ARTIFICIAL NUTRITION it is applied at impossibility or insufficiency of food in the natural, oral way. Distinguish parenteral food (see) and probe enteroalimentation. Full parenteral food with use of mixes of amino acids, fatty emulsions, vitamins, electrolytes and other substances can is long to provide existence of the patient.
Great practical value has a method of a probe enteroalimentation. Probe food is carried out in three types: through oro-or the nazogastralny probe, through a gastrostomy (see. Gastrostomy ) and eyunosty (see. Enterostomy ). In some cases, napr, at sharply exhausted patients, and also after operation of a gastrectomy, transeyunalny or transduodenal probe food is shown. Artificial probe nutrition is more rational, than parenteral, and allows to enter enough necessary nutrients and to compensate a metabolic cost of an organism. Necessary conditions of probe food are lack of mechanical obstacles in went. - kish. path (cicatricial narrowings, obturation tumor) and its normal motor evakuatornaya function.
The artificial enteroalimentation via the probe is applied: after an injury of bodies of an oral cavity, a throat and a throat or after operations on them, at fractures of jaws; at an injury of a gullet and after gullet and stomach operations with recovery of a continuity went. - kish. path; at the enteric fistulas formed as a result of damage of a gut or imposed artificially (jejunostomy) — in these cases food via the probe entered into a gut through fistula is used; at the increased losses of protein and simultaneous anorexia (extensive burns of a body surface, heavy pyoinflammatory processes, etc.); at disturbance of the act of swallowing; at a severe craniocereberal injury with a long loss of consciousness and at comas of other origin; at the neudalimy tumors of a gullet, throat causing obturation of a gleam of these bodies (long food through a gastrostomy is carried out).
For enteral probe food soft plastic, rubber or silicon drainage tubes with outside to dia are used. 3 — 5 mm. For a long time on-zogastralnye and nasoenteric probes patients transfer better, than the probes entered through an oral cavity.
The probe is entered before operation and the beginning of the general anesthesia or during operation. The distal end of the probe during operation shall be spent to initial department of a jejunum or is 20 — 30 cm lower than the imposed anastomosis. At not operated patients exact carrying out the end of the probe can be carried out by means of a gastroduodenoskop. The probes which are specially released for an enteroalimentation have an olive on the end that facilitates control of introduction of the probe and its situation.
Item and. through a gastrostomy and an eyunosto-ma it can be carried out through the tube residing in a gleam of body or entered only for the period of introduction of food. The second option saves the patient from constant carrying a tube, but demands creation of the special closing mechanism during operation of a gastrostomy and a jejunostomy.
Probe food is carried out by specially picked up mixes containing enough proteins, fats, carbohydrates, vitamins. Calculation of necessary amount of the main food ingredients and the general daily kalo-passion (taking into account the possible increased loss of proteins) is facilitated by use of special drugs for an enteroalimentation («enpit») released by the industry. At their absence various feedstuffs in a liquid or semi-fluid state homogenized in the mixer and also children's food mixes can be used.
Probe food can be carried out by a fractional method or kapelno, but it is the best of all by means of special portioning devices at which in the mode of a giperalimen-tation of P. and. it is possible to carry out round the clock.
Intensity of intake of food mixes is defined by feelings of the patient and frequency of a chair. At too intensive introduction pain in a stomach and a repeated liquid chair appears.
Probe food through intestinal fistula in order to avoid regurgitation through fistula of food mix shall be carried out via the probe entered into a gleam of a gut not less than on 40 — 50 cm with use of the obturator of fistula.
After operations on a gullet and an upper part of a stomach need for probe food usually does not exceed 6 — 7 days. The exception of oral food for this term at good probe nutrition allows to create optimal conditions for healing of the line of an anastomosis, and in case of insolvency of seams of an anastomosis — a condition for healing of its defect after drainage of area of an anastomosis. In these cases, and also at extensive burns it is also purulent - necrotic processes probe food via the nazogastralny probe can be carried out during 30 days and more.
In the presence of enteric fistulas probe food allows to recover quickly broken exchange processes and to create optimal conditions for radical operation of elimination of intestinal fistula, at heavy burns and gnoynonekrotichesky processes — to normalize proteinaceous deficit and to create optimal conditions for plastic surgeries and an angenesis.
Contraindications to a method P. and. via the probe is not present.
Complications. At long finding of the nazogastralny or nazoyeyunalny probe owing to regurgitation in a gullet of gastric or intestinal contents development heavy ulcer a reflux esophagitis is possible (see. Esophagitis ), the bleeding leading in certain cases to emergence or a cicatricial stenosis of a gullet. The wrong provision of a gastrostomy or eyunostomiche-sky tube can lead to formation of decubitus and perforation of body with development of heavy complications.
Artificial nutrition at children
Indications for enteral probe artificial nutrition at children are: deep prematurity, patrimonial cranial mozgo-vaya an injury, a brain coma, anorexia nevrol, character, a state after injuries of bodies of an oral cavity, throat and operations on them, burns of an oral cavity, a throat, gullet and stomach, a state after reconstructive gullet and stomach operations. In two last cases carrying out the probe through gastro-or enterosty is reasonable.
Those ways P. are preferable to children and., to-rye do not exclude a gastric phase of digestion that is especially important for children of the first year of life whose diet consists generally of dairy products. In need of P. and. through ente-rosty or a gastrostomy with provede-
niy the probe pretreatment of foodstuff is carried out to initial departments of a small bowel: they are kept in mix with a gastric juice or salt to - that and pepsin to 2 hours at t ° 37 — 38 °.
For newborn children the best feedstuff at enteral P. and. the maternal or donor breast decanted milk sterilized, for babies — milk, kefir and products of a feeding up is if they received a feeding up prior to the beginning of P. and.
The daily diet is calculated normally (see. Feeding of children ). In the presence of individual indications for change in a diet of a ratio of proteins, fats and carbohydrates it is necessary to consider qualitative structure of foodstuff and, besides, water requirement, electrolytes, microelements and calories in each case.
Enteral P.'s mode and. children of the first year of life corresponds to the mode of usual food, i.e. within a day food via the probe is entered by 5 — 7 times, the premature and weakened newborn — to 10 times. Enteral P.'s mode and. years significantly are more senior than children does not differ from regime of adults. The volume of one portion is defined by age of the child and daily amount of food. Rate of introduction of food via the probe shall exclude vomiting, vomiting, aspiration of feedstuffs. The most comfortable position of a body at P. and. the child via the probe can be considered situation on the right side with the raised upper half of a trunk. At children 6 months are more senior, and also during the feeding through enterosty position of a body does not play an essential role.
After long full parenteral food, starvation with a sharp hypotrophy, at considerable oppression of food and sucking reflexes to children of the first months of life enteral P. and. it is carried out for the purpose of normalization of functions went. - kish. path. The volume of the entered portion makes V5 of volume of one-time feeding of the healthy child of this age. Enteral P. and. begins with administration of mix of equal number of 5% of solution of glucose and isotonic solution of sodium chloride since solution of glucose in bigger concentration causes the strengthened fermentation and gas generation in intestines. In the absence of vomiting, vomiting, stagnation in upper parts went. - kish. a path, through each 3 — 4 feedings (sometimes it is more) solution of glucose and isotonic solution replace with milk, and then increase also a single dose of feeding. With gradual increase in tolerance went. - kish. a path to food its daily volume is brought to norm and start attempts of transfer of the child into feeding through a mouth.
Nutritious mixes for an enteroalimentation
the Enteroalimentation unreasonably is considered as an alternative to parenteral food; actually both ways of artificial nutrition pursue one aim: ensuring needs of the patient for plastic and power substances. Practice shows that for adults the composition of feedstuffs in nutritious mixes for an enteroalimentation shall approach on a formula the balanced food: protein 80 — 100 g, fat of 80 — 100 g, carbohydrates of 400 — 500 g and according to a formula of the balanced food necessary amount of vitamins, macro - and microelements since, despite restriction of movements at a bed rest, need of the patient for nutrients and energy after injuries and operations increase.
For an enteroalimentation impose the following requirements to nutritious mixes: high biol, the value and good comprehensibility, balance on irreplaceable and replaceable factors of food, adequacy to metabolic needs of the patient, firmness at storage, speed and convenience in preparation and at a dosage, a high degree of dispersion of particles and passability via probes of small sections, optimum osmolarity, sufficient nutrition value and power density per 1 ml of ready nutritious mix (1,0 — 1,5 kcal! ml). Fullestly the nutritious mixes for an enteroalimentation developed in Ying-those food of the USSR Academy of Medical Sciences and produced by the industry in the form of specialized products («enpita», the homogenized canned and vegetable dietary meat), and also import for food via the probe — Complan, to Isocal, Sus-tacal, Semper, Controlyte, Complea-te B, Meritene, Ensure, Precision, Vivonex, Flexical, Vital, Policose (tables 1 and 2) meet such requirements.
The choice of nutritious mix for the patient is defined by his metabolic requirements and a functional state it went. - kish. path. In cases of malabsorption (see. Malabsorption syndrome ) the nutritious mixes containing monomers in the form of hydrolyzates of proteins, fats or made of crystal amino acids and other monomers (so-called element diets) shall be used. It is necessary to consider also intolerance certain patients because of genetic defects or a metabolic situation of some feedstuffs, napr, the lactoses entering nutritious mix. At the organization of an enteroalimentation mutual enrichment of nutritious mixes from traditional products and dishes and from specialized products for food via the probe, simultaneous or consecutive use of various nutritious mixes is reasonable.
Experience of wide use of nutritious mixes showed their efficiency in improvement of the food status and elimination of the nutritional deficiency which developed at heavy patients owing to a basic disease and deficit of food that was expressed in reduction of mortality, decrease in frequency of complications (pneumonia, discrepancy of seams, eventration, etc.).
At planned operations and existence of indications nutritious mixes shall be used in a complex of preoperative training of patients.
Table 1. COMPOSITION of the BALANCED NUTRITIOUS MIXES FOR the ENTEROALIMENTATION (are developed Ying volume of food of the USSR Academy of Medical Sciences)
Table 2. CONTENT of FEEDSTUFFS IN VARIOUS NUTRITIOUS MIXES GIVING IN TOTAL ENERGY VALUE In &1000nbsp; kcal
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