In recent years, the term “feeding intolerance” has been widely used clinically. As long as the mention of enteral nutrition, many medical staff or patients and their families will associate the problem of tolerance and intolerance. So, what exactly does enteral nutrition tolerance mean? In clinical practice, what if a patient has enteral nutrition intolerance? At the 2018 National Critical Care Medicine Annual Meeting, the reporter interviewed Professor Gao Lan from the Department of Neurology of the First Hospital of Jilin University.
In clinical practice, many patients cannot get enough nutrition through normal diet due to disease. For these patients, enteral nutrition support is needed. However, enteral nutrition is not as simple as imagined. During the feeding process, patients have to face the question of whether they can tolerate it.
Professor Gao Lan pointed out that tolerance is a sign of gastrointestinal function. Studies have found that less than 50% of internal medicine patients can tolerate total enteral nutrition at an early stage; more than 60% of patients in the intensive care unit cause temporary interruption of enteral nutrition due to gastrointestinal intolerance or gastrointestinal motility disorders. When a patient develops feeding intolerance, it can affect the target feeding amount, leading to adverse clinical outcomes.
So, how to judge whether the patient is tolerant to enteral nutrition? Professor Gao Lan said that the patient’s bowel sounds, whether there is vomiting or reflux, whether there is diarrhea, whether there is intestinal dilatation, whether there is an increase in stomach residue, and whether the target volume is reached after 2 to 3 days of enteral nutrition, etc. As an index to judge whether the patient has enteral nutrition tolerance.
If the patient does not experience any discomfort after the application of enteral nutrition, or if abdominal distension, diarrhea, and reflux occur after the application of enteral nutrition, but alleviate after treatment, the patient can be considered to be tolerable. If the patient suffers from vomiting, abdominal distension, and diarrhea after receiving enteral nutrition, he is given corresponding treatment and paused for 12 hours, and the symptoms do not get better after half of the enteral nutrition is given again, which is regarded as enteral nutrition intolerance. Enteral nutrition intolerance can also be subdivided into gastric intolerance (gastric retention, vomiting, reflux, aspiration, etc.) and intestinal intolerance (diarrhea, bloating, increased intra-abdominal pressure).
Professor Gao Lan pointed out that when patients develop intolerance to enteral nutrition, they will usually deal with symptoms according to the following indicators.
Indicator 1: Vomiting.
Check whether the nasogastric tube is in the correct position;
Reduce the nutrient infusion rate by 50%;
Use medication when necessary.
Indicator 2: Bowel sounds.
Stop nutritional infusion;
Give medication;
Recheck every 2 hours.
Index three: abdominal distension/intra-abdominal pressure.
Intra-abdominal pressure can comprehensively reflect the overall situation of small bowel movement and absorption function changes, and is an indicator of enteral nutrition tolerance in critically ill patients.
In mild intra-abdominal hypertension, the rate of enteral nutrition infusion can be maintained, and intra-abdominal pressure can be re-measured every 6 hours;
When the intra-abdominal pressure is moderately high, slow down the infusion rate by 50%, take a plain abdominal film to rule out intestinal obstruction, and repeat the test every 6 hours. If the patient continues to have abdominal distension, gastrodynamic drugs can be used according to the condition. If the intra-abdominal pressure is severely increased, enteral nutrition infusion should be stopped, and then a detailed gastrointestinal examination should be performed.
Indicator 4: Diarrhea.
There are many causes of diarrhea, such as intestinal mucosal necrosis, shedding, erosion, reduction of digestive enzymes, mesenteric ischemia, intestinal edema, and imbalance of intestinal flora.
The treatment method is to slow down the feeding rate, dilute the nutrient culture, or adjust the enteral nutrition formula; carry out targeted treatment according to the cause of the diarrhea, or according to the scale of the diarrhea. It should be noted that when diarrhea occurs in ICU patients, it is not recommended to stop enteral nutrition supplementation, and should continue to feed, and at the same time find the cause of the diarrhea to determine the appropriate treatment plan.
Index five: stomach residue.
There are two reasons for gastric residue: disease factors and therapeutic factors.
Disease factors include advanced age, obesity, diabetes or hyperglycemia, the patient has undergone abdominal surgery, etc.;
Medication factors include the use of tranquilizers or opioids.
Strategies for resolving gastric residues include conducting a comprehensive assessment of the patient before applying enteral nutrition, using drugs that promote gastric motility or acupuncture when necessary, and choosing preparations that have fast gastric emptying;
Duodenal and jejunal feeding are given when there is too much gastric residue; a small dose is selected for initial feeding.
Index six: reflux/aspiration.
In order to prevent aspiration, medical staff will turn over and suck up respiratory secretions in patients with impaired consciousness before nasal feeding; if the condition permits, raise the patient’s head and chest by 30° or higher during nasal feeding, and after nasal feeding Maintain a semi-recumbent position within half an hour.
In addition, it is also very important to monitor the patient’s enteral nutrition tolerance on a daily basis, and easy interruption of enteral nutrition should be avoided.
Post time: Jul-16-2021