Intestinal fistula is a common abdominal surgery in severe diseases, intestinal fistula after impact on the systemic condition depends on the location, size, primary disease of intestinal fistula and. Serious intestinal fistula can cause a series of pathological and physiological changes, mainly including internal environment disorders, malnutrition, infection and organ dysfunction. Therefore, application of reasonable nutrition drugs for patients with intestinal fistula is an effective treatment, the fistula to avoid the lack of nutrients, so as to ensure the body function of important organs. In the process of clinical nutrition support, clinical pharmacists, as a member of the treatment team, put forward constructive suggestions in the treatment of nutritional support, combined with the characteristics of patients with organ function and the change of the disease to develop personalized nutrition drug treatment program, in order to improve the safety and effectiveness of the application of nutrition drugs, improve the prognosis of patients.
1 Summary of medical records
Patients, 67 years old, 168 cm height, weight 55 kg. due to the "incision hernia, incision and abdominal cavity drainage tube with 6 D in the intestinal content" in August 20, 2013. NRS2002 score of 3 points, with a nutritional support to adapt. After the patient is admitted to hospital give fat emulsion, amino acids (17) glucose (11%) injection 1 440mL (Calvin) nutrition support for more than 1 month a, September 25, to 2013, patients complained of nausea, vomiting and a lack of energy, check mild jaundice, total bilirubin (TBIL) 138. 86 mol - L - 1, direct bilirubin (DBIL) 99. 42 mol - L - 1. Clinical pharmacists exclude factors of the disease itself, the judge elevated bilirubin suspected long-term infusion of Cavan lead to cholestasis and recommended to disable Calvin, for patients to develop individualized parenteral nutrition (parenteral nutrition, PN) formulations (table 1) and implementation.
In October 7, 2013, patients with TBIL 80.82 L- - mol 1, DBIL55. 43 mol - L- 1, jaundice was significantly reduced. The decrease of serum bilirubin level showed that the patients with PN were well tolerated, and the liver function was gradually restored, and the individual PN support to obtain the preliminary effect (Figure 1).
October 14th, patients in the general anesthesia, the "incision hernia repair + partial resection of the small intestine".2013 year in October 11, 2013, the level of serum bilirubin increased again, clinical nutrition pharmacist recommended to give the treatment of adenosine. On October 23, 2013, bilirubin level of patients was significantly lower, and further restoration of serum total protein and albumin levels, body weight increased significantly, the gradual recovery of gastrointestinal function, indicating that individual of PN support made good curative effect (Fig. 2). Clinical pharmacist recommended to disable PN, enteral nutritional suspension liquid (SP) (Peptison liquid) and a gradual transition to semi liquid diet. The occurrence of adverse reactions was not seen in patients with the use of individual PN. In October 30, 2013, the patient has no yellow skin and yellow dye, postoperative wound healing well, stopping all treatment drugs, granted discharge.
2 pharmaceutical care
2.1 initial parenteral nutrition support program
In patients with fat milk amino acid (17) glucose (11%) injection 1440 mL for parenteral nutrition support, the total heat of the preparation in the proportion of fat heating is relatively high, and all of the long chain fatty acids, if you lose too fast can lead to fat overload syndrome, long-term application may also lead to abnormal bile secretion, liver and gallbladder function damage, elderly patients in the application of abnormal blood lipids. Therefore, in the process of pharmaceutical care, clinical pharmacists in particular to remind health care workers to pay attention to fat milk amino acid (17) injection of glucose (11%) injection time in 12 ~ 24 h more than [2], at the same time, the patients in the treatment of blood lipids, blood glucose, electrolytes, liver and kidney function and other indicators are closely monitored, when necessary, the program to adjust its program.
2.2 changes in liver function and the adjustment of parenteral nutrition support program
In September 25, 2013, patients with TBIL 138.86 mol L- 1, DBIL99. 42 mol 1 L-, compared with the previous increase, suggesting that patients may have abnormal liver function, which is a common complication of PN. In this case, it is not suitable for the patients to continue to use high fat content and all of the fatty acid (11%) glucose (17) injection has not been suitable for the patients with [3].. Therefore, it is suggested that the use of the individual "full" parenteral nutrition solution is recommended. In the formulation of compound amino acid injection, structural fat emulsion and liver disease, it is beneficial to reduce the burden of the liver and improve liver metabolism, the formula is found in Table 1
First, the structure of fat milk is the same as the structure of the structure of the triglyceride, compared with the simple long chain fat emulsion, the effect of the liver function is smaller; in addition to reduce the inflammatory mediators, maintenance of cell membrane phospholipid composition and other aspects are also better than the long chain fat milk, suitable for the patients with liver function [4-5].
Secondly, used in patients with liver disease compound amino acid injection 20AA (250 ml: 25 g of total amino acids) and up to 33%. Branched chain amino acid content of the branched chain amino acids (leucine, isoleucine, and valine) is a class without absorbed through the liver and the skeletal muscle oxidative metabolism of amino acids, it is to reduce the burden of liver metabolism in the patients.
Again, the addition of PN to the program. Glutamine is an essential amino acid, but also a kind of immune nutrition, which can relieve the decrease of glutamine in the stress state, promote protein synthesis, maintain the integrity of the structure and function of the intestinal mucosa, and reduce the occurrence of [6]. infection.
2.3 the use of adjuvant therapy in the treatment of abnormal liver function
Since the level of serum bilirubin level is elevated, the doctor asked the clinical nutrition pharmacist consultation to help adjust the PN program. Pharmacists to the exclusion of other drugs cause liver damage and disease factors, considering the patients with intestinal fistula due to prolonged fasting, in the digestive tract of lack of food stimulation, gut mucosal atrophy, barrier function failure, gastrointestinal hormone, cholecystokinin (CCK) secreted less, decrease of gallbladder contraction, inhibition of bile acid enterohepatic circulation slows down and its synthesis and translocation, leading to cholestasis. Pharmacists suggested giving ademetionine in treatment of liver. S-adenosyl-L-methionine can be enhanced Na + - K + - ATPase activity and improving the permeability of the membrane, protect cellular microtubule, microfilament and connection system, increase the transport of bile acids and replenish glutathione to protect the liver detoxification capacity, can significantly improve the cholestasis biochemical index. Once the recovery of gastrointestinal function in patients, as soon as possible to start enteral nutrition, prevention and treatment of intestinal fistula complicated with intrahepatic cholestasis, the most effective means of treatment.
2.4 the timing and manner of the transition from parenteral nutrition support to the transition to enteral nutrition support
As long as patients with gastrointestinal function allows one and can safety use, priority should be given to patients with enteral nutrition (,) en support, which is clinical nutrition support basic principle. The cases of patients after stoma contraction good, after 12 days can be a light meal, with a gradual transition to enteral nutrition (Peptison liquid). Pharmacists for patients on enteral nutrition education of medication, told patients should be a small number of times taken before taking can be preheated to 37 DEG C, to increase the tolerance of the gastrointestinal tract. Peptison liquid for short peptide enteral nutrition preparation and its protein composition for hydrolysis of whey protein, oligopeptide. Human intestinal delivery system can be oligopeptide after intestinal brush border peptidase hydrolyzed into the blood, promote recovery of intestinal function. Patients with PN conversion en opportune time, as soon as possible to start the importance of en is maintain intestinal mucosal barrier that prevents the translocation of intestinal bacteria, reduce infection complications and improve the prognosis. To discharge, patients can be normal diet.
3 knots
In this case all mouth hernia postoperative intestinal fistula patients, the fistula healed long, fistula is large, critical condition. Long term infusion of the patients with after the commercialization of intrahepatic cholestasis, which is one of the common complications of PN. According to the changes of organ function in patients with different stages, the clinical nutrition pharmacists assisted in the formulation of individual PN prescriptions and related treatment plans, and promoted the prognosis of patients.
Critically ill patients with parenteral nutrition support the key to success is not only according to the specific situation of patients develop individualized nutritional support program, also includes a close monitoring of the patient clinical status, analyze the reasons, timely adjustment of prescription, to ensure the safety and efficacy of patients with parenteral nutrition support. Supported by clinical pharmacists in the treatment of nutritional support for patients with a full range of nutritional support services, to further strengthen the collaboration between pharmacists and doctors to protect the safety and effectiveness of drug use in patients.
REFERENCES
[1] DAVIS K G,JOHNSON E K. Controversies in the care the en-terocutaneous fistula [J]. Surg Clin North Am,2013,93 （ 1 ） :231-250.
[2] CHEN Y,WANG Y Q,LIN Y,et al. The discussion clinical ap-plication TNA [J]. J China Pharm（ 中国药房） ,2007,18（ 2） :151-153.
[3] MATHIAS P,EDUARD C,BEMARD C,et al. ESPEN Guide-lines on parenteral nutrition: Hepatology [J]. Clin Nutr,2009,28（ 4） : 436-444.