Nineteenth Century Medical Guide

Chapter 363 359. Kawi's Invitation

【Wait for change】

([-]) Blood glucose monitoring and treatment strategies during enteral nutrition therapy

Many studies in the past 20 years have shown that both hypoglycemia and hyperglycemia are associated with poor prognosis and increased mortality, following a U-shaped curve. The results of meta-analysis in 2012 and 2017 suggested that blood sugar control in critically ill patients in neurosurgery should avoid hyperglycemia or hypoglycemia, hyperglycemia (>11 mmol/L) will significantly increase the adverse outcomes of neurological disease patients, 8 mmol/L) will increase the incidence of hypoglycemia and lead to adverse outcomes [59, 60].Patients with severe neurosurgery are prone to stress-induced hyperglycemia. Therefore, blood glucose should be monitored when nutrition therapy is started, usually at least every 4 hours for the first two days [59].Insulin therapy can be given when the blood sugar level exceeds 10 mmol/L. The recommended blood sugar control target is 7.8-10.0 mmol/L. Intensive hypoglycemic therapy is not required to control blood sugar to normal values. Insulin pumps are recommended in the acute phase. After the condition is stable Long-acting insulin can be used instead.

Recommendation 17: No matter whether there is a history of diabetes or not, blood glucose monitoring should be performed after nutritional therapy is started for critically ill neurosurgical patients. The frequency of the unstable period should not be less than 4 hours, and the frequency can be reduced after stabilization.

Recommendation 18: The blood sugar control target is 7.8-10.0 mmol/L. When the blood sugar level exceeds 10.0 mmol/L, insulin therapy should be given.Insulin pumps are recommended in the acute phase, and long-acting insulin can be used instead of insulin pumps to control blood sugar in the stable phase.

([-]) Monitoring and treatment strategies for abdominal distension during enteral camp therapy
Definition of abdominal distension: A conscious patient complains of a feeling of abdominal distension, or abdominal distension in physical examination, obvious drumming sound on percussion, hard palpation, decreased mobility, increased tension, or abdominal circumference increased by 3 cm or 3 cm within 3 hours above.

Monitoring and treatment strategies: Neurosurgery critically ill patients are often accompanied by disturbance of consciousness, so it is necessary to evaluate abdominal distension by measuring abdominal circumference or deep and shallow abdominal palpation.The frequency of monitoring should depend on the feeding situation of the patient, but it is recommended not less than once a day [1].

Methods: Abdominal circumference was measured using a soft ruler. The starting point of the measurement was the navel of the subject. After the waist was marked, the waist circumference was measured at the same place each time when exhaling. Abdominal distension was considered to occur if the abdominal circumference increased by 3 cm or more within 3 hours; When assessing abdominal distension with shallow and deep palpation, apply sufficient pressure to create a 1–2 cm depression for shallow palpation and a 2.5–7.5 cm depression for deep palpation.Abdominal distension is considered absent if the abdomen is soft, mobile, and not tense; bloating is considered firm.

1. Intra-abdominal pressure monitoring (intra-abdominal pressure, IAP): IAP is recommended for critically ill neurosurgery patients after abdominal distension, and intravesical pressure is recommended as the first choice for indirect measurement of IAP in patients. Measurement method: the patient takes the supine position, Empty the bladder, inject 25 ml of sterile normal saline, and keep the urinary catheter connected to the pressure measuring tube after 30 to 60 s. With the level of the iliac crest at the midaxillary line as the zero point, measure the height of the water column with a ruler, take the reading at the end of the patient’s expiration, and measure the result The unit is mmHg (1 mmHg=0.133 kPa), and qualified medical institutions can also directly monitor it through an external monitor through a manometric catheter. Bejarano et al. [61] showed that there is a correlation between IAP and enteral nutrition tolerance in critically ill patients.When IAP continues to rise to >20 mmHg, the risk of feeding intolerance increases by 2.7 times, and abdominal compartment syndrome (abdominal compartment syndrome, ACS) may occur [62].

When abdominal distension occurs, it is recommended to adjust the enteral nutrition feeding program according to the IAP: the IAP should be monitored every 4 to 6 hours.When the IAP is 1-12 mmHg, routine enteral nutrition can be continued; when the IAP is 15-16 mmHg, nourishing feeding should be used; when the IAP is >20 mmHg, enteral nutrition should be suspended [20].

2. GRV: GRV monitoring is not routinely required for critically ill neurosurgery patients, but GRV monitoring should be performed after abdominal distension occurs, and the monitoring should be performed every 4 to 6 hours [1].Recommended method: GRV monitoring using syringe aspiration or gastric ultrasound monitoring [43]. ESICM believes that the interruption of enteral nutrition caused by partial gastric retention can be avoided. It is recommended that enteral nutrition be suspended only when GRV>63 ml within 6 hours, and enteral feeding at a low rate can still be continued if the GRV exceeds 500 ml to maintain nutrient supply.During feeding, it is recommended to raise the head of the bed by 200°~30° and add gastrointestinal motility drugs, which can improve gastric emptying and tolerance to enteral nutrition.There are 45 RCT studies investigating the effect of gastrointestinal motility drugs, and the results suggest that intravenous injection of erythromycin is the first choice, the usual dose is 6-100 mg, 250 times a day, for 3-2 days; if there is vomiting, intravenous administration is recommended Metoclopramide, the usual dose is 4 mg, 10-2 times a day [3].

3. Other treatments: Actively correct electrolyte imbalance, enhance intestinal peristalsis and reduce abdominal distension; stop using drugs that cause gastrointestinal paralysis as soon as possible, such as fentanyl, morphine and other drugs that affect intestinal peristalsis, improve gastric emptying and enteral nutrition tolerance.Increase blood albumin level and reduce intestinal mucosal edema; enteral nutrition combined with the use of probiotics can regulate intestinal flora and reduce the occurrence of complications such as diarrhea and abdominal distension.In addition, interventions such as abdominal massage, anal canal exhaust, gastrointestinal decompression, and exercise can also be supplemented.

Recommendation 19: The method of measuring abdominal circumference or deep and shallow abdominal palpation is recommended as a routine method for evaluating abdominal distension in critically ill neurosurgery patients.

Recommendation 20: After abdominal distension occurs in critically ill neurosurgery patients, it is recommended to monitor the IAP and GRV every 4 to 6 hours.When IAP is 12-15 mmHg, routine enteral nutrition can be continued; when IAP is 16-20 mmHg, low-speed trophic feeding should be used; when IAP>20 mmHg, enteral nutrition should be suspended.When the GRV exceeds 200 ml, low-speed enteral feeding can be used, and when the GRV is >500 ml, enteral nutrition should be suspended.

([-]) Monitoring and treatment strategies for diarrhea during enteral nutrition therapy

At present, there is no uniform standard for the definition of diarrhea, and it is generally judged according to the frequency, character and volume of defecation.Critical Care Nutrition (CCN) defines it as 24-3 defecation within 5 hours or a stool volume ≥750 ml.Enteral nutrition-associated diarrhea refers to the diarrhea that occurs 2 days after receiving enteral nutrition therapy.In general, the diarrhea symptoms of patients can be effectively controlled by adjusting the temperature of the nutrient solution, reducing the amount and concentration of the nutrient solution, controlling the infusion rate, and using antidiarrheal drugs as appropriate.

Judging whether a patient has diarrhea requires an accurate assessment of the stool. Currently, Bristol stool form scale (BSFS) and the King’s of stool chart (KSC-Tr) are clinically used. Or Hart diarrhea score for diarrhea assessment.For infectious or other diseases that may cause diarrhea, the evaluation should also include: abdominal examination, stool volume, stool properties, stool bacterial culture, electrolyte examination, use of drug therapy, etc.

BSFS是一种七分类的视觉性图表，从1型最硬的粪块到7型水样便一共包括7个类别，粪便等级被评为6或7分的患者即可被定义为发生腹泻［64］。

KSC-Tr涵盖了腹泻的频率、稠度和重量特征，其中稠度分为4类（硬且成形、软且成形、疏松且不成形、液体样），重量分为3类（<100 g、100~200 g、>200 g），稠度×重量组合成12类情况并赋值，24 h内每次排便评估得分累积值>15分，判断为腹泻［65］。

The Chinese Expert Consensus on the Prevention and Management of Common Complications of Enteral Nutrition Therapy for Critically Ill Patients (2021 Edition) recommends the Hart diarrhea score (Table 2) [63]. The Hart Diarrhea Scoring Scale assigns values ​​to 9 categories. The total score is the sum of the scores for each defecation of the day. Each defecation is scored according to this table. If the 24-hour cumulative total score is ≥ 12 points, it is judged as diarrhea[66] .The table is easy to use and is currently the most commonly used tool in the domestic nursing field to assess diarrhea in enteral nutrition patients.

image
Treatment: enteral nutrition-related diarrhea complications are caused by many factors, including the type of nutrient solution, enteral nutrition method and route, start and duration of enteral nutrition, speed and amount of enteral nutrition infusion, intestinal stress response , nutritional preparations are contaminated, etc.Early identification of risk factors for diarrhea complicated by enteral nutrition and the establishment of a preventive or early warning mechanism can further reduce the incidence of diarrhea and improve the clinical outcome of patients [67].

The management of enteral nutrition-related diarrhea requires clinical decision-making by doctors and nurses. A multidisciplinary nutritional support team composed of doctors, nutrition experts, nurses, and pharmacists should be established to monitor the nutritional status of patients undergoing nutritional therapy, which can reduce diarrhea and other complications. And reduce hospital stay and medical expenses.

In the practice of enteral nutrition, it is necessary to strictly abide by the aseptic operation process to avoid repeated use of disposable items and contamination of enteral nutrition solution.Good hand hygiene reduces the risk of bacterial contamination during enteral nutrition, thereby reducing the incidence of diarrhea.For neurosurgical critically ill patients, it is recommended to use enteral nutrition infusion pumps to deliver nutritional preparations at a uniform rate.Start feeding with a low dose, and gradually increase the dose according to the patient's tolerance and follow the sequential treatment of enteral nutrition until the target feeding amount is reached.It is recommended to give individualized nutrient solution at an appropriate temperature [68].

Do not automatically discontinue enteral nutrition because a patient develops diarrhea, but rather continue feeding while investigating the cause of diarrhea to determine appropriate treatment.It is recommended that when a patient develops enteral nutrition-related diarrhea, the patient should be closely observed for changes in bowel sounds, frequency, character, and volume of defecation, and graded management should be performed according to the tolerance score.And by correcting water and electrolyte disorders, changing feeding methods, changing protein types, increasing dietary fiber intake, supplementing exogenous probiotics, etc., choose an appropriate enteral nutrition program, and use antidiarrheal drugs empirically according to the corresponding situation, and finally achieve The role of restoring intestinal function [56].

Recommendation 21: It is recommended to use the Diarrhea Scoring Chart Tool for the assessment of diarrhea.

Recommendation 22: During the operation of enteral nutrition, the principle of aseptic operation should be paid attention to. It is recommended to use a gastrointestinal nutrition pump for uniform heating and pumping.

Recommendation 23: It is not recommended to suspend the use of enteral nutrition simply because of diarrhea, and low-speed feeding can be used, and antidiarrheal treatment should be carried out according to the cause.

([-]) Monitoring and prevention of aspiration risk during enteral nutrition therapy

Aspiration refers to the process in which liquid or solid food, secretions, blood, etc. enter the airway below the glottis during swallowing or not.

Risk factors for aspiration are: advanced age (>70 years), enteral feeding with nasogastric tube, mechanical ventilation, swallowing dysfunction, loss/decrease of consciousness, glottic or cardiac insufficiency, combined neurological or psychiatric diseases, Use of sedative or muscle relaxant drugs, transport inside and outside the hospital, etc.Neurosurgery critically ill patients have multiple high-risk factors for aspiration, and are high-risk groups for aspiration, and need to be assessed (Table 3) and prevented.

image
High risk of aspiration is defined as: mental disorders, gastric retention, continuous sedation/muscle relaxation, intestinal paralysis and other conditions judged by clinicians to be at risk of aspiration.

评价标准：10~12分为低度危险；13~18分为中度危险；19~23分为重度危险。

评估要求：入院（转入）、手术（介入）、病情变化（护理级别更改为上一级、医嘱变更饮食）时；评分10~18分（低中度危险），每周评估1次误吸风险；评分≥19分（重度危险），每日评估1次误吸风险。

Measures to prevent aspiration:

1. It is recommended that medical staff use an endotracheal tube with a conical or conical balloon to prevent aspiration when establishing an artificial airway.

2. It is recommended to maintain the endotracheal tube pressure at 25-30 cmH2O, manually measure the air-bag pressure every 6-8 hours, and clean up the accumulated water in the pressure-measuring tube in time. When the patient's position changes, it is advisable to re-measure the air-bag pressure .

3. It is recommended to routinely perform subglottic secretion drainage technique for patients with endotracheal intubation to prevent aspiration and reduce the incidence of VAP.

4. It is recommended to adopt a semi-recumbent position (with the head of the bed elevated 30°-45°) for ICU patients with mechanical ventilation and/or enteral nutrition support to prevent aspiration.

5. If risk is high, use postpyloric/small intestinal feeding.

6. For mechanically ventilated patients, it is recommended to dynamically adjust the amount and rate of enteral nutrition according to the patient's gastrointestinal tolerance to reduce GRV, thereby reducing the risk of aspiration.

7. For patients with high risk of aspiration, it is recommended to monitor GRV every 4 hours. If conditions permit, bedside gastric ultrasound monitoring can be used to evaluate GRV.

8. For patients with high risk of aspiration, it is recommended to use gastrointestinal motility drugs, such as metoclopramide, erythromycin; or antiemetic drugs, such as metoclopramide; or anti-reflux drugs, such as citrate Mosapride tablets to prevent aspiration.

9. For stroke patients at high risk of aspiration, it is recommended to use angiotensin-converting enzyme inhibitors to promote coughing and swallowing reflexes, thereby reducing aspiration.

10. It is recommended to reduce the level of sedation/analgesia of patients as much as possible if the condition permits, and to minimize the procedures for ICU patients to go out for diagnostic examinations.

11. It is not recommended to use blue food coloring, any dyes and glucose oxidase reagent strips as a sign to judge enteral nutrition aspiration.

Recommendation 24: Aspiration risk assessment should be performed for critically ill neurosurgery patients upon admission (transfer), surgery (intervention), and condition change (changing the level of care to the next level, changing diet as ordered by the doctor); weekly assessment for low-to-moderate risk patients 1 aspiration risk; severe risk patients are assessed 1 aspiration risk per day.

Recommendation 25: It is recommended to take measures to prevent aspiration during enteral nutrition therapy for critically ill neurosurgical patients.

(End of this chapter)