Nutrition is a guarantee for the treatment of disease and a long and healthy life. For patients, reasonable, balanced and timely clinical nutritional therapy is extremely important. Nutritional therapy includes enteral nutrition (EN) therapy and parenteral nutrition (PN) therapy, and the former is divided into diet therapy and tube feeding nutrition therapy. The nutritional treatment for critically ill patients is very important, as the saying goes, “Disease should be treated in three parts and nourished in seven parts”, and nutrition is one of them. At all times, if the gastrointestinal system exists, enteral nutrition should be considered first. Compared with parenteral nutrition, enteral nutrition is economical, safe, convenient and in line with the physiological process. Chen Zetao, Department of Health Care, Affiliated Hospital of Shandong University of Traditional Chinese Medicine
In order to improve the effect of clinical nutrition treatment and standardize the procedure of clinical nutrition treatment, based on the reference of relevant domestic and foreign materials and our experience, we formulate the nutrition treatment guideline for clinical application reference.
Enteral nutrition guideline
I. Indications
1.Consciousness disorder, coma and certain neurological diseases: such as patients in coma caused by traumatic brain injury, cerebrovascular disease, brain tumor, encephalitis, etc., Alzheimer’s disease who cannot eat by mouth or mental disorder, severe depression, anorexia nervosa, etc.
2, swallowing difficulties and loss of chewing ability: such as dysphagia, oropharyngeal trauma and post-surgery, those with severe myasthenia gravis, etc.
3, upper gastrointestinal obstruction or surgery: such as esophageal inflammation, chemical injury causing difficulty in chewing or swallowing, esophageal stricture obstruction, esophageal cancer, pyloric obstruction, anastomotic edema stricture, gastroparesis, etc.
4, hypermetabolic state: such as severe trauma, large burns, serious infections, etc. caused by hypermetabolism and negative nitrogen balance of the organism.
5, gastrointestinal fistula: usually applies to low-flow fistula or late stage of fistula, such as esophageal fistula, gastric fistula, intestinal fistula, biliary fistula, pancreatic fistula, etc. best results for low small intestinal fistulas, colonic fistulas and jejunal feeding gastroduodenal fistulas.
6, preoperative preparations and postoperative malnutrition: such as during preoperative intestinal tube preparation, those with additional nutrient loss during surgery, etc.
7, inflammatory bowel disease: such as ulcerative colitis, Crohn’s disease, etc.
8, short bowel syndrome: short bowel syndrome intestinal compensatory stage.
9, pancreatic disease: acute pancreatitis after recovery of intestinal function, chronic pancreatic insufficiency. Note that the feeding tube should be inserted into the proximal jejunum more than 10cm, nutritional preparations can only use small molecules and low-fat elements that can be absorbed without digestion, such as Vivo, Irendo, large elements, etc..
10, chronic nutritional deficiencies: such as malignant tumors, radiotherapy, chemotherapy patients and those with immunodeficiency diseases, etc.
11, organ insufficiency: such as liver, kidney, lung insufficiency or multi-organ failure.
12, some special diseases: acute radiation disease, various organ transplant recipients, including kidney transplant, liver transplant, small intestine transplant, heart transplant, bone marrow transplant, etc.
13, supplementation or transition when parenteral nutrition therapy cannot meet the requirements.
II. Contraindications
1, complete mechanical intestinal obstruction, gastrointestinal bleeding, severe abdominal infection.
2, early stage of severe stress, shock state, persistent paralytic intestinal obstruction.
3, early stage of short bowel syndrome.
4, high-flow jejunal fistula.
5, persistent severe vomiting, intractable diarrhea, severe small bowel inflammation, severe colitis.
6, gastrointestinal dysfunction, or certain conditions requiring gastrointestinal rest.
7, early stage of acute pancreatitis.
8.Infants under 3 months of age, severe sugar or amino acid metabolism abnormalities, should not use the elemental diet .
III. Complications
(A) Gastrointestinal complications
1, nausea, vomiting: mainly due to some nutrient solutions, high osmotic pressure leading to gastric retention, too fast infusion speed, lactose intolerance, high fat content of nutrient solution, especially the poor taste of the elemental diet. Can be treated accordingly according to the above-mentioned etiology, elemental meals are recommended to use tube feeding nutrition, and it is not advisable for patients to take them directly orally.
2, diarrhea: the main causes are excessive osmotic load in the intestinal lumen, small intestine intolerance to fat, lactose intolerance, contamination of nutritional solution by pathogens, low temperature of nutritional solution, hypoproteinemia, etc.
(3) Constipation: causes include dehydration, fecal mass impaction and intestinal obstruction.
(II) Metabolic complications
1, abnormal water metabolism: the most common is hypertonic dehydration, water retention can occur in cardiac, renal and hepatic insufficiency.
2, abnormal glucose metabolism: high sugar content in enteral nutrition solution or decreased glucose tolerance under stress can lead to hyperglycemia. Hypoglycemia mostly occurs in patients who apply the elemental diet for a long time and suddenly stop.
3, electrolyte and trace element abnormalities: the common ones are too high blood potassium and too low blood sodium, other cases are less common.
4, abnormal liver function: compared with parenteral nutrition, the proportion of liver function damage caused by enteral nutrition treatment is very low, clinically it can be manifested as elevated liver related enzyme indexes, which is non-specific, which may be due to the toxic effect of amino acids in the nutrition solution entering the liver after decomposition, or it may be due to the absorption of a large amount of nutrition solution into the liver, which stimulates the new activity of the enzyme system in the liver to enhance.
5, vitamin deficiency: long-term use of low-fat nutrient solution formula, easy to occur essential fatty acid and fat-soluble vitamin deficiency. Others such as biotin sometimes also show deficiency.
(iii) Mechanical complications
Catheter materials are developing rapidly, the texture of feeding tube is getting softer and softer, and the tissue stimulation is getting smaller and smaller, so the mechanical complications are relatively reduced. The main ones are feeding tube obstruction and nasogastric tube ulceration.
For patients with lack of health knowledge, sufficient attention should also be paid to their psycho-psychological factors. Before implementing enteral nutrition, the significance, importance and implementation method of enteral nutrition should be explained in detail. During the process of implementation, communicate with patients frequently to understand the psycho-physiological reaction and give psychological support.
(iv) Staining complications
It is mainly due to aspiration pneumonia and infection caused by contamination of nutrition fluid by mistake.
IV. Precautions
1.Appropriate selection: correctly estimate the nutritional needs of the patient, and choose the appropriate enteral nutrition equipment, feeding route and giving method.
2, careful observation: for the elderly, children and frail patients, pay attention to the smoothness of the stomach and intestines and the presence of gastric retention when dripping, so as not to cause food reflux and lead to aspiration pneumonia.
3, appropriate position: intragastric feeding should be taken in sitting position, semi-sitting position or supine position with the head of the bed raised 30 ° to prevent reflux or accidental aspiration, and this position should be maintained for 30 min after the infusion is completed.
4. Smooth pipeline: After each tube feeding, flush the tube with warm boiled water and gently rub the tube wall with fingers to clean thoroughly and keep the tube smooth.
Ensure the appropriate temperature of nutrition fluid, directly input at room temperature in summer and place hot water bag around the tube in winter to increase the temperature of fluid.
5.Strengthen care: accurately record the amount of water in and out, observe skin elasticity, thirst, pulse, blood pressure and other symptoms, and physical signs.
6.Appropriate temperature: the temperature of nutrient solution is 37 to 42 ℃, too cold or too hot will cause discomfort to the patient, close to body temperature is appropriate.
7, gradually increase the concentration: the concentration of nutrient solution should be gradually increased from low concentration to the required concentration, in order to prevent bloating, diarrhea and other digestive symptoms; concentration can start from 5%, gradually increased to 25%, up to 3O%.
8, pay attention to the speed: pay attention to the infusion speed of nutrition solution, the drip rate should gradually increase, so that the digestive tube has a process of adaptation. The peristaltic pump should be used to control the speed for critically ill or elderly patients, and the speed should be controlled at 120~150ml/h. Do not input evenly and continuously, but have intervals to give rest to the stomach and intestines; it is better to stop using it at night when the patient is sleeping. If the condition permits, gravity drip or syringe injection can be used, and each injection should not exceed 250 ml. Do not push too hard to prevent regurgitation or vomiting.
9, control the total amount: adult patients at least 1000kcal ( 1000m 1) per day, up to 3000ml. If the patient has been fasting for more than 2 days, give 1/3 amount at the beginning, 1/2 amount the next day, and the full amount on the third day. It can also be increased gradually according to the patient’s response.
10.Safety and hygiene: When preparing nutrition solution, ensure hygiene and check whether the nutrition solution is deteriorated before infusion. The prepared nutrition solution should be kept in a refrigerator at 4 ℃ and the storage period should not exceed 24h.
11.Protect gastrointestinal: bedridden and comatose patients who use tube feeding diet for a long time, especially with elemental diet or enteral nutrition preparation without food fiber, often have gradually decreasing gastrointestinal function, which is manifested as small stomach capacity, vomiting can occur when eating a small amount of nutrition liquid, and having decreasing colonic function. You can choose the dose of macronutrient system containing food fiber to protect the gastric digestive function; or give short-chain fatty acid orally or as a reserved enema to maintain the function of the colon.
12, to prevent constipation: long-term use of nutritional preparations that do not contain food fiber, it is easy to constipation. Nutritional preparations containing food fiber can be used to increase the volume of feces, or short-chain fatty acids can be given to enhance the motor function of the colon.
V. Quality control
When enteral nutrition therapy is carried out, it is very important to carry out thorough quality monitoring, which can detect or avoid complications in time and observe whether the nutrition therapy achieves the expected effect.
(A) Feeding tube position monitoring: After the feeding tube is placed, the feeding tube position may change or come out due to the patient’s activities, gastrointestinal peristalsis, long-term feeding and the feeding tube is not firmly fixed. Therefore, attention should be paid to monitoring. For long-term placement of nasogastric tube, attention should be paid to frequently observe the sign of feeding tube outside the body, and X-ray can also be used for observation.
(2) Gastrointestinal tolerance monitoring: When enteral nutrition is carried out, if the osmotic pressure of nutrition solution is high, gastrointestinal reactions may occur, especially when small molecules are used. In addition, patients may show intolerance if the injection speed is too fast, improper formula of nutrition solution, patients fast for a longer period of time, and the nutrition solution is contaminated by bacteria. The main manifestations during intragastric feeding are epigastric distension and nausea, and in severe cases, vomiting and diarrhea may occur. The presence or absence of these phenomena should be noted during observation. During jejunal feeding, the main manifestations are abdominal distension, abdominal pain, nausea, hyperactive bowel sounds, and in severe cases, vomiting and diarrhea. At the beginning of the stage, observation should be made every 4 to 6 hours to check whether there are the above symptoms, and later it can be checked once a day.
(3) Metabolic monitoring: enteral nutrition has less interference with the body’s metabolism and fewer metabolic complications, but it should still be closely monitored.
1.Record the in and out volume: the fluid in and out volume of the patient should be recorded every day.
2.Check urine glucose and ketone body: At the beginning of nutrition, urine glucose and ketone body should be checked every day, later it can be changed to once a week.
3, blood biochemical examination: regular determination of blood glucose, urea, creatinine, serum bilirubin, glutamate transaminase, sodium, potassium and other indicators, at the beginning can be twice a week, later can be changed to once a week.
(iv) Nutritional monitoring: The purpose is to determine the effect of enteral nutrition therapy and adjust the amount of nutrient supplementation in a timely manner.
1.Nutritional evaluation: Before enteral nutrition therapy, a comprehensive nutritional status assessment will be conducted to determine the amount of nutrient supplementation according to the nutritional status of patients.
2.Regular physical examination: before and once a week after the start of nutritional therapy, measure weight, triceps skinfold thickness, upper arm circumference, total lymphocyte count and other indicators.
3.Regular protein measurement: Measure visceral proteins such as albumin, transferrin, prealbumin, etc., which can be measured once every one to two weeks.
4.Measure nitrogen balance: measure the nitrogen balance according to the patient’s condition, which should be measured daily for critical patients and once a week for stable patients.
Enteral nutrition preparation is divided into two categories according to protein source: one is amino acid and short peptide type (element type) preparation; the other is whole protein type (non-element type) preparation. Each type of preparation can be divided into balanced type and disease-specific type. Enteral nutrition preparations also include component-type enteral nutrition preparations abroad.
Note: Elemental enteral nutrition preparations have high osmolarity, poor taste, and are 3 to 4 times more expensive than polymeric diet. The best indications are nasojejunal tube and jejunostomy tube feeding, patients with digestive insufficiency, such as severe pancreatitis and other diseases enteral nutrition treatment. It is not high in osmolarity, good in taste, and 25-33% of the price of the elemental diet. It is suitable for nasogastric tube and gastrostomy tube feeding, and patients with digestive function can also take it orally or inhale it by pipette; it is not suitable for nasojejunal tube and jejunostomy tube feeding patients. Depending on the patient’s condition, the elemental diet can be used simultaneously with the non-elemental diet.