Insert the probe through the lower nasal passage for a length calculated according to the formula "height-100 cm" (or in another way).
8. 
   Check the location of the probe: attach a syringe to the free end of the probe and pull the plunger towards you. If liquid appears in the syringe, then the probe is in the stomach, and if air enters easily, then in the trachea.
9. 
   If the probe is in the stomach, then remove the syringe from the probe, remove the plunger from the syringe, connect the cylinder to the probe and pour in a warm nutrient mixture through the syringe cylinder, like through a funnel.
10. 
    After the introduction of food, rinse the probe with boiled water.
11. 
    Disconnect funnel.
12. 
    The probe is not removed during the entire period artificial feeding(2-3 weeks) in this case, it is necessary to fix the probe with a strip of adhesive tape on the cheek.
13. 
    After removing the probe, it should be processed (washed in "wash water", disinfected in a 3% solution of chloramine, then according to OST 42-21-2-85).

Equipment:

Sterile: button probe (or rubber tube), gauze pads, tweezers, spatula, funnel or Janet syringe;

Non-sterile: liquid or semi-liquid food in volume, drinks (tea or boiled water), diaper, waste container, couch.

Execution algorithm:

1. 
   Explain the course of the forthcoming procedure and obtain consent to its implementation.
2. 
   Put on a clean gown, wash your hands at a hygienic level, put on sterile gloves.
3. 
   Heat food to a temperature of - 38 0 C.
4. 
   Insert a button probe or rubber tube into the opening in the stomach through the anterior abdominal wall(if there is no permanent tube).
5. 
   Slowly pour food through the funnel (hold the funnel at an angle to prevent air from entering the stomach).
6. 
   After the introduction of food, pour in a small amount of boiled water to rinse the probe.
7. 
   Remove the funnel, put the clamp on the probe.
8. 
   Remove gloves, disinfect used items as directed.

NUTRITION THROUGH GASTROSTOMY

This type of nutrition is prescribed to patients with diseases accompanied by obstruction of the pharynx, esophagus, and the inlet of the stomach.
The doctor usually prescribes food through the gastrostomy on the second day after the operation. The same nutrient mixtures are used as when feeding through a tube. Food is introduced warm in small portions (150-200 ml) 5-6 times a day directly into the stomach through the gastrostomy. Gradually, the amount of food introduced is increased to 250-500 ml, but the number of introductions is reduced to 3-4 times. You should be careful not to introduce large amounts of food into the funnel (portion no more than 50 ml), as a spasm of the muscles of the stomach may occur, and food can be thrown out through the stoma. During feeding, it is necessary to monitor the condition of the tube in the stoma, since its kink or displacement may prevent the passage of the nutrient mixture through the probe in the gastrostomy tube.

At the end of feeding, flush the tube with saline (30 ml) to prevent the development of microflora and, if necessary, take care of the skin around the stoma. When feeding the patient with milk, it is necessary to rinse the gastrostomy tube with boiled water (20 ml) every 2 hours until the next feeding.
Gastrostomy care.

It is carried out immediately after feeding the patient through a gastrostomy tube or as needed.

Equipment:

Sterile: 2 tweezers, scissors, dressing tray, gloves, Janet syringe or funnel, vial with antiseptic solution, spatula, adhesive paste (eg Lassar paste) heated.

Non-sterile: soap solution adhesive plaster, waste tray, containers with disinfectant solution, couch.

Execution algorithm:

1. 
   
2. 
   Put on a clean gown, wash your hands at a hygienic level, put on sterile gloves.
3. 
   Lay the patient on his back.
4. 
   Treat the skin around the stoma with a cotton ball dipped in soapy water, then dry with a dry ball from the center to the periphery. Discard the tweezers in disinfection.
5. 
   Take another tweezers and treat the skin around the stoma with a ball moistened with an antiseptic solution, then dry it with a dry tuff in the direction from the center to the periphery.
6. 
   Apply a layer of heated Lassar paste to the skin around the stoma with a spatula.
7. 
   Place sterile napkins on top of the paste, cut like “panties”.
8. 
   Lay a large napkin with a hole in the center on top of sterile wipes.
9. 
   Tie tightly with a strip of bandage the rubber tube brought out through the hole and tie around the waist like a belt.
10. 
    Place the waste material, tools in a container with des. solution.

Nutrition through a drip enema.

Drip (nutritional) enemas are designed for a resorptive effect on the body. They are used to introduce large (up to 2 liters) volumes of nutrients into the intestine (0.9% sodium chloride solution, 5% glucose solution, 15% amino acid solution), when neither natural nor parenteral nutrition is possible.

Patient preparation:

1.Psychological;

2. 1 hour before nutrition, put a cleansing enema.

Equipment:

Sterile: Enema device - Esmarch's mug, clamp, dropper reservoir, rubber tube, glass adapter (currently can be replaced with an IV drip system, but without a needle), gas tube, clamp, nutritional solution heated to 37 -38 ° C, tweezers, tray with napkins, vaseline oil.

Non-sterile: stand-tripod, heating pad, oilcloth, 2 diapers, container for discarding waste material, couch.

Execution algorithm:

1. 
   Explain to the patient the course of the manipulation, obtain the consent of the patient.
2. 
   Put on a clean gown, wash your hands at a hygienic level, put on sterile gloves.
3. 
   Place the patient in a comfortable position.
4. 
   Hang Esmarch's mug (bottle with solution) on a tripod.
5. 
   Pour the heated solution into Esmarch's mug.
6. 
   Fill the system, expel the air, clamp the system with the vent tube.
7. 
   Treat the end with vaseline oil gas tube.
8. 
   Insert a gas outlet tube into the rectum to a depth of 20-30 cm.
9. 
   Use a screw clamp to adjust the rate of drops (60-100 drops / min.)
10. 
    Hang heating pad with hot water next to Esmarch's mug (bottle) to keep the temperature of the solution warm all the time.
11. 
    After the introduction of the solution (before removing the vent tube), apply a clamp.
12. 
    Remove gas tube.
13. 
    Handle anus napkin.
14. 
    Place the waste material, tools in containers with des. solution.

Equipment:

Sterile: 5% glucose solution or 0.9% sodium chloride solution or complex saline solutions(the composition and quantity is determined by the doctor), a system for dripping liquids, an antiseptic solution, sterile dressing.
PARENTERAL NUTRITION
This is a type of artificial nutrition in which nutrients are introduced directly into the bloodstream, bypassing the gastrointestinal tract. Nutrient solutions are administered intravenously by drip through a catheter installed by a doctor in the central (subclavian, jugular, femoral) or peripheral vein (vein of the elbow). Before administration, the solutions are heated in a water bath to body temperature.
Parenteral nutrition should include the same nutritional ingredients as natural nutrition (proteins, fats, carbohydrates, vitamins and minerals).
Indications: inability to use normal food by mouth, i.e. the patient for a long time, due to various circumstances, does not want, cannot or should not take food in a natural way.
Contraindications: intolerance to individual components of nutrition, shock, hyperhydration, fat embolism (for fat emulsions).
Complications: phlebitis and vein thrombosis; water overload, hyperglycemia, hypoglycemia, etc.
The main components of parenteral nutrition
Energy providers

Carbohydrates (20% -25% -30% glucose solutions).
Fat emulsions: 10%-20% solutions of lipofundin, lipovenose, intralipid.
Plastic Material Suppliers for Protein Synthesis - Crystalline Amino Acid Solutions

Aminoplasmal-E 15% solution (20 amino acids).
Aminoplasmal-E 10% (20 amino acids).
Aminosol 800 (18 amino acids).
Vamin 18 (18 amino acids).
Nephramine (8 amino acids).
Vitamins and trace elements

Soluvit (water-soluble vitamins).
Vitalipid (fat-soluble vitamins).
Cernevit (vitamins).
Tracutil (micronutrients).
Addamel (microelements).
Electrolyte solutions

Isotonic sodium chloride solution.
Balanced solutions of electrolytes (lactosol, acesol, trisol, etc.).
0.3% potassium chloride solution.
10% solution of calcium gluconate, calcium lactate.
25% magnesium sulfate solution.
Multicomponent solutions

Two- and three-piece bags for parenteral nutrition are currently used - "all in one":
Nutriflex - Peri 40/80 (amino acids - 40 g / l and glucose - 80 g / l);
Nutriflex Plus - 48/150;
NutriflexSpecial - 70/240;
Nutriflex - Lipid - Plus;
Nutriflex - Lipid - Special.
Multicomponent solutions include all components of parenteral nutrition at once in one sterile bag.
Parenteral administration of nutrient solutions requires strict adherence to the principles of asepsis and injection technique, since post-injection complications may occur.
Rules for parenteral nutrition:

Do not use the patient's nutrient delivery system to transfuse blood, administer drugs, or measure central venous pressure;
enter energy providers (carbohydrates or lipids) always in parallel with amino acids through the V-shaped adapter;
use a system with a filter to prevent infusion (infusion) of large particles;
keep solution refrigerated until use;
check the labeling of liquids to make sure the name and concentration are correct;
change IV systems every 24 hours;
control the rate of infusion of fat emulsions (at a concentration of 10% - 100 ml per hour; at a concentration of 20% - no more than 50 ml per hour);
replace vials when they run out of nutrient solution.
Throughout the procedure, observe the convenience of the patient's position, his condition to identify nutrient intolerance, check if swelling has appeared in the injection area, if the rate of solution intake has changed.
The procedure for parenteral nutrition consists of several stages. Before starting the procedure, you should prepare the necessary equipment.
Recommended literature:

Main:

1. 
   Mukhina S.A., Tarnovskaya I.I. Practical guide to the subject "Fundamentals of Nursing", GEOTAR-Media, 2012.

1. Ostrovskaya I.V., Shirokova N.V. Fundamentals of Nursing: A Textbook for Medical. school and colleges ..-M. : GEOTAR-Media, 2008 -320s.

1. 
   Mukhina S.A., Tarnovskaya I.I. Theoretical basis Nursing: A textbook for honey. uch-shch and colleges. -2nd ed., Rev. and add.-M. : GOETAR-Media, 2009. -366s. :ill.

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

active nutrition- the patient takes food on his own. With active nutrition, the patient sits down at the table, if his condition allows.

passive power- the patient takes food with the help of a nurse. (Seriously ill patients are fed by a nurse with the help of junior medical staff.)

artificial nutrition- feeding the patient with special nutrient mixtures through the mouth or a tube (gastric or intestinal) or by intravenous drip of drugs.

Passive power

When patients cannot eat actively, they are prescribed passive nutrition. with strict bed rest, the weakened and seriously ill, and, if necessary, patients in the elderly and senile age, a nurse provides assistance in feeding. with passive feeding, one should raise the patient's head with a pillow with one hand, and bring a drinker with liquid food or a spoon with food to his mouth with the other. you need to feed the patient in small portions, be sure to leave the patient time to chew and swallow; it should be watered with a drinking bowl or from a glass using a special tube. depending on the nature of the disease, the ratio of proteins, fats, carbohydrates may vary. Required intake of water 1.5-2 liters per day. Importance has regular meals with 3 hour breaks. the patient's body needs a variety of good nutrition. all restrictions (diets) must be reasonable and justified.

artificial nutrition

Artificial nutrition is understood as the introduction of food (nutrients) into the patient's body enterally (Greek entera - intestines), i.e. through the gastrointestinal tract, and parenterally (Greek para - near, entera - intestines) - bypassing the gastrointestinal tract. main indications for artificial nutrition.

Damage to the tongue, pharynx, larynx, esophagus: edema, traumatic injury, injury, swelling, burns, scarring, etc.

Swallowing disorder: after an appropriate operation, with brain damage - cerebrovascular accident, botulism, with traumatic brain injury, etc.

Diseases of the stomach with its obstruction.

Coma. mental illness (refusal of food).

Terminal stage of cachexia.

The order of the procedure:

1. Check the room

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

3. Put a cleansing napkin on the neck and chest of the patient

4. Place a dish with warm food on the bedside table (table)

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

6. Choose a position that is convenient for both the patient and the nurse (for example, if the patient has a fracture or acute cerebrovascular accident).

7. Feed small portions of food, always leaving the patient time to chew and swallow.

8. Water the patient with a drinker or from a glass using a special tube.

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

10. Place the patient in the starting position. Probe feeding of patients

Enteral nutrition is a type of nutritional therapy used when it is impossible to adequately meet the energy and plastic needs of the body in a natural way. while the nutrients are administered through the mouth, either through a gastric tube or through an intra-intestinal tube.

Main indications:

Neoplasms, especially in the head, neck and stomach;

CNS disorders

Radiation and chemotherapy;

Diseases of the gastrointestinal tract;

Diseases of the liver and biliary tract;

Nutrition in pre- and postoperative periods

Trauma, burns, acute poisoning;

Infectious diseases - botulism, tetanus, etc.;

Psychiatric disorders - anorexia nervosa, severe depression