Nutrients in various types of artificial nutrition. "Feeding the seriously ill

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Concepts and possibilities

The problem of artificial nutrition in cases where the patient cannot, does not want or should not eat, still remains one of the priorities in domestic medicine. The "banal" issues of feeding patients remain on the periphery of the attention of many resuscitators, although major monographs on nutriciology- it is enough to name the works of A.L. Kostyuchenko, ED. Kostina and A.A. Kurygin or A. Vretlind and A.V. Sudzhyan. The abundance of solutions and mixtures on the market, due to their high cost, does not affect the diet of the "insolvent", that is, the most massive, domestic patient. Familiarity with physiology does not prevent sometimes prescribing anabolic steroids in the absence of any nutritional support, and media intended for plastic assimilation should be administered in the first few days after major operations. All these contradictions make relevant a reminder of some of the principles and possibilities of modern artificial nutrition. Like natural, artificial nutrition must solve several problems. major conjugated tasks:

• maintaining the water-ion balance of the body, taking into account the loss of water and electrolytes,
• energy and plastic provision in accordance with the level of metabolism characteristic of this stage of development.

It is the state of nutrition that largely determines the patient's ability to endure diseases and critical conditions (due to trauma, infection, surgery, etc.) with less functional loss and more complete rehabilitation.

The studies of domestic and foreign experts have made it possible to put forward three basic principles artificial nutrition.

This is, firstly, timeliness of its start , allowing to exclude the development of intractable cachexia. Secondly, optimal timing of implementation artificial nutrition, which ideally should be carried out until the trophic status is completely stabilized. Finally, thirdly, there must be adequacy artificial nutrition the patient's condition . The quantity and quality of essential and non-essential nutrients should provide not only energy, but also plastic processes (contain essential amino acids, essential fatty acids, electrolytes, trace elements and vitamins).

To these classical provisions, one more, no less important, rule can be added: the decisive criterion for evaluating and correcting artificial nutrition should not be a priori plan and calculation, no matter how modern and perfect the underlying algorithms may be. Clinical, more precisely - clinical and physiological result , controlled daily according to clearly understood and unambiguously interpreted indicators - this is the only legitimate basis for making decisions in this, as, in fact, in any other area of ​​​​therapy.

There are two main types or methods of artificial nutrition - enteral(probe) and parenteral(intravenous).

parenteral nutrition

The very possibility of the parenteral method and its technical basis fully followed from the development of infusion therapy in general.

Despite the fact that images of intravenous infusions appear already on the pages of medieval books, and in 1831 Thomas Latta first performed intravenous infusions of saline solutions to cholera patients, it took more than one decade before infusion therapy turned from extremism into an everyday routine. Its progress was determined primarily by the level of understanding not only of the composition of blood and plasma, but also of their physicochemical properties and, most importantly, the immediate metabolic fate of the substances introduced into the vessels. And although back in 1869 I.R. Tarkhanov in Russia and R. Konheim in Germany experimentally showed that intravenous infusion of saline solutions can support the life of a bloodless animal, the era of mass introduction crystalloid plasma substitutes became World War I.

After the publication in 1915 of RT. Woodyatt, W.D. Sansum and RM. Wilder began the widespread clinical use of intravenous glucose solution - one of the main food substrates. In parallel, ideas about the dynamics of trophic homeostasis under conditions of post-aggressive metabolic stress response to damage of any kind were developed. The basis of modern views on this problem was laid by D.P. Guthbertson, ED. Moore and J.M. Kinney studies of metabolism after surgical aggression. Although they dealt primarily with protein metabolism and nitrogen loss by the traumatized organism, as well as the electrolyte disturbances that are inevitable, their results formed the basis of aggression and played a decisive role in the development of parenteral artificial nutrition.

For nitrogenous parenteral nutrition initially used protein hydrolysates , which consisted of a mixture of poly- and oligopeptides of various molecular weights. The inability of our proteolytic systems, localized outside the gastrointestinal tract, to hydrolyze such substrates significantly reduced their nutritional value and often prompted the use of hydrolysates for tube feeding. Although until recently one could still hear about the "nutrition" of patients with albumin infusions, the actual period of complete hydrolysis of this protein outside the gastrointestinal tract - 70 days - clearly illustrates the futility of such hopes.

In 1943-1944. at the Karolinska Institute in Stockholm, Arvid Wretlind created dialyzed casein hydrolyzate- aminosol, which is still considered one of the best among analogues and even continues to be produced. In our country, the creation of high-quality protein hydrolysates as parenteral sources of amine nitrogen became possible in the 60s thanks to the work of A.N. Filatov (LIPC) and N.F. Koshelev (VMedA).

The direct relationship between the degree of protein hydrolysis and the possibilities of its assimilation led to the next logical step - mixtures of free synthetic L-amino acids . It became possible to translate into reality the classic recommendations for the ratio of amino acids put forward by W.C. Rose back in 1934-1935. (by the way, in 1938 he formulated the provision on essential amino acids). Intravenous administration of just such drugs, provided there is sufficient energy support with carbohydrates and fat emulsions, really provides a vitally important synthesis of one's own protein. So, further development was already in the direction of creating amino acid mixtures - like general purpose (Aminosteril, Moriamin, Freamin, Vamin etc.), and special- for example, safe against the background of hepatocellular ( Hepasteril, Aminosteril-Nera) or renal ( Nephramin, Aminosteril-Nephro) insufficiency.

The combination of carbohydrate and nitrogen components, along with the development of the technique of catheterization of the main veins, for the first time created the possibility of long-term total parenteral artificial nutrition. The priority of this approach, called "American method" , is owned by American Stanley Dudrick and his staff. According to this group (1966-1971), energy needs can be coated with concentrated glucose solutions, a plastic - with the help of protein hydrolysates or other amino acid preparations with the addition of electrolytes, vitamins and trace elements. It turned out that the complete satisfaction of the body's primary and unconditional need - energy - with carbohydrates allows it to use the amino acid "surplus" for plastic needs. These studies for the first time convincingly proved the possibility of not only adequate plastic support for patients in the post-aggressive period or long-term, months-long nutrition of patients with severe insufficiency of intestinal digestion, but also the normal development of the child's body receiving only parenteral nutrition.

However, the introduction of large volumes of high-osmolar solutions created independent problems - from osmodiuresis to phlebitis, and the absence of a fatty component in the "Dadrik scheme" did not allow parenteral nutrition to be fully adequate. Patients often suffered from specific dermatitis and other complications caused by a deficiency of essential fatty acids - linoleic, linolenic and others.

Further development of parenteral nutrition required a more complete and comprehensive restoration of trophic homeostasis. So-called "European method" of total parenteral nutrition , unlike the American one, suggests combination of monosaccharide solutions and amino acid mixtures with fat emulsions. Creation in 1957 in the laboratory of A. Wretlind on the basis of soybean oil of a highly dispersed fat emulsion "Intralipid" and conducting its extensive clinical trials represented the first major step in this direction. Even earlier, the cofactor role of heparin in the absorption of fat emulsions, consisting in the activation of lipoprotein lipase, became clear (H. Endelberg, 1956). Initially, the difficulties of combining dissimilar ingredients in one program were associated with the need to accurately maintain the proportions, pace and sequence of administration of each of them, which required several precisely regulated infusion pumps. Modern technologies of sterilization and pH stabilization have made it possible to produce combined media combining both carbohydrates and amino acids without degradation of the latter in the Maillard reaction. This led to the creation of drugs such as "Aminomvx 1" or "AKE 3000"(Fresenius), containing amino acids, monosaccharides and polyols in concentrations that provide adequate nutrition with a balanced volume of fluid and electrolyte load. This approach simplifies the method of parenteral nutrition, allowing it to be used not only in the clinic, but also at home for many months. This direction has found further development in the concept of complex intravenous nutrition. "all in one" .

It consists in combining in one bottle immediately before using all the ingredients of nutrition (carbohydrates, fats, amino acids, electrolytes, trace elements and vitamins), followed by a round-the-clock infusion of the resulting mixture. The technology was developed and first introduced by S. Solasson and H. Joyeux at the Montpellier Hospital in 1972. Studies have proven the stability of various nutrient substrates combined in one container. The optimal material for containers was also found: it turned out that it can only be ethyl vinyl acetate film, but not polyvinyl chloride, from which the lipids of the nutrient mixture extract toxic diethyl phthalate. To exclude bacterial and fungal contamination, the infusion path should include a filter that retains particles larger than 1.2 microns.

With this method, the calorie content of non-protein nutrieites is brought to 159.6 kcal per 1 g of nitrogen, which is close to the optimal ratio of 150/1. It turned out that fat emulsions are better tolerated and absorbed when implementing this particular scheme. Damage to the walls of the veins and lung parenchyma by high-osmolar solutions is excluded, the risk of metabolic disorders characteristic of total parenteral nutrition is reduced. According to M. Deitel (1987), the main advantages of complex parenteral nutrition "all in one" include:

• a minimum of manipulations with containers containing nutrient substrates, and, consequently, a minimum risk of infection of infusion media and systems;
• saving time of personnel, consumables and technical means (infusion systems, infusion pumps);
• greater freedom of movement of the patient with continued infusion;
• the possibility of parenteral nutrition in a more comfortable home environment.

However, the massive introduction of parenteral nutrition technologies has put on the agenda the problem complications- technical, metabolic, organopathological, septic and organizational or economic.

Technical complications associated with vascular access, venous catheterization, and catheter care. Among them, as potentially lethal, the most dangerous are hemo- and pneumothorax, damage to the veins with the development of bleeding, perforation of the heart chambers with pericardial tamponade, rhythm disturbances and air embolism.

Metabolic Complications occur, as a rule, in connection with inadequate parenteral nutrition and include instability of blood glucose levels, disturbances in the metabolism of administered triglycerides, acid-base balance and electrolyte composition of the extracellular fluid.

To organopathological complications include, for example, acute respiratory failure and impaired liver function.

Septic complications associated with infection of the catheter, infusion tract or the injected solutions themselves.

Organizational problems , which are especially relevant today for our medicine, stem from the high cost of amino acid solutions and fat emulsions, and even more so modern systems for the programmed administration of such solutions and equipment that makes it possible to assess the adequacy of artificial nutrition - for example, the so-called gas metabolographs.

Enteral artificial nutrition

Artificial feeding through a tube was most popular at a time when the possibilities of parenteral nutritional support were still very limited. Over the past 10-15 years, protocols, standards and schemes have been developed abroad that revive the old, but more physiological method based on new principles and technological capabilities.

Tube feeding is still indicated when oral feeding is not possible, for example, in maxillofacial operations, injuries of the esophagus, impaired consciousness, food refusal. There are no exact formalized boundaries for the transition from parenteral to enteral nutrition; the decision is always in the competence of the attending physician. In order to switch to enteral nutrition earlier, enhanced parenteral nutrition is used, which contributes to the gradual restoration of the functions of digestion and resorption.

The basis for the revival of enteral artificial nutrition was balanced diets- mixtures of nutrients that make it possible to qualitatively and quantitatively cover the needs of the body and are produced in a ready-to-use liquid form or in the form of powders diluted in water.

Balanced diets are divided into low and high molecular weight. energy carriers low molecular weight diets are predominantly carbohydrates, and in macromolecular natural proteins predominate - meat, dairy, soy. The content of vitamins, minerals and trace elements is adjusted according to the clinical situation and the amount of essential nutrients. An important advantage of balanced diets is the possibility of their industrial production.

The most popular option for accessing the digestive tract remains the use of nasogastric and nasoenteric (nasoduodenal, nasojejunal) tube catheters. They differ in length, shape, material of manufacture, they can be single-lumen and double-lumen, with holes of different levels, which allows solving a number of other tasks in addition to feeding.

The simplest probing of the stomach through the nose or mouth is still often used; intestinal insertion of the probe is facilitated by various olives. Recently, along with thread-like transnasal probes of long-term use made of silicone rubber and polyurethane, systems for percutaneous endoscopic gastrostomy and puncture catheter jejunostomy have appeared that solve cosmetic problems. A great contribution to the technique of setting catheter probes was made by the development of endoscopic techniques, which make it possible to carry out these manipulations painlessly and atraumatically. An important stage in the development of the technology was the introduction of infusator pumps that provide continuous uniform injection of solutions. They are of two types - refrigerated and small-sized individual, with which you can only enter the mixture at a given pace. The supply of the mixture can be carried out around the clock, without disturbing the night's rest. In most cases, this also allows you to avoid complications in the form of a feeling of fullness in the stomach, nausea, vomiting and diarrhea, which are not uncommon with portioned administration of balanced mixtures.

Until recently, artificial nutrition was the prerogative of the clinic; today it has become possible to continue it at home. Successful implementation of outpatient artificial nutrition requires patient education and the provision of specialized illustrated literature. After a brief consultation in the clinic, the patient receives a system for artificial nutrition; constant counseling is guaranteed to him further.

When enteral nutrition is not possible, long-term parenteral nutrition can also be administered at home through an implanted indwelling venous catheter. Night infusions make the patient mobile, allowing him to do his usual activities during the day. Returning home, to family and friends, significantly improving the quality of life, has a positive effect on the general condition of the patient.

The current level of scientific concepts and artificial nutrition technologies allows solving clinical problems that were inaccessible 20-30 years ago. Became compatible with life and even normal growth extensive resection of the intestine, failure of digestive anastomoses, severe malformations of the gastrointestinal tract. However, before the latest achievements in this area become a daily (and ubiquitous!) reality in our country, there is still a long way to go, the main condition of which is a consistent, fundamental and objective educational program.

Postgraduate student of the Department of Anesthesiology and Resuscitation
and emergency pediatrics with the course of FPC and PP SPbGPMA
Vadim Yurievich Grishmanov;
cand. honey. Sciences, Associate Professor of the Department of Anesthesiology -
reimmatology and emergency pediatrics with the course of FPC and
PP SPbGPMA Konstantin Mikhailovich Lebedinsky

II. Individual supplementary nutrition

Head of department ________________ Diet.sister _________________

Senior Nurse ___________________ Checked

Receptionist Nurse

departments __________________

Medical statistician _______________

(for the combined portioner)

Types of artificial nutrition.

When normal feeding of the patient in a natural way (through the mouth) is impossible or difficult (some diseases of the oral cavity, esophagus, stomach), food is introduced into the stomach or intestines (rarely) artificially.

Artificial nutrition can be done:

With a probe inserted through the mouth or nose, or through a gastrostomy.

Introduce nutrient solutions with an enema (after a cleansing enema).

Administer nutrient solutions parenterally (intravenous drip).

REMEMBER!

With artificial nutrition, the daily calorie content of food is about 2000 calories, the ratio of proteins - fats - carbohydrates is 1: 1: 4.

The patient receives water in the form of water-salt solutions on average 2 liters per day.

Vitamins are added to food mixtures or administered parenterally.

Indications for the use of artificial nutrition:

Difficulty swallowing.

Narrowing or obstruction of the esophagus.

Pyloric stenosis.

Postoperative period (after surgery on the esophagus and gastrointestinal tract).

Indomitable vomiting.

Large fluid loss.

Unconscious state.

Psychosis with food refusal.

Basic nutrient mixtures and solutions.

Recipes for nutrient mixtures:

Liquid nutritional mixture: 200-250 ml of water + 250 g of powdered milk + 200 g of crackers + 4-6 g of salt.

Spasokukotsky's mixture: 400 ml of warm milk + 2 raw eggs + 50 g of sugar + 40 ml of alcohol + a little salt.

Water-salt solutions:

The concentration of salts in them is the same as in human blood plasma.

The simplest solution of water-salt 0.85% isotonic sodium chloride.

Ringer-Locke solution: NaCl - 9 g + KC - 0.2 g + CaCl - 0.2 g + HCO 3 - 0.2 g + glucose - 1 g + water - 1000 ml.

Planning for the necessary assistance to the patient in case of problems associated with feeding.

Conduct an initial assessment of the patient's response to feeding (including artificial).

Provide psychological support to the patient by methods of explanation, persuasion, conversations, so that the patient can maintain his dignity.

Help the patient cope with their feelings, give them the opportunity to express their feelings, emotions about feeding.

Ensure that the patient has informed consent to feed.

Arrange feeding, prepare everything you need.

Help with meals.

Strive to maintain a comfortable and safe feeding environment.

Organize training for the patient and his relatives, if necessary, provide information on the rules of nutrition, feeding.

Assess the patient's response to feeding.

Establish observation of the patient after feeding.

Feeding the patient through a gastric tube inserted into the mouth or nose (nasogastric).

The lungs are used as probes for artificial nutrition. thin tubes:

a) plastic

b) rubber

c) silicone

Their diameter is 3 - 5 - 8 mm, length 100 - 115 cm, at the blind end there are two lateral oval holes, and at a distance of 45, 55, 65 cm from the blind end there are marks that serve as a guideline for determining the length of the probe insertion.

Feeding the patient through a nasogastric tube using a funnel.

Equipment:

thin rubber probe with a diameter of 0.5 - 0.8 cm

towel

napkins

clean gloves

• nutrient mixture (t 38 0 - 40 0 ​​С)

  boiled water 100 ml

Tell the patient what he will be fed (after agreement with the doctor).

Give him 15 minutes notice. about what to eat.

Ventilate the room.

Help the patient to take the high position of Fowler.

Wash your hands, put on gloves.

Treat the probe with Vaseline.

Insert a nasogastric tube through the lower nasal passage to a depth of 15-18 cm.

With the finger of the left hand (in a glove), determine the position of the probe in the nasopharynx and press it against the back wall of the pharynx so that it does not enter the trachea.

Tilt the patient's head slightly forward and move the probe to the middle third of the esophagus with the right hand.

ATTENTION! If the air does not come out of the probe during exhalation and the patient's voice is preserved, then the probe is in the esophagus.

Connect the free end of the probe to the funnel.

Slowly fill the funnel, which is obliquely at the level of the patient's stomach, with a nutrient mixture (tea, fruit drink, raw eggs, still mineral water, broth, cream, etc.).

Slowly raise the funnel above the level of the patient's stomach by 1 m, keeping it straight.

As soon as the nutrient mixture reaches the mouth of the funnel, lower the funnel to the level of the patient's stomach and clamp the probe with a clamp.

Repeat the procedure using all the prepared amount of the nutrient mixture.

Pour 50-100 ml of boiled water into the funnel to rinse the probe.

Disconnect the funnel from the probe and close its distal end with a plug.

Attach the probe to the patient's clothing with a safety pin.

Help the patient get into a comfortable position.

Wash the hands.

Feeding the patient through a nasogastric tube using a Janet syringe.

Equipment:

Janet syringe with a capacity of 300 ml

syringe 50 ml

phonendoscope

nutrient mixture (t 38 0 - 40 0 ​​С)

boiled warm water 100 ml

Move the patient to the Fowler position.

Ventilate the room.

Heat the nutrient mixture in a water bath to t 38 0 - 40 0 ​​С.

Wash your hands (you can wear gloves).

Insert a nasogastric tube (if not already inserted).

Draw the nutrient mixture (prescribed amount) into Janet's syringe.

Place a clamp on the distal end of the probe.

Connect the syringe to the probe, lifting it 50 cm above the patient's torso so that the piston handle is pointing up.

Remove the clamp from the distal end of the probe and allow a gradual flow of nutrient mixture. If the passage of the mixture is difficult, use the plunger of the syringe, shifting it down.

REMEMBER! 300 ml of the nutrient mixture should be injected within 10 minutes!

After emptying the syringe, pinch the probe with a clamp (so that food does not leak out).

Above the tray, disconnect the syringe from the probe.

Attach a Janet syringe with a capacity of 50 ml with boiled water to the probe.

Remove the clamp and flush the probe under pressure.

Disconnect the syringe and plug the distal end of the probe.

Attach the probe to the patient's clothing with a safety pin.

Help the patient get into a comfortable position.

Wash hands (remove gloves).

Make a record of the feeding.

Feeding the patient with a probe inserted into the stomach through the gastrostomy.

Assign with obstruction of the esophagus and stenosis (narrowing) of the pylorus. In these cases, a funnel is attached to the free end of the probe, through which at first small portions (50 ml) 6 times a day warm liquid food is introduced into the stomach. Gradually increase food intake up to 250 - 500 ml, and the number of feedings cut up to 4 times.

Sometimes the patient is allowed to chew food on his own, then it is diluted in a glass with liquid, and already diluted is poured into the funnel. With this option of feeding, the reflex excitation of gastric secretion is preserved. Gastrostomy feeding is used both in hospital and at home. In the latter case, it is necessary to teach relatives the technique of feeding and washing the probe.

Feeding through a gastrostomy.

Equipment:

funnel (syringe Janet)

food container

boiled water 100 ml

Wipe down the bedside table.

Tell the patient what to feed him.

Ventilate the room.

Wash hands (it is better if the patient can see this), you can wear gloves.

Place cooked food on the bedside table.

Assist the patient into the Fowler's position.

Detach the probe from clothing. Remove the clamp (plug) from the probe. Attach the funnel to the probe.

ATTENTION! It is advisable to start feeding with tea (water) in order to free the probe from mucus and food accumulated between feedings.

Pour cooked food into the funnel in small portions.

Rinse the probe with warm boiled water through a Janet syringe (50 ml) or immediately through a funnel.

Disconnect the funnel, close the probe with a plug (clamp with a clamp).

Make sure the patient is comfortable.

Wash the hands.

Useful practical advice.

After use - rinse the probe in a container for washing with one of the disinfectant solutions, then soak in another container with a disinfectant solution for at least 60 minutes, then rinse the probe with running water and boil in distilled water for 30 minutes from the moment of boiling. To prevent sterile probes from drying out and cracking, they are stored in a 1% solution of boric acid, but rinsed again with water before use.

After feeding the patient through a probe inserted through the nose or gastrostomy, the patient should be left in a reclining position for at least 30 minutes.

When washing a patient who has a probe inserted through the nose, use only a towel (mitten) moistened with warm water. Do not use cotton wool or gauze for this purpose.

For the convenience of the patient, the outer end of the nasogastric tube can be fastened (tied up) on his head so that it does not interfere with him (the probe can be left in place during the entire period of artificial feeding, about 2 to 3 weeks).

You can check the correct position of the nasogastric tube in the stomach:

place a clamp over the tray on the distal end of the probe (so that the contents of the stomach do not leak out);

remove the plug from the probe;

draw 30 - 40 ml of air into the syringe;

attach the syringe to the distal end of the probe;

remove the clamp;

put on a phonendoscope, attach its membrane to the stomach area;

inject air from the syringe through the probe and listen to the sounds in the stomach (if there are no sounds, you need to tighten, move the probe).

parenteral nutrition.

Assign to patients with symptoms of obstruction of the digestive tract, with the impossibility of normal nutrition (tumor), as well as after operations on the esophagus, stomach, intestines, etc., as well as exhaustion, weakened patients in preparation for surgery. For this purpose, preparations are used that contain products of protein hydrolysis - amino acids (hydrolysin, casein protein hydrolyzate, fibronosol), as well as artificial mixtures of amino acids (alvezin new, levamine, polyamine, etc.); fat emulsions (lipofundin, intralipid); 10% glucose solution. In addition, up to 1 liter of electrolyte solutions, B vitamins, ascorbic acid are administered.

Means for parenteral nutrition administered by intravenous drip. Before administration, they are heated in a water bath to body temperature (37–38 0 C). It is necessary to strictly observe the rate of administration of drugs: hydrolysin, casein protein hydrolyzate, fibronosol, polyamine in the first 30 minutes. injected at a rate of 10-20 drops per minute, and then, with good tolerance, the rate of administration is increased to 40-60.

Polyamine in the first 30 min. injected at a rate of 10 - 20 drops per minute, and then - 25 - 35 drops per minute. A more rapid administration is impractical, since the excess of amino acids is not absorbed and is excreted in the urine.

With a more rapid introduction of protein preparations, the patient may experience sensations of heat, flushing of the face, difficulty breathing.

LipofundinS(10% solution) is injected in the first 10-15 minutes at a rate of 15-20 drops per minute, and then gradually (within 30 minutes) increase the rate of administration to 60 drops per minute. The introduction of 500 ml of the drug should last approximately 3-5 hours.

Artificial nutrition is understood as the introduction of food (nutrients) into the patient's body enterally, i.e. through the gastrointestinal tract, and parenterally - bypassing the gastrointestinal tract.

Patients who cannot swallow or refuse to eat on their own must be fed through a gastric tube, with nutrient enemas, or parenterally. It is possible to identify the main indications for artificial nutrition of patients: extensive traumatic injuries and swelling of the tongue, pharynx, larynx, esophagus; unconscious state; obstruction of the upper gastrointestinal tract (tumors of the esophagus, pharynx, etc.); refusal of food in mental illness, the terminal stage of cachexia.

There are several ways to enterally administer nutrients:

Separate portions (fractional

Drip, slowly, for a long time;

Automatically adjusting the intake of food using a special dispenser.

For enteral feeding, liquid food (broth, fruit drink, milk mixture), mineral water are used; homogeneous dietary canned food (meat, vegetable) and mixtures balanced in terms of the content of proteins, fats, carbohydrates, mineral salts and vitamins can also be used. Use the following nutrient mixtures for enteral nutrition.

Mixtures that contribute to the early recovery in the small intestine of the function of maintaining homeostasis and maintaining the water and electrolyte balance of the body: Glucosolan, Gastrolit, Regidron.

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

Semi-element balanced nutrient mixtures (as a rule, they also include a complete set of vitamins, macro- and microelements) for the nutrition of patients with digestive disorders: Nutrilon Pepti, Reabilan, Pcptamen, etc.

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

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

The choice of mixtures for adequate enteral nutrition depends on the nature and severity of the course of the disease, as well as on the degree of preservation of the functions of the gastrointestinal tract. So, with normal needs and the preservation of the functions of FA "G, standard nutrient mixtures are prescribed, in critical and immunodeficiency states - nutrient mixtures with a high content of easily digestible protein, enriched with microelements, glutamine, arginine and omega-3 fatty acids, in case of dysfunction of the nights - nutrient mixtures with the content of highly biologically valuable protein and amino acids.With a non-functioning intestine (intestinal obstruction, severe forms of malabsorption), the patient is shown parenteral nutrition.

When feeding a patient through a probe, you can enter any food (and drugs) in liquid and semi-liquid form. Vitamins must be added to food. Cream, eggs, broth, slimy vegetable soup, jelly, tea, etc. are usually introduced.

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

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

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

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

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

Main indications:

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

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

Postoperative management of patients after operations on the gastrointestinal tract.

Burn disease, sepsis.

Big blood loss.

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

Anorexia and food refusal.

For parenteral feeding, the following types of nutrient solutions are used:

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

Fats - fatty emulsions (lipofundin).

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

Blood products, plasma, plasma substitutes.

There are three main types of parenteral nutrition.

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

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

Auxiliary - nutrition through the mouth is not enough and additional administration of a number of nutrients is necessary.

About 2 liters of solutions are administered per day.

Before administration, the following drugs should be heated in a water bath to a temperature of 37-38 ° C: hydrolysin, casein hydrolyzate, aminopeptide. With intravenous drip administration of the "named drugs", a certain rate of administration should be observed: in the first 30 minutes, solutions are administered at a rate of 10-20 drops per minute, then, if the patient is well tolerated by the administered drug, the rate of administration is increased to 30-40 drops per minute. On average, the administration of 500 ml of the drug lasts about 3-4 hours. With a more rapid administration of protein preparations, the patient may experience a feeling of heat, flushing of the face, and difficulty in breathing.

When food is obstructed through the esophagus, the patient is fed through a fistula (gastrostomy) created by surgery. A probe is inserted into the stomach through the fistula, through which food is poured into the stomach. A funnel is attached to the free end of the inserted probe and warmed food is introduced into the stomach in small portions (50 ml each) 6 times a day. Gradually, the volume of the injected liquid is increased to 250-500 ml, and the number of feedings is reduced! up to 4 times. At the same time, it is necessary to ensure that the edges, gastrostomy are not contaminated with food, for which the inserted probe is strengthened with a sticky patch, and after each feeding, the skin around the fistula is toileted, lubricated with 96% ethyl alcohol and a sterile dry bandage is applied.

To comply with the regimen of therapeutic nutrition in each department, control over the food products brought by visitors should be organized. Refrigerators for food storage should be in each department in the wards. The doctor and paramedical personnel systematically check the quality of the products in refrigerators or bedside tables.

Seriously ill food is brought to the ward in a warm form on special heated tables. Before eating, all medical procedures should be completed. Some patients only need to be helped to sit down, cover their chest with an oilcloth or apron, others need to move the bedside table and give it a semi-sitting position by raising the headrest, and others need to be fed. When feeding a seriously ill patient, the nurse slightly raises the patient's head with her left hand, and with her right hand brings him a spoon or a special drinker with food to his mouth. In the case when the patient cannot raise his head so that he does not choke, you can use the following method of feeding. A transparent tube (8-10 mm in diameter and 25 cm long) is put on the nose of the drinker, which is inserted into the mouth. After inserting the tube into the mouth, it is removed with fingers, then slightly raised and tilted, while simultaneously unclenching the fingers for a few seconds, so that food enters the patient's mouth in the volume of one sip (the transparency of the tube allows you to control the amount of missed food).

artificial nutrition

In a number of diseases, when it is impossible to feed the patient through the mouth, artificial nutrition is prescribed. Artificial nutrition is the introduction of nutrients into the body using a gastric tube, enema or parenterally (subcutaneously, intravenously). In all these cases, normal nutrition is either impossible or undesirable, because. can lead to infection of wounds or ingestion of food into the respiratory tract, resulting in inflammation or suppuration in the lungs.

Introduction of food through a gastric tube

With artificial nutrition through a gastric tube, you can enter any food in liquid and semi-liquid form, after wiping it through a sieve. Vitamins must be added to food. Usually, milk, cream, raw eggs, broth, slimy or pureed vegetable soup, jelly, fruit juices, dissolved butter, and tea are introduced.

Artificial nutrition through a gastric tube is carried out as follows:

• 1) a sterile thin probe is lubricated with petroleum jelly and inserted through the nasal passage into the stomach, adhering to the direction perpendicular to the surface of the face. When 15-17 cm of the probe is hidden in the nasopharynx, the patient's head is slightly tilted forward, the index finger of the hand is inserted into the mouth, the end of the probe is felt for and, slightly pressing it against the back wall of the pharynx, is advanced further with the other hand. If the patient's condition allows and there are no contraindications, then during the introduction of the probe the patient sits, if the patient is unconscious, then the probe is inserted in the supine position, if possible, under the control of a finger inserted into the mouth. After the introduction, it is necessary to check whether the probe has entered the trachea: a piece of cotton wool, a piece of tissue paper should be brought to the outer end of the probe and see if they sway when breathing;
• 2) through a funnel (capacity 200 ml) at the free end of the probe, under slight pressure, slowly pour in liquid food (3-4 cups) in small portions (no more than a sip);
• 3) after the introduction of nutrients, clean water is poured in to rinse the probe. If the probe cannot be inserted into the nasal passages, then it is inserted into the mouth, fixing it well to the skin of the cheeks.

Introduction of food with an enema

Another type of artificial nutrition is rectal nutrition - the introduction of nutrients through the rectum. With the help of nutritional enemas, the body's losses in fluid and salt are restored.

The use of nutritional enemas is very limited. in the lower part of the large intestine, only water, saline, glucose solution and alcohol are absorbed. Proteins and amino acids are partially absorbed.

The volume of the nutrient enema should not exceed 200 ml, the temperature of the injected substance should be 38-40°C.

Nutrient enema is placed 1 hour after cleansing and complete emptying of the intestine. To suppress intestinal peristalsis add 5-10 drops of opium tincture.

With the help of a nutrient enema, physiological saline (0.9% sodium chloride solution), glucose solution, meat broth, milk, and cream are administered. It is recommended to put a nutritional enema 1-2 times a day, otherwise you can cause irritation of the rectum.

Subcutaneous and intravenous nutrition

In cases where enteral nutrition cannot provide the patient's body with the required amount of nutrients, parenteral nutrition is used.

Liquid in the amount of 2-4 liters per day can be administered by drip in the form of a 5% glucose solution and sodium chloride solution, complex saline solutions. Glucose can also be administered intravenously as a 40% solution. The amino acids necessary for the body can be introduced in the form of protein hydrolysers (aminopeptide, L-103 hydrolysis, amino blood), plasma.

Preparations for parenteral nutrition are most often administered intravenously. If necessary, frequent and prolonged use of them produce catheterization of the veins. Less often, subcutaneous, intramuscular, intra-arterial routes of administration are used.

The correct use of parenteral drugs, strict consideration of indications and contraindications, calculation of the required dose, compliance with the rules of asepsis and antiseptics can effectively eliminate the patient's various, including very severe, metabolic disorders, eliminate the phenomena of intoxication of the body, normalize the functions of its various organs and systems.

medical nutrition sick feeding

Sometimes normal nutrition of the patient through the mouth is difficult or impossible (some diseases of the oral cavity, esophagus, stomach, unconsciousness). In such cases, organize artificial nutrition.

Artificial feeding can be carried out using a probe inserted into the stomach through the nose or mouth, or through a gastrostomy. You can enter nutrient solutions with an enema, as well as parenterally, bypassing the digestive tract (intravenous drip).

Tube feeding

material support : sterile thin rubber probe with a diameter of 0.5-0.8 cm, petroleum jelly or glycerin, Janet's funnel or syringe, liquid food (tea, fruit drink, raw eggs, gas-free mineral water, broth, cream, etc.) in the amount of 600-800 ml.

Execution sequence:

1. Treat the probe with petroleum jelly (glycerin).

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

Rice. 30. Feeding the seriously ill.

3. With the finger of your left hand, determine the position of the probe in the nasopharynx and press it against the back wall of the pharynx so that it does not enter the trachea.

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

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

6. Slowly pour the cooked food into the funnel.

7. Pour clean water into the funnel (washing the probe) and remove the funnel.

8. Fix the outer end of the probe on the patient's head so that it does not interfere with him (the probe is not removed during the entire period of artificial feeding, about 2-3 weeks).

Feeding the patient through the surgical fistula(Fig. 31) .

Indications for the imposition of a gastric fistula are obstruction of the esophagus, pyloric stenosis. At the same time, food is administered in small portions (150-200 ml) 5-6 times a day in a heated form. Then gradually a single amount of food is increased to 250-500 ml, but the number of injections is reduced to 3-4 times. Through the funnel, you can enter crushed food products diluted with a liquid: finely mashed meat, fish, bread, crackers.

Rice. 31. Feeding a seriously ill person

Through the operating fistula.

Sometimes patients chew food, dilute it with liquid and pour it into the funnel themselves. Care should be taken to introduce large amounts of food into the funnel, as a spasm of the muscles of the stomach may occur, and food can be thrown out through the fistula.

Rectal artificial nutrition- the introduction of nutrients through the rectum to replenish the body's need for fluid and salt. It is used for severe dehydration, complete obstruction of the esophagus and after operations on the esophagus and cardia of the stomach. In addition, nutrient enemas increase diuresis and promote the release of toxins from the body.

Tactics of implementation: an hour before the nutritional enema, a cleansing enema is put until the intestines are completely emptied. Due to the fact that 5% glucose solution and 0.85% sodium chloride solution are well absorbed in the rectum, they are mainly used for artificial nutrition. Small nutrient enemas are made from a rubber pear in an amount of 200 ml of solution (37-38 ° C). Repeat the procedure 3-4 times a day. A larger amount of liquid (up to 1 liter) is administered once by drop. Frequent use of nutrient enemas is not recommended because of the danger of irritation of the rectal sphincter and the appearance of anal fissures. In order to avoid these complications, a thorough toilet of the anus is necessary.

With parenteral nutrition nutrient solutions can be administered intravenously. For this purpose, protein hydrolysis products (hydrolysin, aminopeptide, aminocrovin, polyamine, etc.), fat emulsions (lipofundin), as well as 5-10% glucose solution, isotonic sodium chloride solution, and vitamins are used. Before administration, the following drugs should be heated in a water bath to a temperature of 37-38 ° C: hydrolysin, casein hydrolyzate, aminopeptide. With intravenous drip administration of these drugs, a certain rate of administration should be observed: in the first 30 minutes, a solution is injected at a rate of 10-20 drops per minute, then, with good tolerance to the patient of the administered drug, the rate of administration is increased to 30-40 drops per minute. On average, the administration of 500 ml of the drug lasts about 3-4 hours. With a more rapid introduction of protein preparations, the patient may have a feeling of heat, flushing of the face, difficulty breathing.