危重病人營(yíng)養(yǎng)支持規(guī)范

1、危重病人營(yíng)養(yǎng)支持存在的問(wèn)題,危重病人普遍 (全球性) 存在營(yíng)養(yǎng)不良1970s: USA–Bistrian1, NZ–Hill21980s: USA–Kalmath3, Australia–Zador41990s: UK–McWhirter5, Australia–Middleton62000s: Germany–Pawellek7, UK–NHS Survey營(yíng)養(yǎng)不良影響危重病人預(yù)后8-12,,Bistrian et al.,

2、 JAMA 1976;1567Hill GL et al., Lancet 1977;689Kalmath SK et al., J Am Diet Assoc 1986;203Zador&Truswell. Aust N Z J Med 1987;234McWhirter JP & Pennington CR, BMJ 1994;945Middleton MH et al., Intern Med J. 20

3、01;455,7.Pawellek I et al., ClinNutr 2008;27:728.Thomas R. Am J ClinNutr 1979;32:2469.Reinhardt GF et al., JPEN 1980;4:35710.Askanazi J et al., Crit Care Med 1982;16311.Lopes J et al., Am J ClinNutr 1982.12.Bozzetti

4、 F et al., Surg Gynecol Obstet 1975;141:712-4,各國(guó)危重病人營(yíng)養(yǎng)不良發(fā)生率,Canadian Critical Care Nutrition Survey 2006,危重病人營(yíng)養(yǎng)支持存在的問(wèn)題,To feed or not to feed the critically ill patient約35%危重病人得不到合適營(yíng)養(yǎng)支持營(yíng)養(yǎng)不良影響患者預(yù)后死亡率約增加3倍并發(fā)癥發(fā)生率增加住院時(shí)

5、間延長(zhǎng),,,Berger MM et al:Optimizing nutrition therapy in the ICU. Curr Opin Clin Nutr Metab Care 2009, 12:159–160,能量代謝與能量需求,Overfeeding 并發(fā)癥以及死亡率的增加 住院時(shí)間及機(jī)械通氣時(shí)間延長(zhǎng) (1). Hoffer LJ, Am J Clin Nutr. 2003;78:90

6、6-11 (2).Scurlock c et al:, Curr Opin Clin Nutr Metab Care 2008;11:152-155 (3). Kreymann KG et al; Curr Opin Clin Nutr Metab Care 2008;11:156-159Underfeeding 同樣不利于患者預(yù)后 (1) Villet et al: Clin Nutr 2005

7、;24:502-509 (2) Pichard C, et al: Clin Nutr 2008;3(suppl 1):0015 (3) David Dvira, Clinical Nutrition (2006) 25, 37–44（4） Berger MM et al: Curr Opin Clin Nutr Metab Care 2009, 12:159–160,,,,ESPEN Guidelines Recommenda

8、tion,危重病人能量攝入量應(yīng)盡可能接近機(jī) 體能量消耗值以降低 能量負(fù)平衡(Grade B),,Pierre Singer，et al: ESPEN Guidelines on Parenteral Nutrition: Intensive care . Clinical Nutrition 2009；28：1-14,ESPEN Guidelines Recommendation,間接測(cè)熱法是決定危重病人能量消耗及能量攝入的理

9、想 方法(Grade B),,Pierre Singer，et al: ESPEN Guidelines on Parenteral Nutrition: Intensive care . Clinical Nutrition 2009；28：1-14,ESPEN Guidelines Recommendation,沒(méi)有條件通過(guò)間接測(cè)熱法測(cè)定實(shí)際測(cè)定患者的能量消耗時(shí)，危重病人(非肥胖)推薦熱卡攝入量為 20?25 kcal/kg/

10、day (Grade C),,Mechanick JI, et al: Curr Opin Clin Nutr Metab Care 2008, 11:666–670Kreymann KG, et al: Curr Opin Clin Nutr Metab Care 2008, 11:156–159McClave SA, et al: JPEN 2009;33:277-36Grau T, et al: Curr Opin

11、Clin Nutr Metab Care 2009, 12:175–179Pierre Singer，et al: ESPEN Guidelines on Parenteral Nutrition: Intensive care . Clinical Nutrition 2009；28：1-14,ESPEN Guidelines Recommendation,危重病人單純PN時(shí),至少早期可以允許輕度喂養(yǎng)不足(Permissive u

12、nderfeeding),熱卡攝入量為80%目標(biāo)量，病情穩(wěn)定后達(dá)到目標(biāo)需要量 (Grade C)肥胖病人(BMI≧30),熱卡攝入量≦60?70% 目標(biāo)量,,McClave SA, et al: JPEN 2009;33:277-336Pierre Singer，et al: ESPEN Guidelines on Parenteral Nutrition: Intensive care . Clinical Nutrition

13、2009；28：1-14,,,Controversy:,Parenteral,and/or,Enteral,Evidence ?,危重病人營(yíng)養(yǎng)支持供給途徑,信息繁多，結(jié)論不一？,,,Meta-analysis results regarding Enteral versus parenteral nutrition,,Meta-analysis results regarding Enteral versus parenteral nu

14、trition,,營(yíng)養(yǎng)支持時(shí)機(jī)-早期營(yíng)養(yǎng),,,營(yíng)養(yǎng)支持時(shí)機(jī)-早期營(yíng)養(yǎng),早期營(yíng)養(yǎng)已成為ICU病人常規(guī)治療措施目前公認(rèn)的早期營(yíng)養(yǎng)是指應(yīng)激后24?48 h 內(nèi)開(kāi)始進(jìn)行營(yíng)養(yǎng)支持早期腸內(nèi)營(yíng)養(yǎng)應(yīng)是ICU病人的首選早期腸內(nèi)營(yíng)養(yǎng)可減輕應(yīng)激反應(yīng)程度、降低炎性介質(zhì)產(chǎn)生、維持腸道結(jié)構(gòu)完整性、減少腸源性感染發(fā)生率,,Kreymann KG. Early nutrition support in critical care: a European pers

15、pective。 Curr Opin Clin Nutr Metab Care 2008, 11:156–159Scurlock C. Early nutrition support in critical care: a US perspective。 Curr Opin Clin Nutr Metab Care 2008, 11:152–155,Early vs late enteral nutrition,,Artinian e

16、t al. Chest 2006;129;960-967,N=4049,Early vs late enteral nutrition,Nguyen N, et al:CCM 2008; 36:1469–1474,P=0.049,P=0.048,Meta-analysis results regarding Early vs late enteral nutrition,,Does feed quantity matter?,Jerry

17、 A. Krishnan, Chest 2003;124;297-305,,Binnekade JM, Crit Care Med 2005;9:R218,403SICU病人52%住院日接受EN,第1天39%,第5天51% 平均蛋白質(zhì)攝入量54%,能量攝入量66%,容量為75% 影響EN實(shí)施的主要障礙:置管,應(yīng)用藥物,治療干預(yù) 途徑:經(jīng)十二指腸和空腸喂養(yǎng)成功率>經(jīng)胃喂養(yǎng),危重病人能量攝入情況,,The NICE-SUGAR

18、Study Investigators. N Engl J Med 2009,,Nonprotein calories administered on days 1-14 (kcal/day),Villet et al Clin Nutr 2005,危重病人營(yíng)養(yǎng)支持途徑及時(shí)機(jī),危重病人首選腸內(nèi)營(yíng)養(yǎng)途徑 (Grade B)腸內(nèi)營(yíng)養(yǎng)應(yīng)在24?48h內(nèi)開(kāi)始(Grade C),并在隨后的48?72h達(dá)到目標(biāo)量(Grade E)腸內(nèi)營(yíng)養(yǎng)48h

19、 無(wú)法達(dá)到目標(biāo)量，應(yīng)合并應(yīng)用腸外營(yíng)養(yǎng)(Grade C),,Scurlock C, et al: Curr Opin Clin Nutri Metab Care 2008, 11:152–155Grau T, et al: Curr Opin Clin Nutr Metab Care 2009, 12:175–179Pierre Singer，et al: ESPEN Guidelines on Parenteral Nutritio

20、n: Intensive care . Clinical Nutrition 2009；28：1-14 Martindale RG, et al: ASPEN Guidelines Crit Care Med 2009 ;37:1757,Steps to maximize efficacy of nutrition support,改善危重病人結(jié)局的措施還有避免高血糖癥避免免疫抑制、感染并發(fā)癥減少氧化應(yīng)激反應(yīng)減少瘦組織群丟

21、失,1. Mechanick JI, Chiolero R. . Curr Opin Clin Nutr Metab Care 2008; 11:666–6702. Pierre Singer，et al: ESPEN Guidelines on Parenteral Nutrition: Intensive care . Clinical Nutrition 2009；28：1-14,,目前對(duì)血糖控制的觀點(diǎn),危重病人應(yīng)避免高血糖的

22、發(fā)生，當(dāng)血糖>10mmol/L 胰島素強(qiáng)化治療[1,2]危重病人血糖維持140?180mg/d(7.8?10.0 mmol/L)可降低低血糖風(fēng)險(xiǎn),改善預(yù)后[1,2]危重病人血糖維持110?150mg/d 較合適[3],,Pierre Singer，et al: ESPEN Guidelines on Parenteral Nutrition: Intensive care . Clinical Nutrition 2

23、009；28：1-14Mechanick JI,et al: Curr Opin Clin Nutr Metab Care 2008, 11:666–670 3. McClave SA;et al: Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient. JPEN 20

24、09; 33: 277-3163,,Guidelines Recommendation,危重病人單純PN時(shí),在ICU第一周應(yīng)避免應(yīng)用純大豆油來(lái)源脂肪乳劑 (Grade D) McClave SA;et al: Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient

25、. JPEN 2009; 33: 277-3163“....the experts concluded:the pure soybean lipid emulsions should not longer be used in parenteral nutrition of critically ill patients” DGEM Guideline:PN-Lipid Emulsions Adolph, et al

26、:2007,,特殊營(yíng)養(yǎng)物質(zhì)的作用評(píng)價(jià),藥理營(yíng)養(yǎng)（Pharmaconutrition） -- 在標(biāo)準(zhǔn)營(yíng)養(yǎng)基礎(chǔ)上提供藥理劑量某個(gè)免疫調(diào)節(jié)營(yíng)養(yǎng)素免疫營(yíng)養(yǎng)（Immunonutrition） --傳統(tǒng)的腸內(nèi)膳食中添加一個(gè)或多個(gè)免疫調(diào)節(jié)物質(zhì)（如精氨酸、谷氨酰胺、核苷酸、魚(yú)油、硒等）,,,Effect of Glutamine: Mortality,McClave SA , et al:Nutr Clin Pract. 2009;24:

27、305-315,,,,Effect of Glutamine: Infectious Complications,McClave SA , et al:Nutr Clin Pract. 2009;24:305-315,,,,,Effect of Glutamine: Hospital Length of Stay,McClave SA , et al:Nutr Clin Pract. 2009;24:305-315,,,,Effect

28、of ?-3 Fat acid on critically ill patients,Effect of ?-3 Fat acid on Mortality,Koch T, Heller AR Akt Ern Med 2005,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,p<0.0005,p<0.0005,p=0.032,p=0.033,p<0.0005,total,Sev. Head

29、 injury,Non abd Sepsis,Pancreatitis,Multiple trauma,Peritonitis,postoperative,-1,-0,5,0,0,5,1,,Effect of ?-3 Fat acid on Infection rate,unfavourable,favourable,no effect,Koch T, Heller AR Akt Ern Med 2005,N=661,G

30、uidelines Recommendation,Addition When PN is indicated in ICU patients the amino acid solution should contain 0.2–0.4 g/kg/day of L-glutamine (e.g. 0.3–0.6 g/kg/day alanyl-glutamine dipeptide) (Grade A),,1. Canadian Crit

31、ical Care Clinical Practice Guidelines Committee 20092. Pierre Singer，et al: ESPEN Guidelines on Parenteral Nutrition: Intensive care . Clinical Nutrition 2009；28：1-143. McClave SA;et al: Guidelines for the provision

32、 and assessment of nutrition support therapy in the adult critically ill patient. JPEN 2009; 33: 277-3163,ESPEN Guidelines Recommendation,Addition of EPA and DHA to lipid emulsions has demonstrable effects on cell membr

33、anes and inflammatory processes (Grade B)Fish oil-enriched lipid emulsions probably decrease length of stay in critically ill patients. (Grade B),,1. Grau T, et al: Curr Opin Clin Nutr Metab Care 2009, 12:175–1792. Pie

34、rre Singer，et al: ESPEN Guidelines on Parenteral Nutrition: Intensive care . Clinical Nutrition 2009；28：1-14,Immunonutrition and mortality,Jones NE et al, Curr Opin Gastro 2008,24:215–222,,,Immunonutrition on infections

35、,Marik PEet al, Intensive Care Med (2008) 34:1980–1990,,,Immunonutrition on LOS,Marik PEet al, Intensive Care Med (2008) 34:1980–1990,,,Immunonutrition reduction in length of postoperative stay,Stableforth WD, et al, I

36、nt. J. Oral Maxillofac. Surg. 2009; 38: 103–110,P < 0.01,ESPEN Guidelines Recommendation,Immune-modulating enteral formulations should be used for appropriate patient population, with caution in patients with severe s

37、epsis. For surgical ICU patients (Grade A) For medical ICU patients (Grade B),,Grau T, et al: Curr Opin Clin Nutr Metab Care 2009, 12:175–179McClave SA; et al: ESPEN Guidelines on Parenteral Nutrition: Intensive

38、 care al: JPEN 2009; 33: 277-316.,Combination of EPA/GLA and antioxidant vitamins,Pontes Arruda, Crit Care Med, 2006； 34:2325,Suvival,Nathens et al, Ann Surg, 2002,ARDS,Early administration of AOX after trauma,595 patien

39、ts (91% trauma)Vitamin C(1000 mg IV q 8 h)Vitamin E ( 1000 IU PO q 8 h)Outcome: Decrease organ failure Decrease ICU stay,Nathens et al, Ann Surg, 2002,MOF,Early administration of AOX after trauma,Outcome: Decrea

40、se organ failure,Effect of AOX on the mortality of critically ill patients,Jones NE et al, Curr Opin Gastro 2008,24:215–222,,,,ESPEN Guidelines Recommendation,Patients with ARDS and severe acute lung injury should be pl

41、aced on an enteral formulation characterized by an anti-inflammatory lipid profile (ie,?3 fish oils, borage oil) and antioxidants. (Grade A)A combination of antioxidant vitamins and trace minerals(specifically including

42、 selenium)should be provided to all critically ill patients. (Grade B),,McClave SA; et al: ESPEN Guidelines on Parenteral Nutrition: Intensive care al: JPEN 2009; 33: 277-316.,,Theoretical construct for nutrition therapy

43、 in the critically ill patient of the future,McClave SA , et al:Nutr Clin Pract. 2009;24:305-315,Are we feeding these patients adequately?,Cahill NE et al :Crit Care Med 2010; 38:395– 401,158 ICUs from 20 countries enrol