2016重症营养6.doc

SCCM/ASPEN成年危重病患者营养支持治疗实施与评估指南(6/6)2016年03月02日指南导读,进展交流暂无评论Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (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)Taylor BE, McClave SA, Martindale RG, et al. Crit Care Med 2016; 44: 390-438翻译：清华大学长庚医院 周华 许媛P. CHRONICALLY CRITICALLY ILL慢性危重病患者Question:How should the chronically critically ill patient be managed with nutrition therapy?问题：如何管理慢性危重病患者的营养治疗？P1. Based on expert consensus, we suggest that chronically critically ill patients (defined as those with persistent organ dysfunction requiring ICU LOS 21 days) be managed with aggressive high-protein EN therapy and, when feasible, that a resistance exercise program be used.根据专家共识，我们建议慢性危重病患者（定义为那些因持续存在器官功能不全需要住ICU 21天的患者）给予积极高蛋白质EN治疗，且如有可能，应制订抗阻力功能锻炼计划。O. OBESITY IN CRITICAL ILLNESS肥胖患者的危重病Question:Do obese ICU patients benefit less from early EN in the first week of hospitalization, due to their nutrition reserves, than their lean counterparts?问题：肥胖的ICU患者因具有营养储备，是否比消瘦患者从住院第一周的早期EN中获益更少？Q1. Based on expert consensus, we suggest that early EN start within 2448 hours of admission to the ICU for obese patients who cannot sustain volitional intake.根据专家共识，肥胖患者不能经口摄食时，我们建议在收入ICU 24-48小时内即开始早期EN。Question:What additional parameters should be addressed with a nutrition assessment in critical illness when the patient is obese?问题：对肥胖的危重病患者进行营养评估时，需要额外考虑哪些指标？Q2. Based on expert consensus, we suggest that nutrition assessment of the obese ICU patient focus on biomarkers of metabolic syndrome, an evaluation of comorbidities, and a determination of level of inflammation, in addition to those parameters described for all ICU patients.根据专家共识，建议对ICU肥胖患者进行营养评估时，除所有ICU患者的常规指标外，我们建议重视代谢综合征的生物标志物，评价合并症，并确定炎症反应状态。Question:What factors on assessment identify obese patients in the ICU to be at high risk?问题：哪些评价指标用于确定ICU肥胖症患者存在高营养风险？Q3. Based on expert consensus, we suggest that nutrition assessment of the obese ICU patient focus on evidence of central adiposity, metabolic syndrome, sarcopenia, BMI 40, SIRS, or other comorbidities that correlate with higher obesity-related risk for cardiovascular disease and mortality.根据专家共识，我们建议ICU肥胖患者的营养评估应注重中心型肥胖、代谢综合征，少肌症的表现，以及BMI 40, SIRS, 或与肥胖相关的心血管疾病与死亡高风险的其他合并症。Question:In adult obese ICU patients, does use of high-protein, hypocaloric feeding improve clinical outcomes compared with use of high-protein, eucaloric feeding?问题：对于成年ICU肥胖患者，与高蛋白-等热卡喂养相比，高蛋白-低热卡喂养能否改善临床结局？Q4. Based on expert consensus, we suggest that high-protein hypocaloric feeding be implemented in the care of obese ICU patients to preserve lean body mass, mobilize adipose stores, and minimize the metabolic complications of overfeeding.根据专家共识，我们建议对ICU肥胖患者给予高蛋白-低热卡喂养，以保存瘦体组织，动员储备的脂肪，最大限度降低过度喂养导致的代谢并发症。Question:In adult obese ICU patients, what are the appropriate targets for energy and protein intake to achieve nitrogen equilibrium and meet metabolic requirements?问题：对于成年的ICU肥胖患者，满足氮平衡与代谢需要的恰当能量与蛋白质供给目标是多少？Q5. Based on expert consensus, we suggest that, for all classes of obesity, the goal of the EN regimen should not exceed 6570% of target energy requirements as measured by IC. If IC is unavailable, we suggest using the weight-based equation 1114 kcal/kgactual body weight/day for patients with BMI in the range 3050 and 2225 kcal/kgideal body weight/day for patients with BMI 50. We suggest that protein should be provided in a range from 2.0 g/kg ideal body weight/ day for patients with BMI 3040 up to 2.5 g/kg ideal body weight/day for patients with BMI 40.根据专家共识，对于不同程度的肥胖患者，我们建议EN处方能量供给目标不应超过间接能量消耗测定（IC）的65%-70%。不能进行IC测定时，我们建议使用基于体重的营养估算公式：BMI 30-50者，11-14 kcal/kg实际体重/天；BMI 50折，22-25 kcal/kg理想体重/天。我们建议蛋白质供给量：BMI 30-40者，2.0g/kg理想体重/天；BMI 40者，2.5 g/kg理想体重/天。Question:What indications, if any, exist for use of specialty enteral formulations for adult obese ICU patients?问题：成年ICU肥胖患者应用特殊肠内营养配方制剂指征是什么？Q6. Based on expert consensus, we suggest that, if available, an enteral formula with low caloric density and a reduced NPC: N be used in the adult obese ICU patient. While an exaggerated immune response in obese patients implicates potential benefit from immune-modulating formulas, lack of outcome data precludes a recommendation at this time.根据专家共识，我们建议，如有可能，成年ICU肥胖患者应选用低能量密度、低非蛋白质热氮比（NPC:N）配方的肠内营养制剂。虽然免疫调节型配方可能有益于调控肥胖患者过强的免疫反应，但目前尚缺乏预后数据，因此无法作出推荐。Question:What are appropriate monitors to follow for the obese critically ill patient receiving early EN?问题：对于肥胖的危重症患者，早期EN时应进行哪些监测？Q7. Based on expert consensus, we suggest additional monitoring to assess worsening of hyperglycemia, hyperlipidemia, hypercapnia, fluid overload, and hepatic fat accumulation in the obese critically ill patient receiving EN.根据专家共识，肥胖的危重病患者接受早期EN时，我们建议加强监测，评估高血糖、高脂血症、高碳酸血症、液体负荷过多易记肝脏脂肪堆积等是否恶化。Question:Does the obese ICU patient with a history of bariatric surgery or other malabsorptive condition require any additional supplementation of micronutrients when starting nutrition therapy?问题：曾接受减肥手术或伴有其他吸收不良的ICU肥胖患者开始营养治疗时，是否需额外补充微营养素？Q8. Based on expert consensus, we suggest that the obese ICU patient with a history of bariatric surgery receive supplemental thiamine prior to initiating dextrose-containing IV fluids or nutrition therapy. In addition, evaluation for and treatment of micronutrient deficiencies such as calcium, thiamin, vitamin B12, fat-soluble vitamins (A, D, E, K), and folate, along with the trace minerals iron, selenium, zinc, and copper should be considered.根据专家共识，对于曾接受减肥手术治疗的ICU肥胖患者，开始静脉输注含葡萄糖液体或营养治疗前，我们建议应补充维生素B1（硫胺素）。此外，应考虑评价与治疗微营养素缺乏（包括钙、维生素B1、维生素B12、脂溶性维生素（A, D, E, K）与叶酸，以及微量元素铁、硒、锌、铜）。R. NUTRITION THERAPY END-OF-LIFE SITUATIONS 临终情