Preparations for parenteral nutrition, indications for it, complications. Means for parenteral nutrition

artificial nutrition is today one of the basic types of treatment of patients in a hospital. There is practically no area of ​​medicine in which it would not be used. The most relevant is the use of artificial nutrition (or artificial nutritional support) for surgical, gastroenterological, oncological, nephrological and geriatric patients.

Nutritional Support- a complex of therapeutic measures aimed at identifying and correcting violations of the nutritional status of the body using the methods of nutritional therapy (enteral and parenteral nutrition). It is the process of providing the body with food substances (nutrients) through methods other than regular food intake.

“The inability of the doctor to provide food for the patient should be regarded as a decision to starve him to death. A decision for which in most cases it would be difficult to find an excuse," wrote Arvid Vretlind.

Timely and adequate nutritional support can significantly reduce the incidence of infectious complications and mortality in patients, improve the quality of life of patients and speed up their rehabilitation.

Artificial nutritional support can be complete, when all (or most) of the patient's nutritional needs are provided artificially, or partial, if the introduction of nutrients by enteral and parenteral routes is additional to conventional (oral) nutrition.

Indications for artificial nutritional support are diverse. In general, they can be described as any disease in which the patient's need for nutrients cannot be provided naturally. Usually these are diseases of the gastrointestinal tract, which do not allow the patient to eat adequately. Also, artificial nutrition may be necessary for patients with metabolic problems - severe hypermetabolism and catabolism, high loss of nutrients.

The rule "7 days or weight loss by 7%" is widely known. It means that artificial nutrition should be carried out in cases where the patient cannot eat naturally for 7 days or more, or if the patient has lost more than 7% of the recommended body weight.

Evaluation of the effectiveness of nutritional support includes the following indicators: dynamics of nutritional status parameters; state of nitrogen balance; the course of the underlying disease, the condition of the surgical wound; the general dynamics of the patient's condition, the severity and course of organ dysfunction.

There are two main forms of artificial nutritional support: enteral (tube) and parenteral (intravascular) nutrition.

• Features of human metabolism during fasting

  The primary reaction of the body in response to the cessation of the supply of nutrients from the outside is the use of glycogen and glycogen depots as an energy source (glycogenolysis). However, the stock of glycogen in the body is usually small and depleted during the first two to three days. In the future, the structural proteins of the body (gluconeogenesis) become the easiest and most accessible source of energy. In the process of gluconeogenesis, glucose-dependent tissues produce ketone bodies, which, by feedback reaction, slow down the basal metabolism and begin the oxidation of lipid reserves as an energy source. Gradually, the body switches to a protein-sparing mode of functioning, and gluconeogenesis resumes only when fat reserves are completely depleted. So, if in the first days of fasting, protein losses are 10-12 g per day, then in the fourth week - only 3-4 g in the absence of pronounced external stress.

  In critically ill patients, there is a powerful release of stress hormones - catecholamines, glucagon, which have a pronounced catabolic effect. At the same time, the production or response to anabolic hormones such as somatotropic hormone and insulin is blocked. As is often the case in critical conditions, the adaptive reaction, aimed at destroying proteins and providing the body with substrates for building new tissues and healing wounds, gets out of control and becomes purely destructive. Due to catecholaminemia, the body's transition to using fat as an energy source slows down. In this case (with severe fever, polytrauma, burns), up to 300 g of structural protein per day can be burned. This condition is called autocannibalism. Energy costs increase by 50-150%. For some time, the body can maintain its needs for amino acids and energy, but protein reserves are limited and the loss of 3-4 kg of structural protein is considered irreversible.

  The fundamental difference between physiological adaptation to starvation and adaptive reactions in terminal states is that in the first case, an adaptive decrease in energy demand is noted, and in the second case, energy consumption increases significantly. Therefore, in post-aggressive states, a negative nitrogen balance should be avoided, since protein depletion ultimately leads to death, which occurs when more than 30% of the total body nitrogen is lost.

  • Gastrointestinal tract during fasting and in critical condition

    In critical conditions of the body, conditions often arise in which adequate perfusion and oxygenation of the gastrointestinal tract is impaired. This leads to damage to the cells of the intestinal epithelium with a violation of the barrier function. Violations are aggravated if there are no nutrients in the lumen of the gastrointestinal tract for a long time (during starvation), since the cells of the mucosa receive nutrition to a large extent directly from the chyme.

    An important factor damaging the digestive tract is any centralization of blood circulation. With the centralization of blood circulation, there is a decrease in the perfusion of the intestine and parenchymal organs. In critical conditions, this is aggravated by the frequent use of adrenomimetic drugs to maintain systemic hemodynamics. In time, the restoration of normal intestinal perfusion lags behind the restoration of normal perfusion of vital organs. The absence of chyme in the intestinal lumen impairs the supply of antioxidants and their precursors to enterocytes and exacerbates reperfusion injury. The liver, due to autoregulatory mechanisms, suffers somewhat less from a decrease in blood flow, but still its perfusion decreases.

    During starvation, microbial translocation develops, that is, the penetration of microorganisms from the lumen of the gastrointestinal tract through the mucous barrier into the blood or lymph flow. Escherihia coli, Enterococcus, and bacteria of the genus Candida are mainly involved in translocation. Microbial translocation is always present in certain amounts. Bacteria penetrating the submucosal layer are captured by macrophages and transported to the systemic lymph nodes. When they enter the bloodstream, they are captured and destroyed by the Kupffer cells of the liver. A stable balance is disturbed with uncontrolled growth of the intestinal microflora and a change in its normal composition (i.e. with the development of dysbacteriosis), impaired mucosal permeability, and impaired local intestinal immunity. It has been proven that microbial translocation occurs in critically ill patients. It is exacerbated by the presence of risk factors (burns and severe trauma, broad-spectrum systemic antibiotics, pancreatitis, hemorrhagic shock, reperfusion injury, exclusion of solid food, etc.) and is often the cause of infectious lesions in critically ill patients. In the United States, 10% of hospitalized patients develop a nosocomital infection. That's 2 million people, 580,000 deaths, and about $4.5 billion in treatment costs.

    Violations of the intestinal barrier function, expressed in mucosal atrophy and impaired permeability, develop quite early in critically ill patients and are already expressed on the 4th day of fasting. Many studies have shown the beneficial effect of early enteral nutrition (first 6 hours from admission) to prevent mucosal atrophy.

    In the absence of enteral nutrition, not only atrophy of the intestinal mucosa occurs, but also atrophy of the so-called gut-associated lymphoid tissue (GALT). These are Peyer's patches, mesenteric lymph nodes, epithelial and basement membrane lymphocytes. Maintaining normal nutrition through the intestines helps to maintain the immunity of the whole organism in a normal state.

• Principles of Nutritional Support

  One of the founders of the doctrine of artificial nutrition, Arvid Vretlind (A. Wretlind), formulated the principles of nutritional support:

  • Timeliness.

    Artificial nutrition should be started as early as possible, even before the development of nutritional disorders. It is impossible to wait for the development of protein-energy malnutrition, since cachexia is much easier to prevent than to treat.

  • Optimality.

    Artificial nutrition should be carried out until the nutritional status is stabilized.

  • Adequacy.

    Nutrition should cover the energy needs of the body and be balanced in terms of nutrient composition and meet the patient's needs for them.

• Enteral nutrition

  Enteral nutrition (EN) is a type of nutritional therapy in which nutrients are administered orally or through a gastric (intestinal) tube.

  Enteral nutrition refers to the types of artificial nutrition and, therefore, is not carried out through natural routes. For enteral nutrition, one or another access is required, as well as special devices for the introduction of nutrient mixtures.

  Some authors refer to enteral nutrition only methods that bypass the oral cavity. Others include oral nutrition with mixtures other than regular food. In this case, there are two main options: tube feeding - the introduction of enteral mixtures into a tube or stoma, and "sipping" (sipping, sip feeding) - oral intake of a special mixture for enteral nutrition in small sips (usually through a tube).

  • Benefits of Enteral Nutrition

    Enteral nutrition has several advantages over parenteral nutrition:

    • Enteral nutrition is more physiological.
    • Enteral nutrition is more economical.
    • Enteral nutrition practically does not cause life-threatening complications, does not require compliance with strict sterility conditions.
    • Enteral nutrition allows you to provide the body with the necessary substrates to a greater extent.
    • Enteral nutrition prevents the development of atrophic processes in the gastrointestinal tract.
  • Indications for enteral nutrition

    Indications for EN are almost all situations where it is impossible for a patient with a functioning gastrointestinal tract to meet the protein and energy needs in the usual, oral way.

    The global trend is the use of enteral nutrition in all cases where it is possible, if only because its cost is much lower than parenteral nutrition, and its efficiency is higher.

    For the first time, indications for enteral nutrition were clearly formulated by A. Wretlind, A. Shenkin (1980):

    • Enteral nutrition is indicated when the patient cannot eat food (lack of consciousness, swallowing disorders, etc.).
    • Enteral nutrition is indicated when the patient should not eat food (acute pancreatitis, gastrointestinal bleeding, etc.).
    • Enteral nutrition is indicated when the patient does not want to eat food (anorexia nervosa, infections, etc.).
    • Enteral nutrition is indicated when normal nutrition is not adequate to the needs (injuries, burns, catabolism).

    According to the "Instructions for the organization of enteral nutrition ..." The Ministry of Health of the Russian Federation distinguishes the following nosological indications for the use of enteral nutrition:

    • Protein-energy malnutrition when it is impossible to provide adequate intake of nutrients through the natural oral route.
    • Neoplasms, especially localized in the head, neck and stomach.
    • Disorders of the central nervous system: coma, cerebrovascular stroke or Parkinson's disease, as a result of which nutritional status disorders develop.
    • Radiation and chemotherapy in oncological diseases.
    • Diseases of the gastrointestinal tract: Crohn's disease, malabsorption syndrome, short bowel syndrome, chronic pancreatitis, ulcerative colitis, diseases of the liver and biliary tract.
    • Nutrition in the pre- and early postoperative periods.
    • Trauma, burns, acute poisoning.
    • Complications of the postoperative period (fistulas of the gastrointestinal tract, sepsis, anastomotic suture failure).
    • Infectious diseases.
    • Psychiatric disorders: anorexia nervosa, severe depression.
    • Acute and chronic radiation injuries.
  • Contraindications for enteral nutrition

    Enteral nutrition is a technique that is being intensively researched and used in an increasingly diverse group of patients. There is a breakdown of stereotypes about mandatory fasting in patients after operations on the gastrointestinal tract, in patients immediately after recovery from a state of shock, and even in patients with pancreatitis. As a result, there is no consensus on absolute contraindications for enteral nutrition.

    Absolute contraindications to enteral nutrition:

    • Clinically pronounced shock.
    • intestinal ischemia.
    • Complete intestinal obstruction (ileus).
    • Refusal of the patient or his guardian from the conduct of enteral nutrition.
    • Ongoing gastrointestinal bleeding.

    Relative contraindications to enteral nutrition:

    • Partial bowel obstruction.
    • Severe uncontrollable diarrhea.
    • External enteric fistulas with a discharge of more than 500 ml / day.
    • Acute pancreatitis and pancreatic cyst. However, there are indications that enteral nutrition is possible even in patients with acute pancreatitis in the distal position of the probe and the use of elemental diets, although there is no consensus on this issue.
    • A relative contraindication is also the presence of large residual volumes of food (fecal) masses in the intestines (in fact, intestinal paresis).
  • General recommendations for enteral nutrition
    • Enteral nutrition should be given as early as possible. Conduct nutrition through a nasogastric tube, if there are no contraindications to this.
    • Enteral nutrition should be started at a rate of 30 ml/hour.
    • It is necessary to determine the residual volume as 3 ml/kg.
    • It is necessary to aspirate the contents of the probe every 4 hours and if the residual volume does not exceed 3 ml / hour, then gradually increase the feeding rate until the calculated one is reached (25-35 kcal / kg / day).
    • In cases where the residual volume exceeds 3 ml / kg, then treatment with prokinetics should be prescribed.
    • If after 24-48 hours due to high residual volumes it is still not possible to adequately feed the patient, then a probe should be inserted into the ileum using a blind method (endoscopically or under X-ray control).
    • The nursing nurse who provides enteral nutrition should be taught that if she cannot do it properly, then this means that she cannot provide proper care to the patient at all.
  • When to start enteral nutrition

    The literature mentions the benefits of “early” parenteral nutrition. Data are given that in patients with multiple injuries immediately after stabilization of the condition, in the first 6 hours from admission, enteral nutrition was started. Compared with the control group, when nutrition began after 24 hours from admission, there was a less pronounced violation of the permeability of the intestinal wall and less pronounced multiple organ disorders.

    In many resuscitation centers, the following tactic has been adopted: enteral nutrition should begin as early as possible - not only in order to immediately achieve replenishment of the patient's energy costs, but in order to prevent changes in the intestine, which can be achieved by enteral nutrition with relatively small volumes of food introduced .

    Theoretical substantiation of early enteral nutrition.

    No enteral nutrition leads to:
    Mucosal atrophy.	Proven in animal experiments.
    Excessive colonization of the small intestine.	Enteral nutrition prevents this in the experiment.
    Translocation of bacteria and endotoxins to the portal circulation.	People have a violation of the permeability of the mucosa during burns, trauma and in critical conditions.

  • Enteral feeding regimens

    The choice of diet is determined by the condition of the patient, the underlying and concomitant pathology and the capabilities of the medical institution. The choice of method, volume and speed of EN are determined individually for each patient.

    There are the following modes of enteral nutrition:

    • Feed at a constant rate.

      Nutrition through a gastric tube begins with isotonic mixtures at a rate of 40-60 ml / h. If well tolerated, the feeding rate can be increased by 25 ml/h every 8–12 hours until the desired rate is reached. When feeding through a jejunostomy tube, the initial rate of administration of the mixture should be 20–30 ml/h, especially in the immediate postoperative period.

      With nausea, vomiting, convulsions or diarrhea, it is required to reduce the rate of administration or the concentration of the solution. At the same time, simultaneous changes in the feed rate and the concentration of the nutrient mixture should be avoided.

    • Cyclic food.

      Continuous drip introduction is gradually "squeezed" to a 10-12-hour night period. Such nutrition, convenient for the patient, can be carried out through a gastrostomy.

    • Periodic or session meals.

      Nutrition sessions for 4-6 hours are carried out only in the absence of a history of diarrhea, malabsorption syndrome and operations on the gastrointestinal tract.

    • Bolus nutrition.

      It mimics a normal meal, so it provides a more natural functioning of the gastrointestinal tract. It is carried out only with transgastric accesses. The mixture is administered by drip or syringe at a rate of not more than 240 ml for 30 minutes 3-5 times a day. The initial bolus should not exceed 100 ml. With good tolerance, the injected volume is increased daily by 50 ml. Bolus feeding is more likely to cause diarrhea.

    • Usually, if the patient has not received food for several days, a constant drip of mixtures is preferable to intermittent. Continuous 24-hour nutrition is best used in cases where there are doubts about the preservation of the functions of digestion and absorption.
  • Enteral nutrition mixtures

    The choice of a mixture for enteral nutrition depends on many factors: the disease and the general condition of the patient, the presence of disorders of the patient's digestive tract, the required regimen of enteral nutrition.

    • General requirements for enteral mixtures.
      • The enteral mixture must have sufficient energy density (at least 1 kcal/ml).
      • The enteral mixture should not contain lactose and gluten.
      • The enteral mixture should have a low osmolarity (no more than 300–340 mosm/l).
      • The enteral mixture should have a low viscosity.
      • The enteral mixture should not cause excessive stimulation of intestinal motility.
      • The enteral mixture should contain sufficient data on the composition and manufacturer of the nutrient mixture, as well as indications of the presence of a genetic modification of nutrients (proteins).

    None of the mixtures for complete EN contains enough free water to meet the patient's daily fluid requirement. The daily fluid requirement is usually estimated as 1 ml per 1 kcal. Most mixtures with an energy value of 1 kcal / ml contain approximately 75% of the required water. Therefore, in the absence of indications for fluid restriction, the amount of additional water consumed by the patient should be approximately 25% of the total diet.

    Currently, mixtures prepared from natural products or recommended for infant nutrition are not used for enteral nutrition due to their imbalance and inadequacy to the needs of adult patients.

  • Complications of enteral nutrition

    Prevention of complications is strict adherence to the rules of enteral nutrition.

    The high incidence of complications of enteral nutrition is one of the main limiting factors for its widespread use in critically ill patients. The presence of complications leads to frequent cessation of enteral nutrition. There are quite objective reasons for such a high frequency of complications of enteral nutrition.

    • Enteral nutrition is carried out in a severe category of patients, with damage to all organs and systems of the body, including the gastrointestinal tract.
    • Enteral nutrition is necessary only for those patients who already have intolerance to natural nutrition for various reasons.
    • Enteral nutrition is not natural nutrition, but artificial, specially prepared mixtures.
    • Classification of complications of enteral nutrition

      There are the following types of complications of enteral nutrition:

      • Infectious complications (aspiration pneumonia, sinusitis, otitis, infection of wounds in gastoenterostomies).
      • Gastrointestinal complications (diarrhea, constipation, bloating, regurgitation).
      • Metabolic complications (hyperglycemia, metabolic alkalosis, hypokalemia, hypophosphatemia).

      This classification does not include complications associated with the enteral feeding technique - self-extraction, migration and blockage of feeding tubes and tubes. In addition, a gastrointestinal complication such as regurgitation may coincide with an infectious complication such as aspiration pneumonia. starting with the most frequent and significant.

      The literature indicates the frequency of various complications. The wide spread of data is explained by the fact that there are no common diagnostic criteria for determining a particular complication and there is no single protocol for managing complications.

      • High residual volumes - 25% -39%.
      • Constipation - 15.7%. With long-term enteral nutrition, the frequency of constipation can increase up to 59%.
      • Diarrhea - 14.7% -21% (from 2 to 68%).
      • Bloating - 13.2% -18.6%.
      • Vomiting - 12.2% -17.8%.
      • Regurgitation - 5.5%.
      • Aspiration pneumonia - 2%. According to various authors, the frequency of aspiration pneumonia is indicated from 1 to 70 percent.
  • About Sterility in Enteral Nutrition

    One of the advantages of enteral nutrition over parenteral nutrition is that it is not necessarily sterile. However, it must be remembered that, on the one hand, enteral nutrition mixtures are an ideal environment for the reproduction of microorganisms and, on the other hand, there are all conditions for bacterial aggression in intensive care units. The danger is both the possibility of infection of the patient with microorganisms from the nutrient mixture, and poisoning by the resulting endotoxin. It must be taken into account that enteral nutrition is always carried out bypassing the bactericidal barrier of the oropharynx and, as a rule, enteral mixtures are not treated with gastric juice, which has pronounced bactericidal properties. Antibacterial therapy, immunosuppression, concomitant infectious complications, etc. are called other factors associated with the development of infection.

    The usual recommendations to prevent bacterial contamination are: use no more than 500 ml volumes of locally prepared formula. And use them for no more than 8 hours (for sterile factory solutions - 24 hours). In practice, there are no experimentally substantiated recommendations in the literature on the frequency of replacement of probes, bags, droppers. It seems reasonable that for droppers and bags this should be at least once every 24 hours.

• parenteral nutrition

  Parenteral nutrition (PN) is a special type of substitution therapy in which nutrients are introduced into the body to replenish energy, plastic costs and maintain a normal level of metabolic processes, bypassing the gastrointestinal tract directly into the internal environment of the body (usually into the vascular bed) .

  The essence of parenteral nutrition is to provide the body with all the substrates necessary for normal life, involved in the regulation of protein, carbohydrate, fat, water-electrolyte, vitamin metabolism and acid-base balance.

  • Classification of parenteral nutrition
    • Complete (total) parenteral nutrition.

      Complete (total) parenteral nutrition provides the entire volume of the body's daily need for plastic and energy substrates, as well as maintaining the required level of metabolic processes.

    • Incomplete (partial) parenteral nutrition.

      Incomplete (partial) parenteral nutrition is auxiliary and is aimed at selective replenishment of the deficiency of those ingredients, the intake or assimilation of which is not provided by the enteral route. Incomplete parenteral nutrition is considered supplementary nutrition if it is used in combination with tube or oral nutrition.

    • Mixed artificial nutrition.

      Mixed artificial nutrition is a combination of enteral and parenteral nutrition in cases where neither of them is predominant.

  • The main tasks of parenteral nutrition
    • Restoration and maintenance of water-electrolyte and acid-base balance.
    • Providing the body with energy and plastic substrates.
    • Providing the body with all the necessary vitamins, macro- and microelements.
  • Concepts of parenteral nutrition

    Two main concepts of PP have been developed.

    1. The "American concept" - the hyperalimentation system according to S. Dudrick (1966) - implies the separate introduction of solutions of carbohydrates with electrolytes and nitrogen sources.
    2. The "European concept" created by A. Wretlind (1957) implies the separate introduction of plastic, carbohydrate and fat substrates. Its later version is the "three in one" concept (Solasson C, Joyeux H.; 1974), according to which all the necessary nutritional components (amino acids, monosaccharides, fat emulsions, electrolytes and vitamins) are mixed before administration in a single container under aseptic conditions.

       In recent years, all-in-one parenteral nutrition has been introduced in many countries, using 3 liter containers to mix all the ingredients in one plastic bag. If it is not possible to mix "three in one" solutions, the infusion of plastic and energy substrates should be carried out in parallel (preferably through a V-shaped adapter).

       In recent years, ready-made mixtures of amino acids and fat emulsions have been produced. The advantages of this method are to minimize the manipulation of containers containing nutrients, reduce their infection, reduce the risk of hypoglycemia and hyperosmolar non-ketone coma. Disadvantages: sticking of fatty particles and formation of large globules that can be dangerous for the patient, the problem of catheter occlusion has not been solved, it is not known how long this mixture can be safely refrigerated.

  • Basic principles of parenteral nutrition
    • Timely start of parenteral nutrition.
    • Optimal timing of parenteral nutrition (until normal trophic status is restored).
    • Adequacy (balance) of parenteral nutrition in terms of the amount of nutrients introduced and the degree of their assimilation.
  • Rules for parenteral nutrition
    • Nutrients should be administered in a form adequate to the metabolic needs of the cells, that is, similar to the intake of nutrients into the bloodstream after passing through the enteric barrier. Accordingly: proteins in the form of amino acids, fats - fat emulsions, carbohydrates - monosaccharides.
    • Strict adherence to the appropriate rate of introduction of nutrient substrates is necessary.
    • Plastic and energy substrates must be introduced simultaneously. Be sure to use all the essential nutrients.
    • Infusion of high-osmolar solutions (especially those exceeding 900 mosmol/l) should be carried out only in the central veins.
    • PN infusion sets are changed every 24 hours.
    • When carrying out a complete PP, the inclusion of glucose concentrates in the composition of the mixture is mandatory.
    • The fluid requirement for a stable patient is 1 ml/kcal or 30 ml/kg of body weight. In pathological conditions, the need for water increases.
  • Indications for parenteral nutrition

    When carrying out parenteral nutrition, it is important to take into account that in the conditions of cessation or restriction of the supply of nutrients by exogenous means, the most important adaptive mechanism comes into play: the consumption of mobile reserves of carbohydrates, fats of the body and the intensive breakdown of protein to amino acids with their subsequent transformation into carbohydrates. Such metabolic activity, being initially expedient, designed to ensure vital activity, subsequently has a very negative effect on the course of all life processes. Therefore, it is advisable to cover the needs of the body not due to the decay of its own tissues, but due to the exogenous supply of nutrients.

    The main objective criterion for the use of parenteral nutrition is a pronounced negative nitrogen balance, which cannot be corrected by the enteral route. The average daily loss of nitrogen in intensive care patients ranges from 15 to 32 g, which corresponds to the loss of 94-200 g of tissue protein or 375-800 g of muscle tissue.

    The main indications for PP can be divided into several groups:

    • Impossibility of oral or enteral food intake for at least 7 days in a stable patient, or for a shorter period in a malnourished patient (this group of indications is usually associated with disorders of the gastrointestinal tract).
    • Severe hypermetabolism or significant loss of protein when enteral nutrition alone fails to cope with nutrient deficiencies (burn disease is a classic example).
    • The need for a temporary exclusion of intestinal digestion "intestinal rest mode" (for example, with ulcerative colitis).
    • Indications for total parenteral nutrition

      Total parenteral nutrition is indicated in all cases when it is impossible to take food naturally or through a tube, which is accompanied by an increase in catabolic and inhibition of anabolic processes, as well as a negative nitrogen balance:

      • In the preoperative period in patients with symptoms of complete or partial starvation in diseases of the gastrointestinal tract in cases of functional or organic damage to it with impaired digestion and resorption.
      • In the postoperative period after extensive operations on the abdominal organs or its complicated course (anastomotic failure, fistulas, peritonitis, sepsis).
      • In the post-traumatic period (severe burns, multiple injuries).
      • With increased protein breakdown or a violation of its synthesis (hyperthermia, insufficiency of the liver, kidneys, etc.).
      • Resuscitation patients, when the patient does not regain consciousness for a long time or the activity of the gastrointestinal tract is sharply disturbed (CNS lesions, tetanus, acute poisoning, coma, etc.).
      • In infectious diseases (cholera, dysentery).
      • With neuropsychiatric diseases in cases of anorexia, vomiting, refusal of food.
  • Contraindications for parenteral nutrition
    • Absolute contraindications for PP
      • Period of shock, hypovolemia, electrolyte disturbances.
      • Possibility of adequate enteral and oral nutrition.
      • Allergic reactions to components of parenteral nutrition.
      • Refusal of the patient (or his guardian).
      • Cases in which PN does not improve the prognosis of the disease.

      In some of the listed situations, PP elements can be used in the course of complex intensive care of patients.

    • Contraindications to the use of certain drugs for parenteral nutrition

      Contraindications to the use of certain drugs for parenteral nutrition determine pathological changes in the body due to underlying and concomitant diseases.

      • In hepatic or renal insufficiency, amino acid mixtures and fat emulsions are contraindicated.
      • With hyperlipidemia, lipoid nephrosis, signs of post-traumatic fat embolism, acute myocardial infarction, cerebral edema, diabetes mellitus, in the first 5-6 days of the post-resuscitation period and in violation of the coagulating properties of blood, fat emulsions are contraindicated.
      • Caution must be exercised in patients with allergic diseases.
  • Provision of parenteral nutrition
    • Infusion technology

      The main method of parenteral nutrition is the introduction of energy, plastic substrates and other ingredients into the vascular bed: into the peripheral veins; into the central veins; into the recanalized umbilical vein; through shunts; intra-arterially.

      When conducting parenteral nutrition, infusion pumps, electronic drop regulators are used. The infusion should be carried out within 24 hours at a certain rate, but not more than 30-40 drops per minute. At this rate of administration, there is no overload of enzyme systems with nitrogen-containing substances.

    • Access

      The following access options are currently in use:

      • Through a peripheral vein (using a cannula or catheter), it is usually used when initializing parenteral nutrition for up to 1 day or with additional PN.
      • Through a central vein using temporary central catheters. Among the central veins, preference is given to the subclavian vein. The internal jugular and femoral veins are less commonly used.
      • Through a central vein using indwelling central catheters.
      • Through alternative vascular accesses and extravascular accesses (for example, the peritoneal cavity).
  • Parenteral nutrition regimens
    • Round-the-clock introduction of nutrient media.
    • Extended infusion (within 18-20 hours).
    • Cyclic mode (infusion for 8-12 hours).
  • Preparations for parenteral nutrition
    • Basic requirements for parenteral nutrition products

      Based on the principles of parenteral nutrition, parenteral nutrition products must meet several basic requirements:

      • To have a nutritional effect, that is, to have in its composition all the substances necessary for the body in sufficient quantities and in proper proportions with each other.
      • Replenish the body with fluid, as many conditions are accompanied by dehydration.
      • It is highly desirable that the agents used have a detoxifying and stimulating effect.
      • The replacement and anti-shock effect of the means used is desirable.
      • It is necessary to make sure that the means used are harmless.
      • An important component is ease of use.
    • Characteristics of parenteral nutrition products

      For the competent use of nutrient solutions for parenteral nutrition, it is necessary to evaluate some of their characteristics:

      • Osmolarity of solutions for parenteral nutrition.
      • Energy value of solutions.
      • Limits of maximum infusions - the pace or speed of infusion.
      • When planning parenteral nutrition, the necessary doses of energy substrates, minerals and vitamins are calculated based on their daily requirement and the level of energy consumption.
    • Components of parenteral nutrition

      The main components of parenteral nutrition are usually divided into two groups: energy donators (carbohydrate solutions - monosaccharides and alcohols and fat emulsions) and plastic material donators (amino acid solutions). Means for parenteral nutrition consist of the following components:

      • Carbohydrates and alcohols are the main sources of energy in parenteral nutrition.
      • Sorbitol (20%) and xylitol are used as additional energy sources with glucose and fat emulsions.
      • Fats are the most efficient energy substrate. They are administered in the form of fat emulsions.
      • Proteins - are the most important component for building tissues, blood, synthesis of proteohormones, enzymes.
      • Salt solutions: simple and complex, are introduced to normalize the water-electrolyte and acid-base balance.
      • Vitamins, trace elements, anabolic hormones are also included in the parenteral nutrition complex.
    Read more: Pharmacological group - Means for parenteral nutrition.
  • Assessment of the patient's condition if parenteral nutrition is required

    When conducting parenteral nutrition, it is necessary to take into account the individual characteristics of the patient, the nature of the disease, metabolism, as well as the energy needs of the body.

    • Evaluation of nutrition and control of the adequacy of parenteral nutrition.

      The aim is to determine the type and extent of malnutrition and the need for nutritional support.

      Nutritional status in recent years has been assessed based on the definition of trophic or trophological status, which is considered as an indicator of physical development and health. Trophic insufficiency is established on the basis of anamnesis, somatometric, laboratory and clinical and functional parameters.

      • Somatometric indicators are the most accessible and include the measurement of body weight, shoulder circumference, thickness of the skin-fat fold and the calculation of the body mass index.
      • Laboratory tests.

        Serum albumin. With its decrease below 35 g/l, the number of complications increases by 4 times, mortality by 6 times.

        Serum transferrin. Its decrease indicates the depletion of visceral protein (the norm is 2 g / l or more).

        Excretion of creatinine, urea, 3-methylhistidine (3-MG) in the urine. A decrease in creatinine and 3-MG excreted in the urine indicates a deficiency of muscle protein. The 3-MG / creatinine ratio reflects the direction of metabolic processes towards anabolism or catabolism and the effectiveness of parenteral nutrition in correcting protein deficiency (urinary excretion of 4.2 μM 3-MG corresponds to the breakdown of 1 g of muscle protein).

        Control of blood and urine glucose concentrations: The appearance of sugar in the urine and an increase in blood glucose concentrations of more than 2 g / l requires not so much an increase in the dose of insulin, but a decrease in the amount of glucose administered.

      • Clinical and functional indicators: decrease in tissue turgor, the presence of cracks, edema, etc.
  • Monitoring parenteral nutrition

    The parameters for monitoring homeostasis parameters during complete PN were determined in Amsterdam in 1981.

    Monitoring is carried out over the state of metabolism, the presence of infectious complications and nutritional efficiency. Indicators such as body temperature, pulse rate, blood pressure and respiratory rate are determined in patients daily. The determination of the main laboratory parameters in unstable patients is mainly carried out 1-3 times a day, with nutrition in the pre- and postoperative period 1-3 times a week, with prolonged PN - 1 time per week.

    Particular importance is attached to indicators characterizing the adequacy of nutrition - protein (urea nitrogen, serum albumin and prothrombin time), carbohydrate (

    Alternative - parenteral nutrition is used only when it is impossible to carry out enteral (intestinal fistulas with significant discharge, short bowel syndrome or malabsorption, intestinal obstruction, etc.).

    Parenteral nutrition is several times more expensive than enteral nutrition. When it is carried out, strict observance of sterility and the rate of introduction of ingredients is required, which is associated with certain technical difficulties. Parenteral nutrition gives a sufficient number of complications. There are indications that parenteral nutrition can depress one's own immunity.

    In any case, during complete parenteral nutrition, intestinal atrophy occurs - atrophy from inactivity. Atrophy of the mucosa leads to its ulceration, atrophy of the secreting glands leads to the subsequent occurrence of enzyme deficiency, bile stasis occurs, uncontrolled growth and changes in the composition of the intestinal microflora, atrophy of the lymphoid tissue associated with the intestine.

    Enteral nutrition is more physiological. It does not require sterilization. Enteral nutrition mixtures contain all the necessary components. The calculation of the need for enteral nutrition and the methodology for its implementation are much simpler than with parenteral nutrition. Enteral nutrition allows you to maintain the gastrointestinal tract in a normal physiological state and prevent many complications that occur in critically ill patients. Enteral nutrition leads to improved blood circulation in the intestine and promotes normal healing of anastomoses after intestinal surgery. Thus, whenever possible, the choice of nutritional support should lean towards enteral nutrition.

Based on the principles of parenteral nutrition, parenteral nutrition products must meet several basic requirements:
1. To have a nutritional effect, that is, to have in its composition all the substances necessary for the body in sufficient quantities and in proper proportions with each other.
2. Replenish the body with fluid, since many conditions are accompanied by dehydration.
3. It is highly desirable that the agents used have a detoxifying and stimulating effect.
4. Substitutive and anti-shock effect of the means used.
5. Harmlessness of the means used.
6. Ease of use.
For the competent use of nutrient solutions for parenteral nutrition, it is necessary to evaluate some of their characteristics.

When planning parenteral nutrition, the necessary doses of energy substrates, minerals and vitamins are calculated based on their daily requirement and the level of energy consumption.
Components of parenteral nutrition.

The main components of parenteral nutrition are usually divided into two groups: energy donators (carbohydrate solutions - monosaccharides and alcohols and fat emulsions) and plastic material donators (amino acid solutions).
Energy donors.
Carbohydrates.

Carbohydrates are the most traditional sources of energy in the practice of parenteral nutrition.
Under normal metabolic conditions, 350-400 g of carbohydrates are administered per day, with impaired metabolism (stress, hypoxia, etc.) - 200-300 g. In this case, no more than 50% of the calculated daily volume is prescribed on the first day.
With the introduction of carbohydrates in maximum doses, a 2-hour break infusions is necessarily provided.
Types of carbohydrates.


fat emulsions.

Fat emulsions are analogues of chylomicrons synthesized in enterocytes. These are the most profitable sources of energy - the energy density of 1 gram is on average 9.1–9.3 kcal. More precisely, their energy content depends on the triglyceride spectrum. Usually, the calorie content of 10% fat emulsions is 1.1 kcal / ml, 20% solutions - 2.0 kcal / ml.
Types of fat emulsions.
There are three generations of emulsions that differ in triglyceride composition.
I generation - long-chain fat emulsions (Intralipid, Lipovenoz, Lipofundin S, Liposan).
II generation - emulsions containing medium chain triglycerides (which are more completely oxidized and represent a preferred source of energy). To prevent complications, it is especially important to observe the maximum infusion limits of 0.1 g/kg/h (2.0 g/kg/day). The rate of infusion of fat emulsions: 10% - up to 100 ml per hour, 20% - no more than 50 ml per hour.
III generation - structured lipids and emulsions with a predominance of omega-3 fatty acids.

The ratio of carbohydrates and fats in parenteral nutrition is usually 70:30. However, the proportion of emulsions can be increased, if necessary, up to 2.5 g/kg of body weight, or up to 65% of the daily calorie intake.

The composition of fat emulsions additionally includes glycerol (an energy substrate that provides blood isotonia and an anti-ketogenic effect involved in the synthesis of lipids and glycogen) and emulsifiers - egg phosphatides or lecithin (included in the structure of membranes).

Donators of plastic material.

Choice of amino acids.
When choosing drugs for PP, the following criteria should be considered.
1. It is advisable to use solutions with a higher nitrogen content.
2. The optimal ratio of leucine / isoleucine in solution is 1.6 or more.
3. The optimal ratio of essential amino acids / non-essential amino acids in solution is closer to 1.
4. The optimal ratio of essential amino acids / total nitrogen is closer to 3.
Types of amino acid preparations.
There are standard and specialized solutions.

Two- and three-component food.

The all-in-one technology was first developed by C. Solasson et al. back in 1974. The use of two- and three-component bags for parenteral nutrition, where the necessary quantities and metabolically correct ratios of amino acids, glucose, lipids and electrolytes are already selected, has a number of fundamental advantages before using isolated nutrient infusion:
1. High manufacturability, convenience and ease of use.
2. Simultaneous and safe introduction of all necessary nutrients.
3. Balanced composition.
4. Reducing the risk of infectious complications.
5. The ability to add the necessary micronutrients (vitamins-microelements).
6. Cost-effective technology.
Vitamins and minerals.

Requirements for vitamins and minerals during PN can vary significantly depending on the nature of the disease and the patient's condition.

PN nutrition can cause dyselectrolytemia, so nutritional support should be carried out under the control of the content of the main ions in the blood plasma (K, Na, Mg, Cl, Ca, P) with appropriate correction of their administration in case of clinical or laboratory disorders. Keep in mind that most amino acid solutions already contain a number of electrolytes.

Correction of vitamin and microelement disorders is mainly carried out according to the clinical symptoms of various disorders.

In most cases, standard solutions of vitamins and trace elements provide the daily requirement for them.
Plasma substitute solutions.

Parenteral nutrition also includes some plasma-substituting solutions (if energy substances are added to them - glucose, amino acids, etc.). Along with the delivery of essential nutrients, they increase the volume of circulating plasma, regulate water and electrolyte balance and acid-base balance, and therefore are intended mainly for the treatment and prevention of shock of various origins, normalization of blood pressure and improvement of hemodynamic parameters.

Therapeutic nutrition is one of the main components of the treatment of various diseases today.

Over the past 10 years, dry mixes based on enteral nutrients have especially clearly demonstrated the healing effect. They have a positive effect on the metabolism of the body of a patient with chronic or acute pathology.

Progress in the production of enteral artificial mixtures has awarded these drugs with the same qualities:

• The presence of biological value;
• The balance of various substances in accordance with the daily human need;
• The presence in the composition of proteins;
• An abundance of sugar, cholesterol, gluten, lactose.

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The most popular type of therapeutic mixture is the drug. It is a ready-to-use, high-quality, balanced formula that is ideally suited to the practice of enteral therapeutic nutrition.

There are two types of mixture: Nutrizon Standard And Nutrizon Energy. They are prepared for the nutrition of patients, and the first provides tolerance, is recommended for patients with lesions of the intestinal mucosa, disorders of the gastrointestinal tract, the second is used for hypercatabolism and hypermetabolism.

In general, Nutrizon fights against exhaustion, disorders of the body's swallowing and chewing functions, critical and coma states, and anorexia.

Indications for the use of dry enteral mixtures:

1. For patients suffering from diseases of the internal organs associated with metabolism (hypertension, coronary heart disease).
2. For patients with ailments of the digestive organs (biliary dyskinesia, neurasthenia and psychasthenia in children, chronic gastritis, irritable bowel syndrome).
3. For people with diseases of the internal organs associated with malnutrition (acid-dependent diseases of the digestive organs, enteritis with malabsorption and maldigestion, chronic pancreatitis).
4. For patients with diseases of the internal organs associated with disorders of the intestinal microbiocenosis (bronchopneumonia, eradication therapy for stomach ulcers).
5. With chronic gastritis, hypomotor dyskinesia, reduced secretion in the elderly in geriatrics.
6. To all people during environmentally professional stress in order to increase the level of working capacity.

The use of mixtures of this type can be prescribed by a doctor as oral supplementary or complete nutrition.

The main requirements that an enteral mixture must meet:

• lactose-free or low-lactose composition;
• not less than 1 kcal / ml of caloric density;
• not more than 340 mosm / l - osmolarity;
• must be of low viscosity for continuous administration;
• should not awaken excessive stimulation of intestinal motility;
• should include polyunsaturated fatty acids omega-3 fish oil.

The use of enteral mixtures is successfully used in the treatment of the following diseases in children:

• intestinal fistulas;
• Inflammatory diseases of the colon;
• With a decrease in digestibility;
• With low absorption capacity of the stomach and intestines;
• short bowel syndrome;
• Low dysfunctions of the gastrointestinal tract.

In addition, the use of enteral drugs has been documented in intensive care.

Tube feeding helps to reduce the frequency of postoperative complications, post-traumatic deterioration in health, provides a natural way of excretion of food, helps to reduce the time of treatment of patients with acute injuries, and shortens the period of parenteral nutrition.

Nutrient mixtures for enteral nutrition expand the likelihood of nursing sick children from a critical condition.

The main advantages of dry mixtures of enteral nature are:

• The presence of trace elements and vitamins that strengthen the immune system;
• Balanced composition based on the needs of the body of children;
• The presence of proteins with an optimal composition of amino acids that promote the synthesis of glutathione, an important antioxidant;
• The absence of lactose and gluten, due to which the mixtures can be used with impaired gastrointestinal functions;
• The presence of fatty acids in the ratio of omega 6 / omega 3, which helps to reduce inflammation;
• The presence of L-carnitine, taurine, which are necessary for intensive care patients.

The most popular medicinal preparations for children are dry mixtures for enteral nutrition Nutricia. They are characterized by versatility, a complete balanced diet.

It is taken orally or applied by probe method: for introduction into the gastrointestinal tract using a probe. Can be used for critical stages of enteral nutrition or adaptive.

Enteral therapeutic mixtures help with diabetes, and are primarily designed to reduce the amount of carbohydrates.

All mixtures of this class do not include glucose in their composition, and fructose, dietary fiber, maltodextrin and starch act as a source of carbohydrates. Dietary fiber is presented in the form of petine, and in addition to taurine and L-carnitine, mixtures for diabetics contain M-inositol.

Enteral tube feeding is necessary for patients who cannot independently take food through the mouth for 2-3 days. This may be due to the plastic needs of the body or energy. All patients in the absence of contraindications should receive enteral nutrition.

In general, enteral nutrition is the progress of mankind in the field of medicine.

It is the best stimulant of the body, supports vital functions, helps in the fight against a number of chronic and acute diseases.

The unique composition of the preparations is characterized by high quality, confirmed by certificates and laboratory tests.

The choice of enteral formula depends on a number of factors. Note that a high-quality enteral mixture should:

Have sufficient energy density (at least 1 kcal / ml);

Have a low osmolarity (no more than 300-340 mosm / l);

Have a low viscosity;

Do not cause excessive stimulation of intestinal motility;

Currently, mixtures prepared from natural products or recommended for infant nutrition are not used for enteral nutrition due to their imbalance and inadequacy to the needs of adult patients. In previous years, Spasokukotsky's breakfast and the Zond mixtures developed by Professor E.P. Kurapov (1974) were used for these purposes.

Currently, the following types of mixtures for EP are distinguished (Table 14.1):

1. Standard.

2. Semi-element mixtures.

3. Modular mixtures.

4. Directional mixtures.

Types of mixtures for enteral nutrition

Standard mixtures - contain all the necessary macro- and micronutrients in accordance with the daily needs of the body. Proteins are contained in a whole, non-hydrolyzed form (milk, soy). Fats are represented by vegetable oils (sunflower, soybean, corn, etc.). Carbohydrates - in the form of maltodextrins (starch hydrolysates).

Standard mixtures are used in most clinical situations where there are indications for enteral nutrition, with the exception of severe disorders of digestion and absorption of nutrients, as well as organ pathology (hepatic, renal, etc.).

Semi-elemental mixtures are also fully balanced nutrients, in which proteins are presented in the form of peptides and amino acids (protein hydrolysates). They are prescribed for severe disorders of the digestive and absorption functions (malabsorption, diarrhea), including in the early postoperative period.

In our country, semi-elemental mixtures of Nutrien Elemental and Peptamen are used.

Modular mixtures contain only one of the nutrients (protein, fat) or individual amino acids (glutamine), metabolism regulators (L-carnitine). They are used to supplement the diet of artificial or conventional medical nutrition.

Protein modules (protein hydrolysates) are aimed at increasing the protein quota in the daily diet and are used when protein requirements increase or protein is lost. The energy module (consisting of maltodextrin) allows you to increase the energy value of the diet.

The module of medium chain triglycerides (MCT - medium chain triglycerides) contains fatty acids with 6-12 carbon atoms (caproic, caprylic, etc.), which are absorbed without the participation of lipase and bile acids and are absorbed in the small intestine into the blood of the portal vein, and not into the lymph . This module is prescribed for disorders of digestion, absorption and absorption of fats.

The L-carnitine module promotes fat oxidation in cell mitochondria. In ordinary food, only meat products contain carnitine. It is prescribed for exhaustion of any origin, during pregnancy and lactation, against the background of unloading and vegetarian diets, in sports nutrition.

Modular mixtures can be used to enrich the usual oral diet and added to natural products (cereals, soups, etc.)

Targeted mixtures are created in such a way as to correct metabolic disorders typical for this pathology (hepatic, renal, respiratory failure, immune disorders, diabetes mellitus).

In case of liver dysfunction (liver failure, encephalopathy), mixtures with an altered protein component are prescribed, in which the content of branched-chain amino acids (valine, isoleucine, leucine) is increased and the content of aromatic amino acids (phenylalanine, tyrosine, tryptophan) and methionine are reduced.

In our country, hepatic mixtures for EP Nutrien Gepa and Gepamine are used.

In case of impaired renal function (acute or chronic renal failure), mixtures with an altered protein component, mainly represented by essential amino acids and histidine, and a reduced content of potassium, sodium, chlorides, phosphorus and vitamin D are prescribed.

In Russia, mixtures for EP in renal patients are used Nutricomp ADN Renal, Nutrien Nefro, Renamin.

In case of respiratory failure, mixtures are prescribed with an increase in the proportion of fats and a decrease in the proportion of carbohydrates, with the inclusion of antioxidants - vitamins E and C, p-carotene, selenium and taurine.

In our country, there is an enteral mixture for patients with respiratory failure "Nutrian Pulmo".

In case of impaired immunity, the threat of infection or sepsis, mixtures with a high content of glutamine, arginine, ribonucleic acid, u-3 fatty acids, L-carnitine are prescribed.

The first immuno-oriented mixture for EN was Impact (Switzerland). In Russia, mixtures of Nutrien Immun and Stresson are used.

In diabetes mellitus and hyperglycemic conditions, mixtures containing fructose, pectin and microcrystalline cellulose are prescribed.

In Russia, mixtures of Nutricomp ADN Diabetes, Nutrien Diabetes, Diazon are used.

For additional nutrition of pregnant and lactating women, mixtures containing the necessary pharmaconutrients for both mother and fetus, including growth factors (taurine, choline, carnitine, inositol), are used.

In Russia, for additional EP for pregnant and lactating women, mixtures of Dumil Mama Plus, Dumil Mama, Femilak, Enfa Mama are used.

A number of enteral mixtures are currently presented on the Russian market, differing in energy density, osmolarity, content of pharmaconutrients (Tables 14.2, 14.3, 14.4).

Table 14.2

Table 14.4

Comparative characteristics of specialized dry mixes for enteral nutrition on the example of preparations of the Nutricomp series (per 100 g of dry matter)

Note that none of the mixtures for complete EN contains enough free water to meet the patient's daily fluid requirement (usually 1 ml/kcal). Most mixtures with an energy value of 1 kcal / ml contain approximately 75% of the required water. Therefore, in the absence of indications for fluid restriction, the amount of additional water consumed by the patient should be approximately 25% of the total diet.

In life, there are different situations when an adult cannot eat in the usual way. This happens mostly after surgery. During the recovery period, a person is unable to chew and rise to digest food. But also at this time, the patient needs a constant intake into the body for the functioning of all organs and the restoration of life. In this case, this type of food intake into the body, such as enteral nutrition, is used.

Enteral nutrition - what is it?

This is a type of patient therapy, its peculiarity is that food is supplied through a probe or a special system. Most often, special mixtures are used for this. They differ from the usual food for an adult, since in certain conditions the patient cannot take other foods.

The benefits of this food

This type of nutrition has its advantages for patients:

Indications for enteral nutrition

The development of medicine in the last two centuries has made it possible to determine what will be best for a person after surgery, methods that will help him recover faster and get the necessary strength with the least risk. So nutrition with mixtures after operations with the help of additional medical devices has its advantages and indications. There are certain indications specifically for the mixtures that a person needs, as well as for the very method of eating. Artificial nutrition is prescribed if:

1. The patient, due to his condition, cannot eat when he is unconscious or unable to swallow.
2. The patient should not eat food - this is a condition of acute pancreatitis or bleeding in the gastrointestinal tract.
3. A sick person refuses food, then forced enteral nutrition is used. What is it when such a state arises? This happens with anorexia nervosa, in which it is impossible to immediately load the stomach with ordinary food, since there is a danger of death after a long absence of food. Also, with various infections, the patient may refuse to eat, in which case an enteral nutrition system is used to fill the body with the necessary nutrients to fight this infection.
4. Nutrition does not meet the needs, this happens with injuries, catabolism, burns.

This type of nutrition is also prescribed for the following pathological conditions of the body:

• lack of protein and energy in the body, if it is not possible to ensure the intake of these substances in a natural way;
• in the event of various neoplasms in the head, stomach and neck;
• if there are progressive diseases of the central nervous system, for example, Parkinson's disease, cerebrovascular stroke, various states of unconsciousness;
• in oncological conditions after radiation and chemotherapy;
• often such nutrition is prescribed for severe diseases of the gastrointestinal tract: pancreatitis, pathological processes in the liver and biliary tract, malabsorption syndromes and short intestine, as well as Crohn's disease;
• immediately after the surgical intervention in the body;
• with burns and acute poisoning;
• with the appearance of fistulas, sepsis;
• if complex infectious diseases develop;
• with severe depression;
• with varying degrees of radiation damage to humans.

Ways to administer nutrient mixtures

Enteral nutrition of patients differs in the way of eating:

1. Using a probe to introduce the mixture into the stomach.
2. The "sipping" method of nutrition is the intake of special food orally in small sips.

These methods are also called passive and active. The first is enteral tube feeding, infusion occurs using a special system and a dispenser. The second is active, manual, carried out mainly with a syringe. To use this method, it is necessary to collect a certain amount of the mixture and inject gently into the oral cavity of a sick person. To date, the advantage is given to infusor pumps, which automatically supply the mixture.

Enteral feeding tubes

Many relatives of patients ask: enteral nutrition - what is it and what means are needed for this? Indeed, for this method of filling the body with food, different probes are needed. They are divided into:

• nasogastric (nasoenteric) - thin plastic probes that have holes at a certain level, as well as weights for ease of insertion;
• percutaneous - are introduced after surgery (pharyngoscopy, gastrostomy, esophagostomy, jejunostomy).

Modes of providing nutrition to the body

To understand such a question, enteral nutrition - what it is, is not yet enough for its implementation. There are many nuances of introducing food into the body in this way, for example, the feed rate of the mixture. There are several modes of receiving nutrition by the patient.

Naturally, these regimens cannot be adjusted to all patients who need enteral nutrition. The selection of the method, speed and volume of such a supply of food to the body takes into account individual characteristics.

Features of the choice of mixtures

Enteral nutrition mixtures should also be tailored to the individual needs of patients. Their choice depends on several factors.

It should be noted that formula for children, as well as solutions prepared from natural products, are not suitable for enteral nutrition. They are not balanced for an adult, so they cannot bring the desired result. For patients in need of such nutrition, their own types of mixtures have been developed, which we will consider below.

monomer mixtures

The name of the mixtures determines their purpose. They do not contain the entire necessary set of trace elements, but are also used in such mixtures, which consist of glucose and salts, which makes it possible to restore the functionality of the small intestine immediately after surgery. In the presence of vomiting or diarrhea, such nutrition well maintains the water and electrolyte balance in the human body. Such mixtures include Gastrolit, Mafusol, Regidron, Citroglucosolan, Orasan and some others.

Elemental mixtures for nutrition

This food block for patients is based on precisely selected chemical elements. They are used in specific cases of metabolic disorders in the body with pathologies such as liver and kidney failure, diabetes mellitus and pancreatitis. In this case, the pancreas, liver and kidneys cannot perform their specific functions, therefore such mixtures help a person at least partially restore vital activity. This type of nutrition includes Vivonex, Flexical, Lofenalak and others.

Semi-element mixtures

These nutrient mixtures for patients are used more often than the previous ones. This is due to the fact that they are already more balanced and suitable for a wide range of patients requiring enteral nutrition. Here, proteins are already in the form of amino acids and peptides, which allows them to be more easily absorbed in the body. Such solutions are used immediately after operations in violation of the digestive function of the body. These include Nutrien Elemental, Nutrilon Pepti TSC, Peptisorb, Peptamen.

Standard polymer blends

This type is used for many diseases after operations, when a person is in a coma. They are the most suitable for an adult body in their composition. Such solutions contain all the necessary minerals, trace elements, proteins, fats, carbohydrates. They are divided into three types.

1. Dry, which must be diluted and injected into the body through a probe. This is the following enteral nutrition: Nutrizon, Berlamin Modular, Nutricomp Standard.
2. Liquid, which can be administered immediately. They are designed for situations where there is not a minute to lose, supplying vital nutrition to a person. These include Berlamin Modular, Nutricomp Liquid, Nutrizon Standard and some others.
3. Mixtures that are used orally. These are "Nutridrink", "Forticrem" and so on.

Directional mixes

This type of nutrition is similar in purpose to the elemental type of mixtures. They are designed to restore the functionality of the body in a specific pathology. They correct metabolic disorders in respiratory failure, impaired kidney and liver function, and immunity.