Chapter 365 361 Swiss Small Treasury

Author: Hao Xifeng

【Waiting for change】

[357 was sentenced to be unblocked due to some indescribable content. It happens to be a weekend break and I can only let the editor do it tomorrow]

[To prevent the interruption of updates for more than seven days and no longer give full attendance, I will drop a chapter first, and then try to finish the revision within a week. I will resume normal updates after my mother and father-in-law are discharged from the hospital. Middle-aged people have a lot of things, so forgive me]

(4) Eicosapentaenoic acid and docosahexaenoic acid

The International Association for Fatty Acid and Lipid Research recommends that healthy people consume 500 mg of EPA and DHA every day [89]. 3 to 7 times this dose is defined as high dose. α-Linolenic acid is an essential omega-3 unsaturated fatty acid.

Has potential pleiotropic effects on brain protection, cerebral arterial vasodilation and neuroplasticity.

There are currently no relevant clinical trials on the impact of adding EPA and DHA to enteral nutrition on the prognosis of critically ill neurosurgery patients. Among patients with ARDS and acute lung injury, 8 studies were included in the meta-analysis, and the results did not show any benefit, only indicating PO2 after intervention.

/FiO2 has an increasing trend (RR=22.59, 95%CI:-0.88~46.05, P=0.06), but PO2/FiO2 is affected by ventilator settings, fluid status, body position, etc. The value itself changes rapidly and is not good.

Outcome indicators. In a post hoc study of the large RCT Meta Plus [98] of immunomodulatory nutrients, it was found that GLN-rich, fish oil- and antioxidant-rich high-protein compared with isocaloric high-protein, early (EPA + DHA

)/long-chain fatty acid plasma level ratio may cause harm to critically ill patients. Therefore, high-dose omega-3 UFA-rich nutrition should not be routinely added.

During parenteral nutrition therapy, intravenous fat emulsions based solely on soybean oil, which is rich in 18-carbon omega-6 FA, should be avoided. There are several new fat emulsions that incorporate olive oil, fish oil, and coconut in various combinations.

Oil. Meta-studies have shown that lipid emulsions rich in fish oil or olive oil have advantages [99]. Prospective randomized studies have shown that the incidence rate in the fish oil group is lower compared with other lipid emulsions [100]. Grau-Carmona et al.

[101] In a multi-center prospective randomized double-blind study, it was found that compared with the use of long chain fatty acids (LCT)/MCT emulsions alone, the use of emulsions containing LCT (such as soybean oil), MCT and fish oil

The lipid emulsion can significantly reduce the infection rate. The formula of MCT and special nutrients that help digestion and absorption of LCT, such as taurine and L-carnitine, are easier to digest and absorb. Many prospective studies have compared these new lipid emulsions with each other.

, and compared with soy oil-based lipid emulsion, the results showed that patients using the new lipid emulsion shortened the hospital stay and also helped to reduce the infection rate [102, 103]. The use of fish oil-rich lipid emulsion in patients with sepsis helped shorten the ICU stay

Hospital stay and mechanical ventilation time[104].

Recommendation 34: It is not recommended to routinely add EPA/DHA or use high-dose enteral formulas rich in omega-3 fatty acids for enteral nutrition in critically ill neurosurgery patients.

Recommendation 35: Fat emulsions rich in EPA+DHA can be used for parenteral nutrition treatment in critically ill neurosurgery patients.

[6. Nutritional treatment under special circumstances for critically ill neurosurgery patients]

(1) Shock state

There is controversy over when to initiate enteral nutrition in critically ill neurosurgery patients in a state of shock. In patients who are very hemodynamically unstable, enteral nutrition is unlikely to help improve instability and may even further damage already damaged viscera.

Perfusion, a retrospective clinical observational study of 259 patients with hemodynamic instability found that 3 cases of patients who received early enteral nutrition developed intestinal ischemia and intestinal perforation [105]. Therefore, when shock is not controlled,

, it is recommended to delay the initiation of enteral nutrition. Persistent lactic acidosis may help identify uncontrolled shock states.

After initial hemodynamic stabilization, initiation of low-dose enteral nutrition can be considered without waiting for all vasopressor medications to be discontinued. In a large observational study, compared with late enteral nutrition (>48 h)

, early initiation of enteral nutrition (≤48 h) in hemodynamically “relatively stable” patients who are still receiving at least one vasopressor after fluid resuscitation may reduce mortality. Another recent review

A recent study showed that enteral nutrition did not affect hemodynamic stability, using whether the dosage of norepinephrine increased by more than 50% as an indicator. These results show that after initial control of shock, if the dosage of vasopressors is used to stabilize or

At reduced doses, small-dose enteral nutrition can be initiated [106].

Recommendation 36: If the shock is not controlled and the hemodynamic and tissue perfusion goals are not achieved, it is recommended to postpone enteral nutrition, but after the hemodynamics are initially stabilized (vasoactive drugs are stabilized or reduced), low-intensity nutrition should be started immediately

Dosage of enteral nutrition.

(2) Stress ulcers and upper gastrointestinal bleeding

Acute gastrointestinal mucosal erosion, ulcers, bleeding and other lesions that occur when the body is under severe stress can lead to gastrointestinal bleeding or even perforation in severe cases. The latest multi-center retrospective survey shows the occurrence of gastrointestinal bleeding in critically ill Chinese neurosurgery patients

The rate was 12.6%. A RCT comparing ranitidine and sucralfate reported that enteral nutrition is an independent protective factor against gastrointestinal bleeding [107]. A meta-analysis recommended the use of enteral nutrition to prevent stress-induced

Ulcers and gastrointestinal bleeding[108].

The main reason why patients with upper gastrointestinal bleeding are prohibited from eating/enteral nutrition is the fear of bleeding again, so for patients at high risk of bleeding again, enteral nutrition will be delayed after bleeding. The ESICM guidelines recommend starting enteral nutrition within 24 to 48 hours after the bleeding stops.

Internal nutrition [109]. If the bloody gastric contents are <100 ml/d, an enteral nutrition pump can be used to pump in nutrient solution. It is recommended to feed at a nasogastric feeding speed (20~50 ml/h) and detect gastric juice occult blood test once a day until

2 times are normal; if the bloody gastric contents are >100 ml/d, nasogastric tube feeding should be used with caution, and gastrointestinal decompression combined with nasojejunal tube feeding can be considered [109]. If still intolerable, supplementary enteral feeding should be considered.

External nutritional therapy.

Recommendation 37: Enteral nutrition is a protective factor in preventing stress ulcers and upper gastrointestinal bleeding. It is recommended that patients with stress ulcers use enteral nutrition early. For patients with upper gastrointestinal bleeding, it is recommended that 24 to 48 hours after bleeding stops.

Provide enteral nutrition.

(3) Mild hypothermia treatment

Under mild hypothermia conditions, the human body has a low metabolic rate and weak gastrointestinal motility. Whether enteral nutrition can be tolerated and whether it is complicated by complications such as vomiting and aspiration are issues that need to be solved. British researchers Williams and Nolan [111] studied cardiac arrest.

Patients who underwent hypothermia treatment after stopping found that during the hypothermia period, the enteral nutrition tolerance rate was 72% of the prescribed dose; during the rewarming period, the enteral nutrition tolerance rate was 95% of the prescribed dose; during the normothermia period, the enteral nutrition tolerance rate was 95% of the prescribed dose.

The tolerance rate is 100%. The onset time of complications such as nausea and vomiting is 24 to 48 hours after the start of hypothermia treatment. Therefore, during mild hypothermia treatment, 75% of the corresponding dose at normal temperature is given, or post-pyloric feeding is used

, can increase patient tolerance and reduce the risk of nausea, vomiting, and aspiration.

Recommendation 38: Low-dose (75%) enteral nutrition can be used during mild hypothermia treatment, and the dose can be gradually increased after rewarming. Programs to improve gastrointestinal tolerance should be more actively adopted during mild hypothermia treatment.

(4) Ventilation in prone position

The energy requirements of prone position ventilation patients are 30% to 50% higher than those of ordinary mechanical ventilation patients. Due to the position, the patient's intra-abdominal pressure increases and gastric motility decreases, resulting in 82% of patients with enteral nutrition in the prone position.

Due to tolerance issues, the daily feeding amount is actually lower than that of patients in the supine position, making the risk of malnutrition in patients in the prone position as high as 70% [112]. Some studies have shown that critically ill patients with severe hypoxemia who receive mechanical ventilation in the prone position

Enteral nutrition is feasible, safe, and not associated with an increased risk of gastrointestinal complications [113]. Therefore, it is not recommended to stop enteral nutrition therapy simply because of prone position ventilation.

Measures to improve feeding tolerance in the prone position:

1. Before implementing prone position ventilation, it is recommended to stop enteral nutrition 1 hour in advance and check the GRV with aspiration to prevent reflux and aspiration during turning and prone position ventilation.

2. The artificial airway air bag pressure needs to be measured before and after prone position ventilation is started, and the air bag pressure must be maintained at 2.94 kPa.

3. When placing the patient in the prone ventilation position, pay attention to avoid compressing the patient's abdomen and keep the head of the bed elevated to reduce intra-abdominal pressure and avoid increasing gastric emptying disorders.

4. The use of gastric motility drugs can help reduce the occurrence of enteral nutrition intolerance and increase the dosage of enteral nutrition.

5. Qualified medical institutions can use ultrasound to monitor the gastric antral motility index to guide the implementation of enteral nutrition in patients with prone position ventilation.

Recommendation 39: It is not recommended to stop enteral nutrition therapy simply because of prone position ventilation, and attention should be paid to taking measures to improve feeding tolerance.

(5) Mechanical ventilation

Mechanical ventilation is one of the causes of iatrogenic underfeeding. Spontaneous breathing disorders in critically ill neurosurgery patients will prolong the mechanical ventilation time, which can lead to a high risk of malnutrition and produce adverse clinical outcomes. The hypothalamus, brainstem and other nerves in critically ill neurosurgery patients

Impaired functions are prone to gastric emptying disorders. The lower the Glasgow Coma Scale (GCS) score, the greater the impact of mechanical ventilation support on the patient's energy needs and gastrointestinal function.

Critically ill neurosurgery patients who use mechanical ventilation often have hemodynamic instability in the early stage. The use of enteral nutrition at this stage should refer to the recommendations for enteral nutrition in shock. After resuscitation, as long as the gastrointestinal anatomy is complete and has certain functions

(especially motor function/absorptive function), enteral nutrition should be started as early as possible, and recovery of bowel sounds is not a necessary condition for enteral nutrition. Studies have shown that patients who start enteral nutrition early (within 24~48 hours) can reduce the need for mechanical ventilation

Time, early low-calorie feeding (<20 kcal·kg-1·d-1, protein 1.2~2.0 g·kg-1·d-1) is also suitable for patients with mechanical ventilation [114]. Patients who also receive enteral nutrition

Patients should have their daily energy needs monitored every 7 days so that nutritional support strategies can be adjusted.

Studies have shown that enteral nutrition treatment for critically ill mechanically ventilated neurosurgery patients with nasoenteric tube indwelling can help patients recover their consciousness, improve nutritional indicators, reduce the incidence of complications such as VAP, reflux, aspiration, etc., and shorten the course of the disease. For

For patients with enteral nutrition, raising the head of the bed 45° can help empty the gastric contents and reduce the occurrence of complications such as delayed gastric emptying, increased gastric residual volume, gastroesophageal reflux, vomiting, aspiration and VAP [

115]. Foreign studies have also confirmed that raising the head of the bed >30° can help reduce oral secretions, reflux and aspiration in mechanically ventilated patients without increasing the risk of pressure ulcers [116].

Recommendation 40: It is not recommended to delay the initiation of enteral nutrition in critically ill neurosurgery patients who are on mechanical ventilation alone.

(6) Sedation and analgesia

Patients with sedation and analgesia have reduced energy requirements. Sedation and analgesia will delay gastric emptying. Regardless of whether neuromuscular blockers are used concurrently, the risk of feeding intolerance in patients with deep sedation may increase. The use of opioid sedative and analgesic drugs can affect

Nutritional metabolism of patients reduces gastrointestinal motility, causing gastric retention, constipation, gastroesophageal reflux, weight loss, malnutrition and other nutritional problems, which will hinder the results of neurosurgery treatment.

Recommendation 41: Lower caloric feeding can be adopted for critically ill neurosurgery patients under sedation and analgesia.

[7. Nutritional treatment process management for critically ill patients in neurosurgery]

A number of clinical studies have found that the intervention group that applied feeding process management had significantly longer days of enteral nutrition implementation than the control group, and the start time of enteral nutrition was also earlier, and the mortality rate was reduced, the length of hospitalization was shortened, and the patient's prognosis was effectively improved. Recommendations

During the nutritional treatment process, feeding process management is adopted (Figure 1), and feeding intolerance is monitored and treated (Figure 2).

Recommendation 42: It is recommended to apply process management during nutritional treatment of critically ill neurosurgery patients.

[8. Nursing care during nutritional therapy for critically ill neurosurgery patients]

Nursing is an important part of nutritional therapy practice. During the nutritional therapy of critically ill neurosurgery patients, establishing a multidisciplinary nutritional therapy team composed of doctors, nutrition experts, nurses and pharmacists can help monitor the nutritional status of nutritional therapy patients.

Reduce gastrointestinal intolerance and reduce hospital stay and medical costs.

1. Operational requirements: During enteral nutrition operations, nursing staff need to pay attention to strict aseptic operating procedures, avoid repeated use of disposable items such as syringes and nutrition pump tubes, and maintain good hand hygiene habits to help reduce bacterial contamination of enteral nutrition solutions.

to reduce the risk of bacterial diarrhea. At the same time, care needs to pay attention to the "three degrees" of gastrointestinal nutrition, that is, the temperature, speed and concentration of the nutrient solution. It is recommended to use a dedicated gastrointestinal nutrition pump to provide stable infusion speed and appropriateness.

Warm nutrient solution can reduce gastrointestinal reactions.

2. Monitoring and adjustment of nutritional therapy: During nutritional therapy, it is often necessary to adjust the feeding strategy according to the patient's gastrointestinal condition. It is recommended that nursing staff routinely measure the abdominal circumference every day, monitor and record the frequency, shape and quantity of stools.

Before starting enteral nutrition, aspirate the gastric contents to understand the residual gastric condition and feedback to the doctor, and work with the doctor to formulate an enteral nutrition strategy. When gastrointestinal intolerance occurs, the frequency of monitoring needs to be increased, and the frequency of monitoring needs to be increased according to the patient's condition.
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