Nutrition of surgical patients in general surgery after surgery. Therapeutic nutrition of surgical patients

Nutrition after surgery

Nutrition in the postoperative period is based on the fact that many patients develop a deficiency of protein, vitamins, a tendency to acidosis, and dehydration. Diet therapy is aimed at correcting metabolic disorders, providing the physiological needs of the body for nutrients and energy, sparing the affected organs, increasing the body's resistance and stimulating the healing of the surgical wound.

After operations on the abdominal organs, in order to prevent flatulence, whole milk, concentrated solutions of sugary products, vegetable fiber, and carbonated drinks are excluded. In the first days after operations on the esophagus, stomach and intestines, food and liquid intake through the mouth is prohibited. In the future, the most sparing and, if possible, balanced diet with respect to the content of nutrients is prescribed with a gradual decrease in the degree of sparing (liquid, semi-liquid, wiped). Before the start of a full-fledged natural nutrition, parenteral nutrition is indicated (isotonic sodium chloride solution, 5% glucose solution, protein hydrolysates, plasma, blood transfusions, etc.), the volume of which decreases as natural nutrition expands. In addition, probe feeding can be used.

After operations on the esophagus with the opening of its lumen, only parenteral and tube nutrition is prescribed for the first 5-6 days. From the 6-7th day, liquid food is allowed (sweet tea with lemon, rosehip infusion, fruit juices diluted 2-3 times with water, etc.) in small sips in a volume of up to 150-200 ml. In the future, the frequency of meals gradually increases: 7-8th day - 2 times, 8-9th - Zraza, 9-10th - 4 times, 10-11th - 5 times, from 11-12th day - 6 times. They allow low-fat meat broth, cream, sour cream, kefir, jelly, fruit jellies, etc. Diet No. 0a is taken as the basis. On the 15-16th day, patients are transferred to a diet No. About. At the same time, the diet is expanded by liquid pureed cereals, mucous soups in vegetable or meat broth, steamed protein omelet, soft-boiled eggs, steamed soufflé or mashed lean meat or fish. From the 22-23rd day, a diet No. Ov is prescribed. They allow mashed soups, steamed dishes from mashed boiled meat, fresh cottage cheese mashed with cream, mashed fruit and vegetable purees, baked apples. From the 27th-28th day for 1.5-2 months. patients receive diet No. 1-surgical with a gradual transition to rational nutrition.

After surgical intervention on the stomach (resection, pyloroplasty, etc.) in the first 1-2 days - hunger. On the 2nd - 3rd day, with a satisfactory condition of the patient, no bloating, gas discharge, diet No. Oa is prescribed for 2-3 days, which provides fractional administration of liquid and jelly-like food at least 6-7 times a day. Weak low-fat meat broth, fruit juices (except grape) diluted with water, rosehip broth, tea with lemon and sugar, fruit jellies are used, which at first give the patient 1-2 tablespoons every hour. In the future, the one-time volume of food and the intervals between its intakes are gradually increased. A gradual expansion of the diet is recommended due to mucous soups, liquid pureed cereals, meat soufflé, soft sweet fruits in a homogenized form, soft-boiled eggs, steam protein omelet, low-fat cottage cheese, puddings, mashed potatoes, cream. Thus, a gradual (within 5-6 days) transfer of the patient through diets No. Ob and No. Ov to diet No. 1 or No. 1-surgical with a high content of protein (130-140 g) and vitamins, a limited amount of easily digestible carbohydrates ( 300-350 g) and fats (80-85 g). Protein and vitamins help to increase the body's defenses and accelerate reparative processes. Limiting the amount of carbohydrates, especially easily digestible ones (sugar, honey, jam, etc.), is very appropriate due to the ability of the stomach to empty quickly (after its resection or gastroenterostomy), which is accompanied by significant fluctuations in blood glucose and, in severe cases, can lead to dumping syndrome.

Limiting the amount of carbohydrates also allows you to reduce the volume of the diet to some extent. This is very important in connection with a decrease in the volume of the stomach after its resection (heaviness and bursting in the epigastric region after eating, nausea, regurgitation, etc.).

If the patient is operated on for stomach cancer, then from the 2-3rd week, the inclusion of secretion agents (meat broths, vegetable and mushroom broths, fish soup, jelly, coffee, cocoa) is allowed.

Diet No. 1 is more indicated for patients operated on for peptic ulcer, and diet No. 1 is surgical for patients operated on for cancer or gastric polyposis, with poor milk tolerance.

Meals are made in small portions at least 6 times a day. No more than two meals are allowed at one time. It is recommended to eat food in a horizontal position, which allows you to somewhat reduce the evacuation function of the stomach. You should not eat foods rich in coarse vegetable fiber, and other foods that increase intestinal motility (prunes, fresh kefir, cold dishes, etc.).

On diet No. 1, the patient must be at least 2 snakes, i.e. until the stabilization of the functions of the digestive organs associated with the operation and the adaptation of the body to new conditions. If you feel well, the diet can be expanded by taking the same food in a non-mashed form, additional inclusion of soft vegetables and fruits with a gradual transition (within 1.5-2 months) to an excessive balanced diet. You should adhere to 4-5 meals a day with a limitation of its volume.

After resection of the stomach, as a rule, a persistent hypo- and anacid state is established in most patients. If it is accompanied by painful manifestations (heaviness, bursting in the epigastric region, diarrhea, etc.), then you should adhere to the diet therapy recommended for chronic gastritis with insufficient secretion.

After surgical interventions that do not significantly change gastric secretion (ulcer closure, economical resection of the pylorus, pyloroplasty, etc.), some patients remain at risk of peptic ulcer recurrence. This category of patients needs long-term systematic prophylactic antiulcer treatment, including dietary one.

After resection of the stomach and gastroenterostomy, complications may develop that require a differentiated diet therapy.

Slow evacuation from the stomach can develop as a result of a decrease in its tone, with an ulcer and inflammatory changes in the anastomosis area, or as a result of narrowing of the anastomosis due to technical errors during the operation. Diet therapy of anastomositis is carried out taking into account gastric secretion by analogy with clinical nutrition in chronic gastritis. The presence of an ulcer dictates the need for an appropriate anti-ulcer diet. With a decrease in the tone of the stomach and a narrowing of the anastomosis, the same dietary recommendations are shown as with pyloric stenosis (see "Peptic ulcer", p. 178). In the absence of contraindications, food products that stimulate the motor activity of the stomach stump (meat and fish broths, tomato, cherry, blackcurrant juices, rhubarb infusion, cabbage pickle) can be used.

Excessively rapid emptying of the stomach is often accompanied by various intestinal manifestations. At the same time, a frequent and fractional (small portions) diet is recommended. In order to prevent sharp fluctuations in blood glucose (hyper- and hypoglycemic symptoms), the amount of easily digestible carbohydrates in the diet should be reduced. Foods rich in coarse vegetable fiber, connective tissue, and whole milk are subject to restriction.

Inflammatory lesions of the digestive organs (enterocolitis, gastritis, cholangiohepatitis, pancreatitis, etc.) are observed more often where they occurred before surgery. Damage to the small intestine, pancreas, biliary tract and liver after gastric resection is promoted by insufficient food processing in the stomach due to the anacid state of the mucous membrane. Diet therapy is recommended the same as for the defeat of the relevant digestive organs (enteritis, colitis, gastritis, pancreatitis, etc.). Dumping syndrome develops as a result of rapid evacuation and absorption of easily digestible carbohydrates. At the same time, symptoms of hyperglycemia appear (feeling of heat in the face, hot sweat, nausea, palpitations, increased blood pressure), which, due to significant activation of the insular apparatus, can be replaced by symptoms of hypoglycemia (general weakness up to fainting, cold sweat, hand trembling, a feeling of severe hunger headache, low blood pressure). In this regard, it is necessary to reduce the content of easily digestible carbohydrates in the diet by increasing the amount of protein and to carry out more frequent meals in small portions. It is recommended to eat food in a horizontal position, which slows down its evacuation into the small intestine. Separate intake of liquid and solid parts of the diet is shown. The liquid should be consumed 20 minutes after a solid meal. Instead of sugar, it is advisable to use its substitutes (xylitol, sorbitol).

Anemia is often hypochromic in nature and is the result of insufficient iron resorption. Hyperchromic anemia, which develops as a result of a deficiency of gastromucoprotein (internal Kesla factor), is rare. With hypochromic anemia, the use of foods rich in iron (liver, sausages with the addition of blood, meat, hematogen, etc.) and ascorbic acid (rosehip broth, citrus fruits, etc.) is shown. Elimination of hyperchromic anemia is achieved by the introduction of cyanocobalamin and folacin.

General malnutrition (hypovitaminosis, malnutrition, trophic disorders, asthenia, etc.) often develop with concomitant enteritis with a pronounced violation of the absorption capacity of the small intestine and diarrhea, persistent vomiting with stenosis of the anastomosis. Recommended food with a high energy value of the diet, rich in protein and vitamins.

After gastrectomy, tube feeding can be used in the first days after a starvation diet (see p. 167). As a result of the systematic throwing of contents into the esophagus from the initial sections of the intestines, reflux esophagitis often develops. At the same time, the manifestations of the disease (belching, regurgitation) often increase after drinking whole milk, cream, sour cream, cottage cheese, gravy, sour and salty dishes. Therefore, it is advisable to limit their use and use in a mixture with other products. Patients should avoid bending over, especially after eating. It is recommended to eat food no earlier than 4-5 hours before bedtime. Diet No. 46 or 16 is shown with the exception of whole milk and restriction in dishes. Jellies, jelly, jelly work favorably.

After resection of the intestines in the early postoperative period, therapeutic nutrition is carried out in the same way as it is done after surgical interventions on the stomach, with the only difference being that from the 2-3rd week, patients are transferred to diet No. 4, which must be observed for 1-1, 5 months As the compensatory mechanisms are turned on (decrease in the motor activity of the intestines with a slowdown in the passage, restructuring of the interstitial metabolism, etc.), patients are gradually (within 1-1.5 months) transferred to a normal rational diet.

In the long term, the need for therapeutic nutrition arises if the state of compensation for digestion disturbed as a result of resection does not occur. This happens when removing large sections of the intestine.

Extensive resection of the small intestine leads to a reduction in the digestive and absorptive surface. The absorption of essential nutrients, especially fats, proteins, vitamins, minerals and, to a lesser extent, carbohydrates is impaired. Dyspeptic symptoms develop (flatulence, diarrhea, rumbling, etc.), hypovitaminosis, trophic disorders, anemia, osteoporosis, endocrine insufficiency, and sometimes edema.

It is necessary to eat with a high energy value due to the content in the diet of an increased amount of proteins (130-160 g), slightly reduced fats (70-80 g) and normal carbohydrates (400-450 g).

Fats are somewhat limiting, as they contribute to the maintenance of diarrhea. Preference should be given to easily digestible fats (butter and vegetable oil) and limit the use of indigestible animal fats (beef, lamb, duck, goose, pork, etc.). Lack of cholesterol should be covered by products containing it (egg yolk, liver, heart, kidneys, etc.). Cholesterol is essential for the synthesis of steroid hormones. Decreased production of steroid hormones was found after extensive resection of the small intestines.

At least 60% of proteins must be of animal origin (meat, fish, cottage cheese, eggs, etc.).

It is necessary to give preference to easily digestible carbohydrates.

To prevent the development and progression of osteoporosis, the introduction of an increased amount of calcium in the optimal ratio with phosphorus (cottage cheese) is indicated.

The elimination of hypochromic anemia is facilitated by the use of foods rich in iron (beef liver, kidneys, meat, etc.).

To combat hypochromic anemia, cyanocobalamin is needed.

All vitamins should be administered in increased amounts. For this purpose, it is advisable to use fruit and berry juices, compotes and jelly, which help to fix the stool (cornel, blackcurrant, blueberry, pear, pomegranate). The inclusion in the diet of other food products with antidiarrheal effects is also shown: strong tea, black coffee, chocolate, mucous soups, cereals (except buckwheat).

Food should be fractional - 5-6 times a day. Food should be taken warm.

Excluded products that are among the hard-to-digest and stimulating the motor activity of the intestines. The latter is usually compensatory oppressed. In this regard, vegetables rich in vegetable fiber (radishes, radishes, legumes, gooseberries, cabbage, etc.), foods containing large amounts of connective tissue (stringy meat, cartilage, bird skin, fish, etc.) and salt should be avoided. , cold dishes and drinks, concentrated sugar solutions, products containing or forming carbon dioxide (carbonated drinks, fermented beer, koumiss, etc.) and rich in organic acids (one-day kefir, curdled milk, kvass), beet juice.

The above measures can only partially eliminate alimentary endogenous insufficiency. Therefore, protein preparations (blood serum, plasma, protein hydrolysates), vitamins, iron, and calcium should be additionally administered parenterally.

Extensive resection of the colon, especially its right half, leads to impaired absorption of water and the formation of feces. The passage through the intestines is accelerated, especially when the ileocecal valve is turned off. The synthesis of vitamins and the breakdown of a number of enzymes (enterokinase, alkaline phosphatase), which are normally carried out in the large intestine with the participation of microbial flora, are disrupted. At the same time, the assimilation of nutrients that occurs in the small intestine, if it is not affected, suffers relatively little.

Shown poor in slags, sufficient in energy value nutrition with the introduction of a normal amount of proteins, fats, carbohydrates and minerals.

Food should be taken fractionally - 5-6 times a day in a warm form.

It is necessary to exclude food that promotes bowel emptying: rich in coarse plant fiber, connective tissue, salt, organic acids, concentrated sugar solutions, products containing carbon dioxide, beetroot juice, cold dishes and drinks.

It is necessary to limit the use of products that promote fermentation processes (milk, rye bread, grape juice, legumes, kvass, etc.).

After appendectomy on the 1st-2nd day, diet No. 0a is prescribed, on the 3rd-4th day - diet No. Ob or No. 0b, from the 5th day - diet No. 1-surgical. Before discharge from the hospital, the patient is transferred to diet No. 2 or 15.

After operations on the biliary tract, performed under general anesthesia, you can give to drink only a few hours after waking up. Before that, you can quench your thirst by wiping your lips or mouth with a cotton swab moistened with boiled water (preferably with the addition of a small amount of lemon juice), or by rinsing your mouth. After 10-12 hours after the operation, if desired, the patient may be allowed to take a small amount of liquid food (soups, jelly, rosehip broth, etc.). On the 2nd day, diet No. 0a is prescribed, on the 3-5th day - diets No. Ob and Ov with the replacement of meat broths with slimy soups, eggs - with steam protein omelettes. From the 5-6th day, the patient is transferred to diet No. 5a, on which he should be in a favorable postoperative period for 5-7 days. As the motor regime expands, the patient can be gradually transferred to diet No. 5.

After removal of the gallbladder, according to various authors, pathological symptoms remain in 5-20% of cases. It may be due to technical errors during the operation (narrowing of the common bile duct, long stump of the cystic duct, narrowing of the sphincter of the hepatic-pancreatic ampulla), functional disorders (hypotension or hypertension of the sphincter of the hepatic-pancreatic ampulla or common bile duct) or due to stones of the bile ducts left during the operation, exacerbation after cholecystectomy of chronic pancreatitis, hepatitis, etc. Pathological conditions that can be observed after cholecystectomy are commonly referred to as postcholecystectomy syndrome. Some authors include in this concept other concomitant diseases (gastroduodenitis, peptic ulcer, colitis, etc.).

Naturally, in case of pathology associated with technical errors during the operation, and in the presence of stones in the biliary tract, repeated surgical intervention is necessary. In other cases, with complex conservative treatment, therapeutic nutrition is important.

Diet therapy is aimed at sparing the functions of the affected organs, stimulating bile secretion, correcting metabolic disorders that contribute to the formation of stones in the biliary tract. It is built taking into account the nature of pathological changes and the state of the digestive system.

During the period of exacerbation, therapeutic nutrition should correspond to the main pathological process with correction in the presence of concomitant lesions. In particular, in the presence of concomitant gastroduodenitis, diet No. 5a is indicated. In other cases, therapeutic nutrition should be carried out by prescribing a therapeutic diet No. 5 with some restriction of products that contribute to the formation of stones in the biliary tract. Among them are flour, cereal products and foods rich in calcium salts (see "Cholelithiasis", p. 222). To prevent the formation of stones in the biliary tract, diet No. 5 should be enriched with foods rich in carotene (carrots, apricots, peaches, oranges, tomatoes, etc.).

After surgical interventions on the lungs, mediastinum, heart, major gynecological and urological operations, diet No. Oa is recommended on the 1-2nd day, from the 2-3rd day - No. 1-surgical, from the 5th day - No. 11 or No. 13 ; with an increase in blood pressure, the presence of edema - diet number 10.

After tonsillectomy, after 10-14 hours, liquid food is allowed in pure form (meat broth, cream, sour cream, kefir, jelly). The next day, diet No. Ob is prescribed, from the 3rd day - No. Ov, from the 5th day - No. 1-surgical.

After operations on the thyroid gland, food in liquid form (cream, mucous soups, jelly) is allowed after 8-10 hours. From the 2nd day, diet No. 1a is shown, from the 4th - No. 16, from the 6-7th day - diet No. 15.

^ Types of nutrition for surgical patients

Nutrition of surgical patients can be:

Natural:

active - patients with a general regimen eat themselves;
passive - patients on bed rest are fed by a nurse.

When feeding bedridden patients, they need to be given a position to avoid fatigue. If there are no contraindications, patients are helped to take a sitting or semi-sitting position, the chest and neck are covered with a napkin. Severe and debilitated patients often have to be fed in small portions, giving liquid food (mashed soup, broth, jelly, milk, etc.) in small sips from a drinking bowl or from a spoon. Febrile patients are best fed during the period of improvement and decrease in temperature, trying, especially in cases of insomnia, not to interrupt daytime sleep unless absolutely necessary.

Great patience and tact must be shown when feeding patients suffering from lack of appetite or even aversion to food (for example, with malignant neoplasms). In such cases, attention should be paid to ensuring that the food is tasty, freshly prepared, and includes dishes beloved by the sick. Eating should take place in an appropriate environment (cleanliness, tidiness, absence of various distractions).

In some situations, the natural nutrition of patients has to be supplemented or completely replaced with artificial one.

artificial nutrition

Artificial nutrition is used in cases where the patient cannot eat independently or when nutrition in a natural way due to various reasons (severe, debilitating disease, preoperative preparation and postoperative period) is insufficient. There are several ways of artificial nutrition: through a probe inserted into the stomach; with the help of a gastrostomy or jejunostomy (a surgically placed hole in the stomach and jejunum), as well as through the parenteral administration of various drugs, bypassing the gastrointestinal tract (from the Greek para - near, entera - intestines). Since when applying a gastrostomy or jejunostomy for artificial nutrition, a probe is also often used, the first two methods are often combined into the concept of probe, or enteral, nutrition.

Enteral nutrition

Enteral nutrition is a type of nutritional therapy in which nutrients in the form of special mixtures are administered orally or through a nasogastric tube, nasoduodenal tube, gastrostomy, jejunostomy, etc., when it is impossible to adequately meet the energy and plastic needs of the body naturally in various diseases.

Enteral nutrition is used with the preserved function of the gastrointestinal tract, allows you to maximize the use and maintain the functional activity of the intestine in a physiological way, and therefore has undeniable advantages in comparison with parenteral nutrition.

In a long-term non-functioning intestine, degenerative changes in the villous epithelium develop, the risk of bacterial translocations(penetration of microbial bodies from the intestinal lumen into the free abdominal cavity and systemic circulation).

Indications for enteral nutrition:

protein-energy insufficiency;
neoplasms localized in the head, neck, stomach;
radiotherapy and chemotherapy for cancer;
acute and chronic radiation injuries, gastrointestinal diseases: Crohn's disease, malabsorption syndrome, short loop syndrome, chronic pancreatitis, ulcerative colitis, diseases of the liver and biliary tract;
nutrition in the pre- and postoperative periods;
injury, burns, acute poisoning;
complications of the postoperative period (fistulas of the housing and communal services, sepsis, failure of the sutures of anatomists);
infectious diseases.

Advantages of enteral nutrition in comparison with parenteral nutrition: use and maintenance of intestinal functions, physiology, use of the natural immunological barrier of the intestinal mucosa, the possibility of various methods of administration (oral, nasogastric and nasoenteric tube, gastrostomy, jejunostomy), can be used as a supplement to ordinary food, cheaper and safer.

As probes for artificial nutrition, 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, which facilitate subsequent control over the position of the probe.

For enteral (tube) nutrition, you can use various mixtures containing broth, milk, butter, raw eggs, juices, homogenized canned meat and vegetable diets, as well as baby food mixtures. In addition, at present, special preparations are produced for enteral nutrition (protein, fat, oat, rice and other enpits), in which proteins, fats, carbohydrates, mineral salts and vitamins are selected in strictly defined ratios. The introduction of nutrients through a probe or gastrostomy can be done fractionally, i.e. in separate portions, for example 5-6 times a day; drip slowly, for a long time, as well as with the help of special dispensers that automatically regulate the flow of food mixtures.

^ Feeding the patient through a tube

In resuscitation and intensive care units for feeding unconscious patients, either permanent gastric tubes are used, which are changed after 1-2 days, or they are introduced for each feeding. The introduction of a probe with a diameter of 5 mm through the nose is more often used, a probe with a diameter of 8 mm is inserted only through the mouth for each feeding.

To carry out the procedure, it is necessary to prepare: a gastric tube, a Janet syringe, an aerosol can with 10% lidocaine, liquid paraffin, a phonendoscope, a tray, cotton wool, a diaper and liquid food.

The nasal passages are cleaned with cotton wool, for the purpose of anesthesia, lidocaine is injected twice, lubricated with vaseline oil.
Carefully, with rotational movements, a probe lubricated with vaseline oil is inserted through the nasal passage into the esophagus, and then into the stomach.
You need to make sure that the tube is in the stomach. To do this, air is supplied through the probe with the help of a syringe to Zhane and at this time the stomach is auscultated with a phonendoscope installed in the epigastric region - the noise of the blown air is detected (if it enters the trachea, a cough begins).
The introduction of the nutrient mixture is carried out fractionally - 50 ml in 2 minutes, in a volume of 500-800 ml.

It is advisable to continuously introduce a nutrient solution, especially in cases where the probe is installed in the small intestine. When feeding through a gastric tube, it is possible to carry out a fractional introduction of a mixture of 200-300 ml every 3-4 hours. With the rapid introduction, especially concentrated mixtures, patients may complain of the occurrence of cramping abdominal pain, diarrhea. The probe must be washed after each feeding of the patient or, with continuous administration, every 8 hours.

Contraindications for enteral nutrition are the following:

obstructive acute intestinal obstruction;
intestinal ischemia;
failure of the interintestinal anastomosis;
intolerance to the components of the enteral mixture;
discharge through a nasogastric tube more than 1200 ml per day.

One of the methods of artificial enteral nutrition - nutritional enema, which 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.

In cases where enteral nutrition fails to provide the body with the required amount of nutrients, parenteral nutrition is used.

^ parenteral nutrition - a way to provide the patient with nutrients, bypassing the gastrointestinal tract, while special infusion solutions that can be actively involved in the body's metabolic processes are administered through a peripheral or central vein.

Parenteral nutrition can be divided into the following groups:

in relation to enteral nutrition - additional and complete;
by time - around the clock, extended (18-20 hours), cyclic (8-12 hours).

The need for its use often arises in patients with extensive abdominal operations, both in the process of 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 disorders 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), indomitable vomiting, refusal to eat.

Donor blood, protein hydrolysates, saline solutions and glucose solutions with trace elements and vitamin supplements are used as preparations for parenteral nutrition. Well-balanced solutions of amino acids are now widely used in clinical practice.

^ Classification of components of parenteral nutrition

Donators of plastic material:

standard solutions of crystalline amino acids (aminoplasmal, aminosteril, vamine, aminosol);
specialized in age and pathology (aminoplasmal hepa, aminosteril hepa, aminosteril-nefro, aminoven infant, vaminolact).

Energy donors:

fat emulsions (structolipid MST/LST; omegaven, lipoplus 3 omega FA; lipofundin MST/LST; lipovenosis LST; Intralipid LST);
solutions of carbohydrates (glucose solutions of 20% or more).

Vitamin and microelement complexes for parenteral nutrition.

Two - and three-component mixtures ( bags) for parenteral nutrition [Nutriflex peri (amino acids + glucose, Nutriflex lipid plus)].

New directions in parenteral nutrition: limited use of glucose, wider inclusion of structured lipids, omega-3 acids, three-component mixtures in parenteral nutrition protocols.

About 5% of patients with diabetes mellitus, 50-75% with insulin resistance are admitted to intensive care units. The use of glucose in these patients can lead to conditions that aggravate both the course and the prognosis of the underlying disease.

Main contraindications for parenteral nutrition:

intolerance to individual components of nutrition;
refractory shock syndrome;
hyperhydration;
fat embolism;
anaphylaxis to components of nutrient media.

Complications of parenteral nutrition:

Technical (5%): air embolism; artery damage; damage to the brachial plexus; arteriovenous fistula; perforation of the heart; embolism with a catheter; displacement of the catheter; pneumothorax; subclavian vein thrombosis; damage to the thoracic duct; vein damage.
Infectious (5%): infection at the venipuncture site; "tunnel" infection; catheter-associated sepsis.
Micronutrient deficiency.
Metabolic (5%): azotemia; excess fluid intake; hyperglycemia; hyperchloremic metabolic acidosis; hypercalcemia; hyperkalemia; hyperphosphatemia; hypervitaminosis A; hypervitaminosis D; hyperglycemia; hypocalcemia; hyponatremia; hypophosphatemia.
^ Impaired liver function (including an increased risk of developing gallstone disease).
Metabolic disorders of bone tissue.

Ways of using medicines. The technique of performing intradermal, subcutaneous and intramuscular injections.

In modern practical medicine, there is not a single area in which medicines would not be successfully used. Drug therapy is an essential part of the treatment process.

There are the following ways of administering drugs:

outdoor method;
Enteral way;
Inhalation method - through the respiratory tract;
Parenteral way.

Enteral method

General rules for the use of medicines

Before giving the medicine to the patient, it is necessary to wash your hands thoroughly, carefully read the inscription on the label, check the expiration date, the prescribed dose, then check the patient's intake of the medicine (he must take the medicine in the presence of a nurse).
If the drug is prescribed to be taken several times a day, the correct time intervals must be observed in order to maintain a constant concentration in the blood.
Medications prescribed for fasting should be distributed in the morning 30-60 minutes before breakfast. If the doctor has recommended taking the medicine before meals, the patient should receive it 15 minutes before meals. The medicine prescribed during meals, the patient takes with food. The remedy prescribed after a meal, the patient should drink 15-20 minutes after eating. Sleeping drugs are given to patients 30 minutes before bedtime.

^ Parenteral route of drug administration

Parenteral (gr. para- nearby, nearby entern- intestines) is a method of introducing drugs into the body, bypassing the digestive tract. There are the following parenteral routes of drug administration.

in tissue;
into vessels;
in the cavity;
into the subarachnoid space.

Injection technique

Currently, there are three main methods of parenteral (i.e. bypassing the digestive tract) administration of drugs: subcutaneous, intramuscular and intravenous. The main advantages of these methods include the speed of action and the accuracy of dosage. It is also important that the drug enters the bloodstream unchanged, without being degraded by the enzymes of the stomach and intestines, as well as the liver. Administration of drugs by injection is not always possible due to some mental illnesses accompanied by fear of injection and pain, as well as bleeding, skin changes at the site of the proposed injection (for example, burns, purulent process), skin hypersensitivity, obesity or malnutrition. In order to avoid complications after an injection, you need to choose the right length of the needle. For injections into a vein, needles 4-5 cm long are used, for subcutaneous injections - 3-4 cm, and for intramuscular injections - 7-10 cm. Needles for intravenous injections should have a cut at an angle of 45 °, and for subcutaneous injections, the cut angle should be sharper. It should be remembered that all instruments and injection solutions must be sterile. For injections and intravenous infusions, only disposable syringes, needles, catheters and infusion sets should be used. Before performing the injection, it is necessary to read the doctor's prescription again; carefully check the name of the drug on the package and on the ampoule or vial; check the expiration date of the medicinal product, disposable medical instrument.

Currently used, single use syringe issued in assembled form. These plastic syringes are factory sterilized and packaged in individual bags. Each bag contains a syringe with a needle attached to it or with a needle in a separate plastic container.

^ The order of the procedure:

When taking the solution from the vial, pierce the rubber stopper with a needle, put the needle with the vial on the needle cone of the syringe, lift the vial upside down and draw the required amount of contents into the syringe, disconnect the vial, change the needle before injection.

10. Remove air bubbles present in the syringe: turn the syringe with the needle up and, holding it vertically at eye level, release air and the first drop of the drug by pressing on the piston.

intradermal injection

Draw up the prescribed amount of the drug solution into the syringe.
Ask the patient to take a comfortable position (sit down or lie down) and free the injection site from clothing.
Treat the injection site with a sterile cotton ball dipped in a 70% alcohol solution, making movements in one direction from top to bottom; wait until the skin at the injection site is dry.
Grab the patient's forearm with the left hand from the outside and fix the skin (do not pull!).
With the right hand, drive the needle into the skin with the cut up in the direction from the bottom up at an angle of 15 ° to the skin surface for the length of only the cut of the needle so that the cut is visible through the skin.
Without removing the needle, slightly lifting the skin with the cut of the needle (forming a “tent”), transfer the left hand to the syringe plunger and, pressing the plunger, inject the medicinal substance.
Withdraw the needle with a quick movement.
Put the used syringe, needles into the tray; Place used cotton balls in a container with a disinfectant solution.

Subcutaneous injections

Due to the fact that the subcutaneous fat layer is well supplied with blood vessels, subcutaneous injections are used for faster action of the drug. Subcutaneously administered medicinal substances have a faster effect than when administered through the mouth. Subcutaneous injections are made with a needle of the smallest diameter to a depth of 15 mm and up to 2 ml of drugs are injected, which are quickly absorbed from loose subcutaneous tissue and do not have a harmful effect on it. The most convenient sites for subcutaneous injection are: the outer surface of the shoulder; subscapular space; anterior surface of the thigh; lateral surface of the abdominal wall; lower armpit.

In these places, the skin is easily captured in the fold and there is no danger of damage to blood vessels, nerves and periosteum. It is not recommended to inject into places with edematous subcutaneous fat, into seals from poorly absorbed previous injections.

^ Technique:

Attention!If there is a small air bubble in the syringe, inject the medicine slowly and do not release the entire solution under the skin, leave a small amount with the air bubble in the syringe:

remove the needle by holding it by the cannula;
press the injection site with a cotton ball with alcohol;
make a light massage of the injection site without removing the cotton wool from the skin;
put a cap on a disposable needle, discard the syringe in a trash can.

^ Intramuscular injections

Some subcutaneous drugs cause pain and are poorly absorbed, leading to the formation of infiltrates. When using such drugs, as well as in cases where they want to get a faster effect, subcutaneous administration is replaced by intramuscular. Muscles have a wide network of blood and lymphatic vessels, which creates conditions for the rapid and complete absorption of drugs. With intramuscular injection, a depot is created, from which the drug is slowly absorbed into the bloodstream, and this maintains the necessary concentration in the body, which is especially important in relation to antibiotics. Intramuscular injections should be made in certain places of the body where there is a significant layer of muscle tissue and large vessels and nerve trunks do not come close. The length of the needle depends on the thickness of the layer of subcutaneous fat, since it is necessary that when inserted, the needle passes through the subcutaneous tissue and enters the thickness of the muscles. So, with an excessive subcutaneous fat layer, the length of the needle is 60 mm, with a moderate one - 40 mm. The most suitable places for intramuscular injections are the muscles of the buttocks, shoulder, thigh.

^ For intramuscular injections in the gluteal region use only the upper part of it. It should be remembered that accidentally hitting the sciatic nerve with a needle can cause partial or complete paralysis of the limb. In addition, there is a bone (sacrum) and large vessels nearby. In patients with flabby muscles, this place is localized with difficulty.

Lay the patient either on their stomach (toes turned in) or on their side (the leg that will be on top is bent at the hip and knee to relax

gluteal muscle). Palpate the following anatomical structures: the superior posterior iliac spine and the greater trochanter of the femur. Draw one line perpendicular down from the middle

awn to the middle of the popliteal fossa, the other - from the trochanter to the spine (the projection of the sciatic nerve passes slightly below the horizontal line along the perpendicular). Locate the injection site, which is located in the upper outer quadrant at the upper outer portion, approximately 5-8 cm below the iliac crest. With repeated injections, it is necessary to alternate the right and left sides, change the injection sites: this reduces the pain of the procedure and is the prevention of complications.

^ Intramuscular injection into the vastus lateralis muscle carried out in the middle third. Place the right hand 1-2 cm below the trochanter of the femur, the left hand 1-2 cm above the patella, the thumbs of both hands should be on the same line. Locate the injection site, which is located in the center of the area formed by the index and thumbs of both hands. When injecting young children and malnourished adults, take the skin and muscle into a fold to ensure that the drug is delivered to the muscle.

^ Intramuscular injection can be done and into the deltoid muscle. The brachial artery, veins and nerves run along the shoulder, so this area is used only when other injection sites are not available or when several intramuscular injections are performed daily. Release the patient's shoulder and shoulder blade from clothing. Ask the patient to relax the arm and bend it at the elbow joint. Feel the edge of the acromial process of the scapula, which is the base of the triangle, the apex of which is in the center of the shoulder. Determine the injection site - in the center of the triangle, approximately 2.5-5 cm below the acromial process. The injection site can also be determined in another way by placing four fingers across the deltoid muscle, starting from the acromial process.

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KARAGANDA STATE MEDICAL UNIVERSITY

Department of Surgical Diseases No. 1, military field surgery with a course of physiotherapy and exercise therapy SRS on the topic:

"Nutrition for surgical patients"

Introduction

Nutrition of surgical patients

Nutrition before and after surgery

Diet for acute pancreatitis

Therapeutic nutrition for cholelithiasis

Conclusion

Introduction

Good nutrition is an essential part of the quality treatment of a surgical patient. It is known that its deficiency significantly aggravates wound healing and leads to a severe course of nosocomial infection.

In turn, a sufficient balanced diet is the key to high tolerance to surgical trauma, strong immunobiological reactions and adequate reparative processes. In this regard, intensive care of any surgical pathology is impossible without proper nutrition, and its organization is included in the circle of skills of a doctor of any medical specialty.

food surgical patient

Nutrition of surgical patients

Satisfaction of the energy and plastic needs of the body of a surgical patient is provided by a balanced diet. This is understood as the intake of a sufficient amount of nutrients in accordance with energy costs, which increase in a pathological condition due to an increase in basal metabolism. The optimal ratio of these substances is the daily intake of proteins - 13-17%, fats - 30-35%, carbohydrates - 50-55%. In a surgical patient, protein serves as the most important plastic material in wound regeneration, enzymes and other biologically active substances are formed from protein structures, proteins form the basis of immune complexes that are vital for fighting infection. During illness, catabolism processes predominate in the body, the greatest expression of which is manifested in the loss, first of all, of proteins with a short half-life (liver proteins and enzymes of the gastrointestinal tract). The resulting amino acid imbalance often leads to toxic manifestations. Lipids have a high energy value. They can be replaced in terms of calories with other nutrients, such as carbohydrates. However, some fatty acids are essential. They are involved in the formation of phospholipids - the most important component of all cellular structures. Therefore, the inclusion of fats in the diet also becomes life-defining. Carbohydrates serve as one of the main sources of energy. The lack of these nutrients leads to the rapid utilization of fats and proteins to obtain the necessary energy material. This situation is fraught with irreversible changes in the metabolism in the body, which can lead to the death of the patient. In addition to proteins, fats and carbohydrates, vitamins, trace elements and water must be included in the diet. Their number is taken into account when drawing up the appropriate diets. Depending on the disease, the necessary diet and the route of intake of nutrients into the body are chosen. There are two methods of food delivery - natural and artificial. With natural nutrition, the attending physician prescribes an appropriate diet or table. In our country, there is a single numbered system of dietary nutrition according to N.I. Pevzner, which includes 15 basic diets. Each of them contains indications for use, the purpose of the appointment, a general description of the main features of the chemical composition, a set of products and their culinary processing, the chemical composition and energy value, diet, a list of acceptable and contraindicated dishes and products, as well as some ways of preparing them. The number of diets that are used in a health care facility depends on local conditions and mainly on the profile of the population served. In the general surgical department, the most commonly used diets are N0-a, N0-b, N0-c, N1-a, N1, N5-a, N9, N11, N13, N15, a tubular table and parenteral nutrition. A zero diet is indicated after operations on the organs of the gastrointestinal tract, with a semi-conscious state (traumatic brain injury). This diet provides maximum sparing of the digestive organs, prevents flatulence and provides nutrition when it is difficult or impossible to take ordinary food. Sometimes diets N0-b and N0-c are called N1-a and N1-b - surgical. The N0-a diet is prescribed for 2-3 days. It includes jelly-like and liquid dishes, free liquid 1.8-2.2 liters with food temperature not higher than 45°C. Food is consumed 7-8 times a day with a volume of not more than 200-300 g at a time. Fat-free meat broth, rice broth with butter, berry jelly, strained compote, rosehip infusion with sugar, freshly prepared fruit and berry juices, tea with lemon are allowed. After 2-3 days, when the condition improves, add a soft-boiled egg, 50 ml of cream. Prohibit dense and mashed dishes, carbonated drinks, whole milk. Diet N0-b is prescribed for 2-4 days after N0-a. It additionally includes liquid pureed cereals from oatmeal, buckwheat and rice, boiled in meat broth or water, slimy cereal soups in vegetable broth, steam protein omelet, steam soufflé or mashed lean fish or meat. Food is given no more than 350-400 g per reception 6 times a day. The N0-B diet is a continuation of the previous dietary nutrition and serves for a smooth transition to a physiologically complete food intake. This diet includes cream soups and puree soups, steamed dishes from mashed boiled meat, chicken or fish, fresh cottage cheese, sour milk drinks, mashed vegetable and fruit purees, 50-75 g of white crackers. Milk can be added to porridge. Food is given 6 times a day. N1-a diet is prescribed 6-7 days after stomach surgery. It is designed for maximum mechanical, chemical and thermal sparing of the gastrointestinal tract in the conditions of bed rest. According to this diet, food is prepared in liquid and semi-liquid form and taken in uniform portions every 2-3 hours. For cooking dishes (steam soufflé or mashed potatoes) of low-fat types of fish or meats of medium fatness. Soufflé made from freshly prepared cottage cheese is limited. Whole milk, cream, unsalted butter, liquid milk porridges from grated cereals or baby food, homogenized vegetables, milk soup, mucous decoctions in milk, jelly, jelly from non-acidic berries, weak tea, rosehip broth are consumed. Exclude substances that stimulate gastric secretion, hot and cold dishes, including cheese, sour cream, ordinary cottage cheese, bread, flour and confectionery products, raw fruits and berries, sauces, spices, coffee, cocoa, carbonated drinks. The N1 diet is indicated after gastric surgery as a transitional diet from the N1-a diet to physiologically complete food. It is designed to reduce the inflammatory response and heal the mucosa by limiting thermal, chemical and mechanical stimuli. According to the chemical composition and energy value, this diet is physiological. Dishes are prepared mainly in pure form, boiled in water or steamed. For cooking use low-fat meats and types of fish. It is allowed to use steam cutlets, meatballs, soufflé, mashed potatoes, zrazy, beef stroganoff, aspic on vegetable broth. From dairy products, non-acid mashed cottage cheese, sour cream, mild cheese, dumplings, cheesecakes, semi-viscous porridge with milk, pudding, steamed scrambled eggs or scrambled eggs are recommended. Allowed dried wheat bread or yesterday's baking, boiled potatoes, carrots, beets, pureed vegetable soups, sugar, honey, fresh ripe berries and fruits, weak cocoa, coffee with milk, juices from fruits and berries. You can not use hot and cold dishes, almost all sausages, spicy and salty foods, strong broths, smoked meats, sour and unripe berries and fruits, chocolate, ice cream, kvass, black coffee. The N5-a diet is used for acute cholecystitis 3-7 days after the onset of the disease, 5-6 days after operations on the biliary tract and for acute pancreatitis. Mechanically and chemically sparing food used maintains the functional rest of all digestive organs. Dishes are cooked boiled or pureed, served warm. Food is taken 5-6 times a day. For cooking, lean meat and fish are used in the form of cutlet mass products, low-fat cottage cheese, non-acidic sour cream and cheese. It is permissible to use a steam omelette, porridge with milk in half with water, boiled vermicelli, wheat bread, unbread cookies, mashed potatoes, milk jelly, mashed dried fruits, honey, sugar, tea with milk, lemon, sweet fruit and berry juices, tomato juice, broth wild rose. Exclude from food foods rich in extractives, coarse fiber, fatty and fried foods, smoked meats, fresh and rye bread, rich and puff pastry, mushrooms, cold snacks, chocolate, ice cream, spices, cocoa, black coffee, carbonated and cold drinks. The N9 diet is indicated for diabetes mellitus. It contributes to the normalization of carbohydrate metabolism.

With this diet, the energy value is moderately reduced due to the reduced content of carbohydrates and fats in food. Sugar and sweets are excluded from the diet, substitutes are used instead, table salt is moderately limited. Among the excluded foods are fatty meats and fish, salted cheeses, rice, semolina and pasta, pastry and puff pastry, salted and pickled vegetables, grapes, raisins, bananas, sugar, honey, jam, sweets, ice cream, sweet juices. The N11 diet is prescribed when the body is depleted after surgery or injury in the absence of diseases of the digestive system.

It aims to increase the body's defenses and improve nutritional status. The products used in this case contain an increased amount of proteins, vitamins, and minerals. Cooking and food temperature is normal. Meals are carried out 5 times a day with the use of free liquid up to 1.5 liters. The recommended list of products is very diverse, ranging from meat and fish dishes to various flour products. The exception is very fatty meat and poultry, lamb, beef and cooking fats, spicy and fatty sauces, cakes and pastries with a lot of cream. The N15 diet is used for various diseases that do not require a special therapeutic diet, and also as a transition to normal nutrition after using other diets. Its goal is to provide physiologically complete nutrition. Proteins, fats and carbohydrates are contained in the amount necessary for a healthy person who is not engaged in physical labor, and vitamins are in an increased amount. Food temperature and cooking are normal.

Free liquid is not limited. Food is consumed 4-5 times a day. Recommended daily use of fermented milk products, fresh vegetables and fruits, juices, rosehip broth. Limit spices, and exclude fatty meats, beef, lamb, pork and cooking fats. After some surgical interventions and in many diseases, natural eating is not possible. In these cases, artificial nutrition is used: enteral (through a tube or stoma), parenteral and combined. Enteral (tube) nutrition is carried out through a tube inserted into the stomach or small intestine.

In surgical patients, it is indicated for:

* impaired consciousness due to traumatic brain injury or severe intoxication;

* the presence of mechanical obstacles in the oral cavity, pharynx and esophagus (tumors and strictures);

* a condition accompanied by increased catabolism (sepsis, burn disease, polytrauma);

* anorexia of any origin. Tube feeding is contraindicated in:

* disorders of digestion and absorption of the small intestine;

* acute bleeding from the upper gastrointestinal tract;

* intractable vomiting and diarrhea;

* dynamic intestinal obstruction;

* intestinal paresis after surgical interventions; * Anomalies in the development of the gastrointestinal tract. For tube nutrition, mixtures prepared just from liquid products (cream, milk, broths, eggs, juices) in combination with easily soluble (milk powder, sugar, starch) or crushed (meat, fish, cottage cheese) components are used. High-calorie and convenient mixtures from baby food, ENPIT (protein, fat-free), homogenized canned mixtures from natural products, as well as industrially prepared instant mixtures from proteins, fats and carbohydrates of vegetable origin. With tube feeding, to get used to the new conditions of food intake, 50% of the daily calorie intake is introduced on the first day. Further, the dose is increased, and from the fourth day they give the entire estimated volume.

Uniform intake of food during the day is achieved with the help of special pumps, thereby preventing nausea, vomiting, dumping syndrome and diarrhea. In cases where it is impossible to pass the probe into the stomach, for example, with a tumor of the esophagus, a gastrostomy operation is performed. A tube is inserted into the artificially created fistulous passage through which the patient is fed.

To do this, use a liquid nutrient mixture (tubular table). Nutrition through the gastrostomy is started on the second day after the operation. 100-150 ml of the mixture is injected into the stomach at the same time using a Janet syringe or by gravity through a funnel connected to a tube, every 2-3 hours. After each feeding, the tube is washed with water and a clamp is placed on it. After 5-7 days, it is allowed to use mushy food 400-500 ml 4-5 times a day.

For the preparation of the mixture, the same food substrates are recommended that are used for feeding through a tube. Due to the fact that there is a gap between the tube and the wall of the fistula, which is almost impossible to completely seal, leakage of gastric contents along the tube is observed, and the skin around the gastrostomy is macerated. Accession of an infection is fraught with development in this place of a purulent inflammation. For its prevention, careful care of the gastrostomy is necessary. After each feeding in the stoma area, the skin toilet is performed, wiping it with a cotton or gauze swab moistened with 0.1-0.5% potassium permanganate solution. After thoroughly drying the skin, a layer of Lassar paste is applied to its surface and an aseptic dressing is applied. In some diseases of the stomach (total tumor damage, chemical burns), for the purpose of feeding, a jejunostomy is imposed - a small intestinal fistula.

Nutrient mixtures are introduced into the intestine through a tube, the chemical composition of which approaches the chyme of a healthy person. Initially, a saline solution is used with the addition of glucose, which stimulates the absorption of these substances. After 3-4 days, protein solutions (hydrolysin, aminopeptide) are added to enteral nutrition. And, finally, the last stage of the adaptive nutrition program is the addition of fat emulsions (lipozin). Enterostomy care is carried out in the same way as with a gastrostomy. The greatest danger is the failure of the sutures that fix the wall of the stomach or intestines to the parietal peritoneum.

In this case, they move away from the anterior abdominal wall and the gastric or intestinal contents flow into the abdominal cavity with the development of peritonitis. Such a complication is treated only surgically. In cases where it is not possible to feed naturally or through a tube, parenteral nutrition is used as the most simplified way to supply the body with nutrients. For this, well-tolerated solutions are made up of individual nutrients. They include proteins, fats, carbohydrates, water and electrolytes, providing full satisfaction of the energy and plastic needs of the body. Such a complete high-calorie diet (up to 3000 kcal per day) can be used if necessary for a long (years) time. For the introduction of nutrients by the parenteral route, the main (jugular, subclavian) vein is catheterized. The duration of operation of the catheter depends on the quality of its care.

Nutrition before and after surgery

Proper diet therapy before and after surgery helps to reduce the frequency of complications and faster recovery of the patient. In the absence of contraindications to food intake, nutrition in the preoperative period should create reserves of nutrients in the body. The diet should contain 100-120 g of protein, 100 g of fat, 400 g of carbohydrates (100-120 g of easily digestible); 12.6 MJ (3000 kcal), an increased amount of vitamins compared to the physiological norm, in particular C and P, due to fruits, vegetables, their juices, rosehip broth. It is necessary to saturate the body with fluid (up to 2.5 liters per day), if there are no edema.

3-5 days before surgery, fiber-rich foods that cause flatulence (legumes, white cabbage, wholemeal bread, millet, nuts, whole milk, etc.) are excluded from the diet.

Patients should not eat for 8 hours before surgery. Longer fasting is not indicated, as it weakens the patient.

One of the reasons for urgent hospitalizations and possible operations are acute diseases of the abdominal organs, united under the name "acute abdomen" (acute appendicitis, pancreatitis, cholecystitis, perforated stomach ulcer, intestinal obstruction, etc.). Patients with an "acute abdomen" are prohibited from eating.

The surgical operation causes not only local, but also a general reaction from the body, including changes in metabolism.

Nutrition in the postoperative period should:

1) to ensure sparing of the affected organs, especially during operations on the digestive organs;

2) contribute to the normalization of metabolism and the restoration of the general forces of the body;

3) increase the body's resistance to inflammation and intoxication;

4) promote the healing of the surgical wound.

After operations on the abdominal organs, a starvation diet is often prescribed. The liquid is administered intravenously, and the mouth is only rinsed. In the future, the most sparing food (liquid, semi-liquid, mashed) is gradually prescribed, containing a sufficient amount of liquid, the most easily digestible sources of nutrients. To prevent flatulence, whole milk, concentrated sugar solutions and fiber are excluded from the diet. The most important task of therapeutic nutrition is to overcome protein and vitamin deficiency within 10-15 days after surgery, which develops in many patients due to malnutrition in the first days after surgery, blood loss, tissue protein breakdown, and fever. Therefore, perhaps an earlier transfer to a full-fledged diet with a wide food set is necessary, but taking into account the patient's condition, the abilities of his body in relation to the intake and digestion of food.

It is necessary to reduce the phenomena of metabolic acidosis by including dairy products, fruits and vegetables in the diet. After surgery, patients often have a large loss of fluid. The approximate daily requirement for the latter in this period is: 2-3 liters - with an uncomplicated course, 3-4 liters - with complicated (sepsis, fever, intoxication), 4-4.5 liters - in severe patients with drainage . If it is impossible to provide nutrition to operated patients in the usual way, parenteral (intravenous) and tube nutrition are prescribed. Especially indicated for feeding through a tube or sippy Enpita - water-soluble highly nutritious concentrates

Diet for acute pancreatitis

Acute pancreatitis is an acute inflammation of the pancreas. The pancreas plays an important role in the process of digestion and metabolism. During digestion, the pancreas secretes enzymes that enter the duodenum and promote the digestion of proteins, fats and carbohydrates. An enzyme such as trypsin promotes the absorption of proteins, lipase - fats, amylase - carbohydrates. Acute inflammation of the pancreas is accompanied by edema, necrosis, and often suppuration or fibrosis, while the release of enzymes slows down, and normal digestion is disturbed. contribute to the development of pancreatitis overeating, prolonged consumption of fatty, fried, spicy, too hot or too cold food, alcohol abuse, insufficient protein intake. The disease can develop against the background of chronic cholecystitis, cholelithiasis, vascular lesions, peptic ulcer, infectious diseases, various intoxications, pancreatic injuries. Nutrition in acute pancreatitis is directed to ensure maximum rest of the pancreas, reducing gastric and pancreatic secretion. Both at home and in a hospital, fasting is prescribed for the first 2 = 4 days, you can drink mineral water without gas (Borjomi, Essentuki No. 4) in small quantities, in small sips. Further, the diet is gradually expanded so that it is complete, contains a lot of protein, a sufficient amount of fat and few carbohydrates. The energy value of the diet is 2500-2700 kcal. Dishes should be consumed boiled or steamed.

The composition of the diet: 80g of proteins (60% of animal origin), 40-60g of fat, 200g of carbohydrates, salt restriction (this helps to reduce pancreatic edema, reduce the production of hydrochloric acid in the stomach, but also slows down digestion). Food must be cooked without salt for the first 2 weeks. Meals should be 5-6 times a day in small portions. Food should be taken warm (45-60C). It is necessary that the dishes were liquid, semi-liquid in consistency. Stewed and fried foods are prohibited, it is recommended to eat grated food. The diet on the 6-7th day of the disease includes mucous soups, kissels, kefir, rare cereals (except for millet), crackers from premium wheat flour, steam cutlets from lean beef, chicken, fish, mashed potatoes, curd mass, rosehip broth , blackcurrant, weak tea. Further, the diet can be expanded with steam puddings from fresh cheese, protein omelet, carrot puree. Milk is allowed to be consumed only as part of dishes, apples - baked, mashed.

Fried foods, smoked meats, pickles, marinades, canned food, lard, sour cream, pastry, cream, alcoholic beverages are excluded for a long time. Patients with pancreatitis need to follow a diet for about a year, to be wary of overeating. These recommendations must be followed so that acute pancreatitis does not become chronic.

sample menu

1st breakfast: steam scrambled eggs, oatmeal porridge mashed on water, weak tea. 2nd breakfast: fresh cheese with milk. Lunch: buckwheat soup, boiled meat stew, apple jelly. Dinner: steamed fish cutlets, carrot puree, rosehip broth - 1 glass. Before going to bed: 1 glass of kefir.

Therapeutic nutrition for gallstone disease

Some nutritional factors contribute to the occurrence of gallstones: an increased energy value of the diet, an excess of flour and cereal dishes that cause a shift in the pH of bile to the acid side, a lack of vegetable oils and vitamin A, and a low content of dietary fiber. In the pathogenesis of the formation of cholesterol stones, which occur in approximately 80% of cases, the role of changes in the chemical composition of bile (an increase in cholesterol, a decrease in bile acids and lecithin), inflammation of the gallbladder, stagnation of bile and a shift in its pH to the acid side. The main role in the occurrence of gallstones belongs to the accelerated synthesis of endogenous cholesterol in the liver. With improper nutrition, there is an increase in the concentration of secondary bile acids in bile, for example, deoxycholic, which makes bile more lithogenic. Refined carbohydrates increase the saturation of bile with cholesterol, while small doses of alcohol have the opposite effect.

Patients with cholelithiasis without exacerbation are prescribed diet number 5, with exacerbation of calculous cholecystitis - diet number 5a. Patients with cholelithiasis are shown to limit foods rich in cholesterol (offal, eggs, lard). The synthesis of bile acids is improved by protein products (meat, cottage cheese, fish, egg white), and vegetable oils are rich in lecithin, which also have a choleretic effect.

In patients with frequent attacks of hepatic colic, the consumption of vegetable oils is limited. From animal fats, butter is recommended. It is well emulsified and contains vitamins A and K.

To change the reaction of bile to the alkaline side, milk, lactic acid products, cottage cheese, cheese, vegetables (except pumpkin, legumes and mushrooms), fruits and berries (except lingonberries and red currants) are prescribed.

In order to reduce the concentration of bile, drinking plenty of water, courses of drinking treatment with mineral waters are indicated.

The diet of patients with diseases of the biliary tract should contain a sufficient amount of magnesium salts, which reduce spasm of smooth muscles, improve bile secretion, bowel movements and excretion of cholesterol from the body, and have a sedative effect. Wheat bran, buckwheat, millet, watermelon, soybeans, crabs, sea kale are richest in magnesium.

In hospitals, patients with cholelithiasis without exacerbation are prescribed the main variant of the standard diet for exacerbation of calculous cholecystitis - a variant of the diet with mechanical and chemical sparing.

Indications for diet number 5

Chronic hepatitis of a progressive but benign course with signs of mild functional liver failure, chronic cholecystitis, cholelithiasis, acute hepatitis during the recovery period. The diet is also used for chronic colitis with a tendency to constipation, chronic gastritis without sharp disturbances. Chronic pancreatitis in remission.

Purpose of diet number 5

Providing the physiological needs of the body for nutrients and energy, restoring impaired functions of the liver and biliary tract, mechanical and chemical sparing of the stomach and intestines, which, as a rule, are involved in the pathological process. It also unloads fat and cholesterol metabolism, stimulates the normal activity of the intestine.

Diet number 5 can be used for a long time, for 1.5-2 years, it should be expanded only on the recommendation of a doctor. During periods of exacerbation of liver diseases, it is recommended that the patient be transferred to a more sparing diet No. 5a.

General characteristics of diet number 5

Physiologically normal content of proteins and carbohydrates with limited refractory fats, nitrogenous extractives and cholesterol. All dishes are cooked boiled or steamed, and also baked in the oven. Wipe only sinewy meat and fiber-rich vegetables. Flour and vegetables are not sautéed. The temperature of ready meals is 20-52°C.

Chemical composition and energy value of diet No. 5

Proteins 100 g, fats 90 g (of which 1/3 are vegetable), carbohydrates 300-350 g (of which simple carbohydrates 50-60 g); calorie content 2800-3000 kcal; retinol 0.5 mg, carotene 10.5 mg, thiamine 2 mg, riboflavin 4 mg, nicotinic acid 20 mg, ascorbic acid 200 mg; sodium 4 g, potassium 4.5 g, calcium 1.2 g, phosphorus 1.6 g, magnesium 0.5 g, iron 0.015 g. Daily intake of table salt is 6-10 g, free fluid - up to 2 liters. Compliance with the principle of frequent and fractional nutrition - meals every 3-4 hours in small portions.

o Wheat bread from flour of I and II grades, rye bread from seeded peeled flour, yesterday's baking. You can add baked lean products with boiled meat and fish, cottage cheese, apples, dry biscuit to the diet.

o Vegetable and cereal soups with vegetable broth, dairy soups with pasta, fruit soups, vegetarian borscht and cabbage soup; flour and vegetables for dressing are not fried, but dried; meat, fish and mushroom broths are excluded.

o Meat and poultry - lean beef, veal, meat pork, rabbit, chicken boiled or baked after boiling. They use meat, skinless poultry and low-fat fish, boiled, baked after boiling, in pieces or chopped. Doctor's, dairy and diabetic sausages, non-spicy low-fat ham, dairy sausages, herring soaked in milk, jellied fish (after boiling) are allowed; fish stuffed with vegetables; seafood salads.

o Dairy products of low fat content - milk, kefir, acidophilus, yogurt. Semi-fat cottage cheese up to 20% fat in its natural form and in the form of casseroles, puddings, lazy dumplings, yogurt. Sour cream is used only as a seasoning for dishes.

o Cereals - any dishes from cereals.

o Various boiled, baked and stewed vegetables; spinach, sorrel, radish, radish, garlic, mushrooms are excluded.

o From sauces, sour cream, milk, vegetable, sweet vegetable sauces are shown, from spices - dill, parsley, cinnamon.

o Appetizers - fresh vegetable salad with vegetable oil, fruit salads, vinaigrettes. Fruits, non-acidic berries, compotes, kissels.

o From sweets, meringues, snowballs, marmalade, non-chocolate sweets, honey, jam are allowed. Sugar is partially replaced with xylitol or sorbitol.

o Drinks - tea, coffee with milk, fruit, berry and vegetable juices.

Excluded foods and dishes of diet number 5

o Foods rich in extractives, oxalic acid and essential oils that stimulate the secretory activity of the stomach and pancreas are excluded from the menu.

o Meat, fish and mushroom broths, okroshka, salty cabbage soup are excluded.

o Undesirable fatty meats and fish, liver, kidneys, brains, smoked meats, salted fish, caviar, most sausages, canned food.

o Excluded pork, beef and lamb fat; cooking oils.

o Goose, duck, liver, kidneys, brains, smoked meats, sausages, canned meat and fish are excluded; fatty meats, poultry, fish.

o Hard-boiled and fried eggs are excluded.

o No fresh bread. Puff and pastry, pastries, cakes, fried pies remain prohibited.

o Excluded cream, milk 6% fat.

o Legumes, sorrel, radishes, green onions, garlic, mushrooms, pickled vegetables.

o Be extremely careful with hot spices: horseradish, mustard, pepper, ketchup.

o Excluded: chocolate, cream products, black coffee, cocoa.

Sample diet menu number 5 for one day

o Option number 1.

§ First breakfast. Cottage cheese pudding - 150 g. Oatmeal - 150 g. Tea with milk - 1 cup.

§ Second breakfast. Raw carrots, fruits - 150 g. Tea with lemon - 1 cup.

§ Dinner. Vegetarian potato soup with sour cream - 1 plate. Boiled meat baked with white milk sauce - 125 g. Zucchini stewed in sour cream - 200 g. Kissel from apple juice - 200 g.

§ Snack. Rosehip decoction - 1 cup. Cracker.

§ Dinner. Boiled fish - 100 g. Mashed potatoes - 200 g. Tea with lemon - 1 cup.

§ For the whole day: White bread - 200 g, rye bread - 200 g, sugar - 50-70 g.

Diet number 5a

Indications for diet No. 5a

Acute hepatitis, acute cholecystitis, cholangitis, exacerbation of chronic hepatitis and cholecystitis at the stage of exacerbation of diseases of the liver and biliary tract, when combined with colitis and gastritis, chronic colitis.

Purpose of diet No. 5a

Ensuring good nutrition in conditions of pronounced inflammatory changes in the liver and bile ducts, maximum sparing of the affected organs, normalization of the functional state of the liver and other digestive organs. This table is based on the principles of table number 5 and the exclusion of mechanical irritations of the stomach and intestines.

General characteristics of diet No. 5a

Physiologically complete, mechanically, chemically and thermally gentle. A diet with a normal content of proteins and carbohydrates, with some restriction of fat, salt. In order to detoxify the body for the first time (up to 3-5 days), increase the intake of free fluid; with fluid retention in the body, table salt is limited to 3 g / day.

Products containing coarse vegetable fiber are excluded. All dishes are boiled, steamed, mashed; stewing, sautéing and roasting are excluded. The temperature of ready meals is 20-52°C. Compliance with the principle of frequent and fractional nutrition - meals every 3-4 hours (5-6 times a day) in small portions.

Diet No. 5a is prescribed for 1.5-2 weeks, and then the patient is gradually transferred to diet No. 5. Diet number 5a is also transitional after diet number 4.

Chemical composition and energy value of diet No. 5a

Proteins 80-100 g, fats 70-80 g, carbohydrates 350-400 g; calorie content 2350-2700 kcal; retinol 0.4 mg, carotene 11.6 mg, thiamine 1.3 mg, riboflavin 2 mg, nicotinic acid 16 mg, ascorbic acid 100 mg; sodium 3 g, potassium 3.4 g, calcium 0.8 g, magnesium 0.4 g, phosphorus 1.4 g, iron 0.040 g. Daily intake of table salt is 6-10 g, free fluid - up to 2-2 .5 l.

§ Bread and bakery products: white bread, dried, dry non-bread biscuits.

§ Soups: vegetarian, dairy, with pureed vegetables and cereals, milk soups mixed with water.

§ Meat, fish and poultry dishes: steam chopped products (souffle, dumplings, cutlets). Skinless chicken and fish (low-fat varieties) in boiled form are allowed in a piece.

§ Vegetable dishes and side dishes: potatoes, carrots, beets, pumpkins, zucchini, cauliflower - in the form of mashed potatoes and steam soufflés; raw grated vegetables.

§ Dishes from cereals, legumes and pasta: liquid mashed and viscous cereals with milk from oatmeal, buckwheat, rice and semolina; steam puddings from mashed cereals; boiled vermicelli.

§ Egg dishes: protein steam omelettes.

§ Sweet dishes, fruits, berries: purees, juices, jelly, mashed compotes, jelly, mousse, sambuco, soufflé from sweet varieties of berries and fruits; baked apples.

§ Milk and dairy products: milk, kefir, curdled milk, acidophilus, fermented baked milk, mild cheeses, non-acidic cottage cheese and puddings from it.

§ Sauces: on vegetable and cereal broths, milk, fruit. Only white fat-free flour sautéing is used.

§ Fruits, berries are ripe, soft, sweet in raw and mashed form.

§ Drinks: tea, tea with milk, rosehip broth.

§ Fats: butter and vegetable oil are added to ready meals.

Excluded foods and dishes of diet No. 5a

§ Fatty meats and fish.

§ Internal organs of animals.

§ Refractory fats (pork, lamb, goose, duck).

§ Fatty varieties of fish (halibut, catfish, sturgeon, etc.).

§ Confectionery with cream, muffin, brown bread, millet.

§ Coffee, cocoa, chocolate, ice cream.

§ Spices, spices, pickles, marinades.

§ Sour varieties of fruits and berries, raw vegetables and fruits.

§ Legumes, turnips, sorrel, spinach, mushrooms, white cabbage, vegetables rich in essential oils (onion, garlic, radish, radish), nuts, seeds.

§ Broths, egg yolks, canned meat and fish.

§ Alcohol.

§ Carbonated drinks.

Diet number 5a in the presence of ascites

With ascites, it is recommended to prescribe a diet with a reduced energy value of up to 1500-2000 kcal, containing 70 g of protein and no more than 22 mmol of sodium per day (0.5 g). The diet should be essentially vegetarian. Most high protein foods are also high in sodium. The diet should be supplemented with low-sodium protein foods. Salt-free bread and butter are used for food. All dishes are prepared without adding salt.

Conclusion

Thus, clinical nutrition should meet the needs of the sick organism in nutrients, but always taking into account the state of metabolic processes of functional systems. When a patient is prescribed a diet for pain in the stomach, it is necessary to be guided not only by knowledge of the biochemical laws that determine the assimilation of nutrients in the body of a healthy person, but also by the characteristic features of their transformation in pathologically altered conditions of the diseased organism. The task of therapeutic nutrition is primarily to restore the disturbed correspondence between the enzyme systems of the stomach and the diseased organism as a whole, with the chemical structures of food by adapting the chemical and physical state of nutrients to the metabolic characteristics of the organism.

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	BMI values at age
18 - 25 years old	26 years and older
Normal	19,5 - 22,9	20,0 - 25,9
Increased nutrition	23,0 - 27,4	26,0 - 27,9
Obesity 1 degree	27,5 - 29,9	28,0 - 30,9
Obesity 2 degrees	30,0 - 34,9	31,0 - 35,9
Obesity 3 degrees	35,0 - 39,9	36,0 - 40,9
Obesity 4 degrees	40.0 and above	41.0 and above
Reduced nutrition	18,5 - 19,4	19,0 - 19,9
Hypotrophy 1 degree	17,0 - 18,4	17,5 - 18,9
Hypotrophy 2 degrees	15,0 - 16,9	15,5 - 17,4
Hypotrophy 3 degrees	below 15.0	below 15.5

Characteristics of nutritional status	BMI values at age
18 - 25 years old	26 years and older
Normal	19,5 - 22,9	20,0 - 25,9
Increased nutrition	23,0 - 27,4	26,0 - 27,9
Obesity 1 degree	27,5 - 29,9	28,0 - 30,9
Obesity 2 degrees	30,0 - 34,9	31,0 - 35,9
Obesity 3 degrees	35,0 - 39,9	36,0 - 40,9
Obesity 4 degrees	40.0 and above	41.0 and above
Reduced nutrition	18,5 - 19,4	19,0 - 19,9
Hypotrophy 1 degree	17,0 - 18,4	17,5 - 18,9
Hypotrophy 2 degrees	15,0 - 16,9	15,5 - 17,4
Hypotrophy 3 degrees	below 15.0	below 15.5

Nutrition of surgical patients in general surgery after surgery. Therapeutic nutrition of surgical patients

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Diet for acute pancreatitis

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