齐鲁医学欧洲ESPEN关于危重症患者的肠内营养指南

ESPENGuidelinesonEnteral

Nutrition:Intensivecare程俊峰普外科欧洲ESPEN关于危重症患者的肠内营养指南共20页，您现在浏览的是第1页!GeriatricsLiverdiseaseSurgeryincludingorgantransplantationWastinginHIVandotherchronicinfectiousdiseasesAdultrenalfailureGastroenterologyPancreasCardiologyandpulmonologyNon-surgicaloncologyIntensivecareESPEN

GuidelinesonEN:ESPEN

GuidelinesonPN:GeriatricsHepatologysurgeryCardiologyandpneumologyAdultrenalfailureGastroenterologyPancreashomeparenteralnutrition(HPN)inadultpatients欧洲ESPEN关于危重症患者的肠内营养指南共20页，您现在浏览的是第2页!SummaryEnteralnutrition(EN)的定义及目的：1、ENisthepreferredwayoffeedingthecriticallyillpatientandcounteractingforthecatabolicstateinducedbyseverediseases.2、Intendedtogiveevidence-basedremendationsfortheICUpatient,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.欧洲ESPEN关于危重症患者的肠内营养指南共20页，您现在浏览的是第3页!ViaENcannotbefedsufficiently,PNShouldsupplementCTypeofformulaWholeproteinformulaearesuperiortothepeptide-basedformulaeCImmune-modulatingformulae(formulaeenrichedwitharginine(精氨酸),nucleotides（核苷酸）andw-3fattyacids)aresuperiortostandardenteralformulae:InelectiveupperGIsurgicalpatients;inpatientswithamildsepsis(APACHE≤15);inpatientswithseveresepsis,maybeharmfulandarenotRemended;inpatientswithtrauma;inpatientswithARDS(formulaecontainingo-3fattyacidsandantioxidants).ABBABDuetoinsufficientdata,noremendationsupporttheImmune-modulatingformulaeapplytotheburnedpatients,butthetraceelements(Cu,SeandZn)shouldbesupplementedinahigherthanstandarddoseAthesevereillnessICUpatients,shouldnotreceiveanimmune-modulatingformulaenrichedwitharginine,nucleotidesandw-3fattyacidsiftheEN≤700ml/d.BGlutamineshouldbeaddedtostandardenteralformulainburnedpatientsandtraumapatientsA欧洲ESPEN关于危重症患者的肠内营养指南共20页，您现在浏览的是第4页!1.2EN-IsearlyENsuperiortodelayed

EN?

TherearenodatasupportusingearlyENcanimprovetheirprognosis，butthemitteestillremendtheearly(<24h）appropriateamountoffeeding(C).

a.metaanalysisandsystematicreview

Ametaanalysisof15RCTs(surgery,trauma,headinjury,burnsorsufferingfromacutemedicalconditions),showedearlyENcanreducetheinfectiousplicationsandlengthofstay.

systematicreviewof19studiescanshowearlyENplayapositiveeffectonthesurvivalrate、lengthoftreatment,therateofseptic.andotherplications，theconclusionprovide1levelevidenceforusingtheearlyEN.b.Individualstudies:(remendationlevelC)MooreandJonesGraham和coworkersChiarellietalEyeretalHasseetalSinghetal欧洲ESPEN关于危重症患者的肠内营养指南共20页，您现在浏览的是第5页!1.4whichroute?Jejunalversusgastricfeedingincriticallyillnesspatientisnodifference(C).Jejunalfeedingapplytopatientpostabdominaltraumaorelectiveabdominalsurgeryorintolerancetogastricfeedinga.11randomisedtrials欧洲ESPEN关于危重症患者的肠内营养指南共20页，您现在浏览的是第6页!1.6Whenshouldmotilityagentsbe

usedincriticallyillpatients?Ifthepatientintolerance(suchashighgastricresiduals)toEN,metoclopramid（胃复安）orErythromycin（红霉素）shouldbeconsidered,e.g.withhighgastricresiduals(C).Booth（Meta-analysis）YavagalthreestudiespublishedRecentlyTheconclusion:studiesdonotsupporttheroutineuseofmotilityagentsincriticallyillpatients(A).欧洲ESPEN关于危重症患者的肠内营养指南共20页，您现在浏览的是第7页!2.2Underwhatconditionsshould

PNbeaddedtoEN?OncepatienttolerateENandcanbefedapproximatelytothetargetvalues,PNshouldnotbeadded(A).Patientcannotbefedsufficiententerallythedeficit,SupplementalPNshouldbeadded(C).IfpatientintolerancetotheEN,PNshouldbeproposedataequallevel,avoidoverfeeding(C).A.meta-analysisB.blood-sugar欧洲ESPEN关于危重症患者的肠内营养指南共20页，您现在浏览的是第8页!3.1Isaimmune-modulatingformula

superiortoastandardenteral

formulainanygroupofcriticallyill

patients?Enteralimmune-modulatingnutritionimpliesaformulaenrichedwithseveral‘‘functional’’substrates；manyofthestudieshaveusedaparticularformula,enrichedwitharginine,nucleotidesandw-3fattyacids.A.electiveupperGIsurgicalpatients,yes(A)B.mildsepsispatients,yes(A);severesepsispatients,harmfulandnotremend(B)GalbanBowerBertoliniimmune-modulatingnutritionimprovesouteonlyinlessseveresepsis(APACHE＜15),whereasthiseffect，tendstobeofharminseveresepsisandseverelyillpatientsBaseonthepossibleassociationwithanincreasedmortalityinpatientswithseveresepsis,theseformulaeshouldnotbeusedinpatientswithseveresepsis欧洲ESPEN关于危重症患者的肠内营养指南共20页，您现在浏览的是第9页!E.ARDS:PatientswithARDSshouldreceiveENenrichedwithx-3fattyacidsandantioxidants(B).

Onlyoneprospective,randomizeddoubleblindcontrolledtrialhadbereported.

欧洲ESPEN关于危重症患者的肠内营养指南共20页，您现在浏览的是第10页!3.2ShouldENnutritionbe

supplementedwithglutamine？Glutamineshouldbeaddedtoastandardenteralformulainburnedpatients(A)andtraumapatients(A)nosufficientdatatosupportenteralglutaminesupplementationinsurgicalorheterogeneouscriticallyillpatients.

Onestudy欧洲ESPEN关于危重症患者的肠内营养指南共20页，您现在浏览的是第11页!SubjectRemendationsGradeindicationAllpatientswhoarenotexpectedtobeonafulloraldietwithin3daysCApplicationTherearenodatasupportusingearlyENcanimprovetheirPrognosis，butthemitteestillremendtheearly（<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.A欧洲ESPEN关于危重症患者的肠内营养指南共20页，您现在浏览的是第12页!1.1EN-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,soweetothetitleconclusion.欧洲ESPEN关于危重症患者的肠内营养指南共20页，您现在浏览的是第13页!NogeneralamountremendtobeadjustENtherapyaccordingtocourseofdisease.Butexogenousenergysupplyoftheacuteandinitialphase:≤25kcal/kg/dandrecovery：≥25kcal/kg/dmaybefavourable(C)ProspectiveobservationalcohortstudyIbrahimArecenttrial1.3EN-howmuch?欧洲ESPEN关于危重症患者的肠内营养指南共20页，您现在浏览的是第14页!1.5Isapeptide-basedformula

preferabletoawholeprotein

formula?Wholeproteinformulaeareappropriateinmostpatients（C）Exocrinepancreaticfunctionisreducedinsepsis，thedigestionandabsorptionofwholeproteinformulaeshouldbeconcerned.a.fourrandomisedtrials.欧洲ESPEN关于危重症患者的肠内营养指南共20页，您现在浏览的是第15页!2.1ENVSPNPatientswhocanbefedviatheenteralrouteshouldreceiveEN(C).a.metaanalysisandsystematicreviewb.IndividualstudiesKudskMooreConclusion：thereisnodefiniteadvantageofENoverPNexceptforcostreduction;buttheexpertopinionispatientswhocanbefedenterallyshouldreceiveit,overaggressiveENmaycauseharmandavoidoverfeeding.欧洲ESPEN关于危重症患者的肠内营养指南共20页，您现在浏览的是第16页!2.3Shouldvulnerablepatientsbe

treatedinadifferentway?vulnerablepatientsi.e.undernourished,chroniccatabolicdisease.Patientswithasevereunder-nutritionshouldreceiveENup25–30totalkcal/kgBW/day.Ifthesetargetvaluesarenotreached,supplementaryPNshouldbegiven(C).A.ReviewWhetherthesevereunder-nutritionpatientorthechroniccatabolicdisease，targetvaluesshouldbemetfullyusingsupplementaryPNifnecessary（C）欧洲ESPEN关于危重症患者的肠内营养指南共20页，您现在浏览的是第17页!C.Trauma:Yes(A)D.Burns:Duetotheinsufficientdata,noremendatio