359. Kawei's invitation

Author: Xifeng

359. Kawei's invitation

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(V) Monitoring and treatment strategies for blood sugar during enteral nutrition treatment

Many studies in the past 20 years have shown that both hypoglycemia and hyperglycemia are associated with adverse prognosis and increased mortality, which is consistent with the U-shaped curve. The results of the 2012 and 2017 meta-analysis suggest that blood sugar control in critically ill patients in neurosurgery needs to avoid excessive blood sugar or

Too low and high blood sugar (>11 mmol/L) will significantly increase the adverse outcomes of neurological diseases, while too low blood sugar (<8 mmol/L) will increase the incidence of hypoglycemia and lead to adverse outcomes [59, 60].

Severe surgical patients are prone to stress-induced increase in blood sugar. Therefore, blood sugar needs to be monitored when starting nutritional treatment. Usually, blood sugar needs to be measured at least every 4 hours in the first two days [59]. Insulin treatment can be given when the blood sugar level exceeds 10 mmol/L.

The blood sugar control target is recommended to be 7.8~10.0 mmol/L, and blood sugar can be controlled at normal values ​​without intensive blood sugar reduction treatment. In the acute phase, it is recommended to use an insulin pump. After the condition is stable, long-acting insulin can be used instead.

Recommendation 17: Regardless of whether you have a history of diabetes, severe neurosurgery patients should undergo blood sugar monitoring after starting nutritional treatment. The frequency of the unstable period should not be less than 4 hours, and the frequency can be reduced after stability.

Recommendation 18: The blood sugar control target is 7.8~10.0 mmol/L. When the blood sugar level exceeds 10.0 mmol/L, insulin treatment should be given. In the acute phase, it is recommended to use an insulin pump. In the stable phase, long-acting insulin replacement insulin pump can be used to control blood sugar.

(VI) Monitoring and treatment strategies for abdominal distension during intestinal camp treatment

Definition of abdominal distension: Awakening patients complain of a feeling of bloating in the abdomen, or abdomen bloating in physical examination, with obvious drum sounds of percussion, hard palpation, reduced mobility, increased tension or increased abdominal circumference within 3 hours

above.

Monitoring and processing strategies: Neurosurgery critically ill patients are often accompanied by consciousness disorders, so abdominal distension needs to be evaluated by measuring abdominal circumference or abdominal depth and shallow palpation. The frequency of monitoring should depend on the patient's feeding status, but it is recommended that no less than

Once a day [56].

Method: A soft ruler was used to measure the abdominal circumference. The starting point of the measurement was the subject's navel. After marking the waist, the waist circumference was measured at the same place every time the breath was exhaled. The abdominal circumference increased by 3 cm or more within 3 hours. It was considered that abdominal distension occurred;

When evaluating abdominal distension by shallow palpation and deep palpation, apply sufficient pressure to make the shallow palpation form a depression of 1 to 2 cm, and deep palpation form a depression of 2.5 to 7.5 cm. If the abdomen is soft, active, and not tense,

If the abdomen is not bloating, if the abdomen is hard, it is considered bloating.

1. Intra-abdominal pressure monitoring (IAP): IAP is recommended for severe neurosurgery patients after abdominal distension, and it is recommended to use intra-vesic pressure as the preferred method for indirect measurement of IAP in patients. The measurement method: the patient takes a flat position,

Empty the bladder, inject 25 ml of sterile saline, keep the urinary catheter connected to the pressure measuring tube after 30~60 s, use the iliac crest level in the mid-axillary line to measure the height of the water column with a ruler, read the last thirst of the patient, and measure the results.

In mmHg units (1 mmHg = 0.133 kPa), medical institutions with conditions can also directly monitor through the external monitor of the urinary catheter. The results of Bejarano et al. [61] show that IAP and intestinal in critically ill patients

There is a correlation between nutritional tolerance. When IAP continues to rise to >20 mmHg, the risk of feeding intolerance increases by 2.7 times, and abdominal compartment syndrome (ACS) may occur [62].

When abdominal distension occurs, it is recommended to adjust the enteral nutrition feeding plan according to IAP: IAP should be monitored every 4 to 6 hours. When IAP is 12 to 15 mmHg, conventional enteral nutrition can be continued; when IAP is 16 to 20 mmHg, nourishment should be used.

Type feeding; when IAP>20 mmHg, enteral nutrition should be suspended [56].

2. GRV: GRV monitoring is not required for critically ill patients in neurosurgery, but GRV monitoring should be performed after abdominal distension, and once every 4 to 6 hours [43]. Recommended method: Use syringe aspiration method or gastric ultrasound monitoring.

GRV monitoring is performed [63].ESICM believes that enteral nutrition interruption caused by partial gastric retention can be avoided. It is recommended that enteral nutrition be suspended only when GRV>500 ml within 6 hours, and that intestinal hypertension can still be continued if more than 200 ml is exceeded.

Feeding to maintain nutritional supply. It is recommended to raise the head of the bed by 30°~45° and add gastrointestinal motility drugs during feeding, which can improve gastric emptying and tolerance to enteral nutrition. There are 6 research projects to explore the effects of gastrointestinal motility drugs.

The results of RCT study suggest that intravenous erythromycin is the first choice, usually the dose is 100~250 mg, 3 times a day, lasting for 2~4 days; if there is vomiting, it is recommended to use metoclopramide intravenously, usually the dose is

10 mg, 2 to 3 times a day [43].

3. Other treatments: Actively correct electrolyte disorders, enhance intestinal peristalsis and relieve abdominal distension; stop using drugs that cause gastrointestinal paralysis as soon as possible, such as fentanyl, morphine and other drugs that affect intestinal peristalsis, improve gastric emptying and enteral nutrition

Tolerance. Improve blood albumin levels and reduce intestinal mucosal edema; use of enteral nutrition combined with probiotics to regulate intestinal flora and reduce the occurrence of complications such as diarrhea and bloating. In addition, it can also be supplemented with abdominal massage.

Intervention measures such as anal tube exhaust, gastrointestinal decompression, exercise, etc.

Recommendation 19: It is recommended to measure abdominal circumference or abdominal depth and shallow palpation as a method for routine evaluation of abdominal distension in severe neurosurgery patients.

Recommendation 20: After severe neurosurgery patients develop abdominal distension, it is recommended to monitor the patients IAP and GRV, and monitor them every 4 to 6 hours. When IAP 12 to 15 mmHg, routine enteral nutrition can be continued; IAP 16 to 20

When mmHg, low-speed trophic feeding should be used; when IAP>20 mmHg, enteral nutrition should be suspended. When GRV exceeds 200 ml, enteral nutrition should be suspended. When GRV>500 ml, enteral nutrition should be suspended.

(VII) Monitoring and treatment strategies for diarrhea during enteral nutrition treatment

Currently, there is no unified standard for the definition of diarrhea, and it is generally judged based on the frequency, characteristics and amount of defecation. Critical Care Nutrition (CCN) defines it as 3 to 5 defecations or the amount of feces ≥750 within 24 hours

ml. Enteral nutrition-related diarrhea refers to the diarrhea that a patient develops after receiving enteral nutrition treatment for 2 days. Generally speaking, by adjusting the temperature of the input nutrient solution, reducing the amount and concentration of the nutrient solution input, and controlling the infusion.

After using antidiarrhea drugs as appropriate, the patient's diarrhea symptoms can be effectively controlled.

Determining whether a patient has diarrhea requires accurate evaluation of feces. Currently, Bristol stool form scale (BSFS) and the King's of stool chart (KSC-Tr) are used clinically.

Or the Hart diarrhea scoring method to conduct diarrhea evaluation. For infectious or other diseases that may cause diarrhea, the evaluation content should also include: abdominal examination, defecation volume, fecal traits, fecal bacterial culture, electrolyte examination, drug treatment use, etc.

BSFS is a visual chart of seven categories. From the hardest feces in type 1 to the 7-type water sample, there are 7 categories. Patients with feces grades rated 6 or 7 points can be defined as diarrhea.

64].

KSC-Tr covers the frequency, consistency and weight characteristics of diarrhea. Consistency is divided into 4 categories (hard and shaped, soft and shaped, loose and unformed, liquid sample), and weight is divided into 3 categories (<100 g, 100~

200 g,>200 g), consistency × weight combined into 12 types of situations and assigned values. The cumulative value of each bowel movement assessment score is >15 points within 24 hours, and it is judged as diarrhea [65].

"Expert Consensus on Prevention and Management of Common Complications of Enteral Nutrition Treatment in Critical Patients in China (2021 Edition)" Recommends the use of Hart diarrhea scoring method (Table 2) [63]. The Hart diarrhea score table assigns values ​​to 9 categories, and their total scores are

It is the sum of the scores of each bowel movement on the day. Each bowel movement is scored according to this table. If the cumulative total score of ≥12 points in 24 hours, it is judged as diarrhea [66]. This table is simple to use and is currently used in the domestic nursing field to evaluate intestinal intestinal

The most commonly used tool for diarrhea in nutrition patients.

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Treatment: Enteral nutrition-related diarrhea complications are caused by multiple factors, including the type of nutrient solution, enteral nutrition methods and pathways, enteral nutrition initiation and duration, the rate and amount of enteral nutrition infusion, and intestinal stress response

, Nutritional preparations are contaminated, etc. Early identification of risk factors for enteral nutritional concomitant diarrhea, establish prevention or early warning mechanisms, thereby further reducing the incidence of diarrhea and improving the clinical outcome of patients [67].

The treatment of enteral nutrition-related diarrhea requires medical and nursing to jointly formulate clinical decisions, establish a multidisciplinary nutrition support team composed of doctors, nutrition experts, nurses and pharmacists, responsible for monitoring the nutritional status of patients with nutritional treatment, which can reduce complications such as diarrhea.

and reduce hospital stays and medical expenses.

In enteral nutrition practice, sterile operation procedures must be strictly followed to avoid repeated use of disposable items and contaminate enteral nutrient solution. Good hand hygiene habits can reduce the risk of bacterial contamination during enteral nutrition, thereby reducing the occurrence of diarrhea

.For critically ill patients in neurosurgery, it is recommended to use a constant delivery method of enteral nutritional infusion pump for nutritional preparations. Feeding starts at low doses, and gradually increase the dosage according to the patient's tolerance, and follow the sequential treatment of enteral nutrition until

To achieve the target feeding amount, it is recommended to give individualized nutrient solution with appropriate temperature [68].

Do not automatically stop enteral nutrition because the patient has diarrhea. Instead, feeding should be continued. At the same time, find the cause of diarrhea to determine appropriate treatment. It is recommended that when the patient has enteral nutrition-related diarrhea, the patient should be closely observed for intestinal rumbling changes and defecation.

The number of times, characteristics and amounts are graded and managed according to the tolerance score. Select appropriate enteral nutrition by correcting water electrolyte disorders, changing feeding methods, changing protein types, increasing dietary fiber intake, supplementing exogenous probiotics, etc.

The plan and empirically use antidiarrhea drugs according to the corresponding situation, and ultimately achieve the effect of restoring intestinal function [56].

Recommendation 21: It is recommended to use the diarrhea score chart tool to evaluate diarrhea.

Recommended recommendation 22: During enteral nutrition operation, you should pay attention to the principle of sterile operation. It is recommended to use a gastrointestinal nutrition pump for a uniform heating pump.

Recommendation 23: It is not recommended to suspend enteral nutrition simply because of diarrhea. Low-speed feeding can be used and antidiarrhea treatment can be performed based on the cause.

(8) Monitoring and prevention of risk of aspiration during enteral nutrition treatment

Aspiration refers to the process in which different amounts of liquid or solid food, secretions, blood, etc. enter the respiratory tract below the glottis during swallowing or not.

Risk factors for aspiration include: advanced age (>70 years old), nutritional feeding in the nasogastric duct, mechanical ventilation, swallowing dysfunction, loss/declination of consciousness, glottic or cardia closure insufficiency, combined with nervous system or psychiatric diseases,

Use sedation or muscle relaxation drugs, transport within and outside the hospital, etc. Neurosurgery critically ill patients have high risk factors for multiple aspiration, which is a high-risk group for aspiration, and needs to be evaluated for the risk of aspiration (Table 3) and prevention.

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The risk of hyper aspiration is defined as: mental disorders, gastric retention, continuous sedation/muscle loosening, intestinal paralysis and other conditions in which clinicians judge the risk of aspiration.

Evaluation criteria: 10~12 points are low-grade hazards; 13~18 points are moderate-grade hazards; 19~23 points are severe hazards.

Evaluation requirements: admission (transfer), surgery (intervention), change of condition (care level changed to previous level, doctor's orders changed to diet); score 10-18 points (low and moderate risk), and missed aspiration once a week

Risk; score ≥19 points (severe risk), and the risk of aspiration is evaluated once a day.

Measures to prevent aspiration:

1. It is recommended that medical personnel use tracheal catheters with conical or conical airbags to prevent aspiration when establishing artificial airways.

2. It is recommended to maintain the intracapsular pressure of the tracheal catheter at 25~30 cmH2O, manually measure the airbag pressure every 6~8 hours, and clean the accumulated water in the pressure measuring tube in time. When the patient's position changes, it is advisable to re-measure the airbag pressure.

.

3. It is recommended to routinely perform subglottic secretion drainage technology in patients with intubation to prevent aspiration and thus reduce the incidence of VAP.

4. It is recommended to use a semi-recumbent position (30°~45° elevation of the head of the bed) for ICU mechanical ventilation patients and (or) enteral nutrition support patients to prevent aspiration.

5. If the risk is high, use post-pyloric/small intestine feeding.

6. For mechanically ventilated patients, it is recommended to dynamically adjust the amount and rate of enteral nutrition according to the patient's gastrointestinal tolerance to reduce GRV, thereby reducing the risk of aspiration.

7. For patients with high risk of aspiration, it is recommended to monitor GRV once every 4 hours. If conditions permit, bedside gastric ultrasound monitoring can be used to evaluate GRV.

8. For patients with high risk of aspiration, it is recommended to use gastrointestinal motility drugs, such as metoclopramide and erythromycin; or antiemetic drugs, such as metoclopramide; or antireflux drugs, such as citrate.

Mosapriligy tablets to prevent aspiration.

9. For stroke patients with high risk of aspiration, it is recommended to use angiotensin converter inhibitors to promote cough and swallowing reflexes, thereby reducing aspiration.

10. It is recommended to minimize the patient's sedation/analgesia level as much as possible when the condition allows, and to minimize the procedures for going out for diagnostic examinations in ICU patients.

11. It is not recommended to use blue food coloring, any dye and glucose oxidase reagent strips as markers for judging enteric nutrient aspiration.

Recommended recommendation 24: Neurosurgery critically ill patients undergo aspiration risk assessment when they are admitted to the hospital (transferred), surgery (intervention), and changes in the condition (the nursing level is changed to the previous level, and the doctor's orders are changed to diet); weekly assessment of low- and moderate-risk patients

The risk of 1 aspiration; patients with severely dangerous patients are evaluated for the risk of 1 aspiration once a day.

Recommended recommendation 25: It is recommended to take preventive aspiration measures during enteral nutrition treatment for critically ill patients in neurosurgery.
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