Method for early enteric therapy and nutritional maintenance of patients following pancreaticoduodenal resection

FIELD: medicine.

SUBSTANCE: enteric therapy is started intraoperatively with introducing a glucose-electrolyte mixture 100 ml by means of a silicone probe inserted behind a gastroentero- or duodenoenteroanastomosis. On the first postoperative day, the amount of the fractionally introduced GEM is increased to 300.0 ml at 60 ml/hour, which is followed by enabling a passive outflow of the intestinal content. If the intestinal peristalsis tends to recover from the second postoperative day, a nutritional probe therapy is added with Nutrison Advanced Diason isocaloric formula 498 ml that is 10.0 kcal/kg at 60 ml/hour, which is followed by enabling the passive outflow of the intestinal content. If the probe spillage makes more than 50% of the amount of the nutritional formula administered for 1 hour, the previous rate of the washout intestinal infusion is maintained. If the nutritional formula is digested, the amount of Nutrison Advanced Diason isocaloric formula is increased to 700-800 ml/day. If the patient has a compensated glucose profile on the 4th postoperative day, the amount of the tube feeding is increased to 1398 ml of Nutrison Standard that is 15.0 kcal/kg with the infusion rate to be increased to 90 ml/hour. On the fifth postoperative day, the patients having a good tube feeding tolerance are given with Nutrison Energy hypercaloric hypernitrogenous polymer nutritional formula with dietary fibres in an amount of 1000.0 ml that is 20.0 kcal/kg with keeping the infusion rate the same. On the sixth day, the patient starts unassisted enteric nutrition and is nutritionally supported with Nutridrink hypercaloric nutritional formula in an amount of 200.0 ml 2 or 3 times a day by sipping.

EFFECT: improving the trophological values that causes reducing the number of postoperative complications, mortality and length of staying in hospital by the optimum regimen of treatment.

6 tbl

 

The invention relates to medicine, in particular to early enteral therapy, and can be used for the treatment of patients after pancreatoduodenal resection.

It is known that patients after undergoing surgery on the abdominal organs should be appointed early enteral nutrition in progressively increasing mode enteric infusion in the sequence: glucose-salt of the monomer mixture is polyelemental mixture of the polymer mixture, in which the shift is sufficient absorption of the mixture prior to re homeostasis function of the small intestine and the digestive process in General [Luft, V. M. and others Clinical nutrition in intensive medicine: a Practical guide, St. Petersburg, 2002]. However, this method does not consider features of patients with neoplastic intestinal obstruction: the presence of a source of protein and carbohydrate and intestinal failure, thus limiting the effectiveness of the treatment.

A method of treating patients with neoplastic intestinal obstruction in intraoperative and postoperative period by the application of early enteral therapy and nutritional support, including decompression of the gastrointestinal tract, active lavage, enterosorption, enteral nutrition, inwhich enteral therapy is started intraoperatively, minimum of early enteral nutrition administered on the first day of the postoperative period and in the future, if tolerated by patients probe power and minimal reset, hold a succession of different mixtures for enteral nutrition: on the first day of the postoperative period enter the monomer mixture with the addition of 200 ml of 20% Nutrient-elemental, on the second day introduced Nutrient-elemental to a degree corresponding to 10 kcal/kg, on the third day administered nutrizone-Standard in a volume corresponding to 15 kcal/kg, on the fourth day injected a mixture such as nutrizone-Energy with dietary fibers in the volume corresponding to 20 kcal/kg, and on the fifth day, after extraction nazointestinalnyh probe and in the presence of an independent chair, appointed medical diet # 1 Pevzner, which complement the introduction of the mixture such as nutrizone-Energy with dietary fibre method of siping (patent RF №2457003, AM 25/00, AK 31/7004, AK 38/01, AK 31/715, AR 3/02, A23L 1/29, publ. 27.07.2012).

The above methods of enteral nutrition have a certain range of applications and are not intended for patients after undergoing da. In addition, they do not take into account the specific nutritional status of patients with this profile. The proposed method allows for the early enteral feeding of patients after the implementation of the da based factory�th ' nutritional status.

The basis of the invention is to provide a method of early enteral therapy and nutritional support of patients after pancreatoduodenal resection, the result of the application of which is integrated in the perioperative treatment of patients undergoing da is an improvement in nutritional status, reducing the number of postoperative complications, mortality and length of hospital stay.

The solution of this problem is achieved in that in the method of early enteral therapy and nutritional support of patients after pancreatoduodenal resection, including enteral nutrition, enteral therapy is started intraoperatively using installed for gastroentero - or duodenopancreatectomy silicone probe in a volume of 100 ml of glucose-electrolyte mixture, on the first day of the postoperative period increase the amount of fractional introduction of HPP at 60 ml/HR in a volume of 300.0 ml with subsequent passive outflow of intestinal contents; under normal restoration of intestinal peristalsis at the second day of the postoperative period in nutritivo probe therapy add 498 ml isocalorically mixture nutrizone edvanst Deason, which corresponds to 10.0 kcal/kg, with a speed of 60 ml/h, with subsequent passive outflow of intestinal contents, wherein if the reset p� the probe is more than 50% of the administered 1 hour the volume of the nutrient mixture, we retain the previous rate of intestinal infusion mode lavage; then in the assimilation of the nutrient mixture the following day, the quantity of injected isocalorically mixture nutrizone edvanst Deason increased to 700-800 ml/day; then when compensated glycemic profile and in the assimilation of the nutrient mixture on day 4 post-operative period, the volume of probe power increase of up to $ 1398 ml nutrizone Standard, the appropriate is 15.0 kcal/kg, with a simultaneous increase in the infusion rate of up to 90 ml/h; on the fifth day of the postoperative period good tolerability probe power switch to the introduction giperbaricheskoi hypernatraemia nutrient mixture polymer such as nutrizone-Energy with dietary fibre in volume 1000,0 ml, corresponding to 20.0 kcal/kg and maintain the same speed infusion; on the sixth day the patient is transferred to an independent enteral nutrition with initiatives support giperbaricheskoi nutrient mixture on Nutridrink 200.0 ml 2-3 times a day method of siping.

The clinic Naval surgery of the Military medical Academy and its clinical sites in the period from 2005 to 2013, made 84 pancreaticoduodenal resections, tumor typical of the zone. In the present study included 60 patients who were divided into two groups. The main group costabili patients which in the perioperative period was conducted nutritional support. Men was 17 (56,6%), women - 13 (43.4 percent). The average age amounted to $ 52.1±3.7 years.

In the control group of 30 patients early enteral nutrition was conducted. Men was 14 (46,6%), female 16 (53.4 percent). The average age was 57±3.1 years (table. 1).

To obtain objective data about the nutritional status of the analysis of the data somatometricos and laboratory research. It is established that the vast majority of patients undergoing da (66.6 per cent) have protein-energy malnutrition (BEN) of varying severity. Atropinic nutritional status in the main group was identified in 9 patients (30%), control in 11 patients (36,6%) (tab. 2).

Control and the main group of patients after the da, were comparable on key indicators and compare these groups correctly.

In the analysis of treatment results established that the vast majority of postoperative complications (72,5%) in patients undergoing da, associated with the development of postoperative pancreatic fistula and infectious-inflammatory process. A high percentage of patients with malnutrition and large number of infectious and inflammatory OS�of ogneni in the postoperative period gave rise to the development of methods for early enteral therapy and nutritional support.

Enteral therapy was started intraoperatively using installed for gastroentero - or duodenopancreatectomy silicone probe in a volume of 100 ml of glucose-electrolyte mixture (HPP).

On the first day of the postoperative period increased fractional volume (drip) introduction HEPP at 60 ml/HR in a volume of 300.0 ml with subsequent passive outflow of intestinal contents. Under normal restoration of intestinal peristalsis at the second day of the postoperative period in nutritional probe therapy was added 598 ml isocalorically mixture nutrizone edvanst Diazon, which corresponded to 10 kcal/kg. the Choice of this nutrient mixture was determined with impaired glucose tolerance in the early postoperative period in most patients who have undergone da. Infusion was carried out in a probe for enteral nutrition at a speed of 60 ml/h, with subsequent passive outflow of intestinal contents. Control of mastering the nutrient mixture was carried out for the determination of residual volume. If the reset probe was more than 50% of the administered 1 hour the volume of the nutrient mixture, was maintained the same rate of intestinal infusion mode lavage. In the assimilation of the nutrient mixture (reset less than 50%) the following day, the quantity of injected isocalorically mixture nutrizone edvanst Deason increased to 700-800 ml/day which was sootvetsvovalo of 10.0 kcal/kg. When compensated glycemic profile and in the assimilation of the nutrient mixture on day 4 post-operative period, the volume of probe power was increased to 1398 ml of the mixture nutrizone Standard, the appropriate is 15.0 kcal/kg, with a simultaneous increase in the infusion rate of up to 90 ml/h. the volume of the substrate support of patients was 50-60% of the calculated value. On the fifth day of the postoperative period if tolerated the feeding tube passed for the introduction giperbaricheskoi hypernatraemia nutrient mixture polymer such as nutrizone-Energy with dietary fibre in volume 1000,0 ml, corresponding to 20.0 kcal/kg, and maintain the same speed of infusion. The amount of substrate provision in this case, as a rule, reached 70-80% of the calculated value. On the sixth day, as a rule, the patient was transferred to an independent enteral nutrition with initiatives support giperbaricheskoi nutrient mixture on Nutridrink 200.0 ml 2-3 times a day method of siping. The amount of substrate provision while the majority of patients almost reached 100% of the calculated value.

The efficiency of the method was evaluated on the basis of comparison of indicators of nutritional status, nitrogen balance, and immediate results of treatment: the rate of postoperative complications, mortality, and the average duration �prebyvania patients in the hospital.

Postoperative complications occurred in 49 (81%) patients. From different causes died 4 (6,6%) patients. The average duration of inpatient treatment in the study group was 15 days, in the control and 18 days. Structure complications are presented in table. 3.

When comparing indicators of nutritional status revealed that the decrease somatometricos indicators in the course of treatment was determined in patients of both groups. However, in patients of the main group these lower rates was less significant than in patients in the control group. So the average loss of body weight during the treatment period in patients of the main group was 1.3±0.2 kg, and in patients of the control group was 3.4±0.9 kg. Differences were statistically significant (p<0,05).

In the postoperative period is marked by the deterioration and laboratory parameters in patients of both groups, due to the natural reaction of the body to the surgical trauma, blood loss. Further on the background of treatment there was a natural increase in the level of total protein and albumin. However, in patients of the main group, this process was much faster, and the time of discharge of their laboratory values did not differ from baseline and were significantly higher than in patients of the control group (tab. 4).

Thus, in patients undergoing da postoperative depletion occurs, both somatic and visceral pool of proteins, manifesting as progressive hypoproteinemia and hypoalbuminemia. The use of early enteral therapy and nutritional support in patients of the main group helped significantly to raise their blood levels of albumin and total protein. In the study of the dynamics of changes in nitrogen balance identified that all after the implementation of the da when entering notes catabolic phase of metabolism. The patients of the main group, in contrast to the control, more rapid recovery of the direction of anabolic metabolism, respectively, 7 and 10 day postoperative period.

Thus, the use of early enteral therapy and nutritional support can reduce the severity and duration hypercatabolism syndrome (tab. 5).

In the analysis of treatment results revealed that patients receiving early enteral therapy and nutritional support, a decrease in the frequency of complications such as suppuration of postoperative wounds (from 14.3% to 9.6%), intraabdominal abscess (from 13.6% to 10.0%). Early enteral therapy and nutritional support beneficial tales�recover on the frequency of formation of pancreatic fistulas the incidence of fistula has decreased from 33% to 26%. Application of the developed method allows to reduce the postoperative complication rate from 80% to 76%. The analysis showed the feasibility of using this technique for early stabilization of the main indicators of their nutritional status. Thus, the inclusion of early enteral nutrition in comprehensive perioperative therapy for patients undergoing da, can reduce the number of purulent-inflammatory complications and frequency of formation of pancreatic fistula and to improve the immediate results of this category of patients.

Method of early enteral therapy and nutritional support of patients after pancreatoduodenectomy, including enteral nutrition, characterized in that enteral therapy is started intraoperatively using installed for gastroentero - or duodenopancreatectomy silicone probe in a volume of 100 ml of glucose-electrolyte mixture, on the first day of the postoperative period increase the amount of fractional introduction of HPP at 60 ml/HR in a volume of 300.0 ml with subsequent passive outflow of intestinal contents; under normal restoration of intestinal peristalsis second with�current of the postoperative period in nutritive probe therapy add 498 ml isocalorically mixture nutrizone edvanst Deason, which corresponds to 10.0 kcal/kg, at a speed of 60 ml/hour, with subsequent passive outflow of intestinal contents, wherein if the reset probe is more than 50% of the administered 1 hour the volume of the nutrient mixture, then retain the previous rate of intestinal infusion mode lavage; then in the assimilation of the nutrient mixture the following day, the quantity of injected isocalorically mixture nutrizone edvanst Deason increased to 700-800 ml/day; then when compensated glycemic profile and in the assimilation of the nutrient mixture on day 4 post-operative period, the volume of probe power increase of up to $ 1398 ml of the mixture nutrizone Standard, appropriate of 15.0 kcal/kg, with a simultaneous increase in the infusion rate of 90 ml/hour; on the fifth day of the postoperative period good tolerability probe power switch to the introduction giperbaricheskoi hypernatraemia nutrient mixture polymer such as nutrizone-Energy with dietary fibre in volume 1000,0 ml, corresponding to 20.0 kcal/kg and maintain the same speed infusion; on the sixth day the patient is transferred to an independent enteral nutrition with nutritional support giperbaricheskoi nutrient mixture on Nutridrink 200.0 ml 2-3 times a day method of siping.



 

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2 tbl

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1 ex

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17 cl, 10 dwg, 1 tbl

FIELD: medicine.

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9 cl, 11 dwg

FIELD: medicine.

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25 cl, 5 dwg

FIELD: medicine.

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6 ex

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