INTESTINAL AND NUTRITIONAL INSUFFICIENCY IN COMPLICATED CERVICAL SPINE INJURY Sirota G.G., Kirilina S.I., Sirota V.S., Lebedeva M.N., Ivanova E.Yu., Pervukhin S.A., Statsenko I.A.,Gusev A.F.
Sirota G.G., Kirilina S.I., Sirota V.S., Lebedeva M.N., Ivanova E.Yu., Pervukhin S.A., Statsenko I.A.,Gusev A.F.
Tsivyan Novosibirsk Research Institute of Traumatology and Orthopedics, Novosibirsk, Russia
Among closed injuries, the proportion of spinal injury is 3-5 %, among other locomotor system injuries – 5.5-17.8 %. Complicated spinal fractures encounter in 11-53 cases per one million [1-5]. During the recent years, one can observe the increase in cases of spine and spinal cord injury (SSCI) as result of road traffic accidents (50 % of all SSCI cases), falling from height (20 %), home injuries (15-20 %) and sport injuries (10-15 %) [5-7].
Among spinal injuries, cervical spine fractures consist 20-30 %, with spinal cord injuries in 10-30 % [8-11].
As result of spinal cord injury, reflectory depression happens lower than the injury level because of disruption of descending stimulating impulsation, with such clinical manifestation as neurogenic shock, resulting in disordered functions of the vital systems of the body such as respiratory, vasomotor, urinary, hemostasis, immune and digestive systems [12, 13].
Intestinal atony develops immediately after trauma and can be active from several days to 2-4 weeks, resulting in microbial flora dislocation after disruption of intestinal barrier [14-16]. Paresis, which develops at the background of intestinal atony, worsens the course of respiratory insufficiency, increases the risk of infectious complications, and forms a specific vicious circle in the pathogenesis of multiple organ dysfunction in the complicated injury to the cervical spine (CS).
At the background of paresis with disordered motor evacuator function of the gastrointestinal tract, it is necessary to perform maximally early nutritive support since energetic and protein losses increases after injury [17].
The aim of early nutritive support with metabolic direction is preservation of intestinal cells. Glutamine serves as plastic and energetic substrate for all fast growing cells of the body – enterocytes, lymphocytes, macrophages [8].
In 2003, Ding L.A. and Li J.S. and other researches proved that glutamate is an important component for supporting the structure and function of gastrointestinal mucosa. Its injury decreases the barrier function and increases bacterial and toxin translocation in the blood stream, resulting in sepsis and multiple organ dysfunction [4, 18-20].
Nutrition of enterocytes and colonocytes mainly depends on delivery of nutrients and lumen of the intestine. Absence of this source during fasting causes atrophy and rapid decrease in function of intestinal wall mucosa functioning [21].
Morphological and functional changes are reversible in conditions of enteral nutrition. Therefore, along with surgical treatment and supporting the function of the vital systems of the body, the priority is given to timely prevention, early diagnostics and treatment of nutritive insufficiency.
Objective – to assess the intestinal and nutritional failure associated with complicated cervical spine injury.
MATERIALS AND METHODS
The study included 38 patients with complicated CS injury.
The exclusion criteria were postresuscitation disease, aspiration of gastric contents, pulmonary bleeding, neurological deficiency ASIA B, C and D.
The age of the patients varied from 34.2 ± 13.5. All patients were the men, with severe spinal cord injuries according to the ASIA A classification from American Spinal Injury Association. The time from injury to surgery was 8.2 ± 5.8. After hospital admission, all patients received the complex presurgical examination with obligatory use of the high tech radial techniques (MSCT and MRI), SOFA and APACHE II. Before the surgery, the intensive care was directed to treatment of traumatic and spinal shock, prevention of respiratory, cardiovascular and intestinal failure, diagnostics of occult bleeding sources. All patients received the assessment of the nutritive status. After surgical treatment with spinal cord decompression and stabilization of an injured spinal segment such patients need for follow-up and intensive care in ICU.
Mixed nutrition was initiated for provision of energetic requirements in the first day. The volume of enteral and parenteral mixtures depended on the functional condition of the gastrointestinal tract. The laboratory techniques for measuring total protein and albumin were used for estimation of protein and energy insufficiency. The requirements for nutrients and energy were assessed with indirect calorimetry (CCM Express metabolimeter).
A degree of intestinal paresis intensity was used for estimation of intestinal failure course with the scale used in ICU [16].
For objectification of estimation of auscultation sound in intestinal paresis and quantitative and qualitative analysis, we used the computer programs with real-time phonoenterogram recording with the experimental model of the phonoenterograph developed on the basis of the chair of electronic devices of Novosibirsk State Technical University. This device recorded the sound with discretization interval of 8 kHz and 16 bit capacity and single-channel mode. The low-frequency filter was set to 1,200 Hz for removal of pulmonary and other sounds. Cardiac souffles (their main power is lower frequency range in comparison with intestinal sounds) are removed with computer techniques. The received signal was transmitted to PC, where the sound analysis (intestinal sounds) was conducted. Audacity 2.1.2 was used for displaying the phonoenterogram. The graphic display of intestinal sounds allowed diagnosing the changes in their frequency. The electronic stethoscope (its head) was placed 7-8 cm above the omphalos, in the epigastral region under the xyphoid process. The recording lasted for 30 minutes with the empty stomach and 30 minutes after food acceptance (siping, probe) for 30-60 minutes.
The data of fiberoptic gastroduodenoscopy were analyzed. Unometer™Abdo-Pressure™ system was used for measurement of intraabdominal pressure.
The statistical analysis of the study results was conducted with calculation of mean arithmetic (M), error in the mean (m) and was presented as Ì ± m. The statistical relationship was estimated with IBM SPSS Statistica v25.0 with calculation of the correlation ratios of Spearman and Cendal non-parametric tests.
The conducted study corresponds to the standards of Helsinki Declare – Ethical Principles for Medical Research with Human Subjects, and the Rules for Clinical Practice in the Russian Federation. The informed consent for preparation of the personal data was received (the protocol of the session of the biomedical ethical committee of Tsivyan Novosibirsk Research Institute of Traumatology and Orthopedics, No.035/8, June 1, 2018).
RESULTS AND DISCUSSION
The mean age of the patients with injuries of ASIA A type was 34.3 ± 13.6. All patients were men. The severity of the patients’ condition was 10 according to APACHE II and 3 according to SOFA.
In 96 % of the cases, the patients received the urgent surgical intervention within 8.2 ± 5.8 hours after injury. Surgical management included the spinal cord decompression and the injured spinal segment stabilization.
The treatment was oriented to prevention and correction of multiple organ dysfunction since the severity of the patients’ condition (in the first day) was determined by intense neurological deficiency, cardiovascular insufficiency, respiratory insufficiency of central origin (because of respiratory muscles paresis) and disorder of drain function of the lungs (because of weak cough impulse) and disordered gastrointestinal motor and evacuation function.
The nasogastric probe was placed for all patients at admission. The real-time phonoenterogram was used for estimation of motor and evacuation function of the gastrointestinal tract in the real-time mode. A degree of gastrointestinal paresis was estimated in points. The table 1 shows the time course of bowel paresis. The direction of the time course of bowel paresis shows that the peak clinical manifestations of paresis were recorded on the days 7-10.
Table 1
Dynamics of intestinal paresis
|
Intestinal paresis degree |
Timing of measurements |
|||||
|
day 1 |
day 3 |
day 7 |
day 10 |
day 15 |
day 20 |
|
|
Intestinal paresis of degree 1 (9-11 b) |
37 % |
37 % |
39 % |
33 % |
27 % |
17 % |
|
Intestinal paresis of degree 2 (12-20 b) |
0 % |
3 % |
20 % |
15 % |
3 % |
6 % |
The real-time phonoenterogram shows the clear trends of decreasing frequency, intensity and amplitude of bowel sounds depending on a paresis stage. The figure 4 (a, b, c) shows the data of the real-time phonoenterogram.
Figure 1
Data of computer phonoenterography: a) CPEG at admission, WBD 10 cm of water. p.; b) CPEG at a paresis of 1 item, WBD of 10-15 cm of water. p.; c) CPEG for paresis of 2 items, WBD 15-21 cm of water. p.
|
Figure 1a CPEG at admission, WBD 10 cm of water. p. |
Figure 1b CPEG at a paresis of 1 item, WBD of 10-15 cm of water. p. |
Figure 1c CPEG for paresis of 2 items, WBD 15-21 cm of water. p. |
|
|
|
Gastrointestinal paresis was diagnosed in 37 % of the cases in the first day. By the days 7-10, 33 % of the patients had the gastrointestinal paresis of the degree 1 (the variant of real-time phonoenterogram is presented in the figure 4b) and the degree 2 (the figure 4c) in 10 % of the patients. The real-time graphic images of bowel sounds show the depression of movements – decreasing amplitude and frequency of bowel sounds. By the 20th day, 23 % of the patients demonstrated the persistent disorders of gastrointestinal motor and evacuation function including manifestations of various degrees of bowel paresis. The maximal intensity of bowel paresis correlated with the intraabdominal pressure (IAP) values. The maximal IAP was noted on the days 7-10, with the average values of 20 ± 3 cm H2O. A significant direct relationship was found between the degrees of bowel paresis and IAP, with r = 0.9 on the day 7.
Bowel insufficiency was treated and prevented with the nasogastric probe, medical agents (gastrokinetic agents, prokinetics, anti-paretic therapy with anticholinesterase inhibitors), physiotherapeutic procedures (bowel electrostimulation), purgation with hypertonic enema (3-4 times per day) with placement of the colonic tube for intense abdominal distention. Gastric protective therapy with proton pup inhibitors was initiated for prevention of stress ulcers.
From the first day (2-4 hours after surgery), early enteral nutrition (EEN) was conducted through the probe with constant infusion of 10-20 ml/h and subsequent calculated increase in the rate of introduction on the days 10-21, with subsequent switch to full enteral nutrition (2,000-2,400 ml per day).
For EEN, firstly, the metabolic mixtures with high levels of glutamine were used. Then the half-element mixtures were introduced, with subsequent inclusion of the mixtures with fibers. Enteral feeding was conducted with the syringe pumps with continuous twenty-four-hour mode and periodical estimation of the residual volume.
EEN for preservation of intestinal cells was one of the main tasks of intensive care of critical state. The second task was replacement of energetic and protein deficiency.
If replacement of protein and energetic requirements was not sufficient, EEN was added with three-in-one enteral mixtures with additional parenteral forms of glutamine (0.3-0.4 g/kg) and pharmaconutrients (fat- and water-soluble vitamins and minerals). The mixtures for parenteral nutrition (PN) were introduced intravenously with lineal batchers in continuous mode and obligatory control of glycemia level. The blood level of glucose was supported at the level of 6-10 mmol/l.
According to the data of the analyzed medical cases, in the first day in ICU, the patients received 1.4 ± 0.63 grams of protein per kg on average, with 85 % of protein with parenteral nutrition. On the 7th day, the amount of protein increased to 1.9 ± 0.6 g per kg of body mass, with 76 % in parenteral nutrition, with switch to hemi-element mixtures (Peptisorb type) and possibility for increasing the proportion of enteral nutrition to 50-60 % on the days 10-15. The switch to hypercaloric mixtures with fibers and beginning of sipping were recorded by the days 16-20. The high level of significance between gastrointestinal paresis and the protein profile with a direct negative correlation was identified: r = -0.85 on the day 7 (total protein), r = -0.82 on the day 10 (albumin).
The value of basal metabolism (BM) was 1,841.2 ± 199.6 kcal according to Harrison-Benedict equation. On the days 7-10 after trauma, BM was higher by 30-50 % (2,393.3-2,761.0 kcl/day) than the value calculated by Harrison-Benedict formula. The respiratory quotient (RQ) was 0.65 ± 0.01 on the first day after trauma, 0.9 ± 0.09 on the days 7-10. RQ shows that oxidation and generation of energy is realized by means of fats in the first 24 hours after trauma and surgery. RQ on the days 7-10 shows that oxidation and generation of energy is realized by means of proteins.
The erosive changes in gastric and duodenal mucosa were identified on the first day after fiberoptic gastroduodenoscopy in 50 % of the patients. Erosive gastroduodenitis was persistent on the days 3, 7 and 10 according to fiberoptic gastroduodenoscopy. Regression of erosive lesions was in 30 % of the patients only on the day 20 that corresponded to the endoscopic picture of superficial gastroduodenitis. No clinical and endoscopic signs of gastrointestinal bleedings and perforations were found within the whole period of the follow-up.
The quantitative estimation of nutritive support was conducted according to total protein and albumin, nitrogen balance, with estimation of basic metabolism with Harrison-Benedict formula. The general direction and specificity of changes in total protein and albumin are shown in the figures 1 and 2. The maximal decrease in the values was on the days 3-7 in ICU, with subsequent increase by the days 15-20, but without achievement of the basic values even on the day 20.
The level of albumin was decreasing rapidly during 15 days in ICU. The positive time trends of albumin were observed only after 15 days from the injury. It is explained by intense hypercatabolism and hypermetabolism (Fig. 2, 3). The nitrogen balance was negative during the whole period of ICU stay (Fig. 4). The time course of nitrogen balance, which was calculated with the level of urea nitrogen excretion, also confirms the maximal values of protein losses on the days 7-10 after trauma.
Figure 2
Dynamics of the protein level
Figure 3
Dynamics of the level of albumin
Figure 4
Dynamics of nitrogen balance
The patents with neurological deficiency and confirmed spinal cord injury (ASIA A type) were in ICU within 30.84 ± 9.9 days on average.
CONCLUSION
The clinical, endoscopic, laboratory and phonoenterographic parallels in cervical SSCI demonstrate that the days 7-10 after trauma were critical for condition of the gastrointestinal tract and the values of the protein profile. Therefore, prevention, diagnostics and treatment of intestinal nutritive insufficiency present the priority directions of intensive care for SSCI.
Information on financing and conflict of interests
The study was conducted without sponsorship.
The authors declare the absence of clear or potential conflicts of interests relating to publishing this article.