【持续性肾脏替代治疗crrt英文精品课件】jpen guideline for critical care nutrition support

JPENGUIDELINEFORCRITICALCARENUTRITIONSUPPORT Presenter Dr 歐軒甫Supervisor Dr 陳奇祥 本檔僅供內部教學使用檔案內所使用之照片之版權仍屬於原期刊公開使用時 須獲得原期刊之同意授權 A InitiateEnteralFeedingB WhentoUseParenteralNutritionC DosingofEnteralFeeding D MonitoringToleranceandAdequacyofEnteralNutritionE SelectionofAppropriateEnteralFormulationF AdjunctiveTherapy G WhenIndicated MaximizeEfficacyofParenteralNutritionH PulmonaryFailureI RenalFailureJ HepaticFailureK AcutePancreatitisL NutritionTherapyinEnd of LifeSituations I II III AcriticallyillICUpatientmaybeanappropriatecandidateforPNundercertaincircumstances 1 wellnourishedpriortoadmission butafter7daysofhospitalization ENhasnotbeenfeasibleortargetgoalcalorieshavenotbeenmetconsistentlybyENalone 2 Onadmission thepatientismalnourishedandENisnotfeasible 3 Amajorsurgicalprocedureisplanned thepreoperativeassessmentindicatesthatENisnotfeasiblethroughtheperioperativeperiod andthepatientismalnourished G WHENINDICATED MAXIMIZEEFFICACYOFPARENTERALNUTRITION IfENisnotavailableorfeasible theneedforPNtherapyshouldbeevaluated Grade C IfthepatientisdeemedtobeacandidateforPN stepstomaximizeefficacy regardingdose content monitoring andchoiceofsupplementaladditives shouldbeused Grade C Hyperglycemia Immunsupression OxidativeStress Infect Morbidity InallICUpatientsreceivingPN mildpermissiveunderfeedingshouldbeconsideredatleastinitially Onceenergyrequirementsaredetermined 80 oftheserequirementsshouldserveastheultimategoalordoseofparenteralfeeding Grade C Eventually asthpatientstabilizes PNmaybeincreasedtomeetenergrequirements Grade E Forobesepatients BMI 30 thedoseofPNwithregardtoproteinandcaloricprovisionshouldfollowthesamerecommendationsgivenforENinguidelineC5 Grade D C5 BMI 30thegoaloftheEN 60 70 oftargetenergyrequirementsor11 14kcal kg day or22 25kcal kgidealbodyweightperday Proteinshouldbeprovidedinarange 2 0g kgidealbodyweightperdayforClassIandIIpatients BMI30 40 2 5g kgidealbodyweightperdayforClassIII BMI 40 PERMISSIVEUNDERFEEDING Thisstrategy thepotentialfor insulinresistance infectiousmorbidity durationofmechanicalventilation hospitallengthofstayIn2studies lowerdosehypocaloricv s highereucaloricdosesPN reducetheincidenceofhyperglycemiaandinfections ICUandhospitallengthofstay anddurationofmechanicalventilation Soy based18 carbon 6fattyacidpreparation inNorthAmericaSoy basedlipid free vs lipid containing PN infectiousmorbidity pneumoniaandcatheter relatedsepsis hospitalandICUlengthofstay durationofmechanicalventilation InthefirstweekofhospitalizationintheICU whenPNisrequiredandENisnotfeasible patientsshouldbegivenaparenteralformulationwithoutsoybasedlipids Grade D JobanN GarrelDR ChampouxJ BernierJ Improvedimmunefunctionswithadministrationofalow fatdietinaburnanimalmodel CellImmunol 2000 206 71 84 Long chainfattyacids immunosuppressive BattistellaFD WidergrenJT AndersonJT etal Aprospective randomizedtrialofintravenousfatemulsionadministrationintraumavictimsrequiringtotalparenteralnutrition JTrauma 1997 43 52 58 Strictglucosecontrol BS 80 110mg dL v s conventionalinsulintherapy BS 200mg dL sepsis ICUlengthofstay and hospitalmortality Aprotocolshouldbeinplacetopromotemoderatelystrictcontrolofserumglucosewhenprovidingnutritionsupporttherapy Grade B Arangeof110 150mg dLmaybemostappropriate Grade E VandenBergheG WoutersP WeekersF etal Intensiveinsulintherapyinthecriticallyillpatients NEnglJMed 2001 345 1359 1367 SICU MICU Moderatecontrol BS140 180mg dL mightavoidproblemsofhypoglycemiaandsubsequentlyreducethemortalityassociatedwithhypoglycemiacomparedtotightercontrol DevosP PreiserJC Currentcontroversiesaroundtightglucosecontrolincriticallyillpatients CurrOpinClinNutrMetabCare 2007 10 206 209 Theadditionofparenteralglutamine atadoseof0 5g kg d toaPNregimenhasbeenshownto infectiouscomplications ICUlengthofstay andmortalityincriticallyillpatients comparedtothesamePNregimenwithoutglutamine WhenPNisusedinthecriticalcaresetting considerationshouldbegiventosupplementationwithparenteralglutamine Grade C Xian LiH Qing JuiM Kian GuoL Yan KuiC Xi LinD Effectoftotalparenteralnutrition TPN withandwithoutglutaminedipeptidesupplementationonoutcomeinsevereacutepancreatitis SAP ClinNutrSuppl 2004 1 43 47 Fuentes OrozcoC Anaya PradoR Gonzalez OjedaA etal L alanyl L glutamine supplementedparenteralnutritionimprovesinfectiousmorbidityinsecondaryperitonitis ClinNutr 2004 23 13 21 ZeiglerTR Fernandez EstivarizC GriffthP etal Parenteralnutritionsupplementedwithalanyl glutaminedipeptidedecreasesinfectiousmorbidityandimprovesorganfunctionincriticallyillpost operativepatients resultsofadouble blind randomized controlledpilotstudy NutritionWeekAbstracts 2004 023 52 GoetersC WennA MertesN etal ParenteralL alanyl Lglutamineimproves6 monthoutcomeincriticallyillpatients CritCareMed 2002 30 2032 2037 GLUTAMINE Theproposedmechanismofthisbenefitrelatestogenerationofasystemicantioxidanteffect maintenanceofgutintegrity inductionofheatshockproteins anduseasafuelsourceforrapidlyreplicatingcells Europedipeptide NorthAmericaL glutamine InpatientsstabilizedonPN periodicallyrepeatedeffortsshouldbemadetoinitiateEN AstoleranceimprovesandthevolumeofENcaloriesdeliveredincreases theamountofPNcaloriessuppliedshouldbereduced PNshouldnotbeterminateduntil 60 oftargetenergyrequirementsarebeingdeliveredbytheenteralroute Grade E H PULMONARYFAILURE Thereisalackofconsensusabouttheoptimumsourceandcompositionoflipids medium vslongchaintriglyceride soybeanoil oliveoil 3fattyacids 10 or20 solution inenteralandparenteralformulationsforthepatientwithrespiratoryfailure Specialtyhigh lipidlow carbohydrateformulationsdesignedtomanipulatetherespiratoryquotientandreduceCO2productionarenotrecommendedforroutineuseinICUpatientswithacuterespiratoryfailure Grade E E2 PatientswithARDSandsevereacutelunginjury ALI shouldbeplacedonanenteralformulationcharacterizedbyananti inflammatorylipidprofile ie 3fishoils borageoil andantioxidants Grade A Rapidinfusionoffatemulsions especiallysoybean based regardlessofthetotalamount shouldbeavoidedinpatientssufferingfromseverepulmonaryfailure Fluidaccumulationandpulmonaryedemaarecommoninpatientswithacuterespiratoryfailureandhavebeenassociatedwithpoorclinicaloutcomes Itisthereforesuggestedthatafluid restrictedcaloricallydensenutrientformulation 1 5 2 0kcal mL beconsideredforpatientswithacuterespiratoryfailurethatnecessitatesvolumerestriction Fluid restrictedcaloricallydenseformulationsshouldbeconsideredforpatientswithacuterespiratoryfailure Grade E Ex 1500Kcal 1000ml Phosphateisessentialforthesynthesisofadenosinetriphosphate ATP and2 3 disphosphoglycerate 2 3 DPG bothofwhicharecriticalfornormaldiaphragmaticcontractilityandoptimalpulmonaryfunction Lengthofstayanddurationofmechanicalventilationareincreasedinpatientswhobecomehypophosphatemicwhencomparedtothosewhodonothavethiselectrolyteimbalance Serumphosphatelevelsshouldbemonitoredcloselyandreplacedappropriatelywhenneeded Grade E I RENALFAILURE ARFseldomexistsasanisolatedorganfailureincriticallyillpatients WhenprescribingENtotheICUpatient theunderlyingdiseaseprocess preexistingcomorbidities andcurrentcomplicationsshouldbetakenintoaccount Specialtyformulationslowerincertainelectrolytes ie phosphateandpotassium thanstandardproductsmaybebeneficialintheICUpatientwithARF ICUpatientswithacuterenalfailure ARF oracutekidneyinjury AKI shouldbeplacedonstandardenteralformulations andstandardICUrecommendationsforproteinandcalorieprovisionshouldbefollowed Ifsignificantelectrolyteabnormalitiesexistordevelop aspecialtyformulationdesignedforrenalfailure withappropriateelectrolyteprofile maybeconsidered Grade E Thereisanapproximateaminoacidlossof10 15g dduringCRRT Providing 1g kg dofproteinmayresultinincreasednitrogendeficitsforpatientsonhemodialysisorCRRT PatientsundergoingCRRTshouldreceiveformulationswith1 5 2 0g kg dofprotein Atleast1randomizedprospectivetrialhassuggestedanintakeof2 5g kg disnecessarytoachievepositivenitrogenbalanceinthispatientpopulation Patientsreceivinghemodialysisorcontinuousrenalreplacementtherapy CRRT shouldreceiveincreasedprotein uptoamaximumof2 5g kg d Proteinshouldnotberestrictedinpatientswithrenalinsufficiencyasameanstoavoidordelayinitiationofdialysistherapy Grade C J HEPATICFAILURE Whilemalnutritionishighlyprevalentamongpatientswithchronicliverdiseaseandnearlyuniversalamongpatientsawaitinglivertransplantation Theprimaryetiologyofmalnutritionispoororalintakestemmingfrommultiplefactors Malnutritioninpatientswithcirrhosisleadstoincreasedmorbidityandmortalityrates Furthermore patientswhoareseverelymalnourishedbeforetransplantsurgeryhaveahigherrateofcomplicationsandadecreasedoverallsurvivalrateafterlivertransplantation Traditionalassessmenttoolsshouldbeusedwithcautioninpatientswithcirrhosisandhepaticfailure asthesetoolsarelessaccurateandlessreliableduetocomplicationsofascites intravascularvolumedepletion edema portalhypertension andhypoalbuminemia Grade E EN decreasedinfectionratesandfewermetaboliccomplicationsinliverdiseaseandafterlivertransplantwhencomparedtoPN Long termPN hepaticcomplications includingworseningofexistingcirrhosisandliverfailurewiththeconcomitantrisksofsepsis coagulopathy anddeath Nutrition associatedcholestasisusuallypresentwithprolongedPNisalsoasignificantproblem ENimprovesnutritionstatus reducescomplications andprolongssurvivalinliverdiseasepatientsandisthereforerecommendedastheoptimalrouteofnutrientdelivery ENisthepreferredrouteofnutritiontherapyinICUpatientswithacuteand orchronicliverdisease Nutritionregimensshouldavoidrestrictingproteininpatientswithliverfailure Grade E Proteinshouldnotberestrictedasamanagementstrategytoreduceriskofdevelopinghepaticencephalopathy FindingsfromlevelIIrandomizedoutpatienttrialssuggestthatlongterm 12and24months nutritionalsupplementationwithoralBCAAgranulesmaybeusefulinslowingtheprogressionofhepaticdiseaseand orfailureandprolongingevent freesurvival Inpatientswithhepaticencephalopathyrefractorytousualtherapy useofBCAAformulationsmayimprovecomagradecomparedtostandardformulations StandardenteralformulationsshouldbeusedinICUpatientswithacuteandchronicliverdisease Branchedchainaminoacidformulations BCAA shouldbereservedfortherareencephalopathicpatientwhoisrefractorytostandardtreatmentwithluminalactingantibioticsandlactulose Grade C K ACUTEPANCREATITIS Organfailureisdefinedbyshock systolicbloodpressure2mg dL orGIbleeding 500mLbloodlosswithin24hours Onadmission patientswithacutepancreatitisshouldbeevaluatedfordiseaseseverity Grade E PatientswithsevereacutepancreatitisshouldhaveanasoenterictubeplacedandENinitiatedassoonasfluidvolumeresuscitationiscomplete Grade C LocalcomplicationsonCTscanincludepseudocyst abscess ornecrosis Unfavorableprognosticsigns APACHEIIscore 8orRansonCriteria 3 ACUTEPANCREATITIS Patientswithsevereacutepancreatitishaveanincreasedrateofcomplications 38 andahighermortality 19 thanpatientswithmildtomoderatediseaseandhavecloseto0 chanceofadvancingtooraldietwithin7days Lossofgutintegritywithincreasedintestinalpermeabilityisworsewithgreaterdiseaseseverity PatientswithsevereacutepancreatitiswillexperienceimprovedoutcomewhenprovidedearlyEN OutofthreelevelIIrandomizedstudieswhichincludedpatientswithlessdiseaseseverity 62 81 ofpatientshadmildtomoderateacutepancreatitis noneshowedsignificantoutcomebenefitswithuseofENcomparedtoPN Provisionofnutritionsupporttherapyinthesepatientsshouldbeconsideredifasubsequentunanticipatedcomplicationdevelops eg sepsis shock organfailure orthepatientfailstoadvancetooraldietafter7daysofhospitalization Patientswithmildtomoderateacutepancreatitisdonotrequirenutritionsupporttherapy unlessanunexpectedcomplicationdevelopsorthereisfailuretoadvancetooraldietwithin7days Grade C TwolevelIIprospectiverandomizedtrialscomparinggastricwithjejunalfeedinginpatientswithsevereacutepancreatitisshowednosignificantdifferencesbetweenthe2levelsofENinfusionwithintheGItract Patientswithsevereacutepancreatitismaybefedenterallybythegastricorjejunalroute Grade C EatockFC ChongP MenezesN etal Arandomizedstudyofearlynasogastricversusnasojejunalfeedinginsevereacutepancreatitis AmJGastroenterol 2005 100 432 439 KumarA SinghN PrakashS SarayaA JoshiYK Earlyenteralnutritioninsevereacutepancreatitis aprospectiverandomizedcontrol