RU2294147C2 - Method for detecting terms for the onset of enteral nutrition in children in resuscitation department - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: the present innovation deals with detecting the terms for the onset of enteral nutrition in children in Resuscitation Department due to injecting a test medium. One should fulfill an aqueous-evacuatory gastric sample due to intragastric, probe injection of 5-10 ml/min distilled water of 25-28°C, at the volume up to 10 ml in 1-yr-aged children, up to 20 ml - in 1-3-yr-aged children, up to 30-40 ml - in 3-7-yr-aged children, 50 ml and more - in children above 7 yr old or at the rate of 3 ml/kg body weight followed by fixing the time for the onset of evacuation of water introduced into duodenum from stomach with the help of ultrasound trial with ultrasound sensor at 5 MHz frequency constantly, for 20 min against the onset of investigation. If the time since the moment of liquid entering the stomach till the onset of its evacuation into intestinal lumen does not exceed 20 min it is possible to conclude upon the necessity for the onset of enteral nutrition. If the time of introduced liquid evacuation exceeds the first 20 min one should conclude upon impossibility of enteral nutrition; investigation should be carried out again once or twice daily, at interval of 8-12 h. The innovation enables to detect the method for artificial nutrition in every concrete case being adequate to patient's state and in optimal terms.

EFFECT: higher accuracy and efficiency of detection.

1 cl, 2 ex, 5 dwg

Description

The invention relates to medicine, namely to the diagnosis of the capacity of the gastrointestinal tract, and can be used in medical institutions and intensive care units.

Most researchers dealing with the problem of artificial nutrition of children in the intensive care unit consider enteral nutrition (EP) to be more physiological and economically affordable than parenteral [Clinical Nutrition Basics (Lecture Materials for courses of the European Association of Parenteral and Enteral Nutrition), trans. from English, - Petrozavodsk, 2003, p.11., 31. Barton R.G. Nutrition support in critical illness. - Nutr. Clin. Pract., 1994, Aug; 9 (4): 127-39., 39. Irving S.Y., Simone S.D., Hicks F.W., Verger J.T. Nutrition for the critically ill child: enteral and parenteral support. - AACN Clin Issues, 2000, Nov; 11 (4): 541-58].

However, the possibility of using enteral nutrition is limited by the state of the gastrointestinal tract (GIT), its functional capabilities for assimilation of food. Activation of the hypothalamic-pituitary-adrenal system in the early post-aggressive period, followed by the incretion of catecholamines and glucocorticoids in the bloodstream, characteristic of the early post-stress state, causes 25-65% of children admitted to the intensive care unit, dynamic gastrointestinal obstruction, manifested by depression of mobility complete stoppage of the intestine), malabsorption and evacuation, while increasing the tone of the sphincters [I.Haulike. Autonomic nervous system. - Bucharest, 1978, p. 82-83]. In this regard, the possibility of starting an EP requires an assessment of the intestinal motor function, the restoration of which is a necessary condition for the transition to EP.

Existing methods for determining the timing of the onset of enteral nutrition in children in critical conditions are divided into clinical (test for assimilation, auscultation of the abdomen), instrumental (electromyography of the muscles of the anterior abdominal wall, fibroesophagogastroduodenoscopy) and radiological (radiography of the abdominal cavity) [Miftakhov RN, Abdusheva GR DL Model predictions of electrical activity of the small bowel. - Biol. Cybern., 1996, Feb; 74 (2): 167-79, I. L. Tiger, M. A. Filippkin "X-ray diagnosis of diseases of the digestive system in children", Moscow, 1974, p.14-15].

The assimilation test is stressful, it requires the installation of a gastric tube, and the data obtained with its help on the ability of patients to absorb enteral nutrition are purely indicative, especially in young children. In addition, in violation of the technology of its implementation, passive reflux of acidic gastric contents into the respiratory tract of a child (regurgitation) with the development of severe tracheobronchial complications is possible.

Equipment for electromyography of the muscles of the anterior abdominal wall that records the bioelectrical activity of the muscles of the anterior abdominal wall is not manufactured by the medical industry and therefore the use of this method is limited to a narrow circle of specialized clinics of specialized research institutes. In addition, to date, no standards have been developed for assessing the electromyographic activity of the muscles of the anterior abdominal wall in children in critical conditions.

Fibroesophagoduodenoscopy is an effective way to assess the state of the digestive system, due to the possibility of direct visualization of the upper and middle sections of the gastrointestinal tract, but its use in this contingent is fraught with mechanical damage to the mucous and muscle layers of the gastrointestinal tract, due to a significant increase in the tone of the sphincter apparatus Gastrointestinal tract in the early post-aggressive period.

Thus, these methods for determining the timing of the onset of enteral nutrition in children in the intensive care unit are not sufficiently effective, cannot be used in the daily practice of children's intensive care units, and do not shorten the duration of treatment. Their use is limited by the presence of a large number of contraindications and requires the use of expensive equipment and special treatment rooms.

The prototype of this method for determining the timing of the start of enteral nutrition is an X-ray of the abdominal organs with a barium mixture, which consists in an X-ray study of the abdominal organs after receiving contrast agents (suspended barium) with subsequent fixation of the results on photographic plates [I.L. Tiger, M.A. . Filippkin "X-ray diagnosis of diseases of the digestive system in children", Moscow, 1974, S. 27-30].

However, the implementation of this method, adopted as a prototype, requires the transportation of a resuscitation patient, as well as the use of radiopaque substances (suspension of barium, iodolipol, etc.) that can induce the development of allergic reactions to administration, up to anaphylactic shock. To assess the function of the digestive tract in this way in dynamics, serial radiography of the abdominal organs is required (from 2 to 4 images), which leads to additional radiation exposure to the child.

The TECHNICAL RESULT of the proposed method is the possibility of carrying out the method in non-transportable patients, eliminating radiation exposure, and also eliminating the development of allergic reactions to the introduction of radiopaque substances in children in critical conditions.

The specified technical result is achieved by the fact that a water-evacuation stomach test is carried out directly in the intensive care unit by intragastric, tube injection of 5-10 ml per minute of distilled water at a temperature of 25-28 ° C, in a volume of up to 10 ml in children 1 year old, up to 20 ml - 1-3 years, up to 30-40 ml - 3-7 years, 50 ml or more - in children older than 7 years or at the rate of 3 ml per kg of body weight, followed by fixing the time for the start of evacuation of the introduced water from the stomach at 12- duodenum through ultrasound with a frequency sensor th 5 MHz continuously, for 20 minutes from the start of the study and, if the time from the receipt of fluid into the stomach before its evacuation into the intestinal lumen is less than 20 minutes, then make a conclusion about the possibility of starting enteral nutrition.

If the evacuation time of the injected fluid exceeds the first 20 minutes, then a conclusion is made about the impossibility of enteral nutrition, and the study is repeated 1-2 times a day, with an interval of 8-12 hours.

The proposed method registers the state of hypertonicity of the pyloric sphincter of the stomach and consists in determining the time from the introduction of distilled water into the stomach until it begins to be evacuated into the duodenum (water-evacuation test), determined visually, in real time, by means of ultrasound examination of the abdominal organs. Studies in the control group of 26 healthy children aged 1 month to 15 years indicate that normally the time of such evacuation does not exceed 20 minutes, averaging 14.35 + 3.5 minutes. The lengthening of the time of the beginning of evacuation for more than 20 minutes indicates the hypertonicity of the sphincter apparatus of the gastrointestinal tract and, accordingly, the functional failure of the intestine, i.e. about the impossibility of conducting EP.

The method is as follows.

Before the start of the study, a soft, plastic (polyurethane), single-channel nasogastric tube is installed for the child, the size corresponding to the age of the child. The probe is fixed with stripes of patch on two levels. To prevent possible regurgitation (passive reflux) of the test fluid, the patient is given a position with an elevated head end at an angle of 20-25 °.

After conducting a survey ultrasound examination of the abdominal organs, the emitter of the ultrasound apparatus is installed motionless above the pylorus area. In this case, the ultrasound probe is transversely positioned in the epigastric region, and by changing the angle of the probe, a clear image of the output section of the stomach and the initial section of the duodenum is achieved. Then, through a gastric tube, distilled water is introduced slowly into the patient’s stomach (injection rate of 5-10 ml per minute) in a volume of up to 10 ml in children 1 year old, up to 20 ml in 1-3 years, up to 30-40 ml - 3 7 years, 50 ml or more - in children older than 7 years (or at the rate of 3 ml per kg of body weight), with a temperature of 25-28 ° C. The indicated limitations in the volume of injected test fluid are used to prevent possible regurgitation (passive reflux) in patients in a coma. The temperature of 25-28 ° C is comfortable and does not irritate the mucous membrane of the esophagus and stomach.

The time of administration is noted. Over the next 20 minutes, in the U3 observation mode, the time is determined after which the evacuation of the first portion of the introduced fluid through the pyloric sphincter apparatus into the lumen of the duodenum begins. If the time from the receipt of the test fluid into the stomach before the start of its evacuation into the intestinal lumen does not exceed 20 minutes, the water-evacuation test is considered positive. This serves as an indication of the restoration of the motor function of the gastrointestinal tract and the possibility of the onset of enteral nutrition. The absence during the first 20 minutes of the study of the evacuation of distilled water from the stomach indicates the preservation of the hypertonicity of the sphincter apparatus of the intestine and the impossibility of enteral nutrition. Water evacuation test can be carried out repeatedly during the day, but not more often than every 8-12 hours. The time of occurrence of evacuation is recorded on an ultrasound scan.

To fix the start time of evacuation of the test fluid, a Hitachi EUB-405 mid-range portable ultrasound machine with a 5 MHz convex sensor is used.

Examples of the method

Example 1

Patient S.D., 3 months. The history of the disease №4263. Diagnosis: Intestinal invagination. Adhesive obstruction. He entered the general resuscitation department of the Tushino Children's City Clinical Hospital in Moscow on February 18, 2005 with intestinal obstruction. It was operated on 02.19.2005. In the early postoperative period, he received complete parenteral nutrition, including a solution of crystalline amino acids (10% amino steril), fat emulsion (10% lipovenosis), 10 and 40% glucose solutions, vitamins, anticholinesterase drugs, prokinetics.

On the fifth day of the early postoperative period, with the patient elevated at 20 °, after a survey ultrasound scan of the abdominal organs, an ultrasound probe is installed in the epigastric region (Fig. 1).

02.24.2005. 12 hours 21 minutes. The stretched bulb of 12 p / gut (bulbostasis) is clearly visible.

12 hours 22 minutes. Through a polyurethane probe, distilled water was introduced into the stomach slowly (injection rate of 8 ml per minute) in a volume of 10 ml, at a temperature of 28 ° C (Fig. 2).

12 hours 30 minutes. At 9 minutes, water is evacuated from the stomach at 12 p / c, the bulb of which stretches at that moment to 25 mm, then contracts to 10 mm, pushing the test fluid into the lumen of the duodenum (Fig. 3).

12 hours 32 minutes. The duodenum 12 returns to its original size (17 mm) (Fig. 4).

Conclusion: positive water evacuation test (9 minutes). Enteral nutrition can be carried out.

On the day of the study, the child started enteral nutrition with the Nutrilon-1 mixture.

The transition to enteral nutrition has reduced the treatment time and improved treatment results, contributing to the rapid restoration of the gastrointestinal tract in the early post-aggressive period.

Example 2

Patient H.N., 2 years old. Case history No. 1900. He entered the department of general resuscitation of the Tushino children's city hospital on January 25, 2005. Diagnosis: Bowel obstruction. Operated for intestinal obstruction, colonic invagination 01/26/2005

In the early postoperative period, he received complete parenteral nutrition, including solutions of crystalline amino acids (10% aminosteril), fat emulsion (10% lipovenosis), solutions of 10 and 40% glucose, prokinetics (cerucal), anticholinesterase (uretide), antibiotics.

On the 4th day of the early postoperative period, a water-evacuation gastric test was performed. The patient was in an elevated position of 20 °. After a survey ultrasound scan of the abdominal organs, an ultrasound probe with a frequency of 5 MHz was installed in the epigastric region. Then, through a polyurethane gastric tube, 20 ml of distilled water at a temperature of 25 ° C were introduced slowly (at a rate of 10 ml per minute) into the stomach. The time of completion of administration was recorded (12 h 30 m). Then, in the ultrasound observation mode, the time of the start of evacuation of test fluid from the lumen of the stomach to the lumen of the duodenum 12 was determined (Fig. 5). Conclusion: Evacuation occurred at 13 minutes (initial study time 12:30). Water evacuation test is positive. Enteral nutrition can be carried out.

On the day the child was examined, enteral nutrition with the Nutrison mixture was successfully started.

The transition to enteral nutrition has reduced the treatment time and improved treatment results, contributing to the rapid restoration of the gastrointestinal tract in the early post-aggressive period.

The proposed method for determining the timing of the onset of enteral nutrition in children in the intensive care unit was successfully applied in 42 children aged 3 months to 14 years with severe traumatic brain injury, peritonitis of the appendicular etiology, polytrauma and polysegmental pneumonia. The use of this method of determination made it possible to exclude radiation exposure in patients in the intensive care unit, and also to improve treatment results by assigning an artificial nutrition method adequate to the condition of patients at the optimal time for each particular clinical case.

The advantages of the proposed method:

1. The possibility of conducting directly in the intensive care unit, in non-transportable patients.

2. Non-invasive nature.

3. Does not require the use of radiopaque substances.

4. Eliminates radiation exposure of patients.

5. The possibility of re-conducting.

6. Allows real-time assessment of gastrointestinal function, as well as the effectiveness of prokinetic therapy in children in critical conditions.

7. The possibility of carrying out in children with pretumor and tumor processes.

Thus, on the basis of the studies established the high efficiency of the proposed method compared to the prototype, non-invasiveness and absolute radiation safety.

The method allows to determine in each specific clinical case, the method of artificial nutrition, adequate to the condition of patients in the optimal time.

The method can be used in non-transportable patients.

This method, unlike the prototype, can be used in children with pre-tumor and tumor processes.

Adverse reactions, complications against the background of the application of the method is not registered.

The simplicity, reliability and accessibility of the proposed method of treatment, the possibility of use in non-transportable patients makes it indispensable for the diagnosis of disorders of the motor function of the small intestine in children in critical conditions.

Claims (2)

1. A method for determining the timing of the onset of enteral nutrition in children in the intensive care unit by introducing a test medium, characterized in that they carry out a water-evacuation gastric test by intragastric, tube administration of 5-10 ml per minute of distilled water at a temperature of 25-28 ° C, in volume up to 10 ml in children 1 year of life, up to 20 ml - 1-3 years, up to 30-40 ml - 3-7 years, 50 ml or more - in children over 7 years old or at the rate of 3 ml per kg of body weight, followed by fixing the time of the beginning of the evacuation of the introduced water from the stomach into the duodenum 12 using ultrasound ultrasound probe ultrasound probe with a frequency of 5 MHz continuously for 20 minutes from the start of the study and if the time from fluid intake to the stomach before it begins to evacuate into the intestinal lumen does not exceed 20 minutes, then a conclusion is made about the possibility of starting enteral nutrition. 2. The method according to claim 1, characterized in that if the evacuation time of the injected liquid exceeds the first 20 minutes, then a conclusion is made about the impossibility of enteral nutrition and the study is repeated 1-2 times a day with an interval of 8-12 hours.

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