RU2122345C1 - Method of post-operation enteric diet nutrition - Google Patents

Abstract

FIELD: enteric surgery. SUBSTANCE: invention relates to surgery of abdominal cavity and retroperitoneal space and aims at developing safe method of enteric nutrition allowing alimentation to be started in maximally early terms after surgical intervention, which is necessary to early suppression of catabolic phase of postoperative period. That aim is achieved by continuously monitoring intralumen pressure at the level of instillation of perfusion media as well as in proximal segment of small intestine near anastomoses being formed, and when propulsive activity of intestinal wall is present, transintestinal infusions are performed to reveal physiologically founded requirements for composition of solutions and mixtures. EFFECT: achieved safety of enteric nutrition.

Description

 The invention relates to medicine, namely to surgery of the organs of the abdominal cavity and retroperitoneal space.

 Most widely in the first days of the postoperative period, parenteral nutrition of patients operated on in connection with the pathology of the digestive tract is used.

 However, the possibilities of parenteral nutrition with adequate replenishment of the necessary calories, proteins, vitamins are limited, which forces us to look for other ways of delivering nutrients to the patient's body.

 Most specialists who develop this problem tend to believe that the most optimal combination of parenteral and enteral nutrition.

 The choice of products for enteral nutrition is also quite debatable. Most authors are looking for their own way to saturate the patient’s body with the necessary number of calories for existing postoperative disorders of the motor-evacuation and absorption functions of the intestine. Additional difficulties in resolving this problem are that with a number of surgical interventions, the pacemaker zone is damaged, which is responsible for the spread of the action potential along the length of the small intestine [1].

 The problem of maintaining a low osmolarity of the intestinal environment against the background of feeding is also extremely difficult, since this alone gives hope for the possibility of decompression of the upper digestive tract under the influence of absorption from the intestine. The overgrown intestine cannot adequately contract, and if contraction is noted, then without a propulsive effect, which is due to a reduction in blood flow in the organ wall. It is possible to restore blood flow by preparing for enteral nutrition, but this must be done purposefully in relation to a particular patient, which is only possible with modern methods of monitoring the state of the digestive system. Indirect methods - passage speed, electroenterography, phonography - are more suitable for scientific research and have not found application in clinical practice [1]. The most important condition for recognizing the control method as meeting all the requirements is the duration of registration, the possibility of constant monitoring of the patient and analysis of information even in the absence of a doctor (night time).

 As a prototype, we have chosen a method of postoperative enteral nutrition, which involves the appointment of nutrient mixtures in response to the appearance of signs of electrical activity of the intestine with traditional methods of its registration [2].

 A similar embodiment of postoperative enteral nutrition can be demonstrated by the following clinical observation.

 Patient D., 61 years old (IB N 12675) was operated on for a malignant tumor of the body of the stomach. Performed gastrectomy with the imposition of esophageojunoanastomosis. In the postoperative period, on the first day the patient was prescribed enteral nutrition according to the results of electroenterography - the occurrence of rapid fluctuations in the action potential. The usual rate of infusion of nutrient media (4–8 ml / min), which was usual for this technique, was used; the number of injected solutions at the indicated time was 800 ml. Immediately during feeding, the patient's condition changed little, but shortly after the end of the infusion of solutions into the intestine, severe paroxysmal pain appeared, accompanied by bloating, difficulty breathing. Only a few hours later the pain was stopped, other clinical signs of intestinal paresis persisted up to 5 days of the postoperative period, the severity of symptoms was significant. Further attempts to repeat enteral feeding were unsuccessful. The use of a complex of therapeutic measures (HBO, epidural anesthesia, gangliolytics, etc.) made it possible to improve the patient's condition a week after the intervention.

 The objective of the present invention is to develop a safe method of enteral introduction of nutrients into the patient’s body, which allows to begin alimony as soon as possible after the intervention in the volume necessary for the early elimination of the catabolic phase of the postoperative period.

 The basis for the effectiveness of the method is the monitor control of intraluminal pressure in response to the enteral administration of nutrients, answering the question of the time of onset of enteral nutrition, its qualitative and quantitative composition.

 The problem is achieved by the fact that they carry out controlled monitoring of intraluminal pressure at two levels, and when detecting propulsive activity of the intestine, they enter the intestines by the introduction of nutrient substrates.

 The method is as follows. To monitor the features of the functioning of the digestive tract, a surgical monitor MX-03 is used, which analyzes the state of the intraluminal environment and the parameters of the bioelectric activity of the hollow organ using electrodes fixed to the small intestine, brought to the front abdominal wall. Information about the activity of the intestine is included in the memory of the device, which allows you to create a program of enteral nutrition, taking into account the characteristics of the motor activity of the digestive tract over the past time.

 Manometry is performed by the open catheter method through a double-lumen probe inserted into the initial segment of the jejunum. Information about fluctuations in intraluminal pressure and the frequency of contractions of the intestine is entered into the monitor's memory in the mode of one- and eight-hour trends. Nutrient mixtures are introduced through a distally located segment of the intraluminal probe connected via a tee to a pressure gauge. At the same time, pressure is recorded on another segment of the probe and the bioelectric activity of the intestine (through the channel for monitor electroencephalography).

 The monitor operates in the "alarm" mode with an increase in intraluminal pressure of more than 30 cm of the water column. In case of excess pressure, changes in the enteral nutrition program are required (reduction in the rate of infusion; replacement of any component with distilled water to reduce the osmotic pressure in the intestinal lumen, stimulation of lymphatic drainage and absorption processes, decompression of the probe channels). An additional reason for making adjustments to the nutritional scheme is the occurrence of dysrhythmia or tachyenteria (an increase in the frequency of slow electric waves of more than 16 per minute). In the latter case, the occurrence of paretic changes from the intestinal loops, as well as the development of postoperative pancreatitis, are not ruled out.

 The rationale for the use of the proposed method of enteral nutrition was carried out on the basis of 70 clinical observations, which used the above-described method of controlled continuous monitoring of intraluminal pressure. In the examined patients there were no negative consequences of the early onset of tube feeding (failure of anastomoses, pancreatitis, obstruction, etc.). Special studies of protein metabolism showed that the duration of catabolic processes was significantly reduced in the analyzed cases. We give one of these clinical observations.

 Patient S., 68 years old, was operated on for a tumor lesion of the stomach (extirpation of the stomach with direct esophagoduodenoanastomosis was performed - source.ball. N 964 for 1992). In the preoperative period, a reduced nutrition of the patient was noted against the background of the phenomena of tumor intoxication, violation of the evacuation of food from the stomach. The need for early and complete enteral nutrition of the patient seemed quite obvious. Alimentation was carried out through a probe conducted to the jejunum, starting from the first day after the intervention. Analysis of the results of manometry and studies of bioelectric activity showed satisfactory parameters of intestinal activity at the indicated times, which allowed the introduction of 1.5 liters of solutions in the first 24 hours (distilled water, Ringer's solution, amino acid mixture). At the same time, no increase in intraluminal pressure was recorded, periodic activity of the small intestine was quickly restored, periods of activity were effective - they were accompanied by a decrease in intraluminal pressure by 10-15%, and there was not a single period of rhythm disturbance of slow electric waves according to electromyography. On the next day, there was also no traditional bowel paresis, the patient was not worried about bloating, signs of adequate evacuation activity of the digestive tract appeared. The patient was discharged from the clinic on the 12th day after the intervention in satisfactory condition, there were no postoperative complications, the nitrogen balance on the 5th day of the postoperative period was +35 g.

 Thus, the main goal was achieved - nutritional deficiency is eliminated in the optimal time with minimal risk.

 A comparative analysis of clinical observations with various methods of postoperative nutrition allows speaking out in favor of controlled enteral nutrition using monitor monitoring of intraluminal pressure, which is due to a significant decrease in the frequency of the most dangerous postoperative complications: anastomotic insufficiency by 8%, pancreatic necrosis by 5%.

 Thus, the proposed method for the controlled nutrition of postoperative patients not only approaches the requirements of guaranteed surgical care, but also reduces the catabolic phase of the postoperative period, allows predicting certain disorders of the intestinal activity, and optimizing the course of the postoperative period.

Claims (1)

 A method of postoperative enteral nutrition, including dynamic monitoring of the functional state of the small intestine and the introduction of nutrient media, taking into account this condition, characterized in that they carry out controlled monitoring of intraluminal pressure at the level of introduction of nutrient media and in the proximal small intestine, as well as measuring the bioelectric activity of the intestine and in the presence of its propulsive activity, nutrient media are introduced, and with an increase in intraluminal pressure above 30 cm aq. Art. and the occurrence of dyskritia or tachyenteria, the enteral nutrition program is corrected in compliance with physiologically sound requirements for the composition of solutions and mixtures.