1、重症营养常规与2016SCCM/ASPEN营养指南解读,重症医学科 苏龙翔,营养支持目的,供给细胞代谢所需要的能量与营养底物，维持组织器官结构与功能通过营养素的药理作用调理代谢紊乱，调节免疫功能，增强机体抗病能力，从而影响疾病的发展与转归，这是实现重症病人营养支持的总目标合理的营养支持，可减少净蛋白的分解及增加合成，改善潜在和已发生的营养不良状态，防治其并发症。营养不良对预后的影响：增加感染等并发症的发生率、延长住ICU与住院时间（LOS）、增加死亡率、增加医疗花费（Costs）,评估,015,采用ASPEN评分法（NRS-2002）,营养支持的原则,015,重症病人的营养支持应尽早开始重症病
2、人的营养支持应充分到考虑受损器官的耐受能力只要胃肠道解剖与功能允许，并能安全使用，应积极采用肠内营养支持任何原因导致胃肠道不能使用或应用不足，应考虑肠外营养，或联合应用肠内营养,营养支持途径,015,肠外营养支持（PN）肠内营养营养支持（EN）随着临床营养支持的发展，营养支持方式已由PN为主要的营养供给方式，转变为通过鼻胃/鼻空肠导管或胃/肠造口途径为主的肠内营养支持（EN） PN与感染性并发症的增加有关，而接受EN病人感染的风险比要接受PN者为低 早期EN，使感染性并发症的发生率降低，住院时间缩短,危重病人能量补充原则,急性应激期营养支持应掌握“允许性低热卡”原则（20 - 25 kcal/
3、kgday）；在应激与代谢状态稳定后，能量供给量需要适当的增加（30-35 kcal/kgday）,“允许性低热卡”其目的在于：避免营养支持相关的并发症，如高血糖、高碳酸血症、淤胆与脂肪沉积等 。,肠内营养支持（EN）,胃肠道功能存在（或部分存在），但不能经口正常摄食的重症病人，应优先考虑给予肠内营养只有肠内营养不可实施时才考虑肠外营养 对不耐受经胃营养或有返流和误吸高风险的重症病人，宜选择经空肠营养重症病人在接受肠内营养（特别经胃）时应采取半卧位，理想情况为30-45度无论是否存在肠鸣音以及有无排气/排便证据，无禁忌情况下均应启动肠内营养通常早期肠内营养是指：“进入ICU 24-48小时内”
4、，并且血液动力学稳定、无肠内营养禁忌症的情况下开始肠道喂养,肠内营养的禁忌症,当出现肠梗阻、肠道缺血时，肠内营养往往造成肠管过度扩张，肠道血运恶化，甚至肠坏死、肠穿孔严重腹胀或腹腔间室综合症时，肠内营养增加腹腔内压力，高腹压将增加返流及吸入性肺炎的发生率，并使呼吸循环等功能进一步恶化对于严重腹胀、腹泻，经一般处理无改善的病人，建议暂时停用肠内营养,肠内营养途径选择与营养管放置,鼻胃管（最常用）鼻空肠（最合适）经皮内镜下胃造口（percutaneous endoscopic gastrostomy, PEG）经皮内镜下空肠造口术（percutaneous endoscopic jejunosto
5、my, PEJ）其他,肠内营养的制剂选择,华瑞系列,流程,病人能经口进食吗?,胃肠是否有功能？,肠外营养,无,是,否,否,是,有,否,经口进食(能摄入80以上的营养),消化吸收功能？,预消化配方,肠道功能问题？（腹泻便秘）,膳食纤维配方,是,高血糖？,低糖配方,高血脂？,低脂配方,需要限制水的摄入？,高热卡配方,标准配方,是,是,是,否,否,常见并发症及处理,在EN 支持早期应密切注意胃肠功能状态, 出现腹胀、腹泻、呕吐等不耐受症状即应减量或停止, 防止误吸等并发症。持续滴注营养液, 从等渗型营养液、30m l/h 开始, 逐渐增加量与浓度。并发症：胃潴留：1）每6h抽空一次，如潴留量200则
6、维持原速度，如100，可增加输注速度，如200ml则应降低速度或停止；2）应用胃肠动力药物，必要时可加用辅助治疗；3）保持肠道通畅，定期灌肠，保证定期排便加快肠内容物排出，保证每日大便通畅；腹胀、腹痛、腹泻：发现病因、去除诱因，减量、暂停，注意乳糖不耐受；误吸：极为严重，重在预防！其他：管路堵塞,肠外营养支持（PN）,指征：胃肠道功能障碍的重症病人由于手术或解剖问题胃肠道禁止使用的重症病人存在有尚未控制的腹部情况，如腹腔感染、肠梗阻、肠瘘等 相对禁忌：早期复苏阶段、血流动力学尚未稳定或存在严重水电介质与酸碱失衡严重肝功能衰竭，肝性脑病急性肾功能衰竭存在严重氮质血症严重高血糖尚未控制,肠外营养途
7、径,经中心静脉实施肠外营养首选锁骨下静脉置管途径（或PICC）；营养液容量、浓度不高，接受部分肠外营养支持的病人，可采取经外周静脉途径； 荟萃分析表明，与多腔导管相比，单腔导管施行肠外营养，中心静脉导管相关性感染 （CRBI）和导管细菌定植的发生率明显降低；,肠外营养支持（PN）的时机,如果入ICU最初7天内肠内营养不可行或未能进行，应给与非营养支持治疗。对于既往体健、无蛋白质-热量营养不良的重症患者，可在患者入院7天后采用肠外营养。若有证据证实入院时即存在蛋白质-热卡缺乏型营养不良且不能实施肠内营养，宜在充分复苏后开始肠外营养当患者备上消手术，无法肠内营养时营养不良：术前5-7天开始肠外营养
8、，并持续至术后无营养不良：推迟至术后5-7天开始肠外营养仅对估计疗程7天患者采用,肠外营养补充该给多少？,评估营养需要：间接能量测定仪HB公式（通常偏高10%）：A=年龄（y），H=身高（cm），W=体重（kg） BEE(男)kcal/d=66.47+13.75W+5.0H-6.76A BEE(女)kcal/d=65.10+9.56W+1.85H-4.68A根据体重：BMI30kg/m2使用调整体重调整体重=IBW+0.25(ABW-IBW)或1.1IBW理想体重（IBW） 男性=50kg+2.3kg（身高cm152）/2.54 女性=45.5kg+2.3kg（身高cm152）/2.54校正体
9、重（Adjusted body weight, ABW) =IBW+0.4 (实际体重IBW) (kg)；如IBW高于/低于实际体重30%应计算校正体重使第一周内肠内营养能达到目标能量的50-65%；如果7-10天后单纯EN不能满足100%能量需求，考虑启动PN；过早地启动PN可能对患者不利,肠外补充的主要营养素,碳水化合物脂肪乳剂 氨基酸/蛋白质 水、电解质的补充 微营养素的补充（维生素与微量元素）,原则,葡萄糖（ 3.4kcal/g ）是肠外营养中主要的碳水化合物来源，一般占非蛋白质热卡的5060，应根据糖代谢状态进行调整；（肠内营养4kcal/g）；脂肪（ 9kcal/g ）补充量一般为
10、非蛋白质热卡的4050；摄入量可达11.5g/kg.d，应根据血脂廓清能力进行调整，脂肪乳剂应匀速缓慢输注； 异丙酚：1kal/ml；蛋白质（ 4kcal/g ）供给量一般为1.2-1.5g/kgday，约相当于氮0.20-0.25g/kgday；热氮比100-150kcal：1gN；降低非蛋白质热量中的葡萄糖补充，葡萄糖：脂肪保持在60:4050:50；维生素与微量元素应作为重症病人营养支持的组成成分。创伤、感染及ARDS病人，应适当增加抗氧化维生素及硒的补充量。,肠外营养相关并发症,代谢性并发症技术性并发症感染性并发症,TPN配制,确定目标能量计算非蛋白热卡供给量：糖+脂肪确定蛋白质供给添
11、加维生素等微量元素注意调整液体量和渗透压,Tips：Dextrose 5g=1mOsmAA 10g=1mOsm20% fat emulsion 1.3-1.5g=1mOsmElectrolytes 1 mEq(毫克/当量) =1mOsm,营养支持监测,A 营养评估,Question: Does the use of a nutrition risk indicator identify patients who will most likely benefit from nutrition therapy?问题：营养风险筛查工具能否鉴别哪些患者最可能从营养治疗中获益？A1. Based on
12、expert consensus, we suggest a determination of nutrition risk (for example, nutritional risk score NRS-2002, NUTRIC score) be performed on all patients admitted to the ICU for whom volitional intake is anticipated to be insufficient. High nutrition risk identifies those patients most likely to bene
13、fit from early EN therapy.根据专家共识，我们建议对收入ICU且预计摄食不足的患者进行营养风险评估（如营养风险评分NRS-2002，NUTRIC 评分）。高营养风险患者的识别，最可能使其从早期肠内营养治疗中获益。A2. Based on expert consensus, we suggest that nutritional assessment include an evaluation of comorbid conditions, function of the gastrointestinal (GI) tract, and risk of aspiratio
14、n. We suggest not using traditional nutrition indicators or surrogate markers, as they are not validated in critical care.根据专家共识，我们建议营养评估应当包括对于合并症、胃肠道功能以及误吸风险的评估。我们建议不要使用传统的营养指标或其替代指标，因为这些指标在ICU的应用并非得到验证。,NRS-2002,Risk3；High risk5,NUTRIC评分,Without IL-65；IL-66,A 营养评估,Question: What is the best method
15、 for determining energy needs in the critically ill adult patient?问题：确定成年危重病患者能量需求的最佳方法是什么？A3a. We suggest that indirect calorimetry (IC) be used to determine energy requirements, when available and in the absence of variables that affect the accuracy of measurement.Quality of Evidence: Very Low。如果有
16、条件且不影响测量准确性的因素时，建议应用间接能量测定(间接测热法，indirect calorimetry，IC) 确定能量需求。证据质量：非常低A3b. Based on expert consensus, in the absence of IC, we suggest that a published predictive equation or a simplistic weight-based equation (2530 kcal/kg/ day) be used to determine energy requirements. (see section Q for obesit
17、y recommendations.)根据专家共识，当没有IC时，我们建议使用已发表的预测公式或基于体重的简化公式(2530 kcal/kg/ day)确定能量需求。（见Q部分有关肥胖患者的推荐意见。）,A 营养评估,Question: Should protein provision be monitored independently from energy provision in critically ill adult patients?问题：对于成年危重病患者，除能量提供外，是否需要单独监测提供的蛋白质量？A4. Based on expert consensus, we sugg
18、est an ongoing evaluation of adequacy of protein provision be performed.根据专家共识，我们建议连续评估蛋白质供给的充分性。The decision to add protein modules should be based on an ongoing assessment of adequacy of protein intake. Weight-based equations (e.g., 1.22.0 g/kg/day) may be used to monitor adequacy of protein provi
19、sion by comparing the amount of protein delivered to that prescribed, especially when nitrogen balance studies are not available to assess needs (see section C4).,B 开始肠内营养,Question: What is the benefit of early EN in critically ill adult patients compared to withholding or delaying this therapy?问题：对
20、于成年危重病患者而言，与不给予或延迟给予EN相比，早期EN有何益处？B1. We recommend that nutrition support therapy in the form of early EN be initiated within 2448 hours in the critically ill patient who is unable to maintain volitional intake.Quality of Evidence: Very Low对于不能维持自主进食的危重病患者，我们推荐在24 48小时内通过早期EN开始营养支持治疗。证据质量：非常低,B 开始肠内
21、营养,Question: Is there a difference in outcome between the use of EN or PN for adult critically ill patients?问题：成年危重病患者使用EN或PN对预后的影响有何不同？B2. We suggest the use of EN over PN in critically ill patients who require nutrition support therapy.Quality of Evidence: Low to Very Low对于需要营养支持治疗的危重病患者，我们建议首选EN而
22、非PN的营养供给方式。证据质量：低至非常低,B 开始肠内营养,Question: Is the clinical evidence of contractility (bowel sounds, flatus) required prior to initiating EN in critically ill adult patients?问题：在成年危重病患者开始EN前是否需要有肠道蠕动的证据（肠鸣音，排气）？B3. Based on expert consensus, we suggest that, in the majority of MICU and SICU patient pop
23、ulations, while GI contractility factors should be evaluated when initiating EN, overt signs of contractility should not be required prior to initiation of EN.基于专家共识，我们建议，对于多数MICU和SICU患者，尽管启用EN时需要对胃肠道蠕动情况进行评估，但此前并不需要有肠道蠕动的体征。,B 开始肠内营养,Question: What is the preferred level of infusion of EN within th
24、e GI tract for critically ill patients? How does the level of infusion of EN affect patient outcomes?问题：危重病患者胃肠道输注EN的最佳速度是多少？EN输注速度如何影响患者预后？B4a. We recommend that the level of infusion be diverted lower in the GI tract in those critically ill patients at high risk for aspiration (see section D4) or
25、those who have shown intolerance to gastric EN.Quality of Evidence: Moderate to High对于具有误吸高危因素（见D4部分）或不能耐受经胃喂养的重症患者，我们推荐减慢EN输注的速度。证据质量：中至高B4b. Based on expert consensus we suggest that, in most critically ill patients, it is acceptable to initiate EN in the stomach.基于专家的共识，我们建议经胃开始喂养是多数危重病患者可接受的EN方式
26、。,B 开始肠内营养,Question: Is EN safe during periods of hemodynamic instability in adult critically ill patients?问题：对于成年危重病患者，血流动力学不稳定时EN是否安全？B5. Based on expert consensus, we suggest that in the setting of hemodynamic compromise or instability, EN should be withheld until the patient is fully resuscitate
27、d and/or stable. Initiation/reinitiation of EN may be considered with caution in patients undergoing withdrawal of vasopressor support.根据专家共识，我们建议在血流动力学不稳定时，应当暂停EN直至患者接受了充分的复苏治疗和（或）病情稳定。对于正在撤除升压药物的患者，可以考虑谨慎开始或重新开始EN。,C 肠内营养剂量,Question: What population of patients in the ICU setting does not require
28、nutrition support therapy over the first week of hospitalization?问题：哪些患者住ICU的第一周内无需营养支持治疗？C1. Based on expert consensus, we suggest that patients who are at low nutrition risk with normal baseline nutrition status and low disease severity (for example, NRS-2002 3 or NUTRIC score 5) who cannot mainta
29、in volitional intake do NOT require specialized nutrition therapy over the first week of hospitalization in the ICU.根据专家共识，我们建议那些营养风险较低及基础营养状况正常、疾病较轻（例如NRS-2002 3 或 NUTRIC评分 5）的患者，即使不能自主进食，住ICU的第一周内不需要特别给予营养治疗。,C 肠内营养剂量,Question: For which population of patients in the ICU setting is it appropriate
30、to provide trophic EN over the first week of hospitalization?问题：哪些ICU患者在住院第一周内适合滋养型喂养 (trophic EN)？We recommend that either trophic or full nutrition by EN is appropriate for patients with acute respiratory distress syndrome (ARDS)/acute lung injury (ALI) and those expected to have a duration of mec
31、hanical ventilation 72 hours, as these two strategies of feeding have similar patient outcomes over the first week of hospitalization.Quality of Evidence: High对于急性呼吸窘迫综合征(ARDS)/急性肺损伤(ALI)患者以及预期机械通气时间 72小时的患者，我们推荐给予滋养型或充分的肠内营养，这两种营养补充策略对患者住院第一周预后的影响并无差异。证据质量：高trophic EN (defined as 1020 kcal/hr or up
32、 to 500 kcal/day) for one week,C 肠内营养剂量,Question: What population of patients in the ICU requires full EN (as close as possible to target nutrition goals) beginning in the first week of hospitalization? How soon should target nutrition goals be reached in these patients?问题：哪些ICU患者住院第一周需要足量EN（尽可能接近目标
33、喂养量）？这些患者应多长时间达到目标量？C3. Based on expert consensus, we suggest that patients who are at high nutrition risk (for example, NRS-2002 5 or NUTRIC score 5, without interleukin-6) or severely malnourished should be advanced toward goal as quickly as tolerated over 2448 hours while monitoring for refeeding
34、 syndrome. Efforts to provide 80% of estimated or calculated goal energy and protein within 4872 hours should be made in order to achieve the clinical benefit of EN over the first week of hospitalization.根据专家共识，我们建议具有高营养风险患者（如：NRS-2002 3 或不考虑IL-6情况下NUTRIC评分 5）或严重营养不良患者（ NRS-2002 5 ）， 应在24 48小时达到并耐受目
35、标喂养量；监测再喂养综合征。争取于48 72小时提供 80%预计蛋白质与能量供给目标，从入院第一周的EN中获益。,C 肠内营养剂量,Question: Does the amount of protein provided make a difference in clinical outcomes of adult critically ill patients?问题：蛋白质供给量对成年危重病患者临床结局有何不同影响？C4. We suggest that sufficient (high-dose) protein should be provided. Protein requireme
36、nts are expected to be in the range of 1.22.0g/kg actual body weight per day, and may likely be even higher in burn or multi- trauma patients (see sections M and P).Quality of Evidence: Very Low我们建议充分的（大剂量的）蛋白质供给。蛋白质需求预计为1.2 2.0 g/kg（实际体重）/天，烧伤或多发伤患者对蛋白质的需求量可能更高（见M和P部分）。证据质量：非常低,D 肠内营养的耐受性与充分性,Quest
37、ion: How should tolerance of EN be monitored in the adult critically ill population?问题：如何监测成年危重病患者EN耐受性？D1. Based on expert consensus, we suggest that patients should be monitored daily for tolerance of EN. We suggest that inappropriate cessation of EN should be avoided. We suggest that ordering a f
38、eeding status of nil per os (NPO) for the patient surrounding the time of diagnostic tests or procedures should be minimized to limit propagation of ileus and to prevent inadequate nutrient delivery.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。,D
39、肠内营养的耐受性与充分性,Question: Should GRVs be used as a marker for aspiration to monitor ICU patients on EN?问题：GRV是否应当作为接受EN的ICU患者监测误吸的指标？D2a. We suggest that GRVs not be used as part of routine care to monitor ICU patients on EN.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. We suggest that, for those ICUs where GRVs
40、 are still utilized, holding EN for GRVs 500 ml in the absence of other signs of intolerance (see section D1) should be avoided.Quality of Evidence: Low我们建议，对于仍然监测GRV的ICU，应当避免在GRV 500 ml且无其他不耐受表现（见D1部分）时中止EN。证据质量：低,D 肠内营养的耐受性与充分性,Question: Should EN feeding protocols be used in the adult ICU setting
41、?问题：成人ICU是否需要制定EN喂养方案？D3a. We recommend that enteral feeding protocols be designed and implemented to increase the overall percentage of goal calories provided.Quality of Evidence: Moderate to High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. Based on expert consensus, we suggest that use of a volume-
42、based feeding protocol or a top-down multi-strategy protocol be considered.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-down multi-strategy protocol)。Topdown multi-strategy protocols typically use volume-based feeding in conjunction with prokinetic agents and post-pyloric tube placement initiall
43、y (among other strategies), with prokinetic agents stopped in patients who demonstrate lack of need,D 肠内营养的耐受性与充分性,Question: How can risk of aspiration be assessed in critically ill adults patients receiving EN, and what measures may be taken to reduce the likelihood of aspiration pneumonia?问题：对于接受E
44、N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. Based on expert consensus, we suggest that patients placed on EN should be assessed for risk of aspiration, and that steps to reduce risk of aspiration and aspiration pneumonia should be proactively employed.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。D4
45、a. We recommend diverting the level of feeding by post-pyloric enteral access device placement in patients deemed to be at high risk for aspiration (see also section B5)Quality of Evidence: Moderate to High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,D 肠内营养的耐受性与充分性,D4b. Based on expert consensus,
46、 we suggest that for high-risk patients or those shown to be intolerant to bolus gastric EN, delivery of EN should be switched to continuous infusion.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. We suggest that, in patients at high risk of aspiration, agents to promote motility, such as prok
47、inetic medications (metoclopramide or erythromycin), be initiated where clinically feasible.Quality of Evidence: 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. Based on expert consensus, we suggest that nursing directives to reduce risk of aspiration and VAP be employed. In al
48、l intubated ICU patients receiving EN, the head of the bed should be elevated 3045 and use of chlorhexidine mouthwash twice a day should be considered.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。,D 肠内营养的耐受性与充分性,Question: Are surrogate markers useful in determining
49、aspiration in the critical care setting?问题：在ICU中，替代指标能否判断是否发生误吸？D5. Based on expert consensus, we suggest that neither blue food coloring nor any coloring agent be used as a marker for aspiration of EN. Based on expert consensus, we also suggest that glucose oxidase strips not be used as surrogate markers for aspiration in the critical care setting.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。,
