Chapter 364 360. Paris World Expo

Author: Hao Xifeng

Chapter 364 360. Paris World Expo

【Waiting for change】

(9) Assessment of gastrointestinal function during enteral nutrition treatment

During the enteral nutrition process, the enteral nutrition tolerance score scale [70] (Table 4) can be used to evaluate the patient's feeding tolerance.

picture

Gastrointestinal function assessment: (1) Normal gastrointestinal function: 0 points; (2) Mild impairment of gastrointestinal function: 1 to 2 points; (3) Moderate impairment of gastrointestinal function: 3 to 4 points; (4) Stomach

Severe impairment of intestinal function: 5 points and above.

When feeding intolerance occurs during enteral nutrition, the patient's enteral nutrition tolerance score needs to be assessed every 6 to 8 hours, and the enteral nutrition infusion is adjusted based on the score results: (1) Increase in score

If the score is ≤1 point: continue enteral nutrition and increase the speed; (2) The score increases by 2 to 3 points: continue enteral nutrition, maintain the original speed or slow down the speed and receive symptomatic treatment; (3) The score increases by ≥4 points or the total score

≥5 points: suspend enteral nutrition and handle accordingly

Recommendation 26: The enteral nutrition tolerance scale is recommended as a tool to assess patients' gastrointestinal tolerance.

[4. Parenteral nutrition treatment for critically ill neurosurgery patients]

(1) Timing to start parenteral nutrition therapy

Enteral nutrition for critically ill neurological patients is affected by many factors, and sometimes it is difficult to achieve nutritional goals. When enteral nutrition cannot achieve nutritional goals, and if the patient is in a state of long-term nutritional deficiencies, supplementing parenteral nutrition is not controversial. However, supplementation

The optimal timing to initiate parenteral nutrition is controversial.

Some people suggest that, after 3 days of ICU admission, when the energy level provided by enteral nutrition cannot reach 60%, supplementary parenteral nutrition should be initiated to achieve the maximum 100% energy requirement (indirect calorimetry). However, the EPaNIC study [

71] observed that early parenteral nutrition was associated with prolonged ICU length of stay and mechanical ventilation, increased infection rates, and the need for renal replacement therapy. These findings may be related to the administration of excessive amounts of energy targets based on predictive formulas rather than indirect calorimetry.

Energy related. Reveals the potential harm of giving complete, potentially overestimated energy goals to critically ill patients during the acute phase. However, it is unclear whether the use of indirect calorimetry in setting goals in studies would lead to different results, while

, the optimal time point to initiate supplementary parenteral nutrition with the goal of achieving complete caloric requirements is also uncertain.

ASPEN/SCCM recommends that if >60% of energy and protein requirements cannot be met by the enteral route alone, supplemental parenteral nutrition should be considered after 7 to 10 days. This recommendation is based on an assessment that after ICU admission, supplemental parenteral nutrition should be considered.

Supplementing parenteral nutrition to enteral nutrition before 7 to 10 days will not improve clinical outcomes and may even have harmful consequences. However, there is currently no data to support starting parenteral nutrition after day 8, or comparing it to days 4 to 10.

Differences in the effects of starting parenteral nutrition between 7 days and 8 to 10 days.

Recommendation 27: For critically ill neurosurgery patients who still cannot achieve nutritional goals (80% EE by indirect calorimetry, 60% by predictive formula) despite maximizing enteral nutrition strategies, enteral nutrition can be considered to be started after 7 to 10 days.

Parenteral nutrition. It is not recommended to start parenteral nutrition treatment in advance.

(2) Selection of parenteral nutrition treatment preparations

Parenteral nutrition is an important part of nutritional therapy, and the configuration of its nutrient solution has always attracted widespread attention. Premixed parenteral nutrition and compound parenteral nutrition are the two main types of parenteral nutrition. The advantages and disadvantages of the two have been criticized by clinicians.

has received widespread attention. Premixed parenteral nutrition minimizes compounding errors and improves safety; compounded parenteral nutrition can achieve individualized treatment based on the patient's actual situation.

1. Comparison of compound parenteral nutrition and premixed parenteral nutrition formulas: Both compound parenteral nutrition and premixed parenteral nutrition can basically meet the nutritional needs of patients. Compound parenteral nutrition has a large gap between the caloric nitrogen ratio, sugar-to-lipid ratio and recommended values.

Large, while the heat-to-nitrogen ratio and sugar-to-lipid ratio in premixed parenteral nutrition are more ideal.

A clinical survey collected 1,207 parenteral nutrition prescriptions from 6 different regional hospitals to compare premixed parenteral nutrition and compound parenteral nutrition in terms of nutrient supply, total fluid volume, non-protein calories, total nitrogen,

Differences in indicators such as heat-to-nitrogen ratio. Both compound parenteral nutrition and premixed parenteral nutrition can basically meet the nutritional needs of patients. Compound parenteral nutrition has a heat-to-nitrogen ratio [(180~250):1] and a sugar-to-lipid ratio [(0.56).

~1.26):1] is quite different from the recommended caloric nitrogen ratio [(100~150):1], sugar-lipid ratio (1.0:1), and the caloric nitrogen ratio in premixed parenteral nutrition (167:1)

, the glycolipid ratio (0.8:1) is more ideal [72].

2. Comparison of complications between compound parenteral nutrition and premixed parenteral nutrition: The blood infection rate of patients treated with premixed parenteral nutrition is lower than that of patients treated with compound parenteral nutrition.

Two retrospective analyzes on bloodstream infections related to parenteral nutrition included 113 342 patients who received parenteral nutrition. The experimental group included 7 925 patients who received premixed parenteral nutrition; the control group included patients who received compound enteral nutrition.

A total of 105 417 patients were treated with parenteral nutrition. Baseline differences, risk factors and potential confounders were adjusted by using multiple logistic regression, and propensity score matching was used as a sensitivity analysis. The blood infection rate of premixed parenteral nutrition was lower than that of composite

The blood infection rate of parenteral nutrition (19.6% vs. 25.9%, P<0.001; 11.3% vs. 16.1%, P<0.0001) [72, 73].

A retrospective analysis of gastrointestinal symptoms caused by compound parenteral nutrition and premixed parenteral nutrition, a total of 49 patients. The control group was patients who received compound parenteral nutrition, a total of 29 patients; the experimental group was patients who received premixed parenteral nutrition

There were 20 patients receiving parenteral nutrition. All patients in the test group had nausea symptoms, and 6 patients in the control group had nausea symptoms. The control group had better gastrointestinal tolerance.

Recommendation 28: Both compound parenteral nutrition and premixed parenteral nutrition can meet the basic needs of patients who need supplementary parenteral nutrition treatment. Premixed parenteral nutrition has a lower blood infection rate and high safety, and can be used as

First choice. For patients who need to supplement more electrolytes or have higher nutritional needs, compound parenteral nutrition can be chosen for personalized parenteral nutrition.

(3) Timing to terminate parenteral nutrition therapy

The purpose of parenteral nutrition therapy is to enable patients to maintain nutritional status, gain weight, and heal wounds even when they are unable to eat normally. For corresponding patients, if parenteral nutrition is stopped prematurely, the patient will suffer from malnutrition and complications.

However, the longer the parenteral nutrition is continued, the greater the risk of catheter-related infection and parenteral nutrition-related liver disease [74]. Therefore, for critically ill neurosurgery patients who use parenteral nutrition, efforts should always be made to transfer the patient to

For enteral treatment. In order to avoid overfeeding, while increasing enteral nutrition, the energy from the parenteral route should be appropriately reduced. Once the supply of enteral nutrition exceeds 60% of the target energy demand and can still be gradually increased, you can choose

Terminate parenteral nutrition.

Recommendation 29: It is recommended that critically ill neurosurgery patients who receive parenteral nutrition and have no contraindications to enteral nutrition should strive to switch to enteral nutrition. As the amount of enteral nutrition increases, the amount of parenteral nutrition should be reduced accordingly.

Energy, until enteral nutrition reaches 60% of the energy goal, parenteral nutrition can be terminated.

[5. Use of nutritional therapy additives in critically ill neurosurgery patients]

(1) Micronutrients and antioxidants

Providing micronutrients containing various trace elements and vitamins is an integral part of nutritional therapy. The difference between parenteral and enteral preparations is that generally parenteral preparations do not contain micronutrients for stability reasons, so parenteral preparations

It needs to be added separately. Some studies have shown that the lack of micronutrients is related to the poor prognosis of critically ill patients [75]. However, there is controversy about whether supplementing micronutrients can improve the prognosis, which may be related to the differences among patients.

Oxidative stress is defined as the imbalance between the increase in nitric oxygen radical reactions and the endogenous antioxidant mechanism. It is commonly seen in patients with septic shock, severe pancreatitis, acute respiratory distress syndrome, severe burns and trauma.

Antioxidant micronutrients, mainly copper, selenium, zinc and vitamins E and C. In severe inflammatory conditions, their circulating levels will drop below normal reference values. Note that these micronutrients often require more time when used as antioxidants.

High doses, here should not be confused with nutrient doses required for daily supplementation. Doses exceeding 10 times the DRI are not recommended in clinical settings if a severe deficiency is not demonstrated.

1. Selenium: The antioxidant mechanism of selenium is to activate the activity of glutathione peroxidase family antioxidant enzymes. Low selenium levels are associated with severe inflammation, organ failure and poor prognosis. A total of 792 cases of pus were included in 9 trials

In a meta-analysis of patients with sepsis, the safety of high-dose selenium treatment (1 000~4 000 mg) was studied [76] and was observed to help reduce mortality in sepsis. However, in the REDOXS trial,

Selenium supplementation did not show this effect [77]. The meta-analysis by Manzanares et al. [78] and the German cohort study [79] did not find any improvement in clinical efficacy. Moreover, since selenium is excreted through the kidneys, in the case of renal failure,

Doses exceeding the DRI should be avoided.

2. Vitamin C: Critically ill patients have lower blood concentrations of vitamin C. Low plasma concentrations are related to inflammation, severity of organ failure, and mortality. Preclinical studies have shown that large doses of vitamin C can inhibit nicotinamide adenine dinucleotide

The activation of phosphate oxidase and inducible nitric oxide synthase prevents or restores microcirculatory blood flow damage, and can also prevent thrombin-induced platelet aggregation and the expression of selectins on the platelet surface, thereby preventing the formation of microthrombi [80].

Additionally, it restores vascular responsiveness to vasoconstrictors, protects the endothelial barrier by sustaining cyclic guanosine monophosphate phosphatase, blocking phosphorylation, and preventing apoptosis. Finally, high doses of vitamin C enhance antimicrobial defenses. 24

Among patients randomized to receive vitamin C (50~200 mg·kg-1·d-1) or placebo, no adverse safety events were observed in patients infused with vitamin C. Compared with the placebo group, the vitamin C group

The patient's SOFA score decreased rapidly, and at the same time, the inflammatory biomarkers (CRP and procalcitonin) were significantly reduced [81]. Recently, Marik et al. [82] proposed that taking high-dose vitamin C, thiamine and hydrocortisone can

Reduce the mortality rate and prevent the occurrence of multiple organ failure in severe sepsis and septic shock. In fact, under the acidosis conditions of sepsis, vitamin C promotes the dissolution of microthrombi in capillaries, thereby helping

To improve microcirculation.

Recommendation 30: Providing micronutrients is an important part of nutritional therapy. When critically ill neurosurgery patients undergo parenteral nutrition, micronutrients (i.e., trace elements and vitamins) should be added separately every day.

Recommendation 31: Antioxidant micronutrients require higher doses when used as antioxidants and should not be used routinely until serious deficiency is proven.

(2) Vitamin D

As long as there is sunlight exposure and good liver and kidney function, the human body can synthesize sufficient amounts of vitamin D3. Critically ill patients are exposed to sunlight for a long time and are often accompanied by abnormal liver and kidney function, so they will suffer from repeated vitamin D deficiency and poor prognosis.

Related, including increased mortality, prolonged hospitalization, higher incidence of sepsis, and longer need for mechanical ventilation [83].

It has been confirmed that critically ill patients cannot correct low plasma concentrations of vitamin D simply by relying on nutritional doses and require loading therapy [84]. Based on body weight and initial level, it is safe to give a high dose at one time in the first week.

The meta-analysis on vitamin D included 7 randomized trials with a total of 716 severely ill adult patients. The trial doses ranged from 200,000 to 540,000 units of vitamin D3. Compared with placebo, the mortality rate of patients who supplemented vitamin D3 was reduced, and the mortality rate was lower.

No adverse reactions were observed during the 6-month follow-up [85].

Recommendation 32: Severe neurosurgery patients with confirmed vitamin D deficiency (25-hydroxyvitamin D <12.5 ng/ml or 50 nmol/L) need vitamin D3 supplementation. During treatment, it is recommended to give a loading dose (single dose 50 000~600 000).

unit of vitamin D3) followed by nutritional dose (DRI 600 units) treatment.

(3) Glutamine

GLN is a normal component of protein, accounting for about 8% of all amino acids. It mainly plays the role of transporting nitrogen between cells and/or organs, and serves as a raw material for rapid cell proliferation. Under physiological conditions, the human body can pass each

Daily nutritional intake and endogenous synthesis (skeletal muscle and liver) to maintain adequate GLN levels. Generally, standard enteral nutrition preparations contain GLN, but for stability reasons, standard parenteral nutrition solutions do not.

the ingredient.

There is currently no direct research support for GLN levels and prognosis in critically ill patients in neurosurgery. In other studies on critically ill patients, Rodas et al. [86] showed that there is a U-shaped association between plasma GLN levels and prognosis. Low levels in critically ill patients

Plasma GLN levels are associated with poor prognosis. Multiple randomized trials have confirmed that in burn and trauma patients, if plasma GLN levels are low, additional supplementation of GLN can reduce the occurrence of infectious complications and promote wound healing [87, 88].

However, not all critically ill patients are GLN deficient.

Recommendation 33: Critically ill neurosurgery patients do not need to supplement GLN when their enteral nutritional therapy protein reaches the target; patients with severe craniocerebral trauma may consider supplementing GLN when their plasma GLN levels decrease; for patients using standard total parenteral nutrition,

Pay attention to supplementing GLN. For patients with liver and kidney failure, additional supplementation of GLN is not recommended.
Chapter completed!