Enteralna prehrana nekad i sad

Datum objave: 01. 01. 2005.

Spoznaje o značenju prehrane u liječenju bolesnika prisutne su odavno i sastavni su dio svih medicinskih kultura i škola, uključivši i našu sadašnju. Pojam "klinička prehrana" obuhvaća sve oblike prehrane bolesnika , tj. uobičajenu peroralnu prehranu, dijetne modifikacije i pripravke te enteralnu i parenteralnu prehranu..
Pravilna prehrana temeljni je uvjet opstanka živog bića, tj. preduvjet održanja energetskih i metaboličnih homeostatskih procesa. U suvremenoj ljudskoj zajednici uzimanje hrane nije samo ispunjavanje fiziološke potrebe nego postaje obilježjem kulture i statusa, zrcalom životne filozofije i religijskih nazora. Istovremeno, značajan je rast interesa i brige za održanje zdravlja i potrebe da se dijetnim modifikacijama produlji životni vijek, spriječe ili izliječe kronične bolesti, osigura dugovječnost i zdrava starost.
Osnovni koncept nutritivne potpore bolesnicima datira još iz vremena ranih civilizacija Egipta, Grčke i Rima kada se postavljaju i temelji enteralne prehrane.
Enteralna prehrana je važan segment kliničke prehrane, a osnovni preduvjet njene primjene je strukturalno i funkcionalno podoban probavni sustav, a osobito tanko i debelo crijevo. U ovom obliku nutritivne podrške hrana i/ ili komercijalne nutritivne otopine i pripravci, unose se različitim hranidbenim sondama u želudac, dvanaesnik ili jejunum.
Nutritivna potpora enteralnim putem u posljednja dva desetljeća doživljava upravo neviđen uzlet. Značajan napredak u razvoju posebnih enteralnih formula te različitih akcesorija (sonde, pumpe) doveo je do toga da je enteralna prehrana postala najprihvatljiviji i ekonomski najpovoljniji način nutritivne potpore u bolničkim i kućnim uvjetima liječenja.
Različiti oblici enteralnih pripravaka razvijaju se unatrag više stotina, ako ne i tisuća godina. Medicinski zapisi iz perioda Starog Egipta, 3000 godina prije Krista opisuju primjenu nutritivnih klizmi (mješavina vina, mlijeka, sirutke, pšenice, bujona) kao alternativnog načina hranjenja bolesnika i liječenja proljeva.
Zanimljivost je da modificirani koncept nutritivnih klizmi primjenom krantolančanih masnih kiselina (butiratne ili maslačne) u liječenju ulceroznog kolitisa predstavlja danas gotovo vrhunac razvoja nutritivne potpore i održanja integriteta sluznice debelog crijeva. Capivacceus (1598.), Aquapendente (1617.), Von Helmont (1646.) i Boerhave (1710.) svojim idejama otvaraju put razvoju nazogastričnog načina hranjenja primjenom primitivnih oblika sondi. John Hunter, rodonačelnik britanske kirurgije 1790.godine opisuje, na način sukladan suvremenom medicinskom razmišljanju primjenu nutritivne sonde za dopremanje hrane u želudac.

Ta sonda je bila načinjena od jeguljine kože i kitove kosti. Sljedeći značajni koraci u razvoju enteralne prehrane zbili su se 1910. godine, kada je Max Einhorn opisao prvu primjenu duodenalne sonde, te 1958. godine, kada Barron i Fallis razvijaju prvu enteralnu pumpu i načine kontinuirane primjene enteralnih pripravaka.
Enteralne formule razvijaju se kontinuirano od sredine dvadesetog stoljeća, a prekretnica je Rosov prototip elementarnog enteralnog pripravka koji se pojavio 1949 godine. Ruski astronaut German Titov (kolovoz, 1961.) i američki John Glenn (veljača, 1962.) prvi su ljudi koji su se hranili u svemiru, ali su i prvi ljudi koji su se suočili sa situacijama mikrogravitacije i hipogravitacije, te posljedicama djelovanja na hranjenje.
**Osobit značaj za razvoj enteralnih pripravaka ima NASA-in program svemirskih letova sa ljudskom posadom i potreba za razvojem enteralnih pripravaka pogodnih za hranjenje astronauta, s naglaskom na smanjenju količine stolice. Iz tog perioda tipičan je prikaz Greensteina i Winitza koji se ubraja u klasike nutricionističke literature, a objavljen u časopisu Nature, 1965 godine.
Od tihog ulaska enteralnih formula u kliničku medicinu prije 50 godina pa do danas učinjen je značajan napredak. Sredinom prošlog stoljeća imali smo ograničene spoznaje o značenju hranjenja bolesnika koji nisu mogli konzumirati normalnu hranu, o komplikacijama enteralne, ali i parenteralne nutritivne potpore, a razvoj enteralnih otopina bio je tek u začetku.
Klinička prehrana danas, a osobito enteralna prehrana uspada u sam vrh medicinske misli i djelovanja, rastu spoznaje o interakciji hrane i gena, a različiti nutritivni sastojci svojim farmakološkim djelovanjima afirmiraju imunonutriciju kao jedan sasvim novi koncept u razvoju ovog segmenta liječenja.
Na europskom tržištu trenutno je prisutno više od 150 različitih enteralnih pripravaka, a na listi Hrvatskog zavoda za zdravstveno osiguranje nalazi se 19 enteralnih pripravaka. Ovo omogućuje različite oblike nutritivne podrške bolesnika ne samo u institucijama, već i u kućnom liječenju što je iskorak gotovo istovjetan razvoju najsofisticiranijih formula ili sustava za aplikaciju.
Enteralna prehrana, kao temelj, te eventualna nadopuna iste parenteralnim pripravcima do zadovoljenja potpunih nutritivnih potreba, vrh su nutritivne piramide.
Doc.dr.sc. Željko Krznarić
KBC i Medicinski fakultet- Zagreb
Ovaj članak uvodnik je posljednjeg broja časopisa "Medicina" - glasila Hrvatskoga liječničkog zbora Podružnice Rijeka.

Tematski broj u potpunosti je posvećen enteralnoj prehrani, a gosti urednici su prof.dr.sc. Mladen Peršić (KBC Rijeka) i doc. dr. sc. Željko Krznarić (KBC Zagreb).
U tematskom broju objavljen je niz preglednih i stručnih radova te kliničke smjernice za primjenu enteralne prehrane, a posebna važnost data je ulozi adekvatne procjene nutritivnog statusa bolesnika.
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