Recent studies on early enteral nutrition in patients undergoing gastric cancer surgery are described. This paper is only for reference
1. Ways, approaches and timing of enteral nutrition
1.1 enteral nutrition
Three infusion methods can be used to provide nutritional support for patients with gastric cancer after operation: one-time administration, continuous pumping through infusion pump and intermittent gravity drip. Clinical studies have found that the effect of continuous infusion by infusion pump is significantly better than intermittent gravity infusion, and it is not easy to have adverse gastrointestinal reactions. Before nutritional support, 50ml of 5% glucose sodium chloride injection was routinely used for flushing. In winter, take a hot water bag or an electric heater and place it at one end of the infusion pipe close to the orifice of the fistula tube for heating, or heat the infusion pipe through a thermos bottle filled with hot water. Generally, the temperature of the nutrient solution should be 37 ℃ ~ 40 ℃. After opening the Enteral Nutrition Bag, it should be used immediately. The nutrient solution is 500ml / bottle, and the suspension infusion time should be maintained at about 4H. The dropping rate is 20 drops / min 30 minutes before the start of infusion. After there is no discomfort, adjust the dropping rate to 40 ~ 50 drops / min. after infusion, flush the tube with 50ml of 5% glucose sodium chloride injection. If infusion is not needed for the time being, the nutrient solution shall be stored in a cold storage environment of 2 ℃ ~ 10 ℃, and the cold storage time shall not exceed 24h.
1.2 enteral nutrition pathway
Enteral nutrition mainly includes Nasogastric Tubes, gastrojejunostomy tube, nasoduodenal tube, spiral naso intestinal tube and Nasojejunal Tube. In the case of long-term indwelling of Stomach Tube, there is a high probability of causing a series of complications such as pyloric obstruction, bleeding, chronic inflammation of gastric mucosa, ulcer and erosion. Spiral naso intestinal tube is soft in texture, not easy to stimulate the patient’s nasal cavity and throat, easy to bend, and the patient’s tolerance is good, so it can be placed for a long time. However, the long time of placing the pipeline through the nose will often cause discomfort to the patients, increase the probability of nutrient fluid reflux, and misinhalation may occur. The nutritional status of patients undergoing palliative surgery for gastric cancer is poor, so they need long-term nutritional support, but the gastric emptying of patients is seriously blocked. Therefore, it is not recommended to choose transnasal placement of pipeline, and intraoperative placement of fistula is a more reasonable choice. Zhang moucheng and others reported that the gastrojejunostomy tube was used, a small hole was made through the patient’s gastric wall, a thin hose (with a diameter of 3mm) was inserted through the small hole, and entered the jejunum through the pylorus and duodenum. The double purse string suture method was used to deal with the incision of the gastric wall, and the fistula tube was fixed in the gastric wall tunnel. This method is more suitable for palliative patients. Gastrojejunostomy tube has the following advantages: the indwelling time is longer than other implantation methods, which can effectively avoid respiratory tract and pulmonary infection caused by nasogastric jejunostomy tube; Suture and fixation through gastric wall catheter is simpler, and the probability of gastric stenosis and gastric fistula is lower; The position of gastric wall is relatively high, so as to avoid a large number of ascites from liver metastasis after gastric cancer operation, soak fistula tube and reduce the incidence of intestinal fistula and abdominal infection; Less reflux phenomenon, patients are not easy to produce psychological burden.
1.3 timing of enteral nutrition and selection of nutrient solution
According to reports of domestic scholars, patients undergoing radical gastrectomy for gastric cancer begin enteral nutrition through jejunal nutrition tube from 6 to 8 hours after operation, and inject 50ml of warm 5% glucose solution once / 2h, or inject enteral nutrition emulsion through jejunal nutrition tube at a uniform speed. If the patient has no discomfort such as abdominal pain and abdominal distension, gradually increase the amount, and the insufficient liquid is supplemented through vein. After the patient recovers anal exhaust, the gastric tube can be removed, and the liquid food can be eaten through the mouth. After the full amount of liquid can be ingested through the mouth, the Enteral Feeding Tube can be removed. Industry insiders believe that drinking water is given 48 hours after the operation of gastric cancer. On the second day after the operation, clear liquid can be eaten at dinner, full liquid can be eaten at lunch on the third day, and soft food can be eaten at breakfast on the fourth day. Therefore, at present, there is no unified standard for the time and type of early postoperative feeding of gastric cancer. However, the results suggest that the introduction of rapid rehabilitation concept and early enteral nutrition support do not increase the incidence of postoperative complications, which is more conducive to the recovery of gastrointestinal function and effective absorption of nutrients in patients undergoing radical gastrectomy, improve the immune function of patients and promote the rapid rehabilitation of patients.
2. Nursing of early enteral nutrition
2.1 psychological nursing
Psychological nursing is a very important link after gastric cancer surgery. First, medical staff should introduce the advantages of enteral nutrition to patients one by one, inform them of the benefits of primary disease treatment, and introduce successful cases and treatment experience to patients to help them build confidence and improve treatment compliance. Secondly, patients should be informed of the types of enteral nutrition, possible complications and perfusion methods. It is emphasized that only early enteral nutrition support can restore oral feeding in the shortest time and finally realize the recovery of the disease.
2.2 enteral nutrition tube nursing
The nutrition infusion pipeline shall be well cared for and properly fixed to avoid compression, bending, twisting or slipping of the pipeline. For the nutrition tube that has been placed and properly fixed, the nursing staff can mark the place where it passes through the skin with a red marker, handle the shift handover, record the scale of the nutrition tube, and observe and confirm whether the tube is displaced or accidentally detached. When the medicine is administered through the feeding tube, the nursing staff should do a good job in disinfection and cleaning of the feeding tube. The feeding tube should be thoroughly cleaned before and after medication, and the medicine should be fully crushed and dissolved according to the established proportion, so as to avoid the blockage of the pipeline caused by the mixing of too large drug fragments in the medicine solution, or the insufficient fusion of the medicine and the nutrient solution, resulting in the formation of clots and blocking the pipeline. After the infusion of nutrient solution, the pipeline shall be cleaned. Generally, 50ml of 5% glucose sodium chloride injection can be used for flushing, once a day. In the continuous infusion state, the nursing staff should clean the pipeline with a 50ml syringe and flush it every 4H. If the infusion needs to be suspended temporarily during the infusion process, the nursing staff should also flush the catheter in time to avoid solidification or deterioration of the nutrient solution after being placed for a long time. In case of alarm of infusion pump during infusion, first separate the nutrient pipe and pump, and then wash the nutrient pipe thoroughly. If the nutrient pipe is unobstructed, check other reasons.
2.3 nursing of complications
2.3.1 gastrointestinal complications
The most common complications of enteral nutrition support are nausea, vomiting, diarrhea and abdominal pain. The causes of these complications are closely related to the pollution of nutrient solution preparation, too high concentration, too fast infusion and too low temperature. Nursing staff should pay full attention to the above factors, regularly patrol and check every 30min to confirm whether the temperature and dropping speed of nutrient solution are normal. The configuration and preservation of nutrient solution should strictly follow the aseptic operation procedures to prevent nutrient solution pollution. Pay attention to the patient’s performance, confirm whether it is accompanied by changes in bowel sounds or abdominal distension, and observe the nature of stool. If there are discomfort symptoms such as diarrhea and abdominal distension, the infusion should be suspended according to the specific situation, or the infusion speed should be appropriately slowed down. In serious cases, the feeding tube can be operated to inject gastrointestinal motility drugs.
2.3.2 aspiration
Among the enteral nutrition related complications, aspiration is the most serious one. The main causes are poor gastric emptying and nutrient reflux. For such patients, the nursing staff can help them maintain the semi sitting position or sitting position, or raise the head of the bed by 30 ° to avoid the reflux of nutrient solution, and maintain this position within 30 minutes after the infusion of nutrient solution. In case of aspiration by mistake, the nursing staff should stop the infusion in time, help the patient maintain the right lying position, lower the head, guide the patient to cough effectively, suck out the inhaled substances in the airway in time and suck the contents of the patient’s stomach to avoid further reflux; In addition, antibiotics were injected intravenously to prevent and treat pulmonary infection.
2.3.3 gastrointestinal bleeding
Once patients with enteral nutrition infusion have brown gastric juice or black stool, the possibility of gastrointestinal bleeding should be considered. The nursing staff should inform the doctor in time and closely observe the patient’s heart rate, blood pressure and other indicators. For patients with small amount of bleeding, positive gastric juice examination and fecal occult blood, acid inhibiting drugs can be given to protect gastric mucosa, and Nasogastric Feeding can be continued on the basis of hemostatic treatment. At this time, the temperature of Nasogastric Feeding can be reduced to 28 ℃ ~ 30 ℃; Patients with a large amount of bleeding should be fasting immediately, given antacid drugs and hemostatic drugs intravenously, replenish blood volume in time, take 50ml ice saline mixed with 2 ~ 4mg norepinephrine and nasal feeding every 4h, and closely monitor the changes of the condition.
2.3.4 mechanical obstruction
If the infusion pipeline is distorted, bent, blocked or dislocated, the patient’s body position and catheter position should be readjusted. Once the catheter is blocked, use a syringe to draw an appropriate amount of normal saline for pressure flushing. If the flushing is ineffective, take one chymotrypsin and mix it with 20ml normal saline for flushing, and keep gentle action. If none of the above methods is effective, decide whether to re place the tube according to the specific situation. When the jejunostomy tube is blocked, the contents can be pumped clean with a syringe. Do not insert a guide wire to dredge the catheter to prevent damage and rupture of the feeding catheter.
2.3.5 metabolic complications
The use of enteral nutritional support can cause blood glucose disorder, while the hyperglycemic state of the body will lead to accelerated bacterial reproduction. At the same time, the disorder of glucose metabolism will lead to insufficient energy supply, which will lead to the decline of patients’ resistance, induce enterogenous infection, lead to gastrointestinal dysfunction, and is also a main inducement of multi-system organ failure. It should be noted that most patients with gastric cancer after liver transplantation are accompanied by insulin resistance. At the same time, they are given growth hormone, anti rejection drugs and a large number of corticosteroids after operation, which further interferes with glucose metabolism and is difficult to control blood glucose index. Therefore, when supplementing insulin, we should closely monitor the blood glucose level of patients and reasonably adjust the blood glucose concentration. When starting enteral nutrition support, or changing the infusion speed and input amount of nutrient solution, the nursing staff should monitor the finger blood glucose index and urine glucose level of the patient every 2 ~ 4H. After confirming that the glucose metabolism is stable, it should be changed to every 4 ~ 6h. The infusion speed and input amount of islet hormone should be adjusted appropriately in combination with the change of blood glucose level.
To sum up, in the implementation of FIS, it is safe and feasible to carry out enteral nutrition support in the early stage after gastric cancer surgery, which is conducive to improving the nutritional status of the body, increasing the intake of heat and protein, improving the negative nitrogen balance, reducing the loss of the body and reducing various postoperative complications, and has a good protective effect on the gastrointestinal mucosa of patients; It can promote the recovery of patients’ intestinal function, shorten hospital stay and improve the utilization rate of medical resources. It is a scheme accepted by most patients and plays a positive role in the recovery and comprehensive treatment of patients. With the in-depth clinical research on early postoperative enteral nutrition support for gastric cancer, its nursing skills are also continuously improved. Through postoperative psychological nursing, nutrition tube nursing and targeted complication nursing, the probability of gastrointestinal complications, aspiration, metabolic complications, gastrointestinal bleeding and mechanical obstruction is greatly reduced, which creates a favorable premise for the exertion of the inherent advantages of enteral nutrition support.
Original author: Wu Yinjiao
Post time: Apr-15-2022