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1、六安市人民医院重症医学科 刘正东,危重患者肠内肠外营养选择,营养不是万能的，但没有营养是万万不能的！,2,营养支持目的,减少应激状态下机体的自身消耗；预防或纠正营养不良；保证机体代谢正常运转(细胞、组织、器官)。通过营养素的药理作用调理代谢紊乱，调节免疫功能。,发展与现状,解读指南,基本概念,目 录,全胃肠道外营养“TPN”的先驱,1962 Jonathan Rhoads（美国人）经外周静脉输入10%Gs+水解蛋白，每日总量6-7L，并给利尿剂，成为静脉营养的先驱。TPN Total Parenteral Nutrition,胃肠道外营养“TPN”的先驱,外科营养支持的先驱,Francis M
2、oore（英国）1952年对外科手术的代谢反应1959年外科病人的代谢管理-最佳的非蛋白质热卡和氮之比 150：1,著名的Dudrick和Wilmore犬,1967-1968年，U Pen的Rhoads实验室的Stanley Dudrick（肠道外营养之父，美国？）和Douglas Wilmore医生（美国），第一个在幼犬上证实了TPN的效果首先在小儿外科病人获得成功,脂肪乳的创造者,1961瑞典的科学家Arvid Wretlind发明了可安全地应用临床的脂肪乳剂Intralipid大豆油乳化而成,南京军区总医院-肠瘘1889例（2001-2008）治愈率超过90%达国际领先水平，成功经验已广
3、泛推广。,肠外营养配方的发展,葡萄糖 葡萄糖+水解蛋白 单能源 葡萄糖+结晶L-氨基酸 葡萄糖+氨基酸+脂肪乳 双能源 葡萄糖+氨基酸+脂肪乳（LCT/MCT）+特殊营养素,肠外营养支持基本配方,维生素与微量元素应作为重症病人营养支持的组成成分。创伤、感染及ARDS病人，应适当增加抗氧化维生素及硒的补充量。,置管并发症感染并发症代谢并发症脏器并发症其他：Refeeding Syndrome,TPN 并发症分类,一类主要以器官系统功能损害为特征的并发症淤胆和肝胆功能异常肠萎缩和肠道屏障功能障碍（肠源性细菌易位）代谢性骨病免疫系统功能抑制,脏器并发症,代谢性骨病偶见于3个月以上TPN病人，表现为骨
4、软化，肌病，骨病，严重者可致病理性骨折,再灌食综合症（Refeeding Syndrom）指在TPN或TEN时发生的严重的体液和电解质移动，特别是与磷的移动有关的并发症，可出现一系列症状，严重者可致死,肠内营养历史,18世纪末，至19世纪已得到广泛应用。1942年推入市场，用于治疗儿童肠道疾病20世纪50-60年代航天事业的发展，该配方中化学成分明确，不含残渣，无需消化即能吸收，称为要素膳。研究结果显示，正常人在6个月内仅靠该要素膳即可维持正常营养和生理状态。,“当肠道有功能，能安全使用时，使用它”“When the gut works,and can be used safely,use i
5、t”,肠道正常的生理性途径肠外人为的治疗性途径 非生理性,肠道屏障功能,Gut barrier function,生 物 屏 障 Biological barrier,免 疫 屏 障 Immune barrier,机 械 屏 障 mechanical barrier,化 学 屏 障 chemical barrier,肠道功能,肠道功能,1980s以前机体应激时，肠道处于“休眠状态”1980s以后机体应激时，肠是一中心器官 肠道是一免疫器官，含有全身60%的淋巴细胞,内毒素,细菌,PGE2,Il 1,TNF,O2,ARDS,ATN,Shock,损伤的组织,Kupffer 细胞,Gut,Liver
6、,免疫力,过度炎症,C3a,C5a,Moore et al 1989,感染,器官衰竭,禁食在MOF发生过程中的作用,21,但长期禁食,会影响肠粘膜屏障,导致病情恶化,正常肠粘膜,禁食后肠粘膜,22,鼻胃管、鼻肠管、胃造瘘管、空肠造瘘管,选择肠内营养途径,肠内营养剂分类,一.大分子聚合物 1.自制匀浆膳；将牛奶、豆浆。鱼、肉、蔬菜等食物研碎加水而成，为“自然食物”2.大分子聚合物制剂；含有蛋白质、糖、脂肪、维生素、矿物质和水。二.要素饮食：氮源氨基酸、短肽、整蛋白三.特殊配方制剂 1.高支链氨基酸配方 2.必须氨基酸配方 3.组件配方,肠内营养并发症的预防与处理,1.饲管最好通过幽门，避免胃潴留
7、。2.老年人滴注时，应半卧位，防止误吸致肺部感染。3.选择细又软的喂养管，防止咽部炎症。4.喂养管用毕后，用温水冲洗，避免饲管堵塞和污染。5.用泵恒速输入，浓度要适宜，温度要适宜，避免腹泻。,重症患者营养支持现状,重症患者的营养不良发生率更高肠内营养耐受性差早期肠内营养开始晚，热卡不足累积能量供给不足，并发症多,国外住院患者营养不良发生率?,普通外科(瑞典)4-31%髋骨折(美国)18-57%腰椎外科(美国)25%胃癌(德国)31%胰腺癌(德国)61%普通外科(法国)6.9-25.5%,ZM Jiang et al.Chinese Journal of Clinical Nutrition 2
8、006;14(4):263,Malnutrition,Nutritional risk,46.8%,43%,37.9%,37.8%,29.2%,42%,GI,Resp.,Nephro,Neuro.,General Sug.,Thracic Sug.,27%,30%,21%,11%,12%,15%,中国 11个大城市医院 5303住院患者 的营养状况调查,我国住院患者营养不良发生率,重症患者的营养不良发生率更高,43%-88%的ICU患者有营养障碍营养不良与预后明显相关,Giner et al,1996;Barr et al,2004,给予营养素应用原则,胃肠道 胃肠道功能 无功能 胃肠道 正常
9、饮食可行 有功能 目的 摄入 摄入 足够 不足,PN,EN,EN+PN,临床营养,正常饮食,继续EN,不可行,如何实现标准化临床营养诊疗流程,MNANRS2002MUSTSNAQANST.,膳食调查体格检查和人体测量能量需要评估（IC和公式）人体成分分析实验室检查（营养代谢）综合评价,医疗膳食普通膳食特殊营养成分调整膳食肠内营养（ONS和TF）肠外营养,Food/Nutrition-related historyAnthropometric measurementsBiochemical data，medical tests and proceduresNutrition-focused ph
10、ysical findingsClient history,营养风险筛查,营养状况评价,营养支持治疗,营养监测,营养干预,住院患者营养干预原则,注：EN：肠内营养 SPN：补充肠外营养 继续 TPN：全肠外营养,肠梗阻腹膜炎短肠肠缺血难治性呕吐和腹泻,营养支持,需要营养支持,EN是否耐受？,EN摄入足够？,Y,N,Y,N,EN,TPN,SPN,Ukleja A.et al.Nutr Clin Pract.2010；25（4）：403-14,2016年,SCCM和ASPEN发布了成人危重患者营养支持疗法的评估和规定指南（2016版）,A 营养评估,Question:Does the use of
11、 a nutrition risk indicator identify patients who will most likely benefit from nutrition therapy?问题：营养风险筛查工具能否鉴别哪些患者最可能从营养治疗中获益？A1.Based on expert consensus,we suggest a determination of nutrition risk(for example,nutritional risk score NRS-2002,NUTRIC score)be performed on all patients admitted to
12、 the ICU for whom volitional intake is anticipated to be insufficient.High nutrition risk identifies those patients most likely to benefit from early EN therapy.根据专家共识，我们建议对收入ICU且预计摄食不足的患者进行营养风险评估（如营养风险评分NRS-2002，NUTRIC 评分）。高营养风险患者的识别，最可能使其从早期肠内营养治疗中获益。A2.Based on expert consensus,we suggest that nu
13、tritional assessment include an evaluation of comorbid conditions,function of the gastrointestinal(GI)tract,and risk of aspiration.We suggest not using traditional nutrition indicators or surrogate markers,as they are not validated in critical care.根据专家共识，我们建议营养评估应当包括对于合并症、胃肠道功能以及误吸风险的评估。我们建议不要使用传统的
14、营养指标或其替代指标，因为这些指标在ICU的应用并非得到验证。,营 养 评 估,营 养 评 估,Without IL-65；IL-66,A 营养评估,Question:What is the best method for determining energy needs in the critically ill adult patient?问题：确定成年危重病患者能量需求的最佳方法是什么？A3a.We suggest that indirect calorimetry(IC)be used to determine energy requirements,when available an
15、d in the absence of variables that affect the accuracy of measurement.Quality of Evidence:Very Low。如果有条件且不影响测量准确性的因素时，建议应用间接能量测定(间接测热法，indirect calorimetry，IC)确定能量需求。证据质量：非常低A3b.Based on expert consensus,in the absence of IC,we suggest that a published predictive equation or a simplistic weight-base
16、d equation(2530 kcal/kg/day)be used to determine energy requirements.(see section Q for obesity recommendations.)根据专家共识，当没有IC时，我们建议使用已发表的预测公式或基于体重的简化公式(2530 kcal/kg/day)确定能量需求。（见Q部分有关肥胖患者的推荐意见。）,A 营养评估,Question:Should protein provision be monitored independently from energy provision in critically i
17、ll adult patients?问题：对于成年危重病患者，除能量提供外，是否需要单独监测提供的蛋白质量？A4.Based on expert consensus,we suggest an ongoing evaluation of adequacy of protein provision be performed.根据专家共识，我们建议连续评估蛋白质供给的充分性。The decision to add protein modules should be based on an ongoing assessment of adequacy of protein intake.Weight
18、-based equations(e.g.,1.22.0 g/kg/day)may be used to monitor adequacy of protein provision by comparing the amount of protein delivered to that prescribed,especially when nitrogen balance studies are not available to assess needs(see section C4).,B 开始肠内营养,Question:What is the benefit of early EN in
19、critically ill adult patients compared to withholding or delaying this therapy?问题：对于成年危重病患者而言，与不给予或延迟给予EN相比，早期EN有何益处？B1.We recommend that nutrition support therapy in the form of early EN be initiated within 2448 hours in the critically ill patient who is unable to maintain volitional intake.Quality
20、 of Evidence:Very Low对于不能维持自主进食的危重病患者，我们推荐在24 48小时内通过早期EN开始营养支持治疗。证据质量：非常低,B 开始肠内营养,Question:Is there a difference in outcome between the use of EN or PN for adult critically ill patients?问题：成年危重病患者使用EN或PN对预后的影响有何不同？B2.We suggest the use of EN over PN in critically ill patients who require nutrition
21、 support therapy.Quality of Evidence:Low to Very Low对于需要营养支持治疗的危重病患者，我们建议首选EN而非PN的营养供给方式。证据质量：低至非常低,B 开始肠内营养,Question:Is the clinical evidence of contractility(bowel sounds,flatus)required prior to initiating EN in critically ill adult patients?问题：在成年危重病患者开始EN前是否需要有肠道蠕动的证据（肠鸣音，排气）？B3.Based on expert
22、 consensus,we suggest that,in the majority of MICU and SICU patient populations,while GI contractility factors should be evaluated when initiating EN,overt signs of contractility should not be required prior to initiation of EN.基于专家共识，我们建议，对于多数MICU和SICU患者，尽管启用EN时需要对胃肠道蠕动情况进行评估，但此前并不需要有肠道蠕动的体征。,B 开始肠
23、内营养,Question:What is the preferred level of infusion of EN within the GI tract for critically ill patients?How does the level of infusion of EN affect patient outcomes?问题：危重病患者胃肠道输注EN的最佳速度是多少？EN输注速度如何影响患者预后？B4a.We recommend that the level of infusion be diverted lower in the GI tract in those critic
24、ally ill patients at high risk for aspiration(see section D4)or those who have shown intolerance to gastric EN.Quality of Evidence:Moderate to High对于具有误吸高危因素（见D4部分）或不能耐受经胃喂养的重症患者，我们推荐减慢EN输注的速度。证据质量：中至高B4b.Based on expert consensus we suggest that,in most critically ill patients,it is acceptable to i
25、nitiate EN in the stomach.基于专家的共识，我们建议经胃开始喂养是多数危重病患者可接受的EN方式。,B 开始肠内营养,Question:Is EN safe during periods of hemodynamic instability in adult critically ill patients?问题：对于成年危重病患者，血流动力学不稳定时EN是否安全？B5.Based on expert consensus,we suggest that in the setting of hemodynamic compromise or instability,EN s
26、hould be withheld until the patient is fully resuscitated and/or stable.Initiation/reinitiation of EN may be considered with caution in patients undergoing withdrawal of vasopressor support.根据专家共识，我们建议在血流动力学不稳定时，应当暂停EN直至患者接受了充分的复苏治疗和（或）病情稳定。对于正在撤除升压药物的患者，可以考虑谨慎开始或重新开始EN。,C 肠内营养剂量,Question:What popul
27、ation of patients in the ICU setting does not require nutrition support therapy over the first week of hospitalization?问题：哪些患者住ICU的第一周内无需营养支持治疗？C1.Based on expert consensus,we suggest that patients who are at low nutrition risk with normal baseline nutrition status and low disease severity(for examp
28、le,NRS-2002 3 or NUTRIC score 5)who cannot maintain volitional intake do NOT require specialized nutrition therapy over the first week of hospitalization in the ICU.根据专家共识，我们建议那些营养风险较低及基础营养状况正常、疾病较轻（例如NRS-2002 3 或 NUTRIC评分 5）的患者，即使不能自主进食，住ICU的第一周内不需要特别给予营养治疗。,C 肠内营养剂量,Question:For which population o
29、f patients in the ICU setting is it appropriate to provide trophic EN over the first week of hospitalization?问题：哪些ICU患者在住院第一周内适合滋养型喂养(trophic EN)？We recommend that either trophic or full nutrition by EN is appropriate for patients with acute respiratory distress syndrome(ARDS)/acute lung injury(ALI)
30、and those expected to have a duration of mechanical ventilation 72 hours,as these two strategies of feeding have similar patient outcomes over the first week of hospitalization.Quality of Evidence:High对于急性呼吸窘迫综合征(ARDS)/急性肺损伤(ALI)患者以及预期机械通气时间 72小时的患者，我们推荐给予滋养型或充分的肠内营养，这两种营养补充策略对患者住院第一周预后的影响并无差异。证据质量：
31、高trophic EN(defined as 1020 kcal/hr or up to 500 kcal/day)for one week,C 肠内营养剂量,Question:What population of patients in the ICU requires full EN(as close as possible to target nutrition goals)beginning in the first week of hospitalization?How soon should target nutrition goals be reached in these pa
32、tients?问题：哪些ICU患者住院第一周需要足量EN（尽可能接近目标喂养量）？这些患者应多长时间达到目标量？C3.Based on expert consensus,we suggest that patients who are at high nutrition risk(for example,NRS-2002 5 or NUTRIC score 5,without interleukin-6)or severely malnourished should be advanced toward goal as quickly as tolerated over 2448 hours
33、while monitoring for refeeding syndrome.Efforts to provide 80%of estimated or calculated goal energy and protein within 4872 hours should be made in order to achieve the clinical benefit of EN over the first week of hospitalization.根据专家共识，我们建议具有高营养风险患者（如：NRS-2002 3 或不考虑IL-6情况下NUTRIC评分 5）或严重营养不良患者（NR
34、S-2002 5），应在24 48小时达到并耐受目标喂养量；监测再喂养综合征。争取于48 72小时提供 80%预计蛋白质与能量供给目标，从入院第一周的EN中获益。,C 肠内营养剂量,Question:Does the amount of protein provided make a difference in clinical outcomes of adult critically ill patients?问题：蛋白质供给量对成年危重病患者临床结局有何不同影响？C4.We suggest that sufficient(high-dose)protein should be provid
35、ed.Protein requirements are expected to be in the range of 1.22.0g/kg actual body weight per day,and may likely be even higher in burn or multi-trauma patients(see sections M and P).Quality of Evidence:Very Low我们建议充分的（大剂量的）蛋白质供给。蛋白质需求预计为1.2 2.0 g/kg（实际体重）/天，烧伤或多发伤患者对蛋白质的需求量可能更高（见M和P部分）。证据质量：非常低,D 肠内
36、营养的耐受性与充分性,Question:How should tolerance of EN be monitored in the adult critically ill population?问题：如何监测成年危重病患者EN耐受性？D1.Based on expert consensus,we suggest that patients should be monitored daily for tolerance of EN.We suggest that inappropriate cessation of EN should be avoided.We suggest that o
37、rdering a feeding status of nil per os(NPO)for the patient surrounding the time of diagnostic tests or procedures should be minimized to limit propagation of ileus and to prevent inadequate nutrient delivery.根据专家共识，我们建议应每日监测EN耐受性。我们建议应当避免不恰当的中止EN。我们建议，患者在接受诊断性检查或操作期间，应当尽可能缩短禁食状态(NPO)的医嘱，以免肠梗阻加重，并防止营
38、养供给不足。,D 肠内营养的耐受性与充分性,Question:Should GRVs be used as a marker for aspiration to monitor ICU patients on EN?问题：GRV是否应当作为接受EN的ICU患者监测误吸的指标？D2a.We suggest that GRVs not be used as part of routine care to monitor ICU patients on EN.我们建议不应当把GRV作为接受EN的ICU患者常规监测的指标。D2b.We suggest that,for those ICUs where
39、 GRVs are still utilized,holding EN for GRVs 500 ml in the absence of other signs of intolerance(see section D1)should be avoided.Quality of Evidence:Low我们建议，对于仍然监测GRV的ICU，应当避免在GRV 500 ml且无其他不耐受表现（见D1部分）时中止EN。证据质量：低,D 肠内营养的耐受性与充分性,Question:Should EN feeding protocols be used in the adult ICU setting
40、?问题：成人ICU是否需要制定EN喂养方案？D3a.We recommend that enteral feeding protocols be designed and implemented to increase the overall percentage of goal calories provided.Quality of Evidence:Moderate to High我们推荐制定并实施肠内营养喂养方案，以提高实现目标喂养的比例。证据质量：中至高D3b.Based on expert consensus,we suggest that use of a volume-base
41、d feeding protocol or a top-down multi-strategy protocol be considered.D3b.根据专家共识，我们建议考虑采用容量目标为指导的喂养方案或多重措施并举的喂养方案(top-down multi-strategy protocol)。Topdown multi-strategy protocols typically use volume-based feeding in conjunction with prokinetic agents and post-pyloric tube placement initially(amo
42、ng other strategies),with prokinetic agents stopped in patients who demonstrate lack of need,D 肠内营养的耐受性与充分性,Question:How can risk of aspiration be assessed in critically ill adults patients receiving EN,and what measures may be taken to reduce the likelihood of aspiration pneumonia?问题：对于接受EN的危重病患者，如
43、何评估误吸的风险？哪些措施可减少吸入性肺炎的风险？D4.Based on expert consensus,we suggest that patients placed on EN should be assessed for risk of aspiration,and that steps to reduce risk of aspiration and aspiration pneumonia should be proactively employed.根据专家共识，我们建议对接受EN的患者，应当评估其误吸风险，并主动采取措施以减少误吸与吸入性肺炎的风险。D4a.We recomme
44、nd diverting the level of feeding by post-pyloric enteral access device placement in patients deemed to be at high risk for aspiration(see also section B5)Quality of Evidence:Moderate to High对于误吸风险高的患者（见B5部分），我们推荐改变喂养层级，放置幽门后喂养通路。证据质量：中至高,D 肠内营养的耐受性与充分性,D4b.Based on expert consensus,we suggest that
45、for high-risk patients or those shown to be intolerant to bolus gastric EN,delivery of EN should be switched to continuous infusion.根据专家共识，对于高危患者或不能耐受经胃单次输注EN的患者，我们建议采用持续输注的方式给予EN。D4c.We suggest that,in patients at high risk of aspiration,agents to promote motility,such as prokinetic medications(met
46、oclopramide or erythromycin),be initiated where clinically feasible.Quality of Evidence:Low对于存在误吸高风险的患者，我们建议一旦临床情况允许，即给予药物促进胃肠蠕动，如促动力药物（甲氧氯普胺或红霉素）。证据质量：低D4d.Based on expert consensus,we suggest that nursing directives to reduce risk of aspiration and VAP be employed.In all intubated ICU patients rec
47、eiving EN,the head of the bed should be elevated 3045 and use of chlorhexidine mouthwash twice a day should be considered.依据专家共识，我们建议采取相应护理措施降低误吸与VAP的风险。对于接受EN且有气管插管的所有ICU患者，床头应抬高30 45，每日2次使用氯已定进行口腔护理。,D 肠内营养的耐受性与充分性,Question:Are surrogate markers useful in determining aspiration in the critical car
48、e setting?问题：在ICU中，替代指标能否判断是否发生误吸？D5.Based on expert consensus,we suggest that neither blue food coloring nor any coloring agent be used as a marker for aspiration of EN.Based on expert consensus,we also suggest that glucose oxidase strips not be used as surrogate markers for aspiration in the criti
49、cal care setting.根据专家共识，我们建议，无论食物蓝染抑或其他染色剂，均不能作为判断EN误吸的标记物。根据专家共识，我们也不建议在ICU使用葡萄糖氧化酶试纸检测误吸。,D 肠内营养的耐受性与充分性,Question:How should diarrhea associated with EN be assessed in the adult critically ill population?问题：如何评估成年危重病患者EN相关性腹泻？D6.Based on expert consensus,we suggest that EN NOT be automatically int
50、errupted for diarrhea but rather that feeds be continued while evaluating the etiology of diarrhea in an ICU patient to determine appropriate treatment.根据专家共识，我们建议不要因ICU患者发生腹泻而自动中止EN，而应继续喂养，同时查找腹泻的病因以确定适当的治疗。,E 肠内营养制剂选择,Question:Which formula should be used when initiating EN in the critically ill p
