欧洲ESPEN关于危重症患者的肠内营养指南

ESPENGuidelinesonEnteralNutrition:Intensivecare程俊峰普外科GeriatricsLiverdiseaseSurgeryincludingorgantransplantationWastinginHIVandotherchronicinfectiousdiseasesAdultrenalfailureGastroenterologyPancreasCardiologyandpulmonologyNon-surgicaloncologyIntensivecareESPENGuidelinesonEN:ESPENGuidelinesonPN:GeriatricsHepatologysurgeryCardiologyandpneumologyAdultrenalfailureGastroenterologyPancreashomeparenteralnutrition(HPN)inadultpatientsSummaryEnteralnutrition(EN)的定义及目的：1、ENisthepreferredwayoffeedingthecriticallyillpatientandcounteractingforthecatabolicstateinducedbyseverediseases.2、Intendedtogiveevidence-basedrecommendationsfortheICUpatient,focusingparticularlyonthosewhodevelopasevereinflammatoryresponse,i.e.patientswhohavefailureofatleastoneorganduringtheirICUstay.EN的时机及要求：1、ENshouldbegiventoallICUpatientswhoarenotexpectedtobetakingafulloraldietwithinthreedays.2、thefirst24husingastandardhigh-proteinformula.theacuteandinitialphases≤20–25kcal/kg/d（exogenousenergy）.Recovery,25–30kcal/kg/d.3、Glutamineshouldbesupplementedinpatientssufferingfromburnsortrauma.SubjectRecommendationsGradeindicationAllpatientswhoarenotexpectedtobeonafulloraldietwithin3daysCApplicationTherearenodatasupportusingearlyENcanimprovetheirPrognosis，butthecommitteestillrecommendtheearly（24h）appropriateamountoffeeding,oncethepatienthaveahaemo-dynamicallystableandafunctioninggastrointestinaltract.CExogenousenergysupply:theacuteandinitialphase:≥25kcal/kg/dlessfavourableRecovery：≥25kcal/kg/dCsevereunder-nutrition：theENenergysupplyshouldupto25kcal/kg/d，ifnotreached，pleaseaddPNCIfthepatientintolerance(suchashighgastricresiduals)toEN,metoclopramide（胃复安）orErythromycin（红霉素）shouldbeconsidered.CRouteUseENinpatientswhocanbefedviatheenteralroute.CViajejunalversusgastricfeeding,thereisnosignificantdifference.CIfthepatientstolerateENandcanreachthetargetenergyvalue,PNshouldbeavoid.AViaENcannotbefedsufficiently,PNShouldsupplementCTypeofformulaWholeproteinformulaearesuperiortothepeptide-basedformulaeCImmune-modulatingformulae(formulaeenrichedwitharginine(精氨酸),nucleotides（核苷酸）andw-3fattyacids)aresuperiortostandardenteralformulae:InelectiveupperGIsurgicalpatients;inpatientswithamildsepsis(APACHE≤15);inpatientswithseveresepsis,maybeharmfulandarenotRecommended;inpatientswithtrauma;inpatientswithARDS(formulaecontainingo-3fattyacidsandantioxidants).ABBABDuetoinsufficientdata,norecommendationsupporttheImmune-modulatingformulaeapplytotheburnedpatients,butthetraceelements(Cu,SeandZn)shouldbesupplementedinahigherthanstandarddoseAthesevereillnessICUpatients,shouldnotreceiveanimmune-modulatingformulaenrichedwitharginine,nucleotidesandw-3fattyacidsiftheEN≤700ml/d.BGlutamineshouldbeaddedtostandardenteralformulainburnedpatientsandtraumapatientsA1.1EN-when?Allpatients（cannotbeonafulloraldietwithin3days）shouldreceiveEN（C）a.ItisunethicaltoinvestigatethemaximumtimeofICUpatientcansurvivewithoutnutritionalsupport.b.Duetoincreasedsubstratemetabolism（基础代谢）,thecriticalillnessismorelikelytodevelopunder-nutrition.c.Scandinavianshowedthatthemortalityrateofpatienttreatwithglucoseonly250-300g/dover14daysis10timeshigheronadequateTPN.d.soinadequateoralintake,thesurgicalpatientislikelytodevelopwithin8–12daysofpost-operation.e.MosttrialsfocusingtheearlyENorlateENafter4–6days,haveprovedthepositiveeffectofearlyEN,sowecometothetitleconclusion.1.2EN-IsearlyENsuperiortodelayedEN?TherearenodatasupportusingearlyENcanimprovetheirprognosis，butthecommitteestillrecommendtheearly(24h）appropriateamountoffeeding(C).a.metaanalysisandsystematicreviewAmetaanalysisof15RCTs(surgery,trauma,headinjury,burnsorsufferingfromacutemedicalconditions),showedearlyENcanreducetheinfectiouscomplicationsandlengthofstay.systematicreviewof19studiescanshowearlyENplayapositiveeffectonthesurvivalrate、lengthoftreatment,therateofseptic.andothercomplications，theconclusionprovide1levelevidenceforusingtheearlyEN.b.Individualstudies:(recommendationlevelC)MooreandJonesGraham和coworkersChiarellietalEyeretalHasseetalSinghetalNogeneralamountrecommendtobeadjustENtherapyaccordingtocourseofdisease.Butexogenousenergysupplyoftheacuteandinitialphase:≤25kcal/kg/dandrecovery：≥25kcal/kg/dmaybefavourable(C)a.Prospectiveobservationalcohortstudyb.Ibrahimc.Arecenttrial1.3EN-howmuch?1.4whichroute?Jejunalversusgastricfeedingincriticallyillnesspatientisnodifference(C).Jejunalfeedingapplytopatientpostabdominaltraumaorelectiveabdominalsurgeryorintolerancetogastricfeedinga.11randomisedtrials1.5Isapeptide-basedformulapreferabletoawholeproteinformula?Wholeproteinformulaeareappropriateinmostpatients（C）Exocrinepancreaticfunctionisreducedinsepsis，thedigestionandabsorptionofwholeproteinformulaeshouldbeconcerned.a.fourrandomisedtrials.1.6Whenshouldmotilityagentsbeusedincriticallyillpatients?Ifthepatientintolerance(suchashighgastricresiduals)toEN,metoclopramid（胃复安）orErythromycin（红霉素）shouldbeconsidered,e.g.withhighgastricresiduals(C).a.Booth（Meta-analysis）b.Yavagalc.threestudiespublishedRecentlyTheconclusion:studiesdonotsupporttheroutineuseofmotilityagentsincriticallyi