【Waiting for change】
[357 was sentenced to be unblocked due to some indescribable content. It happens to be a weekend break and I can only let the editor do it tomorrow]
[To prevent full attendance after a break of more than seven days, drop a chapter first, and then try to complete the correction within a week. I will resume normal updates after my mother and father-in-law are discharged from the hospital. Middle-aged people have many things to do, so forgive me]
(4) Eicosapentaenoic acid and docosahexaenoic acid
The International Association for the Study of Fatty Acids and Lipids recommends that healthy people consume 500 mg of EPA and DHA every day [89]. 3 to 7 times this dose is defined as high dose. Alpha-linolenic acid is an essential omega-3 unsaturated fatty acid with potential pleiotropic effects in brain protection, cerebral arterial vasodilation, and neuroplasticity.
There are currently no relevant clinical trials on the impact of adding EPA and DHA to enteral nutrition on the prognosis of critically ill neurosurgery patients. Among patients with ARDS and acute lung injury, 8 studies were included in the meta-analysis, and the results did not show any benefit, only indicating PO2 after intervention. /FiO2 has an increasing trend (RR=22.59, 95%CI: -0.88~46.05, P=0.06), but PO2/FiO2 is affected by ventilator settings, fluid status, body position, etc. The value itself changes rapidly, which is not good. outcome indicators. In a post hoc study of the large RCT Meta Plus [98] of immunomodulatory nutrients, it was found that GLN-enriched, fish oil- and antioxidant-enriched high protein had higher early (EPA+DHA)/long-chain protein content than isocaloric high protein. An increase in the ratio of fatty acid plasma levels may be harmful to critically ill patients. Therefore, high-dose omega-3 UFA-rich nutrients should not be routinely added.
Intravenous fat emulsions based solely on soybean oil, which is rich in 18-carbon omega-6 FA, should be avoided during parenteral nutrition therapy. A variety of new lipid emulsions are available that incorporate olive oil, fish oil, and coconut oil in various combinations. Meta-studies have shown the advantages of lipid emulsions enriched with fish oil or olive oil [99]. A prospective randomized study showed that compared with other lipid emulsions, the incidence rate was lower in the fish oil group [100]. Grau-Carmona et al. [101] found in a multi-center prospective randomized double-blind study that compared with the use of long chain fatty acids (LCT)/MCT emulsions alone, the use of emulsions containing LCT (such as soybean oil) Lipid emulsions of , MCT and fish oil can significantly reduce the infection rate. Formulas that add MCT and special nutrients that facilitate the digestion and absorption of LCT, such as taurine and L-carnitine, are easier to digest and absorb. Many prospective studies have compared these new lipids Compared with each other and with soybean oil-based lipid emulsions, the results showed that patients using the new lipid emulsion had shorter hospital stays and also contributed to lower infection rates [102, 103]. The use of fish oil-rich lipid emulsions in patients with sepsis can help shorten the length of ICU stay and mechanical ventilation time [104].
Recommendation 34: It is not recommended to routinely add EPA/DHA or use high-dose enteral formulas rich in omega-3 fatty acids for enteral nutrition in critically ill neurosurgery patients.
Recommendation 35: Fat emulsions rich in EPA+DHA can be used for parenteral nutrition treatment in critically ill neurosurgery patients.
[6. Nutritional treatment under special circumstances for critically ill neurosurgery patients]
(1) Shock state
There is controversy over when to initiate enteral nutrition in critically ill neurosurgery patients in a state of shock. In very hemodynamically unstable patients, enteral nutrition is unlikely to help improve instability and may even further impair already compromised splanchnic perfusion. Retrospective review of 259 patients with hemodynamically unstable patients. Clinical observational studies found that 3 cases of patients who received enteral nutrition early developed intestinal ischemia and intestinal perforation [105]. Therefore, it is recommended to postpone the initiation of enteral nutrition when shock is uncontrolled. Persistent lactic acidosis may help identify a state of uncontrolled shock.
After initial hemodynamic stabilization, initiation of low-dose enteral nutrition can be considered without waiting until all vasopressor medications are discontinued. In a large observational study, early initiation compared with late enteral nutrition (>48 h) after fluid resuscitation in hemodynamically "relatively stable" patients who were still receiving at least one vasopressor Enteral nutrition (≤48 h) can reduce patient mortality. Another recent retrospective study showed that enteral nutrition did not affect hemodynamic stability based on whether the dosage of norepinephrine increased by more than 50%. These results indicate that after initial control of shock, low-dose enteral nutrition can be initiated if the dose of vasopressors is stabilized or reduced [106].
Recommendation 36: If shock is not controlled and hemodynamic and tissue perfusion goals are not achieved, it is recommended to postpone enteral nutrition, but after initial stabilization of hemodynamics (vasoactive drug stabilization or reduction), low-intensity nutrition should be started immediately Dosage enteral nutrition.
(2) Stress ulcers and upper gastrointestinal bleeding
Acute gastrointestinal mucosal erosion, ulcers, bleeding and other lesions that occur when the body is under severe stress can lead to gastrointestinal bleeding or even perforation in severe cases. The latest multi-center retrospective survey showed that the incidence of gastrointestinal bleeding in critically ill neurosurgery patients in China was 12.6%. An RCT comparing ranitidine and sucralfate reported that enteral nutrition is an independent protective factor against gastrointestinal bleeding [107]. A meta-analysis recommended the use of enteral nutrition to prevent stress ulcers and gastrointestinal bleeding [108].
The main reason for prohibiting eating/enteral nutrition in patients with upper gastrointestinal bleeding is the fear of recurrence, so for patients at high risk of recurrence, enteral nutrition is delayed after bleeding. ESICM guidelines recommend starting enteral nutrition within 24 to 48 hours after bleeding stops [109]. If the bloody gastric contents are 100 ml/d, nasogastric tube feeding should be used with caution, and gastrointestinal decompression combined with nasojejunal tube feeding can be considered [109]. If the patient is still unable to tolerate it, supplementary parenteral nutrition treatment should be considered.
Recommendation 37: Enteral nutrition is a protective factor in preventing stress ulcers and upper gastrointestinal bleeding. Early use of enteral nutrition is recommended for patients with stress ulcers. For patients with upper gastrointestinal bleeding, enteral nutrition is recommended 24 to 48 hours after the bleeding stops.
(3) Mild hypothermia treatment
Under mild hypothermia conditions, the human body has a low metabolic rate and weak gastrointestinal motility. Whether enteral nutrition can be tolerated and whether it is complicated by complications such as vomiting and aspiration are issues that need to be resolved. British researchers Williams and Nolan [111] studied patients who underwent hypothermia treatment after cardiac arrest and found that during the hypothermia period, the tolerance rate of enteral nutrition was 72% of the prescribed dose; during the rewarming period, the tolerance rate of enteral nutrition was 72% of the prescribed dose. 95% of the dose; during the normothermic period, the enteral nutrition tolerance rate is 100%. Complications such as nausea and vomiting tend to occur 24 to 48 hours after the start of hypothermia treatment. Therefore, giving 75% of the corresponding dose at normal temperature during mild hypothermia treatment, or using post-pyloric feeding, can increase the patient's tolerance and reduce the risk of nausea, vomiting, and aspiration.
Recommendation 38: Low-dose (75%) enteral nutrition can be used during mild hypothermia treatment, and the dose can be gradually increased after rewarming. Protocols to improve gastrointestinal tolerance should be more aggressively pursued during mild hypothermia therapy.
(4) Ventilation in prone position
The energy requirements of prone position ventilation patients are 30% to 50% higher than those of ordinary mechanical ventilation patients. Due to the position, the patient's intra-abdominal pressure increases and gastric motility decreases, resulting in 82% of patients having enteral nutrition in the prone position. Due to tolerance issues, the daily feeding amount is lower than that of patients in the supine position, making the risk of malnutrition in patients in the prone position as high as 70% [112]. Studies have shown that enteral nutrition is feasible and safe in critically ill patients with severe hypoxemia receiving mechanical ventilation in the prone position, and is not associated with an increased risk of gastrointestinal complications [113]. Therefore, it is not recommended to stop enteral nutrition therapy simply because of prone position ventilation.
Measures to improve feeding tolerance in the prone position:
1. Before implementing prone position ventilation, it is recommended to stop enteral nutrition 1 hour in advance and check the GRV with retraction to prevent reflux and aspiration during turning and prone position ventilation.
2. The artificial airway bag pressure needs to be measured before and after prone position ventilation is started, and the bag pressure must be maintained at 2.94 kPa.
3. When placing the patient in the prone ventilation position, pay attention to avoid compressing the patient's abdomen and keep the head of the bed elevated to reduce intra-abdominal pressure and avoid increasing gastric emptying disorders.
4. The use of gastric motility drugs can help reduce the occurrence of enteral nutrition intolerance and increase the dosage of enteral nutrition.
5. Qualified medical institutions can use ultrasound to monitor the gastric antral motility index to guide the implementation of enteral nutrition in patients with prone position ventilation.
Recommendation 39: It is not recommended to stop enteral nutrition therapy simply because of prone position ventilation, and attention should be paid to taking measures to improve feeding tolerance.
(5) Mechanical ventilation
Mechanical ventilation is one of the causes of iatrogenic underfeeding. Spontaneous breathing impairment in critically ill neurosurgery patients will prolong the duration of mechanical ventilation, leading to a high risk of malnutrition and adverse clinical outcomes. Severe neurosurgery patients have damaged hypothalamus, brainstem and other neurological functions and are prone to gastric emptying disorders. The lower the Glasgow Coma Scale (GCS) score, the greater the impact of mechanical ventilation support on the patient's energy needs and gastrointestinal function.
Critically ill neurosurgery patients who use mechanical ventilation often have hemodynamic instability in the early stage. The use of enteral nutrition at this stage should refer to the recommendations for enteral nutrition in shock. After resuscitation, as long as the anatomy of the gastrointestinal tract is complete and has certain functions (especially motor function/absorptive function), enteral nutrition should be started as early as possible. Recovery of bowel sounds is not a necessary condition for enteral nutrition. Studies have shown that patients who start enteral nutrition early (within 24 to 48 hours) can reduce the time of mechanical ventilation, and early low-calorie feeding (30°) can help reduce oral secretions, reflux and aspiration in patients with mechanical ventilation without increasing pressure. risk of sores [116].
Recommendation 40: It is not recommended to delay the initiation of enteral nutrition in critically ill neurosurgery patients who are on mechanical ventilation alone.
(6) Sedation and analgesia
Patients with sedation and analgesia have reduced energy requirements, sedation and analgesia will delay gastric emptying, and patients with deep sedation may be at increased risk for feeding intolerance regardless of whether neuromuscular blockers are concurrently used. The use of opioid sedative and analgesic drugs can affect patients' nutritional metabolism, reduce gastrointestinal motility, cause gastric retention, constipation, gastroesophageal reflux, weight loss, malnutrition and other nutritional problems, which will hinder the results of neurosurgery treatment.
Recommendation 41: Lower caloric feeding can be adopted for critically ill neurosurgery patients under sedation and analgesia.
[7. Nutritional treatment process management for critically ill patients in neurosurgery]
A number of clinical studies have found that the intervention group using feeding process management significantly increased the number of days of enteral nutrition implementation and the start time of enteral nutrition earlier than the control group. It also reduced the mortality rate, shortened the length of hospitalization, and effectively improved patient prognosis. It is recommended to adopt feeding process management during nutritional treatment (Figure 1), and to monitor and deal with feeding intolerance (Figure 2).
Recommendation 42: It is recommended to apply process management during nutritional treatment of critically ill neurosurgery patients.
[8. Nursing care during nutritional therapy for critically ill neurosurgery patients]
Nursing is an important part of nutritional therapy practice. During the nutritional therapy of critically ill neurosurgery patients, establishing a multidisciplinary nutritional therapy team composed of doctors, nutrition experts, nurses and pharmacists can help monitor the nutritional status of nutritional therapy patients. Reduce gastrointestinal intolerance and reduce hospital stay and medical costs.
1. Operational requirements: During enteral nutrition operations, care needs to pay attention to strict aseptic operating procedures, avoid repeated use of disposable items such as syringes and nutrition pump tubes, and maintain good hand hygiene habits to help reduce bacterial contamination of enteral nutrition solutions. risk, thereby reducing the occurrence of bacterial diarrhea. At the same time, nursing care needs to pay attention to the "three degrees" of gastrointestinal nutrition, namely the temperature, speed and concentration of the nutrient solution. It is recommended to use a dedicated gastrointestinal nutrition pump to provide a stable infusion speed and appropriate temperature nutrient solution to reduce gastrointestinal reactions.
2. Monitoring and adjustment of nutritional therapy: During nutritional therapy, it is often necessary to adjust the feeding strategy according to the patient's gastrointestinal condition. It is recommended that nursing staff routinely measure the abdominal circumference every day, monitor and record the frequency, shape and quantity of stool, and Before starting enteral nutrition, aspirate the gastric contents to understand the residual gastric condition and provide feedback to the doctor, and work with the doctor to formulate an enteral nutrition strategy. When gastrointestinal intolerance occurs, it is necessary to increase the frequency of monitoring and adjust gastrointestinal nutrition in a timely manner according to changes in the patient's condition.
3. Position: In the absence of contraindications, the head of the bed should be elevated 30° to 45° during enteral nutrition, and care should be taken to avoid pressure sores, which can reduce aspiration pneumonia caused by aspiration.
4. Pipeline: For continuous infusion of nutrient solution, flush the pipe with 20~40 ml warm water every 4 hours or every time the infusion is interrupted or before and after administration. Nutritional infusion lines should be replaced daily. When percutaneous fistula tubes are used for enteral nutrition, the stoma needs to be cleaned with warm soapy water or clean water every day to prevent the tube from clogging and falling off.
Recommendation 43: Nursing care is recommended as an important component of the nutritional therapy team for critically ill neurosurgery patients.
