The incidence of Tian Xuemei Erdos Central Hospital (Kang Bashi) Pharmacy
Malnutrition increases infection and other complications:
Source: Center for evaluation of drug Increase hospital stay, increase mortality, and increase medical expenses.
Modern clinical nutritional support has surpassed the past by merely “providing energy” and restoring the “positive nitrogen balance”, while through metabolic regulation and immune function regulation, from structural support to functional support, The important role of “pharmacological nutrition” has become an important part of the treatment of modern critical patients and surgical major surgery patients.
The nutrients needed by the human body are mainly divided into three major nutrients (protein, fat, carbohydrate) and small three nutrients (vitamins, trace elements, water and electrolytes) . In clinical practice, artificial preparations are used to provide nutrients through different routes to meet the nutritional and metabolic needs of different patients and to carry out metabolic conditioning.
I. Nutritional Therapy
There are more comprehensive nutrients in the oral, intestinal or parenteral route, which are metabolically conditioned to become nutritional therapy.
1. Enteral nutrition (EN):
Provides nutrients through the digestive tract. The EN preparation is classified into a whole protein type, an amino acid type, and a short peptide type according to a nitrogen source. According to different ways of giving, it is divided into oral and tube feeding. At present, the main clinical use of EN is as follows, see Table 1.
Table 1: Enteral nutrition currently used mainly
2, parenteral nutrition (PN):
Intravenous route to provide amino acid and fat for patients who cannot pass the digestive tract or take nutrients that cannot meet their metabolic needs. Nutrients such as carbohydrates, vitamins and minerals to promote anabolism, inhibit catabolism, and maintain the structure and function of tissues and organs. Specific parenteral nutrition is shown in Table 2 below.
Scientific parenteral nutrition can meet the needs of patients for energy and protein, adjust nitrogen balance, promote protein synthesis, effectively improve the nutritional status of patients, reduce the incidence of complications, and improve the clinical outcome of patients. ending.
Table 2: Parenteral nutrition currently used mainly
When the timing, dosage and route of feeding for enteral and external nutrition in the clinic, when to switch to enteral or parenteral, or both There is an error in the use of knowledge. The following is a detailed description of these issues.
Question 1: Is the recipient of parenteral and external nutritional support given?
Enteral nutrition (EN) has a physiological state, can maintain the integrity of the structure and function of the intestine, has the advantages of low cost, ease of use and monitoring, and fewer complications, thus becoming The preferred clinical nutritional support treatment.
Parenteral nutrition (PN) is less physiological and prone to complications such as metabolism and catheterization.
At present, nutrition support treatment guidelines for nutrition associations in most countries strongly recommend that enteral nutrition (EN) should be preferred for patients requiring nutritional support because EN has greater conditioning and therapeutic effects than nutritional support itself. the value of.
However, many patients in the clinic are often unable to reach the actual needs of the body due to illness or treatment, resulting in insufficient energy or protein in the body, especially in critically ill patients. .
Clinically many critically ill patients are not only difficult to implement early enteral nutrition (EN) or poor intestinal tolerance due to illness or treatment, and most of the critically ill patients in most of the ICU, The use of enteral nutrition (EN) alone is difficult to meet the body’s energy and protein requirements, and it is easy to cause insufficient energy or protein in the body.
Patients with nutritional support therapy can increase energy and protein by parenteral nutrition (PN) if the energy and protein provided by enteral nutrition (EN) is less than 60% of the body’s target requirement. Intakes that meet the patient’s need for energy and protein, reduce or avoid negative nitrogen balance and inadequate feeding, can improve the patient’s clinical outcomes.
Question 2: When is the nutritional support for enteral and external nutrition?
If NRS-2002 ≤ 3 points or NUTRICScore ≤ 5 points for low-nutrition patients, if enteral nutrition (EN) fails to reach 60 Parenteral nutrition (PN) supportive therapy was initiated when % target energy and protein requirements exceeded 7 days.
If NRS-2002 ≥ 5 points or NUTRICScore ≥ 6 points for patients with high nutritional risk, if enteral nutrition (EN) does not reach 60 within 48 to 72 hours Early application of parenteral nutrition (PN) is recommended when % target energy and protein requirements are required.
How to determine the timing of parenteral nutrition (PN) is a hot topic in the field of clinical nutrition. Different international nutrition society guidelines are also inconsistent in the recommendations for parenteral nutrition (PN) timing.
European Nutrition Society (ESPEN) guidelines recommend that SPN should be initiated at 24 to 48 hours when the target amount is achieved. However, the recommendations of the American Society of Gastroenterology, the American Society of Parenteral and Enteral Nutrition, and the American Society for Critical Care (ASPEN/SCCM) guidelines suggest that regardless of the nutritional risk, the energy and protein provided by EN cannot meet the target requirement of 60. In the case of %, the PN is not used for the first week, but the PN is applied after one week.
Question 3: Dosages for parenteral and external nutrition?
When PN supports treatment, when the intestinal function gradually recovers, the amount of PN should be gradually reduced while gradually increasing the amount of EN, and efforts should be made to return to the oral diet.
How to provide a suitable nutrient substrate for the metabolic state of the body, maintain cell and tissue metabolism and organ structure and function, is an important goal of clinical nutritional support treatment. In clinical practice, due to trauma, infection and surgery, the metabolic changes of the body are not the same, and the demand for energy and nutrient substrates is also changing dynamically. Therefore, the body’s need for nutrients should be based on different disease conditions, different stages of the disease, and the function of important organs of the body.
Currently, the energy and protein requirements of patients are often calculated according to body mass and various energy formulas. However, these methods calculate the patient’s energy demand and cannot accurately reflect the actual condition of the patient, such as Although many patients have low body mass, due to factors such as trauma, infection or mechanical assisted ventilation, the body’s energy demand is high, resulting in a large difference between the actual energy requirement and the estimated value according to the formula. Therefore, it is necessary to accurately determine the actual energy expenditure of the patient to assess the actual target requirement of the body to prevent underfeeding or overfeeding.
Research shows that nutritional support is based on the energy requirements calculated by the Harris-Benedict formula, and 75% of patients will have inadequate feeding or overfeeding. For patients who cannot actually measure the patient’s energy expenditure, the target amount of calorie intake recommended by non-obese patients is 25kcal·kg-1·d-1, which is the key to implementing PN.
A large number of clinical studies have shown that PN-supported supplies should be supplemented with 80% to 85% of the actual EN and protein requirements to achieve the desired clinical outcome.
In recent years, more and more studies have shown that the supply of protein is an independent factor in clinical nutritional support efficacy and clinical outcomes. The protein intake recommended by the Nutrition Society in many countries in the guidelines is 1.2-2.0 g·kg-1·d-1. Patients with high metabolism such as burns or multiple injuries may need to consume more protein to meet the metabolic needs of the body, in order to better play the role of clinical nutritional support. It should be noted that during the PN support treatment, when the intestinal function is gradually restored At the same time, the amount of EN should be gradually increased, while gradually reducing the amount of PN and gradually withdrawing the PN.
At present, the pattern of nutritional support treatment shifts from a single PN or EN to PN combined with EN. This model not only overcomes the shortcomings of PN and EN single application, but also retains the advantages of PN and EN, which makes the patient’s nutritional support more rational, thus improving the effect of clinical nutritional support treatment.
When PN is insufficient as EN, another way of energy and protein supplementation has attracted more and more scholars at home and abroad. PN itself is only a means of nutritional support treatment, no distinction between good and bad.
Rational PN support therapy can improve a patient’s clinical outcome. In clinical practice, the implementation of PN needs to consider the supply of EN, the metabolic state of the body and the severity of the disease, select the appropriate infusion route, and follow the principle of individualization to maximize the benefit of patients.