I. Definition.
Home Nutrition (Home Nutrition): Patients in relatively stable conditions receive nutritional support at home under the guidance of a professional nutritional support team.
Home Enteral Nutrition HEN (Home Enteral Nutrition HEN): It refers to patients who cannot eat for various reasons or whose normal diet cannot maintain the body’s metabolism and growth and development needs, and must take in enough calories and various nutrients through additional means or supplementation with special nutritional preparations to meet the needs of the body’s cells to maintain function, structure and metabolism. Usually these patients need to be hospitalized for treatment. With the development of enteral nutrition preparations and medical technology, enteral nutrition support can be provided at home, i.e. home enteral nutrition, for most of the patients who are in stable condition and need only enteral nutrition in hospital.
Home Parenteral Nutrition HPN: Higher technical requirements, more serious complications, close monitoring by professional staff is required. It is less used.
II. Advantages of home nutritional support.
Nutritional support at home can not only greatly reduce the cost, but more importantly, reduce the stimulation of the hospital environment, reduce anxiety, improve sleep, and live with family members, which improves the quality of life.
Third, the use of home enteral nutrition should meet the following five conditions.
1.The expected duration of enteral nutrition is more than 1 month;
2.Home enteral nutrition must be started in hospital and after 1 week of good tolerance
3.The patient’s disease has been completely stable enough to receive home treatment.
4.The patient or family members get enough training in enteral nutrition before discharge;
5.The social and family environment can ensure the safe implementation of home enteral nutrition.
4.What patients are suitable for home enteral nutrition?
1.Patients with consciousness disorders who lose consciousness and cannot eat consciously, while the gastrointestinal function is normal, can be injected with nutrition solution or homemade food homogenate through nasogastric tube or percutaneous gastrostomy tube regularly.
2.Patients with oral and maxillofacial tumors affecting feeding.
3.Patients with difficulty in swallowing, nasopharyngeal tumor after radiotherapy, stiff neck muscles, loss of swallowing reflex, esophagogastric fistula or esophageal stricture after esophagogastric surgery, can be injected with nutritional fluid or homemade food homogenate regularly through percutaneous gastrostomy tube.
4, patients with severe malnutrition, these patients often have poor general condition, poor appetite, although they can eat, but the quality and quantity of food can not be guaranteed, natural diet can not maintain body weight should be given enteral nutrition supplement, can choose oral supplemental nutrients or feeding nutrition through the tube.
5.Patients with gastrointestinal dysfunction The ordinary diet is not completely digested or absorbed, and it is necessary to take in pre-digested nutrients or commercial nutrition with special treatment. Common gastrointestinal dysfunction are.
(1) Short bowel syndrome, due to various reasons the small intestine is removed, so that the remaining small intestine is less than 1 meter in length, the normal diet is not enough to meet the needs of the organism, and the easily digested and easily absorbed commercial nutrition must be consumed.
(2) Chronic intestinal diseases such as Crohn’s, ulcerative colitis in active stage, enteral nutrition can be given in order to reduce the stimulation of food and help the recovery of intestinal function. In severe radiation enteritis, diarrhea will occur with ordinary diet, and enteral nutrition support is needed when weight cannot be maintained, and even parenteral nutrition support is needed in severe cases.
(3) Patients with gastric emptying disorder and gastroparesis Enteral nutrition can be given through a small intestine nutrition tube crossing the pylorus of the stomach.
(4) Patients with upper gastrointestinal obstruction can be given nutritional support through the feeding tube across the obstruction site.
V. Choice of enteral nutrition route
Different routes can be chosen according to the length of time of enteral nutrition support and disease condition. Short-term nasogastric tube or nasogastric tube can be used, they are non-invasive and low cost, but because of the pressure and irritation of the tube on the nasopharynx, many people do not adapt to it. Patients who require long-term enteral nutrition may opt for percutaneous placement of a gastrostomy tube (PEG) with the assistance of gastroscopy or direct surgical placement of a gastrostomy tube. For patients with gastric pyloric obstruction or impaired gastric emptying or impaired consciousness, a jejunal feeding tube (PEJ) can be placed via PEG or a jejunostomy tube can be placed intraoperatively directly. For some patients with normal gastrointestinal function and clear consciousness, oral supplemental nutrition solution can also be administered.
VI. Choice of nutritional solution.
Select the appropriate nutrition solution according to the patient’s condition and the function of the gastrointestinal tract. For patients with normal gastrointestinal tract function and only swallowing dysfunction, homemade homogenized diet can be made at home. Depending on the situation, a single layer of gauze can be used to remove large particles. For patients with mild gastrointestinal dysfunction, you can choose whole protein type commercial nutrition solutions, such as LISIKANG, NENGYUAN, RISU, ANSU, etc. For patients with poor gastrointestinal digestive and absorption functions, peptide-based nutrition solutions such as Bepli and Bepsu should be used. The preparation of nutrition solution has water and powder, water is shaken directly before use, powder is used now, generally according to the instructions of 250ml-500ml at a time is appropriate. As far as possible to prepare evenly, no hard lumps can be or large particles, otherwise the large particles must be filtered with a single layer of gauze. Home-made nutrition can be stirred and cooked a day’s food, put in the refrigerator for backup. Add juice and milk, etc. as appropriate.
VII. Feeding methods.
There are timed push (bolus feeding), gravity feeding (gravity feeding) and infusion pump drip (pump feeding). Depending on the condition, some patients need to rely entirely on enteral nutrition, some are supplemented by oral diet, and some patients must also be supplemented by parenteral nutrition. Patients should follow the doctor’s prescription to take in enough nutrition. According to the condition, the method of divided feeding can be used, that is, 150-300ml of nutrition solution can be given by syringe 6-8 times a day. Or use the method of circulating gravity drip or continuous gravity drip. Circulating drip is generally chosen during the day to facilitate care, and nighttime can also be chosen for workers who need it during the day. For patients with poor gastrointestinal function, 24-hour continuous drip can be chosen, and it is better to use drip pump to control the speed if necessary.
VIII. Treatment of some complications.
The problems that easily occur in enteral nutrition are: diarrhea (diarrhea), bloating, constipation.
There are many reasons for diarrhea, the most common reasons are too fast infusion speed, the intestine can not be absorbed; nutrition solution in the preparation process of pollution, nutrition solution temperature is too low or too dilute; secondly, gastrointestinal dysfunction, secretion of digestive juices or digestive enzymes is not enough, can not be further digested into absorbable components of nutrition solution; Moreover, poor systemic conditions, such as severe hypoproteinemia caused by intestinal edema can also cause diarrhea. Countermeasures: Prepare suitable concentration according to medical prescription, pay attention to cleanliness and hygiene in the preparation process, and strictly sterilize; maintain proper temperature of nutrient solution, warm up nutrient solution taken out from the refrigerator, and maintain the temperature of nutrient solution between 30-40?degree in winter by various methods, using hot water bags, hot water bottles or special heaters purchased from hospitals according to the situation. Patients with poor gastrointestinal function and digestive enzyme deficiency can be treated by adding digestive enzyme preparations according to medical advice. Mild diarrhea can improve quickly, while severe and persistent diarrhea requires consultation with a physician, administration of anti-diarrheal drugs such as compound phenylephrine and, if necessary, admission to a hospital.
Abdominal distension is the accumulation of gas and fluid in the digestive tract, which cannot be emptied effectively. Common causes include contamination of nutrient solution, fermentation of nutrient solution by bacteria, increased gas production, too rapid input of nutrient solution, failure of the gastrointestinal tract to empty in time, gastrointestinal tract dysfunction, inability to push food down, or obstruction of the gastrointestinal tract due to various reasons. Countermeasures: Control the input speed, especially for those who input through jejunum, use infusion pump if necessary, and also ensure that the nutrition solution is free of contamination. For patients with gastric emptying obstruction, gastric motility drugs can be given to promote gastric emptying in mild cases, and trans-intestinal feeding tube should be used in severe cases. Patients with pathological obstruction must be hospitalized to lift the obstruction.
Constipation is due to lack of dietary fiber in the nutritional solution or insufficient water intake and dry stools, while some bad bowel habits are also related. Countermeasures: adjust the formula of nutrition solution, increase the intake of dietary fiber, increase the intake of honey to lubricate the intestine; increase the intake of water; develop the habit of regular bowel movements. Constipation can be used to massage the abdomen with the palm of the hand in the direction of colon movement to help defecation, severe constipation can take drugs to laxative or enema.
IX. Handling of common faults.
The common failures during enteral nutrition include tube displacement, blockage, dislodgement, fracture, etc.
Tube displacement
Tube displacement refers to the feeding tube due to pulling, violent coughing, vomiting, or not firmly fixed, etc. The tube should be marked in the part where the tube is in contact with the body, and the gastric tube displacement can be sent back to the stomach by hand; and the intestinal tube may cause some discomfort due to its own disease, such as gastric distension in patients with gastric emptying disorder, which must be put back into the stomach in the hospital with the assistance of gastroscope. It must be put back into the stomach with the assistance of gastroscopy.
Tube dislodgement
Patients on long-term home nutritional support with dislodged nasogastric tubes can slowly insert themselves back into the stomach as if swallowing noodles, but some patients who cannot tolerate nasopharyngeal irritation often cannot do so and can be reinserted into the stomach at a nearby community hospital. If the nasogastric tube is dislodged, the tube must be reinserted in a specialized hospital. If the gastrostomy tube or enterostomy tube is dislodged, the tube will be rinsed and slowly placed along the fistula before being treated in a hospital so that the fistula does not shrink and affect the tube.
Blocked tubes
Tube blockage is most common and is related to the thickness of the tube, the viscosity of the nutrient solution, and the administration of drugs, while proper flushing of the tube is very important. Some patients have completely normal gastrointestinal function and can accept homemade diet, but when it tends to cause blockage of the tube, the food must be completely stirred and made into homogenized paste, and the large particles must be filtered with gauze. The tube must be flushed with 30ml of warm boiled water before and after each feeding to prevent the tube from being blocked. When medication is administered through the feeding tube, the medication must be crushed and dissolved with water, and the tube must be flushed with 30ml of warm boiled water before and after the medication is administered. Once blocked, the tube can be flushed repeatedly with warm water, but it must be prevented from rupture due to excessive pressure, and the tube must be re-discharged if it cannot be unblocked.
Pipe breakage or leakage
Repeated flushing of blocked pipes can lead to pipe rupture if the pressure is too high, and pipes can also cause pipe rupture or leakage due to long use of the material itself or incorrect care, once this happens, the pipes should be replaced in time.
X. Self-monitoring during home enteral nutrition.
During family nutrition, daily intake and urine and stool must be monitored. Generally, adults take in 30-35 calories/kg body weight, such as a 60 kg person should take in about 1800-2100 calories a day, and the general nutrition solution is 1 calorie/ml, so generally 4 bottles of nutrition solution (2000 ml) are needed. At the same time, supplement about 1000ml of water to ensure the water demand, which should also be increased appropriately for patients with high activity, and reduced appropriately for bedridden elderly people. Monitor the daily urine volume, which is usually maintained at 1000-2000ml/day. Low urine volume is not conducive to excreting metabolites from the body, which can cause kidney toxicity over time. Low urine volume often indicates inadequate water intake and requires increased water intake. Weight monitoring: Take the weight once a week in the morning on a fixed day. The normal situation is a stable or slow increase in body weight. Significant weight gain should be ruled out first by applying finger pressure to the ankle and noting any depressions. Persistent weight loss should be contacted with the doctor to readjust the nutritional fluid formula. Regularly recheck the blood index to know the protein level and electrolyte level.
XI. Discontinuation of enteral nutrition.
When the disease improves, nutrition improves, and oral diet can meet the needs, enteral nutrition can be gradually stopped under the guidance of doctors. The feeding tube can be removed after a period of trial clamping. Nasogastric tube and nasogastric tube can be pulled out by themselves. When pulling out, the tube should be clamped, and the end of the tube should be held when it reaches the throat to prevent the liquid in the tube from slipping into the trachea. Gastrostomy tubes and jejunostomy tubes should be removed in the hospital with the assistance of gastroscopy.
XII. Outlook.
Some developed countries carry out enteral and parenteral nutrition earlier, and HEN is very common, while the research involving HEN increases accordingly. It is believed that with the growth of China’s economy and the improvement of medical level, especially the improvement of nutritional support level, enteral nutrition support will be able to be carried out safely in the family. With the reform of medical system, the limitation of medical resources and people’s demand for quality of life, more patients will choose HEN. the management of home nutrition support group will play a crucial role in the success or failure of HEN, and reasonable and effective management will enable HEN to develop rapidly.