Coma and plant nutrition support
According to different nutritional screening and evaluation methods, the incidence of malnutrition in stroke is 8-62%; It is suggested that eating for 7 days in the early stage can reduce the mortality of patients with dysphagia after stroke.
After a long period (4 weeks), the patient underwent percutaneous endoscopic gastrostomy (PEG) under life-sustaining conditions. Effect of poor diet on intestinal absorption coma and complications in vegetative state
I. Complications of insufficient intake
Gastrointestinal function reabsorbs water and electrolyte;
Anemia and hypoproteinemia;
Nasal feeding diet, no chewing consciousness, overeating, poor understanding of residual food in the stomach;
Normal intestinal flora imbalance;
Two. Increased energy consumption:
Muscle tension increases, and many patients have uncontrollable involuntary movements and tracheotomy;
Continuous low-flow oxygen inhalation, serious water evaporation; The main function of normal human intestine: reabsorbing water and electrolyte; The main places where dietary fiber is fermented to produce short-chain fatty acids; The main gathering place of normal intestinal flora; Temporary storage and final excretion of metabolic wastes;
Our study found that patients with good enteral nutrition, whether tube feeding or stoma, can prolong the survival time of patients;
Compared with patients without tube feeding, the risk of death after tube feeding for one year is reduced by more than 30%.
Enteral nutrition can increase the survival time of patients with motor neuron disease accompanied by dysphagia and malnutrition by more than 12 months, and the survival time can be increased by 55%.
The principles of nutritional support for patients with short-term coma and long-term coma are:
Short-term (7 days) nasal feeding is recommended;
Long-term (1 month) recommended percutaneous gastrostomy feeding;
China supported nasal feeding for the longest time 10 year. During the period of severe stress metabolism changes, the daily energy consumption increases, glycogen decomposition increases, utilization decreases, protein decomposition increases and synthesis decreases (acute reaction period).
At this time, the improper ratio of energy supply to basic substrate may aggravate the metabolic disorder and organ dysfunction, leading to adverse results.
Principle of energy and basic substrate supply 1. Main methods: indirect calorimetry is used to measure energy demand (it cannot be measured in China, only Austria can pass the measurement);
2. Nutritional support: individualized supplement;
Severe patients in stress period, reduce energy supply, 20-25 kcal/kg/day,
Reducing metabolism is consistent with reducing the ratio of heat to nitrogen (100: 1).
Add protein; Reduce the ratio of sugar to fat (5: 5)
Reduce respiratory quotient and reduce the burden of lung ventilation;
Advantages of enteral nutrition:
1. Stimulate intestinal peristalsis;
2. Stimulate the secretion of gastrointestinal hormones;
3. Improve intestinal blood perfusion;
4. Protect the gastrointestinal mucosal barrier;
5. Reduce pathogen fixed value and bacterial translocation;
6. Reduce the complications of hypoproteinemia and anemia;
Selection of nutrition route:
Nasal feeding diet;
Percutaneous gastrostomy;
Feed a liquid diet directly;
The drainage pump drips evenly;
Intravenous nutrition: blood, plasma, Calvin, protein;
Intramuscular injection: vitamins, placenta, γ-ball;
Start time of enteral nutrition: All coma patients with dysphagia eat little or can't eat, which is easy to cause malnutrition. Early nasal feeding for 72 hours in ICU can well maintain the nutritional status of patients;
Patients with coma and vomiting should start nasal feeding within 3-7 days to reduce mortality or bad outcome;
Long-term coma after 1 month and PEG feeding recommended by vegetative people are more beneficial to patients.
Enteral nutrition formula: two parts: the nutrition of coma patients, we must understand the formula; List of national essential drugs in 2002. According to nitrogen source, it can be divided into complete protein, amino acid and short peptide.
The whole protein formula (full energy) nitrogen source is the natural form of protein.
Protein isolate extracted from natural food;
Protein has a large molecular weight;
It has little effect on the osmotic pressure of the formula;
Need normal digestive enzymes to digest;
Short peptide and amino acid preparation (Baipuli)
Nitrogen sources are composed of short peptides in different proportions.
And amino acids;
The formula has high osmotic pressure;
Almost no digestive enzymes are needed to be completely absorbed by small intestine;
2. According to personal formula
Standard formula (standard)
Is an enteral nutrition formula required by normal people;
Adaptable to disease (specific disease)
Nutritional formulas suitable for special diseases, mainly different enteral nutritional formulas can meet the nutritional needs of different patients;
The purpose of dietary fiber is beneficial.
Maintain intestinal function.
Soluble dietary fiber: increase the production of short-chain fatty acids, stimulate probiotics, help maintain the integrity of colon mucosa structure and function, and reduce diarrhea;
Insoluble dietary fiber: increase the volume and moisture of feces and promote intestinal movement.
Most patients with acute coma are complicated with stress hyperglycemia and diabetes.
What need to be considered are: that selection of nutritional formula;
Infusion speed of nutritional preparation;
Blood sugar monitoring;
Pay attention to the adaptive enteral nutrition formula for diabetes mellitus;
Low sugar ratio;
High fat ratio;
The content of monounsaturated fatty acids is high;
High fructose content;
Adding dietary fiber;
The above purpose is to help improve postprandial blood sugar. Severe patients with low protein coma and vegetative state
About10.7-19%;
Actively treat the primary disease; In the state of decortication, muscle tension increases and oxygen absorption decreases;
Control infection; Especially lung infection, close tracheal intubation as soon as possible;
Reasonable nutritional support;
Recently, a small sample of RCT found that high protein enteral nutrition can improve the nitrogen balance of critically ill patients, but our awakening center believes that it can not improve the nitrogen balance for vegetative patients and patients with many complications; Coma, vegetative nutrition formula recommendation (1) Digestive dysfunction: short peptide and amino acid formula (full of energy); Constipation patients: formula containing insoluble dietary fiber; Coma due to heart disease: limit the amount of liquid and choose high-energy formula; Diarrhea (indigestion diarrhea): formula containing free fatty acids, Jiang Shui+vinegar, fasting and rehydration; Lactation; Hiccup formula: dietary fiber and traditional Chinese medicine formula: tangerine peel 10g, Pinellia ternata 10g, Poria cocos 10g and 7 persimmon ladders; Oral baclofen half tablet, motilium 1 tablet; Bilateral Zusanli injection or acupuncture;
Recommendation of nutritional formula for coma and vegetative state (1)
Diabetes or hyperglycemia:
Conditionally choose a formula suitable for diabetes, with appropriate drugs;
Hyperlipidemia or hyperlipidemia:
Optimize the fat formula;
Lipid-lowering drugs;
Patients with hypoproteinemia:
High protein formula: full 1.5 calories, Baipuli formula;
Intravenous injection of protein or immunoglobulin;
Anti-muscle tension therapy; Baclofen, eperisone hydrochloride tablets, Alma, oxazepam, Antan, etc.
Selection of enteral nutrition infusion pipeline
Acute coma (
Those who are intolerant of nasogastric feeding tube or those with high risk of reflux aspiration choose nasointestinal tube;
Long-term (> 4 weeks) patients underwent gastrostomy (PEG) under this condition.
Selection of enteral nutrition infusion methods
In 2006, Metheng et al. conducted a prospective study on 360 critically ill patients receiving tube feeding, and found that:
Body position is related to aspiration and aspiration pneumonia.
The rate of aspiration when the head of a bed is higher than 30 degrees is 24.3%.
When the bedside is raised below 30 degrees, the aspiration rate is 34.7%.
To sum up, the bedside temperature of enteral nutrition for coma patients is 45 degrees.
Selection of enteral nutrition infusion methods: a prospective cross-sectional study of 100 long-term bedridden patients;
Improve the safety of nutrition input pump group and reduce the incidence of diarrhea, vomiting, reflux and aspiration pneumonia.
Flushing the pipeline before and after nasal feeding can obviously reduce the occurrence of pipeline blockage;
Someone washes the pipeline with 20-30 water every 4 hours;
Detection of enteral nutrition support;
Monthly weight test; Weight/height 2;
Blood sugar monitoring; Routine detection of diabetes; The blood sugar of critically ill and vegetative patients should be 8.3- 10mmol/L, not according to the normal blood sugar standard;
Blood lipid: once a week-1 month;
Serum protein: once a week, once a month in a vegetative state;
Liquid input: recorded every day;
Detection of enteral nutrition support;
Serum electrolytes and renal function:
Normal once a week-1 month, abnormal once a day;
Gastrointestinal diseases: nausea, vomiting, abdominal distension and diarrhea last for 4 hours.
Signs such as hematemesis and bloody stool;
Feeding tube depth: check the depth of nasal tube every four hours until the tip of nose reaches.
The distance from the earlobe to the xiphoid process is 45-55cm.
Gastric residual fluid: sucked out every 4 hours, and the total amount should not exceed.
50ml, > >150ml, indicating food accumulation in the stomach, color and sex.
Form, suspected gastrointestinal bleeding immediately sent for inspection;
Adjustment of enteral nutrition:
Vomiting and bloating:
Slow down the injection speed, slow down the total amount of injection;
Find out the reasons and deal with the symptoms;
Those who do not relieve are changed to parenteral nutrition;
Diarrhea (loose stool) > 3 times/day or 200ml/day:
Change to isotonic nutrition formula; Strict aseptic operation;
On an empty stomach, there is less food accumulation in the stomach;
According to the routine administration of antibacterial drugs;
Constipation (0 times every 3 days):
Strengthen water supplement,
Selecting an insoluble dietary fiber formula; tomato
Persimmon, apple, banana, celery;
It is best to use colon laxatives and kaisailu;
Low pressure enema;
Traditional Chinese medicine laxatives and palliative laxatives: Qirong is taken orally.
Liquid, Maren Runchang Pill, Niuhuang Qingxin Pill;
Mechanical enema: cathartic device;
Upper gastrointestinal bleeding (confirmed by occult blood test) bloody stomach contents
Full dose, full speed or full deceleration (20-50 ml/hour);
The gastric occult blood test is measured once a day until it is normal twice;
When the dosage of bloody gastric contents is > 100ml, the feeding is suspended;
Parenteral feeding when necessary;
Give colloid to protect gastric mucosa or take local medicine on an empty stomach;
Gastrointestinal motility insufficiency:
Metoclopramide and erythromycin were added when gastric residue was >: 100ml.
Motilin, lactase and other gastric motility drugs;
Decompression of gastrointestinal decompression device is beneficial to the recovery of gastric peristalsis;
Stop feeding;
Pay attention to check blood potassium and supplement potassium;
If it can't be improved after more than 24 hours, switch to gastrointestinal tube or
Parenteral nutrition; The combination of six dietary fibers can increase the intestinal absorption function.
Comprehensively solve the six major problems of intestine, promote gastrointestinal peristalsis, maintain intestinal structure and barrier function, increase normal intestinal flora, reduce diarrhea, delay blood sugar fluctuation and reduce constipation.
The ratio of soluble and insoluble dietary fiber is perfect, giving full play to physiological functions.
All glycolysis takes place in the colon.
Short chain fatty acids; Promote the integrity of colonic mucosal structure, maintain intestinal barrier function, stimulate the growth of normal intestinal flora, delay the absorption of glucose by small intestine and improve glucose tolerance.
The ratio of soluble and insoluble dietary fiber is perfect, giving full play to physiological functions.
Increase fecal volume, reduce intestinal passage time and prevent bacterial translocation.
And gastrointestinal motility.
Mechanism of effectively promoting gastrointestinal motility and improving glucose metabolism
Increase the viscosity of small intestine contents and hinder the diffusion of glucose.
Reverse adsorption of glucose reduces the effective concentration of glucose in intestinal juice.
Directly inhibit or coat α-amylase, prolong the time of enzyme acting on starch, and reduce the hydrolysis rate of carbohydrates.
Short-chain fatty acids produced by colon fermentation are absorbed into portal vein, which stimulates glycolysis at liver level, inhibits gluconeogenesis and increases insulin sensitivity by improving glucose metabolism.
Soluble dietary fiber can increase the amount of glucose transporter -4 in skeletal muscle plasma membrane, increase insulin sensitivity and reduce the amount of exogenous insulin.
Can fully cooperate with constipation
Can fully and comprehensively balance nutrition.
protein
fat
carbohydrate
mineral
microelement
vitamin
+
Main dosage of dietary fiber enteral nutrition agent
2000kcal/ day, or determined by the doctor according to the condition.
100- 125ml/ hour (the initial dropping speed should be slower, starting from 50ml/ hour).
The initial dose is 500- 1000 kcal/day, and it will be increased to the required amount 1 within 2-3 days. Patients should have more contact with the external environment.
A) Keep the indoor air fresh, and patients should always bask in the sun.
B) Always push the patient outside and look out. External stimulation is very necessary for patients to wake up.
C) Patients who can't go out should always sit up, and it is best to land on their feet. Exercise your back regularly, keep the functional position of trunk joints, and don't always let patients lie in bed.
2. Observation and nursing care of patients with ventricular shunt.
A) Pay attention to whether the drainage tube is unobstructed. This requires pressing the valve of the drainage tube every day. The time and frequency of pressing shall be subject to the doctor's advice at discharge. If the flattened part can't bulge for a long time after pressing the drainage tube, or it can't be pressed, the local tension is high, the patient's consciousness is indifferent, drowsiness and body temperature rise. Ask an expert to check whether the pipeline is blocked immediately.
B) In another case, the pressure pipe valve is open, but the patient's mental consciousness is obviously poor and the child is crying. It is also possible that the problem lies in the shunt. The shunt pipe is divided into low pressure pipe, medium pressure pipe and high pressure pipe. If the pressure tube is not suitable, there will still be poor shunt of hydrocephalus and continue to expand the ventricle. It is necessary to see a specialist in time to make a definite diagnosis.
3. How to communicate with vegetarians?
A) Sensory stimulation to patients: Psychologists in vegetative state believe that there is information processing mechanism in some patients' brains, so it is necessary to implement sensory stimulation or sensory therapy, which can make external sensory stimulation effective from never being recognized to fuzzy perception. The process of sensory stimulation is also the process of stimulating the continuous operation of patients' information processing mechanism, which plays a positive role in awakening patients.
B) Pay attention to the speed of speech: when communicating with vegetarians, speak slowly and gently, and repeat the same words more often.
C) Singing to patients: You can often sing some songs to patients, especially the songs that patients usually like. When singing, you should be full of emotions, pay attention to the patient's demeanor, and whether you are listening. This way is far better than headphones.
4. How to prevent cough?
A) Acupuncture is the best and most effective way to treat choking cough. Patients with cerebral cortex and brain stem injuries can cause coughing, affecting patients' eating and drinking. Therefore, it is necessary to treat dysphagia with acupuncture in time, which can reduce aspiration and prevent lung infection.
B) When eating and drinking, try to keep the patient in a sitting position. After the patient completely swallows, feed the second mouth. In a word, when feeding and eating water, paying attention to the patient's feelings and expressions and adjusting the speed of eating can effectively reduce water choking and prevent water from being inhaled into the lungs by mistake.
5. How to prevent bedsores?
A) Mattress should be kept dry and clean.
B) If the skin is slightly damaged, you can apply iodine to the affected area twice a day. If possible, blow the damaged part with oxygen twice a day, each time for 10 minute, and the damaged part will be dried immediately, and the local part will be cured quickly.
C) If bedsore has formed and it is inconvenient to go to the hospital, family members can also treat it.
After local cleaning with salt water, apply erythromycin eye ointment. If hip decubitus occurs, it is best to apply chloramphenicol eye drops or gentamicin locally. Because these two drugs have a better effect on bedsores infected by Escherichia coli. If the bedsore is heavy, it can be washed locally with hydrogen peroxide 1-2 ml. After the foam appears, you can immediately rinse it again with salt water, and then use some antibiotics locally and apply gauze strips. Patients with excessive secretion should change their dressing once a day, and once every two days after the wound is dry. After local cleaning, you can also use some traditional Chinese medicines to promote granulation growth.
D) Patients with poor health should eat more high-protein foods, such as tofu, meat, eggs or fat emulsion, which can promote the growth of fat and the healing of bedsores.
(2) How to wake up at home?
1, the patient has not yet awakened, or is still unconscious. What if his family feels helpless when he comes home?
The current assessment of brain injury is based on Glasgow's standard score. We might as well use it to train and observe patients from three aspects.
First, from the aspect of "eyes", for patients who only sleep but don't open their eyes or sleep more and wake up less, they should make more phone calls. Make it active when it's time to wake up. The recovery sequence is 1) No eyes opening 2) Stinging eyes opening 3) Calling eyes opening 4) Automatic eyes opening.
Second, from the aspect of language: 1) The patient can't make a sound; 2) Patients can make sounds (such as humming or mumbling); 3) He can talk; 4) He can speak, which may be incorrect; 5) He can answer correctly.
Third, from the aspect of exercise: 1) the patient's limbs will not move; 2) Pain stimulation such as acupuncture can contract; 3) Patients can bend their limbs; 4) He moves aimlessly; 5) he can locate, that is, the patient can find the stimulated part when he is in pain; 6) He can listen to instructions (the patient is awake at this time).
2. Patients mainly stay in bed for a long time. Can they wake up without activity?
As we all know, labor creates the world, labor creates language, and labor creates human beings. Imagine a lively and healthy young man, lying in bed for three months, half a year, his limbs will be stiff and his muscles will shrink. When you get up, your blood pressure will drop and you will feel dizzy. If you lie down again, will you become a cripple? Awakening the vegetative state is not our ultimate goal. The purpose is to improve the quality of life of patients. First, we should return to the family, that is, we can walk, eat at the dinner table, go to the toilet, and if we recover better, we may even take part in social work. For some patients who get timely or mild treatment, our treatment practice has proved this. Some patients we treat can play chess, climb mountains, pedal tricycles, go shopping and help deliver goods at home. Some patients can walk without outside help. There are still many patients who can make further progress, but we feel very sorry that there is no further rehabilitation treatment. Some family members arrange too much, or let nannies replace them all, thinking that it is too much trouble for patients to eat and dress themselves, so we should help save time. As a result of this arrangement, the patient lost the ability to move from passive to active and the ability to be independent. Therefore, doctors and their families should first emancipate their minds, update their concepts and really let patients "move".