| Research backgroundAt present, for severe stroke patients with complete gastrointestinal function with early EN(enteral nutrition) has the clinical consensus. Because the EN compared with parenteral nutrition is more adaptability for the patients’ physical, mechanical, biological, immunological barrier function,can help to maintain intestinal bacterial translocation, and reduce the incidence of infection. Compared with the previous use of feeder or syringe feeding to feed the patients, the nutrition pump has been wisely used as a method to feed the patients known clinically. Compared to the former, enteral nutrition pump can reduce the complications of EN,such as tube off, aspiration, diarrhea, vomiting, high blood sugar. Even so, for severe stroke patients, these complications happened more than other disease patients. This is due to severe stroke patients generally appear as high energy consumption,high metabolism, abnormal blood sugar, low immunity, digestive disfunction, electrolyte disturbances.Patients usually appears consciousness barrier, dysphagia, which makes the EN implementation process more difficult. And the EN process can also has its complications,which affect the recovery and prognosis of the stroke patients.An direct indicator of the implementation of EN effect for the patients is the feeding of compliance rate, which is the ratio between the complete volume and target volume. According to the "European Society of parenteral and enteral nutrition (ESPEN) enteral nutrition guide", the daily amount of patient nutrition enteral was 25 kcal/(kg.d). When the patient is in medical stress, we can give the patient 60% of the target feeding. Therefore, the goal of third days feeding amount of nutrition in patients with EN,60% of the target feeding can be a dividing line. Patients with early EN is divided into two categories according to it:more than 60% of target feeding as standard, less than 60% of target feeding is not up to the standard. But on the EN feeding standard research, relatively rare in clinic. Clinical go up to also pay little attention to patients with EN feeding standard rate.Similarly, it was better for patients to achieve a reasonable energy and material needs to patients with EN,, the most intuitive and effective method was monitoring the GRV (gastric residual volume) in clinical nursing process. According to the GRV, we can adjust the program of EN of patients in order to achieve the optimal EN. Now the generally measurement method of GRV is the using a syringe or feeder device for nurses in clinical. When a nurse use them suct the tube until negative pressure,the out of the amount of residual gastric fluid volume is GRV. But the accuracy of this method has been questioned. Because this method is easily affected by nurses’ subjective, nasogastric tube diameter, and the accuracy of the impact.So,the result is not accurate, and is also waste of EN. So,Looking for a scientific and accurate method has become an urgent problem. Then, in 2002, You-Chen Chao proposed the use of Brix meter which is a much more precise instruments to monitoring GRV.Brix meter is also called sugar degree instrument or refractive refraction instrument, used for rapid determination of sugar solution concentration or refractive index and other non sugar solution rate. When the light from a medium slant into another medium, the propagation direction is changed, so that the light deflection occurs at the junction of different medium. This is due to the speed of light in two different substances is different, so direction in the two media at the junction of the propagation changes, and the light produces refraction. According to the refraction of light theory, each material has its specific refractive index. While the material refraction in solution were also expressed the reaction of solution optical properties. The refraction was measured by Briex meter can expressed the concentration of solution.So it is widely used in sugar, food, beverages and other industrial sectors and agricultural production and research.Basic research on You-Chen Chao believed that when enteral nutrition was gived through nasogastricby the pump with a certain speed into the stomach, which would mixed with gastric juice.Because of the Gastro upset or other reasons which caused the EN can not into the next phase of digestion, the enteral nutrient would retented in the stomach, and mixed with the gastric juice,which formed of residual gastric juice. Through the research of four kinds of EN, respectively in different pH (pH=1, pH=4, pH=7, pH=8) and different temperature (4℃ 25℃,27℃), only in the pH of gastric juice in extremely acidic value, enteral nutrition Brix values changed -- lower than a desired value. But this prompts us that,enteral nutrition in the stomach, the composition did not change.What change is the concentration only. The research showed that, when the same kind of enteral nutrition or substance diluted to certain concentration in and distilled water, the refractive index change is linear relation with the concentration,the formula is BV=aC+b, where C is the concentration of the nutrient solution, BV for the corresponding Brix values, a, b is a constant.Different nutrition means different a. Which prompts us that refractive index of EN and the dilution concentration are linear relation in normal stomach. The fact proved that residual gastric intestinal nutrition agent refraction rate with a added linear relationship with the concentration (temperature, pH value are independent), different nutritional agent, a linear relationship is not the same type of slope. This is a very important experiment to support the Brix meter as monitoring the GRVMonitoring and calculation of GRV by Brix meter made a breakthrough in 2004, but it hasn’t been widely used in clinical. Scholar Lv Qingqing proved the relationship between different enteral nutrition in gastric juice Brix value and gastric residual volume through experiments (V= (BV1-1.8)*Vwater/(BV1-BV2)), which made the measurement of GRV more objective and scientific, and presented results that this detection method may be more accurate to prevent contact error suction. But the relationship between this measurement with the complications of enteral nutrition is uncertain.Therefore, in order to better ensure the implementation of enteral nutrition of patients, this study will be the implementation of early severe stroke patients with enteral nutrition, to investigate early enteral nutrition feeding standard rate of the situation, and then find out the factors influencing the substandard, and as a point of departure from the GRV, introducing the method of Brix meter monitoring GRV, and through the basic verification, clinical trials, to compare the use of Brix meter monitoring and syringes or feeder monitoring quality,which provide a scientific and accurate measurement results for clinical nurse monitoring gastric residual liquid, to supply the nutrition adjustment intestinal better. Our purpose is to benefit patients.The purpose of the study1 The substandard of early enteral nutrition for severe stroke patients and its affecting factors analysis2 To Verify the method that Brix meter monitor GRV is scientific3 The comparative clinical trial is between the Brix meter monitoring GRV with a syringe or feeder monitoring GRV for the early enteral nutrition in patients with severe strokeThis study is divided into two parts.1. The first part:the cross-sectional study is used.182 cases from 2013 January to 2014 June in three level of first-class hospital department of internal medicine severe stroke patients are surveyed. Inclusion criteria:age older than 18 years old; 48h expert enteral nutrition in Department of internal medicine, ICU, and predicted that the patient time>3days enteral nutrition. Exclusion criteria:abdominal, esophagus, duodenum, pancreas, stomach operation history; from the esophagus, stomach or intestinal administration have contraindication the fistula; enteral nutrition; the pregnant women; the treatment of constraints; pneumonia or suspected pneumonia; the stomach following way catheter; and into the ICU 48 h without intestinal nutrition. The researchers were investigated by a self-designed questionnaire in the access to extensive literature review on the basis of. The questionnaire consists of two parts:1. The patient’s general information and general examination, including gender, age, Glasgow coma score (GCS):and so on; the enteral nutrition related information, including mechanical ventilation, diarrhea, high blood sugar, vomiting or regurgitation, aspiration, gastric residual> 100 mL. According to the "European Society of parenteral and enteral nutrition (ESPEN) enteral nutrition guide", the daily amount of patient nutrition enteral was 25 kcal/(kg-D). When the patient is in stress state, can give the patient target feeding 60%, therefore, the study on nutrition third day target feeding intestinal 60% as a dividing line, will be the early enteral nutrition patients are divided into two categories:more than 60% target feeding as the target group<60% for the feed is not the standard group.2.The second part:the basic test:enteral nutrition (Ruidai, Nutrison Fibre, Jevity)were taken each of 15ml, which were diluted with distilled water for:0%, 6.2%,12.5%,25%,50%,75%,100%, and mixing, measuring Brix value and related indexes to record the phase the related data, and using SPSS 13.0 software to derive the relationship between Enteral Nutritional Emulsion dilution concentration and Brix values. The relationship and through mathematical relationships derived Brix value and gastric residual liquid quantity. Clinical trial:this was a randomized controlled experimental. the patients were divided into Brix meter group and the injector group, from 2014 June to 2014 December in a three level of first-class hospital department of internal medicine, ICU,whose age>18 years old; the expected need for nasogastric enteral nutrition in patients older than 3 days of stroke. Clinical study of exclusion criteria:(1)abdominal esophagus, duodenum, pancreas, stomach operation history; (2) from the esophagus, stomach or intestinal administration have contraindication; (3) via jejunostomy or gastrostomy the enteral nutrition; (4) pregnant women; (5) the treatment of limited; pneumonia or suspected pneumonia; (6) the following ways those stomach catheter (7) EN intolerance; (8) to participate in the research. The comparison of main index for early feeding success rate, two level indicators for the complications of enteral nutrition, such as diarrhea, aspiration, hyperglycemia, vomiting or regurgitation.3. Statistical methodSPSS13.0 was used to carry on the analysis and statistics of data Measurement data were expressed by x±s, count data representation using frequency and percentage. The measurement data using t test, count data using chi square test. Analysis of related factors, logistic regression analysis using two classification. The level of test set alpha=0.05, P<0.05 have significant difference.Result(一) The first partThere were 182 of cases met the inclusion criteria, including 59 cases of target feeding standards (32.4%),123 cases (67.6%) were not up to standard.2 There are no significant difference between two groups among gender, age and whether hyperglycemia (standard group VS standard group,χ2=0.764, P=0.382; t=0.907, P=0.336;χ2=0.156, P=0.693). Differences are statistically significant between two groups among. GCS score, whether the occurrence of diarrhea, vomiting or regurgitation, gastric residual liquid quantity> 100ml, whether mechanical ventilation (group VS compared to standard is not up to the standard group, t=2.180, P=0022;χ2=5.627,χ2=7.319, P=0.018; P=0.007; P=0.034;χ2=4.511,χ2 =8.132, P=0.004)3 The logistic regression analysis showed that, there were 4 variables entered into the Logistic regression analysis model finally.They were diarrhea (OR=2.208, 95%OR=1.042～4.682, P=0.039), vomiting or regurgitation (OR=8.112, 95%OR=1.797～36.610, P=0.006), gastric residual> 100 mL (OR=4.087, 95%OR=1.124～14.868, P=0.033), mechanical ventilation (OR=3.265, 95%OR=1.309～8.143, P=0.011).(二)The second part1 Results of the Basic test1.1 Three kinds of different enteral nutrition agent dilution concentration and Brix values are linear relationship, and respectively is:different concentrations of Nutrison Fibre Brix degree relations is Y=22.8/X; Brix Ruidai relationship type is Y=X/18.4; Brix degree relation of different concentration jevity is Y= X/23.8.1.2 The relationship between Brix value and GRV is V1=50* (BV2-2)/ (BV1-BV2).2 The results of clinical trials2.1 The baseline data comparison between two groups showed that gender, age, GCS score, whether mechanical ventilation had no statistical difference.2.2 Two groups showed statistically significant differences in complications.2.3 There were no statistical significance among aspiration,hyperglycemia, difference of diarrhea vomiting or regurgitation.Conclusions1. Severe stroke patients with early enteral nutrition standard rate is lower than the substandard rate.2.The results showed that GCS score, whether the occurrence of diarrhea, vomiting or regurgitation, gastric residual liquid quantity> 100ml, whether mechanical ventilation standard group were less than the substandard group.3.early enteral nutrition is not up to the standard which may be due to diarrhea, vomiting or reflux, gastric residual> 100 mL, mechanical ventilation.4. Brix meter can be a scientific method for monitoring GRV5.the relationship between GRV and Brix values of gastric residual liquid is V1=50*(BV2-2)/(BV1-BV2).6. use Brix meter to monitor GRV can improve the severe stroke patients with early enteral nutrition feeding standard rate more than using a syringe or feeder monitoring. |
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