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Журнал "Медицина невідкладних станів" 1 (64) 2015

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Features of nutritional support in patients with severe acute necrotizing pancreatitis

Автори: O. I. Dronov, I. A. Kuchynska, D. B. Areshnikov, K. O. Zadorozhna - Department of General Surgery NMU named after O. O. Bogomolets, Kyiv; Department of Anaesthesiology and Intensive Care, National Medical Academy of Postgraduate Education named after P. L. Shupik; Kyiv City Clinical Hospital № 10; Kiev City Center of Liver Disease, Bile ducts and Pancreas named after V.S. Zemskov;

Рубрики: Медицина невідкладних станів

Розділи: Довідник фахівця

Версія для друку

Despite the progress made in recent years in the diagnosis and treatment of patients with acute necrotizing pancreatitis (ANP), mortality among patients with infectious complications of this disease is 80%. In pancreatic necrosis in 40-70 % of patients with necrotic foci of infection is destruction.
Acute pancreatitis - a рolyetiological disease, acute aseptic inflammation of the pancreas, which is based on processes of morphologic alterations, necrosis and endogenous infection involving the process surrounding tissues retroperitoneum and abdomen. The main importance in medical and tactical doctrine in ANP belongs multicomponent intensive care: purchase pain, blockage of exocrine pancreatic secretory function, infusion therapy, fighting toxemia, prevention of stress ulcers, symptomatic therapy (sedation, respiratory support, use of inotrop-therapy, antibiotics, insulin etc.), adequate surgical tactic. An extremely important component is energy intensive treatment volemic therapy aimed at correcting fluid and electrolyte balance, detoxification, adequate supply of energy and plastic substrates. According to the literature 36-38% in critically ill patients (Polly E. Parson, 2009) showing signs malnutrition (lack alimentary) and malabsorption syndrome (loss of one or more nutrients entering the digestive tract due to lack of assimilation in the intestines).

It should be noted the importance of the use of nasogastric-intestinal probe set in the small intestine in cases impossible of food in the stomach. Bradley E.L. (2003) recommends the systematic use of enteral nutrition through a tube introduced into the small intestine, just before the first surgery, which is held to rehabilitation pathological focus. Impossible situations with holding food in the stomach is very common in patients with ANP and accompanied by a marked gastric paresis episodes of gastroesophageal reflux and aspiration with subsequent risk. Intestinal tube is better tolerated than nasogastric, but it requires constant monitoring locations due to frequent dislocations; due to the smaller diameter can obstruction at the distal end, require additional equipment for setting (gastroscopy) or installed during open surgical rehabilitation, conducted usually in branches period.

The main consequences of inadequate clinical nutrition in patients is accompanied by metabolic changes, characterized by a tendency to hypermetabolism and hypercatabolism and release a significant amount of catecholamines, glucocorticoids, proinflammatory mediators and cytokines, including tumor necrosis factor, which inhibits the activity of appetite center in the hypothalamus. The consequence of these changes are anorexia, weight loss, slow weight gain, signs of immune dysfunction with increasing concentrations of proinflammatory cytokines, worsening wound healing, frequent nosocomial infectious complications, multiple organ failure syndrome formation, increase drug exposure to patients, lengthening the duration of stay hospital.
Assessment of nutritional status begins with a history and physical examination. Key markers available malnutrition syndrome: rapid weight loss, namely 10-12% of the original value within 5 days of onset, (it should be noted that weight loss may be masked restriction of water load); disorders of the intestine; signs of deficiency of micronutrients such as glossitis and anemia. Levels of serum liver enzymes and albumin directly related to the nutritional status of the patient and the severity of the disease. For example, the half-life of albumin is 21 days, so it serves the best marker of nutritional status in patients with chronic power failure. Prealbumin is an indicator of the current state of food because its half-life - 2-3 days. Serum albumin, transferrin and prealbuminu, insulin-like growth factor, fibronectin and urinary creatinine is biochemical parameters which are reduced in response to the infection, activation of destructive reactions and increased, respectively, the reverse process these pathological conditions.

ANP is usually accompanied by manifestations hypermetabolism and hypercatabolism. In this situation, covering energy needs at the expense of their own destruction muscle structures that deepens manifestations of systemic organ dysfunction. Nutritional support is seen as a method to prevent the development of severe malnutrition. In our practice we use recommendations ESPEN 2006 concerning the conduct of enteral nutrition in patients with severe pancreatitis.

In conducting the probe enteral nutrition main advantage is the possibility of food is not only the patient, and intestine (most importantly - trophic food) as known for his significant role in the immune status of secondary infectious complications and run sponsored cascade. Enteral nutrition prevents atrophy of intestinal villi, facilitates correction of impaired intestinal pH content, excessive reduction of colonization, reduction of the phenomenon of translocation of intestinal flora, prevention of stress ulcers, reduced activity manifestations of the syndrome hypercatabolism.
If the purpose of parenteral nutrition priority calculates energy needs (non-protein calories - carbohydrates and fats, and protein). It is known that the daily energy needs of the body consists of the sum of the estimated value of basal metabolism, activity factors, damage and temperature factor. Currently preferred "three-chambered" systems with balanced carbohydrate, fat emulsions and amino acids. Safety of 20-25% glucose (lower percentage of glucose is not advised to use due to the very low energy) backed recommendation for speed parameter input - not faster 0.5 g / kg / h "pure" glucose, or no more than 5 g / kg / day, which prevents possible complications such as hyperglycemia with hyperosmolar syndrome, hypokalemia, adipogenesis activation and development of fatty liver. In carrying out continuous monitoring of daily blood glucose is obvious recommendations Grete van de Berge et al., 2001, regarding the acceptable level of sugar is not above 6.1 mmol / l and routine use of intravenous correction of hyperglycemia continuous infusion of insulin action on short circuit.

When choosing a solution fats, the introduction of which even a small amount provides up to 50% of non-protein energy needs of the body, use only with emulsion similar to chylomicrons chemical and physical properties, which are formed in the intestinal mucosa cells. In accordance with earlier studies listed Heyland DK et al., 1998, 2003 fat emulsion may worsen prognosis of patients in critical condition. ESPEN experts in consensus documents in choosing the same for patients in critical condition with liver disease, surgical patients prefer drugs that contain long-chain and medium-chain triglycerides and olive oil (according to the results of the study, which analyzed surrogate indicators). But the relationship outcome type of drug was not studied. For current ANP typical negative balance of protein synthesis from amino acids which occurs only when each gram of nitrogen will be delivered by non-protein energy origin (from glucose and lipids). This figure is generally should not exceed 200 kcal / d (protein nitrogen). It is believed that patients with malnutrition who are not in a state of shock, there must be a lot of energy while reducing the introduction of amino acids, which are a source of nitrogen.

The main complications during parenteral nutrition is technical (1,5-6%), septic (5-6%) and metabolic. The main disadvantages of parenteral nutrition is atrophy of intestinal wall, increasing the frequency of venous thromboembolism risk, immunosuppression, imbalance.
The modern concept of nutritional support is a vector of individual important component of intensive therapy, particularly in ANP - Clinical Nutrition, which is a scientifically based system of therapeutic measures aimed at restoring a functional body of the patient, taking into account the peculiarities of pathogenesis, clinical pathological process, disease stage, level and nature of metabolic disorders. Currently nutritional support is an integral treatment process. Proper use of its various subspecies (parenteral, enteral mixed) doctors can adjust physiologically relatively complex metabolic disorder and support the livelihoods of the organism in critical condition.

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