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SCCM/ASPEN成年危重病患者营养支持治疗实施与评估指南(2/6)2016年02月17日⁄指南导读,进展交流⁄暂无评论GuidelinesfortheProvisionandAssessmentofNutritionSupportTherapyintheAdultCriticallyIllPatient:SocietyofCriticalCareMedicine(SCCM)andAmericanSocietyforParenteralandEnteralNutrition(A.S.P.E.N.)成年危重病患者营养支持治疗的实施与评估指南：美国危重病医学会(SCCM)与美国肠外肠内营养学会(ASPEN)TaylorBE,McClaveSA,MartindaleRG,etal.CritCareMed2016;44:390-438翻译：清华大学长庚医院周华许媛D.MONITORINGTOLERANCEANDADEQUACYOFENEN耐受性与充分性的监测Question:HowshouldtoleranceofENbemonitoredintheadultcriticallyillpopulation?问题：如何监测成年危重病患者EN耐受性？D1.Basedonexpertconsensus,wesuggestthatpatientsshouldbemonitoreddailyfortoleranceofEN.WesuggestthatinappropriatecessationofENshouldbeavoided.Wesuggestthatorderingafeedingstatusofnilperos(NPO)forthepatientsurroundingthetimeofdiagnostictestsorproceduresshouldbeminimizedtolimitpropagationofileusandtopreventinadequatenutrientdelivery.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，并防止营养供给不足。Question:ShouldGRVsbeusedasamarkerforaspirationtomonitorICUpatientsonEN?问题：GRV是否应当作为接受EN的ICU患者监测误吸的指标？D2a.WesuggestthatGRVsnotbeusedaspartofroutinecaretomonitorICUpatientsonEN.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.Wesuggestthat,forthoseICUswhereGRVsarestillutilized,holdingENforGRVs500mlintheabsenceofothersignsofintolerance(seesectionD1)shouldbeavoided.[QualityofEvidence:Low]我们建议，对于仍然监测GRV的ICU，应当避免在GRV500ml且无其他不耐受表现（见D1部分）时中止EN。[证据质量：低]Question:ShouldENfeedingprotocolsbeusedintheadultICUsetting?问题：成人ICU是否需要制定EN喂养方案？D3a.Werecommendthatenteralfeedingprotocolsbedesignedandimplementedtoincreasetheoverallpercentageofgoalcaloriesprovided.[QualityofEvidence:ModeratetoHigh]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.Basedonexpertconsensus,wesuggestthatuseofavolume-basedfeedingprotocoloratop-downmulti-strategyprotocolbeconsidered.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-downmulti-strategyprotocol)。Question:HowcanriskofaspirationbeassessedincriticallyilladultspatientsreceivingEN,andwhatmeasuresmaybetakentoreducethelikelihoodofaspirationpneumonia?问题：对于接受EN的危重病患者，如何评估误吸的风险？哪些措施可减少吸入性肺炎的风险？D4.Basedonexpertconsensus,wesuggestthatpatientsplacedonENshouldbeassessedforriskofaspiration,andthatstepstoreduceriskofaspirationandaspirationpneumoniashouldbeproactivelyemployed.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.Werecommenddivertingtheleveloffeedingbypost-pyloricenteralaccessdeviceplacementinpatientsdeemedtobeathighriskforaspiration(seealsosectionB5)[QualityofEvidence:ModeratetoHigh]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]D4b.Basedonexpertconsensus,wesuggestthatforhigh-riskpatientsorthoseshowntobeintoleranttobolusgastricEN,deliveryofENshouldbeswitchedtocontinuousinfusion.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.Wesuggestthat,inpatientsathighriskofaspiration,agentstopromotemotility,suchasprokineticmedications(metoclopramideorerythromycin),beinitiatedwhereclinicallyfeasible.[QualityofEvidence: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.Basedonexpertconsensus,wesuggestthatnursingdirectivestoreduceriskofaspirationandVAPbeemployed.InallintubatedICUpatientsreceivingEN,theheadofthebedshouldbeelevated30–45°anduseofchlorhexidinemouthwashtwiceadayshouldbeconsidered.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。Question:Aresurrogatemarkersusefulindeterminingaspirationinthecriticalcaresetting?问题：在ICU中，替代指标能否判断是否发生误吸？D5.Basedonexpertconsensus,wesuggestthatneitherbluefoodcoloringnoranycoloringagentbeusedasamarkerforaspirationofEN.Basedonexpertconsensus,wealsosuggestthatglucoseoxidasestripsnotbeusedassurrogatemarkersforaspirationinthecriticalcaresetting.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。Question:HowshoulddiarrheaassociatedwithENbeassessedintheadultcriticallyillpopulation?问题：如何评估成年危重病患者EN相关性腹泻？D6.Basedonexpertconsensus,wesuggestthatENNOTbeautomaticallyinterruptedfordiarrheabutratherthatfeedsbecontinuedwhileevaluatingtheetiologyofdiarrheainanICUpatienttodetermineappropriatetreatment.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.SELECTIONOFAPPROPRIATEENTERALFORMULATION选择适合的肠内营养制剂Question:WhichformulashouldbeusedwheninitiatingENinthecriticallyillpatient?问题：危重病患者的早期EN应使用哪种配方？E1.Basedonexpertconsensus,wesuggestusingastandardpolymericformulawheninitiatingENintheICUsetting.WesuggestavoidingtheroutineuseofallspecialtyformulasincriticallyillpatientsinaMICUanddisease-specificformulasintheSICU.根据专家共识，我们建议ICU患者开始EN时选择标准多聚体配方肠内营养制剂。我们建议MICU的危重病患者应避免常规使用各种特殊配方制剂，SICU患者应避免常规应用疾病专属配方肠内营养制剂。Question:Doimmune-modulatingenteralformulationshaveanimpactonclinicaloutcomesforthecriticallyillpatientregardlessoftheICUsetting?问题：免疫调节型肠内营养制剂能否影响ICU危重病患者的临床结局？E2.Wesuggestimmune-modulatingenteralformulations(argininewithotheragents,includingeicosapentaenoicacid[EPA],docosahexaenoicacid[DHA],glutamine,andnucleicacid)shouldnotbeusedroutinelyintheMICU.ConsiderationfortheseformulationsshouldbereservedforpatientswithTBIandperioperativepatientsintheSICU(seesectionsOandM).[QualityofEvi