危重患者腸內(nèi)腸外營(yíng)養(yǎng)選擇基本概念和發(fā)展

1、危重患者腸內(nèi)腸外營(yíng)養(yǎng)選擇基本概念和發(fā)展2營(yíng)養(yǎng)不是萬能的，但沒有營(yíng)養(yǎng)是萬萬不能的！營(yíng)養(yǎng)支持目的 減少應(yīng)激狀態(tài)下機(jī)體的自身消耗； 預(yù)防或糾正營(yíng)養(yǎng)不良； 保證機(jī)體代謝正常運(yùn)轉(zhuǎn)(細(xì)胞、組織、器官) 。 通過營(yíng)養(yǎng)素的藥理作用調(diào)理代謝紊亂，調(diào)節(jié)免疫功能。 發(fā)展與現(xiàn)狀 解讀指南 基本概念目 錄全胃腸道外營(yíng)養(yǎng)“TPN”的先驅(qū) 1962 Jonathan Rhoads（美國(guó)人） 經(jīng)外周靜脈輸入10%Gs+水解蛋白，每日總量6-7L，并給利尿劑，成為靜脈營(yíng)養(yǎng)的先驅(qū)。 TPN Total Parenteral Nutrition胃腸道外營(yíng)養(yǎng)“TPN”的先驅(qū)外科營(yíng)養(yǎng)支持的先驅(qū)Francis Moore（英國(guó)）1952

2、年對(duì)外科手術(shù)的代謝反應(yīng)1959年外科病人的代謝管理 -最佳的非蛋白質(zhì)熱卡和氮之比 150：1著名的Dudrick和Wilmore犬1967-1968年，U Pen的Rhoads實(shí)驗(yàn)室的Stanley Dudrick（腸道外營(yíng)養(yǎng)之父，美國(guó)？）和Douglas Wilmore醫(yī)生（美國(guó)），第一個(gè)在幼犬上證實(shí)了TPN的效果首先在小兒外科病人獲得成功脂肪乳的創(chuàng)造者1961瑞典的科學(xué)家Arvid Wretlind發(fā)明了可安全地應(yīng)用臨床的脂肪乳劑Intralipid大豆油乳化而成南京軍區(qū)總醫(yī)院-腸瘺1889例（2001-2008）治愈率超過90%達(dá)國(guó)際領(lǐng)先水平，成功經(jīng)驗(yàn)已廣泛推廣。腸外營(yíng)養(yǎng)配方的發(fā)展 葡萄

3、糖 葡萄糖+水解蛋白 單能源 葡萄糖+結(jié)晶L-氨基酸 葡萄糖+氨基酸+脂肪乳 雙能源 葡萄糖+氨基酸+ 脂肪乳（LCT/MCT）+特殊營(yíng)養(yǎng)素腸外營(yíng)養(yǎng)支持基本配方能量 允許性低熱卡 20-30 kcal/kg/d葡萄糖（50） 2-4 g/kg/d脂肪（50） 1-1.5 g/kg/d氮量 0.2-0.25 g/kg/d氨基酸 1.2-1.5 g/kg/d 電 解 質(zhì)鈉 80-100 mmol鉀 60-150 mmol鎂 8-12 mmol鈣 5-10 mmol氯 80-100 mmol磷 10-30 mmol維生素與微量元素應(yīng)作為重癥病人營(yíng)養(yǎng)支持的組成成分。創(chuàng)傷、感染及ARDS病人，應(yīng)適當(dāng)增加

4、抗氧化維生素及硒的補(bǔ)充量。 置管并發(fā)癥感染并發(fā)癥代謝并發(fā)癥臟器并發(fā)癥其他：Refeeding Syndrome TPN 并發(fā)癥分類一類主要以器官系統(tǒng)功能損害為特征的并發(fā)癥淤膽和肝膽功能異常腸萎縮和腸道屏障功能障礙（腸源性細(xì)菌易位）代謝性骨病免疫系統(tǒng)功能抑制 臟器并發(fā)癥代謝性骨病偶見于3個(gè)月以上TPN病人，表現(xiàn)為骨軟化，肌病，骨病，嚴(yán)重者可致病理性骨折再灌食綜合癥（Refeeding Syndrom） 指在TPN或TEN時(shí)發(fā)生的嚴(yán)重的體液和電解質(zhì)移動(dòng)，特別是與磷的移動(dòng)有關(guān)的并發(fā)癥，可出現(xiàn)一系列癥狀，嚴(yán)重者可致死腸內(nèi)營(yíng)養(yǎng)歷史18世紀(jì)末，至19世紀(jì)已得到廣泛應(yīng)用。1942年推入市場(chǎng)，用于治療兒童腸道

5、疾病20世紀(jì)50-60年代航天事業(yè)的發(fā)展，該配方中化學(xué)成分明確，不含殘?jiān)?，無需消化即能吸收，稱為要素膳。研究結(jié)果顯示，正常人在6個(gè)月內(nèi)僅靠該要素膳即可維持正常營(yíng)養(yǎng)和生理狀態(tài)?！爱?dāng)腸道有功能，能安全使用時(shí)，使用它”“When the gut works, and can be used safely, use it ” 腸道正常的生理性途徑腸外人為的治療性途徑 非生理性腸道屏障功能Gut barrier function生 物 屏 障 Biological barrier免 疫 屏 障 Immune barrier機(jī) 械 屏 障 mechanical barrier化 學(xué) 屏 障 chemica

6、l barrier腸道功能腸道功能1980s以前機(jī)體應(yīng)激時(shí)，腸道處于“休眠狀態(tài)”1980s以后機(jī)體應(yīng)激時(shí)，腸是一中心器官 腸道是一免疫器官，含有全身60%的淋巴細(xì)胞內(nèi)毒素細(xì)菌PGE2Il 1TNFO2ARDSATNShock損傷的組織Kupffer 細(xì)胞GutLiver禁食、延遲的腸內(nèi)營(yíng)養(yǎng)免疫力過度炎癥C3aC5aMoore et al 1989Gut: MOF的啟動(dòng)機(jī)Liver: MOF的發(fā)動(dòng)機(jī) 感染器官衰竭禁食在MOF發(fā)生過程中的作用21但長(zhǎng)期禁食會(huì)影響腸粘膜屏障導(dǎo)致病情惡化正常腸粘膜禁食后腸粘膜22 鼻胃管、鼻腸管、胃造瘺管、空腸造瘺管腸內(nèi)營(yíng)養(yǎng)途徑誤吸危險(xiǎn) 有無鼻空腸管或鼻十二指腸管鼻胃

7、管（1790）經(jīng)皮內(nèi)鏡下空腸置管1980（PEJ）經(jīng)皮內(nèi)鏡下胃造口（1979）（PEG）時(shí)間長(zhǎng)于6周選擇腸內(nèi)營(yíng)養(yǎng)途徑腸內(nèi)營(yíng)養(yǎng)劑分類一.大分子聚合物 1.自制勻漿膳；將牛奶、豆?jié){。魚、肉、蔬菜等食物研碎加水而成，為“自然食物” 2.大分子聚合物制劑；含有蛋白質(zhì)、糖、脂肪、維生素、礦物質(zhì)和水。二.要素飲食：氮源氨基酸、短肽、整蛋白三.特殊配方制劑 1.高支鏈氨基酸配方 2.必須氨基酸配方 3.組件配方腸內(nèi)營(yíng)養(yǎng)并發(fā)癥的預(yù)防與處理1.飼管最好通過幽門，避免胃潴留。2.老年人滴注時(shí)，應(yīng)半臥位，防止誤吸致肺部感染。3.選擇細(xì)又軟的喂養(yǎng)管，防止咽部炎癥。4.喂養(yǎng)管用畢后，用溫水沖洗，避免飼管堵塞和污染。5.

8、用泵恒速輸入，濃度要適宜，溫度要適宜，避免腹瀉。重癥患者營(yíng)養(yǎng)支持現(xiàn)狀重癥患者的營(yíng)養(yǎng)不良發(fā)生率更高腸內(nèi)營(yíng)養(yǎng)耐受性差早期腸內(nèi)營(yíng)養(yǎng)開始晚，熱卡不足累積能量供給不足，并發(fā)癥多國(guó)外住院患者營(yíng)養(yǎng)不良發(fā)生率?普通外科 (瑞典) 4-31%髖骨折(美國(guó)) 18-57%腰椎外科 (美國(guó)) 25%胃癌 (德國(guó)) 31%胰腺癌 (德國(guó)) 61%普通外科 (法國(guó)) 6.9-25.5%ZM Jiang et al. Chinese Journal of Clinical Nutrition 2006;14(4):263MalnutritionNutritional risk46.8%43%37.9%37.8%29.2%

9、42%GIResp.NephroNeuro.General Sug.Thracic Sug.27%30%21%11%12%15%中國(guó) 11個(gè)大城市醫(yī)院 5303住院患者 的營(yíng)養(yǎng)狀況調(diào)查我國(guó)住院患者營(yíng)養(yǎng)不良發(fā)生率重癥患者的營(yíng)養(yǎng)不良發(fā)生率更高43% - 88% 的ICU患者有營(yíng)養(yǎng)障礙營(yíng)養(yǎng)不良與預(yù)后明顯相關(guān)Giner et al, 1996; Barr et al, 2004給予營(yíng)養(yǎng)素應(yīng)用原則 胃腸道 胃腸道功能 無功能 胃腸道 正常飲食可行 有功能 目的 攝入 攝入 足夠 不足 PNENEN+PN臨床營(yíng)養(yǎng)正常飲食繼續(xù)EN不可行如何實(shí)現(xiàn)標(biāo)準(zhǔn)化臨床營(yíng)養(yǎng)診療流程MNANRS2002MUSTSNAQANS

10、T.膳食調(diào)查體格檢查和人體測(cè)量能量需要評(píng)估（IC和公式）人體成分分析實(shí)驗(yàn)室檢查（營(yíng)養(yǎng)代謝）綜合評(píng)價(jià)醫(yī)療膳食普通膳食特殊營(yíng)養(yǎng)成分調(diào)整膳食腸內(nèi)營(yíng)養(yǎng)（ONS和TF）腸外營(yíng)養(yǎng)Food/Nutrition-related historyAnthropometric measurementsBiochemical data，medical tests and proceduresNutrition-focused physical findingsClient history營(yíng)養(yǎng)風(fēng)險(xiǎn)篩查營(yíng)養(yǎng)狀況評(píng)價(jià)營(yíng)養(yǎng)支持治療營(yíng)養(yǎng)監(jiān)測(cè)營(yíng)養(yǎng)干預(yù)住院患者營(yíng)養(yǎng)干預(yù)原則 注： EN：腸內(nèi)營(yíng)養(yǎng) SPN：補(bǔ)充腸外營(yíng)養(yǎng) 繼續(xù) TPN：

11、全腸外營(yíng)養(yǎng)腸梗阻腹膜炎短腸腸缺血難治性嘔吐和腹瀉營(yíng)養(yǎng)支持需要營(yíng)養(yǎng)支持EN是否耐受？EN攝入足夠？YNYNENTPNSPN；25（4）：403-142016年,SCCM和ASPEN發(fā)布了成人危重患者營(yíng)養(yǎng)支持療法的評(píng)估和規(guī)定指南（2016版）A 營(yíng)養(yǎng)評(píng)估Question: Does the use of a nutrition risk indicator identify patients who will most likely benefit from nutrition therapy?問題：營(yíng)養(yǎng)風(fēng)險(xiǎn)篩查工具能否鑒別哪些患者最可能從營(yíng)養(yǎng)治療中獲益？A1. Based on expert c

12、onsensus, we suggest a determination of nutrition risk (for example, nutritional risk score NRS-2002, NUTRIC score) be performed on all patients admitted to the ICU for whom volitional intake is anticipated to be insufficient. High nutrition risk identifies those patients most likely to benefit from

13、 early EN therapy.根據(jù)專家共識(shí)，我們建議對(duì)收入ICU且預(yù)計(jì)攝食不足的患者進(jìn)行營(yíng)養(yǎng)風(fēng)險(xiǎn)評(píng)估（如營(yíng)養(yǎng)風(fēng)險(xiǎn)評(píng)分NRS-2002，NUTRIC 評(píng)分）。高營(yíng)養(yǎng)風(fēng)險(xiǎn)患者的識(shí)別，最可能使其從早期腸內(nèi)營(yíng)養(yǎng)治療中獲益。A2. Based on expert consensus, we suggest that nutritional assessment include an evaluation of comorbid conditions, function of the gastrointestinal (GI) tract, and risk of aspiration. We su

14、ggest not using traditional nutrition indicators or surrogate markers, as they are not validated in critical care.根據(jù)專家共識(shí)，我們建議營(yíng)養(yǎng)評(píng)估應(yīng)當(dāng)包括對(duì)于合并癥、胃腸道功能以及誤吸風(fēng)險(xiǎn)的評(píng)估。我們建議不要使用傳統(tǒng)的營(yíng)養(yǎng)指標(biāo)或其替代指標(biāo)，因?yàn)檫@些指標(biāo)在ICU的應(yīng)用并非得到驗(yàn)證。營(yíng) 養(yǎng) 評(píng) 估營(yíng) 養(yǎng) 評(píng) 估Without IL-65；IL-66A 營(yíng)養(yǎng)評(píng)估Question: What is the best method for determining energy needs in

15、 the critically ill adult patient?問題：確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 and in the absence of variables that affect the accuracy of measurement.Quality of Evidence: Very Low。如果有條件且不影響測(cè)量準(zhǔn)確性的因素時(shí)，建議應(yīng)用間接能量測(cè)定(間接測(cè)熱法

16、，indirect calorimetry，IC) 確定能量需求。證據(jù)質(zhì)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-based equation (2530 kcal/kg/ day) be used to determine energy requirements. (see section Q for obesity recommendations.)根據(jù)專家共識(shí)，當(dāng)沒有IC時(shí)

17、，我們建議使用已發(fā)表的預(yù)測(cè)公式或基于體重的簡(jiǎn)化公式(2530 kcal/kg/ day)確定能量需求。（見Q部分有關(guān)肥胖患者的推薦意見。）A 營(yíng)養(yǎng)評(píng)估Question: Should protein provision be monitored independently from energy provision in critically ill adult patients?問題：對(duì)于成年危重病患者，除能量提供外，是否需要單獨(dú)監(jiān)測(cè)提供的蛋白質(zhì)量？A4. Based on expert consensus, we suggest an ongoing evaluation of adequ

18、acy of protein provision be performed.根據(jù)專家共識(shí)，我們建議連續(xù)評(píng)估蛋白質(zhì)供給的充分性。The decision to add protein modules should be based on an ongoing assessment of adequacy of protein intake. Weight-based equations (e.g., 1.22.0 g/kg/day) may be used to monitor adequacy of protein provision by comparing the amount of pr

19、otein delivered to that prescribed, especially when nitrogen balance studies are not available to assess needs (see section C4).B 開始腸內(nèi)營(yíng)養(yǎng)Question: What is the benefit of early EN in critically ill adult patients compared to withholding or delaying this therapy?問題：對(duì)于成年危重病患者而言，與不給予或延遲給予EN相比，早期EN有何益處？B1

20、. 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 of Evidence: Very Low對(duì)于不能維持自主進(jìn)食的危重病患者，我們推薦在24 48小時(shí)內(nèi)通過早期EN開始營(yíng)養(yǎng)支持治療。證據(jù)質(zhì)量：非常低B 開始腸內(nèi)營(yíng)養(yǎng)Question: Is there a difference in

21、outcome between the use of EN or PN for adult critically ill patients?問題：成年危重病患者使用EN或PN對(duì)預(yù)后的影響有何不同？B2. We suggest the use of EN over PN in critically ill patients who require nutrition support therapy.Quality of Evidence: Low to Very Low對(duì)于需要營(yíng)養(yǎng)支持治療的危重病患者，我們建議首選EN而非PN的營(yíng)養(yǎng)供給方式。證據(jù)質(zhì)量：低至非常低B 開始腸內(nèi)營(yíng)養(yǎng)Question:

22、 Is the clinical evidence of contractility (bowel sounds, flatus) required prior to initiating EN in critically ill adult patients?問題：在成年危重病患者開始EN前是否需要有腸道蠕動(dòng)的證據(jù)（腸鳴音，排氣）？B3. Based on expert consensus, we suggest that, in the majority of MICU and SICU patient populations, while GI contractility factors

23、 should be evaluated when initiating EN, overt signs of contractility should not be required prior to initiation of EN.基于專家共識(shí)，我們建議，對(duì)于多數(shù)MICU和SICU患者，盡管啟用EN時(shí)需要對(duì)胃腸道蠕動(dòng)情況進(jìn)行評(píng)估，但此前并不需要有腸道蠕動(dòng)的體征。B 開始腸內(nèi)營(yíng)養(yǎng)Question: What is the preferred level of infusion of EN within the GI tract for critically ill patients? Ho

24、w does the level of infusion of EN affect patient outcomes?問題：危重病患者胃腸道輸注EN的最佳速度是多少？EN輸注速度如何影響患者預(yù)后？B4a. We recommend that the level of infusion be diverted lower in the GI tract in those critically ill patients at high risk for aspiration (see section D4) or those who have shown intolerance to gastri

25、c EN.Quality of Evidence: Moderate to High對(duì)于具有誤吸高危因素（見D4部分）或不能耐受經(jīng)胃喂養(yǎng)的重癥患者，我們推薦減慢EN輸注的速度。證據(jù)質(zhì)量：中至高B4b. Based on expert consensus we suggest that, in most critically ill patients, it is acceptable to initiate EN in the stomach.基于專家的共識(shí)，我們建議經(jīng)胃開始喂養(yǎng)是多數(shù)危重病患者可接受的EN方式。B 開始腸內(nèi)營(yíng)養(yǎng)Question: Is EN safe during perio

26、ds of hemodynamic instability in adult critically ill patients?問題：對(duì)于成年危重病患者，血流動(dòng)力學(xué)不穩(wěn)定時(shí)EN是否安全？B5. Based on expert consensus, we suggest that in the setting of hemodynamic compromise or instability, EN should be withheld until the patient is fully resuscitated and/or stable. Initiation/reinitiation of

27、EN may be considered with caution in patients undergoing withdrawal of vasopressor support.根據(jù)專家共識(shí)，我們建議在血流動(dòng)力學(xué)不穩(wěn)定時(shí)，應(yīng)當(dāng)暫停EN直至患者接受了充分的復(fù)蘇治療和（或）病情穩(wěn)定。對(duì)于正在撤除升壓藥物的患者，可以考慮謹(jǐn)慎開始或重新開始EN。C 腸內(nèi)營(yíng)養(yǎng)劑量Question: What population of patients in the ICU setting does not require nutrition support therapy over the first week

28、of hospitalization?問題：哪些患者住ICU的第一周內(nèi)無需營(yíng)養(yǎng)支持治療？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 example, NRS-2002 3 or NUTRIC score 5) who cannot maintain volitional intake do NOT require specialize

29、d nutrition therapy over the first week of hospitalization in the ICU.根據(jù)專家共識(shí)，我們建議那些營(yíng)養(yǎng)風(fēng)險(xiǎn)較低及基礎(chǔ)營(yíng)養(yǎng)狀況正常、疾病較輕（例如NRS-2002 3 或 NUTRIC評(píng)分 5）的患者，即使不能自主進(jìn)食，住ICU的第一周內(nèi)不需要特別給予營(yíng)養(yǎng)治療。C 腸內(nèi)營(yíng)養(yǎng)劑量Question: For which population of patients in the ICU setting is it appropriate to provide trophic EN over the first week of hos

30、pitalization?問題：哪些ICU患者在住院第一周內(nèi)適合滋養(yǎng)型喂養(yǎng) (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) and those expected to have a duration of mechanical ventilation 72 hours, as these two strat

31、egies of feeding have similar patient outcomes over the first week of hospitalization.Quality of Evidence: High對(duì)于急性呼吸窘迫綜合征(ARDS)/急性肺損傷(ALI)患者以及預(yù)期機(jī)械通氣時(shí)間 72小時(shí)的患者，我們推薦給予滋養(yǎng)型或充分的腸內(nèi)營(yíng)養(yǎng)，這兩種營(yíng)養(yǎng)補(bǔ)充策略對(duì)患者住院第一周預(yù)后的影響并無差異。證據(jù)質(zhì)量：高trophic EN (defined as 1020 kcal/hr or up to 500 kcal/day) for one weekC 腸內(nèi)營(yíng)養(yǎng)劑量Question:

32、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 patients?問題：哪些ICU患者住院第一周需要足量EN（盡可能接近目標(biāo)喂養(yǎng)量）？這些患者應(yīng)多長(zhǎng)時(shí)間達(dá)到目標(biāo)量？C3. Based on expert consensus,

33、 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 while monitoring for refeeding syndrome. Efforts to provide 80% of estimated or

34、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.根據(jù)專家共識(shí)，我們建議具有高營(yíng)養(yǎng)風(fēng)險(xiǎn)患者（如：NRS-2002 3 或不考慮IL-6情況下NUTRIC評(píng)分 5）或嚴(yán)重營(yíng)養(yǎng)不良患者（ NRS-2002 5 ）， 應(yīng)在24 48小時(shí)達(dá)到并耐受目標(biāo)喂養(yǎng)量；監(jiān)測(cè)再喂養(yǎng)綜合征。爭(zhēng)取于48 72小時(shí)提供 80%預(yù)計(jì)蛋白質(zhì)與能量供給目標(biāo)，從入院第一周的

35、EN中獲益。C 腸內(nèi)營(yíng)養(yǎng)劑量Question: Does the amount of protein provided make a difference in clinical outcomes of adult critically ill patients?問題：蛋白質(zhì)供給量對(duì)成年危重病患者臨床結(jié)局有何不同影響？C4. We suggest that sufficient (high-dose) protein should be provided. Protein requirements are expected to be in the range of 1.22.0g/kg ac

36、tual 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我們建議充分的（大劑量的）蛋白質(zhì)供給。蛋白質(zhì)需求預(yù)計(jì)為1.2 2.0 g/kg（實(shí)際體重）/天，燒傷或多發(fā)傷患者對(duì)蛋白質(zhì)的需求量可能更高（見M和P部分）。證據(jù)質(zhì)量：非常低D 腸內(nèi)營(yíng)養(yǎng)的耐受性與充分性 Question: How should tolerance of EN be monitored in the a

37、dult critically ill population?問題：如何監(jiān)測(cè)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 ordering a feeding status of nil per os (NPO) for the patient sur

38、rounding the time of diagnostic tests or procedures should be minimized to limit propagation of ileus and to prevent inadequate nutrient delivery.根據(jù)專家共識(shí)，我們建議應(yīng)每日監(jiān)測(cè)EN耐受性。我們建議應(yīng)當(dāng)避免不恰當(dāng)?shù)闹兄笶N。我們建議，患者在接受診斷性檢查或操作期間，應(yīng)當(dāng)盡可能縮短禁食狀態(tài)(NPO)的醫(yī)囑，以免腸梗阻加重，并防止?fàn)I養(yǎng)供給不足。D 腸內(nèi)營(yíng)養(yǎng)的耐受性與充分性 Question: Should GRVs be used as a marker

39、 for aspiration to monitor ICU patients on EN?問題：GRV是否應(yīng)當(dāng)作為接受EN的ICU患者監(jiān)測(cè)誤吸的指標(biāo)？D2a. We suggest that GRVs not be used as part of routine care to monitor ICU patients on EN.我們建議不應(yīng)當(dāng)把GRV作為接受EN的ICU患者常規(guī)監(jiān)測(cè)的指標(biāo)。D2b. We suggest that, for those ICUs where GRVs are still utilized, holding EN for GRVs 500 ml in the

40、 absence of other signs of intolerance (see section D1) should be avoided.Quality of Evidence: Low我們建議，對(duì)于仍然監(jiān)測(cè)GRV的ICU，應(yīng)當(dāng)避免在GRV 60% of energy and protein requirements by the enteral route alone. Initiating supplemental PN prior to this 710-day period in critically ill patients on some en does not impr

41、ove outcomes and may be detrimental to the patient.Quality of Evidence: Moderate無論低或高營(yíng)養(yǎng)風(fēng)險(xiǎn)患者，接受腸內(nèi)營(yíng)養(yǎng)7-10天，如果經(jīng)EN攝入能量與蛋白質(zhì)量仍不足目標(biāo)的60%，我們推薦應(yīng)考慮給予補(bǔ)充型PN。在開始EN7天內(nèi)給予補(bǔ)充型PN，不僅不能改善預(yù)后，甚至可能有害。證據(jù)質(zhì)量：中H PN最大獲益的適應(yīng)癥 Question: In the appropriate candidate for PN (high risk or severely malnourished), should the dose be adj

42、usted over the first week of hospitalization in the ICU?問題：對(duì)于具有PN適應(yīng)癥的患者（高風(fēng)險(xiǎn)或嚴(yán)重營(yíng)養(yǎng)不良），住ICU第一周應(yīng)如何調(diào)整營(yíng)養(yǎng)供給量？H2. We suggest that hypocaloric PN dosing ( 20 kcal/kg/day or 80% of estimated energy needs) with adequate protein ( 1.2g protein/kg/day) be considered in appropriate patients (high risk or severely

43、 malnourished) requiring PN, initially over the first week of hospitalization in the ICU.Quality of Evidence: Low對(duì)于高營(yíng)養(yǎng)風(fēng)險(xiǎn)或嚴(yán)重營(yíng)養(yǎng)不良、需要PN支持的患者，我們建議住ICU第一周內(nèi)給予低熱卡PN（20 kcal/kg/day 或能量需要目標(biāo)的80%），以及充分的蛋白質(zhì)補(bǔ)充（ 1.2 g/kg/day）。證據(jù)質(zhì)量：低H PN最大獲益的適應(yīng)癥 Question:Should soy-based IV fat emulsions (IVFE) be provided in the

44、first week of ICU stay? Is there an advantage to using alternative IVFE (i.e., medium-chain triglycerides MCT, olive oil OO, FO, mixture of oils) over traditional soybean oil (SO)-based lipid emulsions in critically ill adult patients?問題：成年危重癥患者在收住ICU第一周內(nèi)是否給予大豆油基礎(chǔ)的靜脈脂肪乳劑(IVFE)？給予新一代的靜脈脂肪乳劑（含中鏈甘油三酯MC

45、T，橄欖油OO，魚油FO，混合油類），是否比傳統(tǒng)大豆油基礎(chǔ)的脂肪乳劑更有優(yōu)勢(shì)？H3a. We suggest withholding or limiting SO-based IVFE during the first week following initiation of PN in the critically ill patient to a maximum of 100 g/week (often divided into 2 doses/week) if there is concern for essential fatty acid deficiency.Quality of

46、Evidence: Very Low危重病患者開始PN的第一周，我們建議暫緩或限制大豆油基礎(chǔ)的靜脈脂肪乳劑輸注，如果考慮必需脂肪酸缺乏，其最大補(bǔ)充劑量為100g每周（常分2次補(bǔ)充）。證據(jù)質(zhì)量：非常低H PN最大獲益的適應(yīng)癥 H3b. Alternative IVFE may provide outcome benefit over soy-based IVFE; however, we cannot make a recommendation at this time due to lack of availability of these products in the U.S. When

47、these alternative IVFEs (SMOF, MCT, OO and FO) become available in the United States, based on expert opinion, we suggest that their use be considered in the critically ill patient who is an appropriate candidate for PN.新一代的IVFE比大豆油基礎(chǔ)的IVFE對(duì)預(yù)后具有更好影響；但是，鑒于美國(guó)這類產(chǎn)品的缺乏，故尚不能做出任何推薦意見。根據(jù)專家意見，一旦這類脂肪乳劑（SMOF, M

48、CT, OO, FO）在美國(guó)上市，建議在有PN適應(yīng)癥的重癥患者使用。H PN最大獲益的適應(yīng)癥 Question:Is there an advantage to using standardized commercially available PN (premixed PN) versus compounded PN admixtures?問題：標(biāo)準(zhǔn)商品化的PN（預(yù)混合的PN制劑）比配置的PN混合液更有優(yōu)勢(shì)嗎？H4. Based on expert consensus, use of standardized commercially available PN versus compound

49、ed PN admixtures in the ICU patient has no advantage in terms of clinical outcomes.根據(jù)專家共識(shí)，標(biāo)準(zhǔn)商品化的PN制劑（多腔袋）與配置PN液相比，未見任何影響ICU患者臨床結(jié)局的優(yōu)勢(shì)。H PN最大獲益的適應(yīng)癥 Question:What is the desired target blood glucose range in adult ICU patients?問題：成年ICU患者預(yù)期的血糖控制目標(biāo)是多少？H5. We recommend a target blood glucose range of 140

50、or 150180 mg/dl for the general ICU population; ranges for specific patient populations (post-cardiovascular surgery, head trauma) may differ and are beyond the scope of this guideline.Quality of Evidence: Moderate我們推薦綜合ICU患者的血糖控制目標(biāo)在：140180 或 150180 mg/dl；特殊患者（心血管術(shù)后，顱腦損傷）可能有超出指南的不同推薦。證據(jù)質(zhì)量：中H PN最大獲益的

51、適應(yīng)癥 Question:Should parenteral glutamine be used in the adult ICU patient?問題：成年ICU患者腸外支持是否應(yīng)補(bǔ)充谷氨酰胺？H6. We recommend that parenteral glutamine supplementation NOT be used routinely in the critical care setting.Quality of Evidence: Moderate我們推薦危重病患者腸外營(yíng)養(yǎng)期間無需常規(guī)補(bǔ)充谷氨酰胺。證據(jù)質(zhì)量：中H PN最大獲益的適應(yīng)癥 Question:In transi

52、tion feeding, as an increasing volume of EN is tolerated by a patient already receiving PN, at what point should the PN be terminated?問題：接受PN支持的患者向EN過渡期間，如EN量逐漸增加，何時(shí)應(yīng)終止PN？H7. Based on expert consensus, we suggest that, as tolerance to EN improves, the amount of PN energy should be reduced and finall

53、y discontinued when the patient is receiving 60% of target energy requirements from EN.根據(jù)專家共識(shí)，當(dāng)EN耐受性提高，達(dá)到目標(biāo)能量60%以上時(shí)，我們建議經(jīng)PN途徑供給的能量可逐漸減量至終止。I 呼吸衰竭 I1、我們建議，對(duì)于ICU內(nèi)急性呼吸衰竭患者，不使用特殊配制的高脂低糖營(yíng)養(yǎng)配方，用于調(diào)節(jié)呼吸商以減少二氧化碳的產(chǎn)生（注意勿與第E3條混淆）。(證據(jù)級(jí)別：極低）I2、依據(jù)專家共識(shí)，對(duì)于急性呼吸衰竭的患者，建議給予高能量密度的腸內(nèi)營(yíng)養(yǎng)以限制液體入量（特別是容量負(fù)荷較高的患者）。I3、依據(jù)專家共識(shí)，建議密切監(jiān)測(cè)血

54、磷，必要時(shí)適當(dāng)?shù)难a(bǔ)充磷酸鹽J 腎功能衰竭 J1、依據(jù)專家共識(shí)，對(duì)于急性腎功能衰竭或者急性腎損傷的ICU患者，建議使用標(biāo)準(zhǔn)的腸內(nèi)營(yíng)養(yǎng)配方，推薦每日給予的蛋白和25-30kcal/kg的熱卡。如果存在明顯的電解質(zhì)紊亂，可考慮使用電解質(zhì)結(jié)構(gòu)比合適的腎衰專用營(yíng)養(yǎng)配方。J2、我們推薦，對(duì)于血液透析或CRRT的患者增加蛋白供給，最大可到每日。對(duì)于腎功能不全的患者，不應(yīng)該通過限制蛋白攝入的手段來減少透析治療。（證據(jù)級(jí)別：極低）K 肝功能衰竭 K1、依據(jù)專家共識(shí)，建議對(duì)于肝硬化和肝衰竭的患者，由于腹水、血管內(nèi)容量減少、水腫、門脈高壓和低蛋白血癥多重因素的影響，在用預(yù)測(cè)公式計(jì)算能量和蛋白時(shí)，使用干重或者正常體重

55、來替代目前體重。肝衰竭患者不建議限制蛋白攝入，具體可參考其他重癥患者的營(yíng)養(yǎng)方案（見C4）。K2、依據(jù)專家共識(shí)，對(duì)于ICU內(nèi)急性或者慢性肝病患者，在實(shí)施營(yíng)養(yǎng)治療時(shí)優(yōu)先給予腸內(nèi)營(yíng)養(yǎng)。K3、依據(jù)專家共識(shí)，對(duì)于ICU內(nèi)急性或者慢性肝病患者，建議給予標(biāo)準(zhǔn)腸內(nèi)營(yíng)養(yǎng)配方。目前沒有證據(jù)表明，對(duì)于已經(jīng)接受一線藥物（作用于腸道內(nèi)的抗生素和乳果糖等）治療的肝性腦病患者改用支鏈氨基酸營(yíng)養(yǎng)配方可以改善其昏迷程度。L 急性胰腺炎 L1a、依據(jù)專家共識(shí)，建議急性胰腺炎患者啟動(dòng)營(yíng)養(yǎng)治療前應(yīng)評(píng)估疾病嚴(yán)重程度來指導(dǎo)營(yíng)養(yǎng)治療。由于急性胰腺炎病情變化快，建議反復(fù)重新評(píng)估是否能夠耐受腸內(nèi)營(yíng)養(yǎng)以及是否需要制定特殊的營(yíng)養(yǎng)治療方案。L1b、

56、我們建議，對(duì)于輕型急性胰腺炎患者，無需額外制定特殊的營(yíng)養(yǎng)治療方案，只要患者能夠耐受，逐漸增加經(jīng)口進(jìn)食量即可。如果7天內(nèi)發(fā)生了一些無法預(yù)計(jì)的并發(fā)癥，或者增加經(jīng)口進(jìn)食量后患者不能耐受，則應(yīng)該考慮制定特殊的營(yíng)養(yǎng)治療方案。（證據(jù)級(jí)別：極低）L1c、我們建議，中重度急性胰腺炎患者放置鼻空腸管，啟動(dòng)腸內(nèi)營(yíng)養(yǎng)時(shí)以滋養(yǎng)性的速度，并在容量復(fù)蘇完成后（收入后24-48小時(shí)）增加至目標(biāo)量。（證據(jù)級(jí)別：極低）L 急性胰腺炎 L2、我們建議，對(duì)于重癥急性胰腺炎患者，啟動(dòng)腸內(nèi)營(yíng)養(yǎng)時(shí)，使用標(biāo)準(zhǔn)的聚合配方。雖然重癥急性胰腺炎使用免疫增強(qiáng)配方可能很有前途，但是目前仍然缺乏足夠的數(shù)據(jù)支持這一觀點(diǎn)。（證據(jù)級(jí)別：極低）L3a、我們建

57、議，對(duì)于需要營(yíng)養(yǎng)治療的重癥急性胰腺炎患者，腸內(nèi)營(yíng)養(yǎng)優(yōu)于腸外營(yíng)養(yǎng)。（證據(jù)級(jí)別：低）L3b、我們建議，對(duì)于重癥急性胰腺炎患者，行腸內(nèi)營(yíng)養(yǎng)經(jīng)胃管或空腸管都是可行的，耐受情況和臨床預(yù)后沒有差異。（證據(jù)級(jí)別：低）L 急性胰腺炎 L4、依據(jù)專家共識(shí)，建議不能耐受腸內(nèi)營(yíng)養(yǎng)的中到重度急性胰腺炎患者，應(yīng)該采取一些措施提高患者的耐受程度。L5、我們建議，重癥急性胰腺炎患者早期行腸內(nèi)營(yíng)養(yǎng)時(shí)添加益生菌。（證據(jù)級(jí)別：低）L6、依據(jù)專家共識(shí)，建議對(duì)于不適合行腸內(nèi)營(yíng)養(yǎng)的重癥急性胰腺炎患者，起病一周后應(yīng)考慮給予腸外營(yíng)養(yǎng)。（證據(jù)級(jí)別：低）M 外科疾病 創(chuàng)傷M1a、我們建議，與其他重癥患者相似，對(duì)于外傷后早期（24-48小時(shí)內(nèi)）

58、患者，只要血流動(dòng)力學(xué)穩(wěn)定，早期給予高蛋白腸內(nèi)營(yíng)養(yǎng)。（證據(jù)級(jí)別：極低）M1b、我們建議，嚴(yán)重外傷患者可以考慮給予含有精氨酸和魚油等免疫調(diào)節(jié)配方的營(yíng)養(yǎng)制劑。（證據(jù)級(jí)別：極低）顱腦創(chuàng)傷M2a、我們推薦，與其他重癥患者相似，外傷后早期（24-48小時(shí)內(nèi)）只要患者血流動(dòng)力學(xué)穩(wěn)定，建議立即啟動(dòng)腸內(nèi)營(yíng)養(yǎng)。（證據(jù)級(jí)別：極低）M2b、依據(jù)專家共識(shí)，建議對(duì)于顱腦創(chuàng)傷患者，在標(biāo)準(zhǔn)腸內(nèi)營(yíng)養(yǎng)配方中添加含精氨酸的免疫調(diào)節(jié)制劑或者EPA/DHA。M 外科疾病 腹部開放性損傷M3a、依據(jù)專家共識(shí)，對(duì)于無腸道損傷的腹部外傷患者建議早期腸內(nèi)營(yíng)養(yǎng)（外傷后24-48小時(shí)）。M3b、依據(jù)專家共識(shí)，腹部開放性損傷患者每升滲出液中會(huì)損失1

59、5-30克蛋白，須相應(yīng)給予補(bǔ)充。能量需求量的制定和其他ICU患者相同（見A節(jié)）。M 外科疾病 燒傷M4a、依據(jù)專家共識(shí)，對(duì)于胃腸道功能正常且飲食量不足以滿足能量需求的燒傷患者，應(yīng)給予腸內(nèi)營(yíng)養(yǎng)。對(duì)于不適合或者不能耐受腸內(nèi)營(yíng)養(yǎng)的患者，才給予腸外營(yíng)養(yǎng)。M4b、依據(jù)專家共識(shí)，建議如果條件允許，每周重復(fù)一次用間接測(cè)熱法評(píng)估患者能量需求。M4c、依據(jù)專家共識(shí)，建議燒傷患者每日應(yīng)給予蛋白。M4d、依據(jù)專家共識(shí)，只要情況允許，燒傷患者應(yīng)盡早啟動(dòng)腸內(nèi)營(yíng)養(yǎng)（傷后4-6小時(shí)）。N 膿毒癥 N1、依據(jù)專家共識(shí)，建議重癥患者在確診嚴(yán)重膿毒癥或膿毒性休克后的24-48內(nèi)，盡快完成復(fù)蘇血流動(dòng)力學(xué)后立即啟動(dòng)腸內(nèi)營(yíng)養(yǎng)。N2、我們建議，無論營(yíng)養(yǎng)風(fēng)險(xiǎn)程度高低，對(duì)于急性期的嚴(yán)重膿毒癥或膿毒性休克患者，早期不單獨(dú)使用腸外營(yíng)養(yǎng)或補(bǔ)充性腸外聯(lián)合腸內(nèi)營(yíng)養(yǎng)。（證據(jù)級(jí)別：極低）N3、我們目前不能作出關(guān)于硒、鋅和抗氧化添加劑在膿毒癥中使用的推薦意見，因?yàn)橄嚓P(guān)研究尚有爭(zhēng)議。（證據(jù)級(jí)