2016重癥營養(yǎng)5.doc

SCCM/ASPEN成年危重病患者營養(yǎng)支持治療實施與評估指南(5/6)2016年02月29日指南導(dǎo)讀,進展交流暫無評論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.)成年危重病患者營養(yǎng)支持治療的實施與評估指南：美國危重病醫(yī)學(xué)會(SCCM)與美國腸外腸內(nèi)營養(yǎng)學(xué)會(ASPEN)Taylor BE, McClave SA, Martindale RG, et al. Crit Care Med 2016; 44: 390-438翻譯：清華大學(xué)長庚醫(yī)院 張振宇 許媛M. SURGICAL SUBSETS外科部分TRAUMA創(chuàng)傷Question: Does the nutrition therapy approach for the trauma patient differ from that for other critically ill patients?問題：創(chuàng)傷患者的營養(yǎng)治療方案與其他危重病患者有何不同？M1a. We suggest that, similar to other critically ill patients, early enteral feeding with a high protein polymeric diet be initiated in the immediate post-trauma period (within 24 to 48 hours of injury) once the patient is hemodynamically stable.Quality of Evidence: Very Low與其他危重病患者相似，我們建議一旦創(chuàng)傷患者血流動力學(xué)穩(wěn)定，應(yīng)盡早（創(chuàng)傷后24-48小時）開始高蛋白配方腸內(nèi)營養(yǎng)?！咀C據(jù)質(zhì)量：非常低】Question: Should immune-modulation formulas be used routinely to improve outcomes in a patient with severe trauma?問題：嚴重創(chuàng)傷患者是否應(yīng)常規(guī)使用免疫調(diào)節(jié)配方以改善預(yù)后？M1b. We suggest that immune-modulating formulations containing arginine and FO be considered in patients with severe trauma.Quality of Evidence: Very Low我們建議嚴重創(chuàng)傷患者給予富含精氨酸與魚油的免疫調(diào)節(jié)配方腸內(nèi)營養(yǎng)?！咀C據(jù)質(zhì)量：非常低】TRAUMATIC BRAIN INJURY顱腦創(chuàng)傷Question: Does the approach for nutrition therapy for the TBI patient differ from that of other critically ill patients or trauma patients without head injury?問題：TBI患者的營養(yǎng)治療方案與其他危重病患者或沒有顱腦損傷的其他創(chuàng)傷患者有何不同？M2a. We recommend that, similar to other critically ill patients, early enteral feeding be initiated in the immediate post-trauma period (within 24 to 48 hours of injury) once the patient is hemodynamically stable.Quality of Evidence: Very Low與其他危重病患者相似，我們建議一旦患者血流動力學(xué)穩(wěn)定，在創(chuàng)傷后（損傷24-48小時內(nèi)）立即開始早期腸內(nèi)營養(yǎng)?！咀C據(jù)質(zhì)量：非常低】Question: Should immune-modulating formulas be used in a patient with TBI?問題：TBI患者是否應(yīng)當(dāng)使用免疫調(diào)節(jié)配方嗎？M2b: Based on expert consensus, we suggest the use of either arginine-containing immune-modulating formulations or EPA/DHA supplement with standard enteral formula in patients with TBI.基于專家共識，我們建議TBI患者使用含有精氨酸的免疫調(diào)節(jié)配方，或使用添加EPA/DHA的標(biāo)準配方。OPEN ABDOMEN 開放腹腔Question: Is it safe to provide EN to patients with an OA?問題：開放腹腔患者應(yīng)用EN是否安全？M3a. Based on expert consensus, we suggest early EN (2448 hours post-injury) in patients treated with an OA in the absence of a bowel injury.根據(jù)專家共識，我們建議沒有腸道損傷的開放腹腔患者應(yīng)盡早（傷后24-48小時）開始EN。Question: Do patients with OA have increased protein or energy needs?問題：開放腹腔患者的蛋白質(zhì)或能量需求是否增加？M3b. Based on expert consensus, we suggest providing an additional 15 to 30 grams protein per liter of exudate lost for patients with OA. Energy needs should be determined as for other ICU patients (see section a).基于專家共識，我們建議開放腹腔患者按照15-30 g每升滲液丟失量額外增加蛋白質(zhì)補充。能量需求與其他ICU患者相同（見a部分）。BURNS燒傷Question: What mode of nutrition support should be used to feed burn patients?問題：燒傷患者應(yīng)用何種營養(yǎng)支持方式？M4a. Based on expert consensus, EN should be provided to burn patients whose GI tracts are functional and for whom volitional intake is inadequate to meet estimated energy needs. PN should be reserved for those burn patients for whom EN is not feasible or not tolerated.根據(jù)專家共識，對于保留胃腸道功能且口服飲食不能達到預(yù)計能量需求的燒傷患者，應(yīng)當(dāng)給予EN。不能實施EN或EN不能耐受時考慮給予PN。Question: How should energy requirements be determined in burn patients?問題：如何確定燒傷患者的能量需求？M4b. Based on expert consensus, we suggest that IC be used when available to assess energy needs in burn patients with weekly repeated measures.基于專家共識，我們建議可能時使用IC每周重復(fù)測定以評估燒傷患者的能量需要。Question: What is the optimal quantity of protein to deliver to patients with large burns requiring ICU care?問題：需要ICU治療的大面積燒傷患者，理想的蛋白質(zhì)補充量是多少？M4c. Based on expert consensus, we suggest that patients with burn injury should receive protein in the range of 1.52g/kg/day.根據(jù)專家共識，我們建議燒傷患者蛋白質(zhì)補充量為1.5-2.0g/kg/天。Question: When should nutrition support be initiated?問題：何時開始營養(yǎng)支持？M4d. Based on expert consensus, we suggest very early initiation of EN (if possible, within 46 hours of injury) in a patient with burn injury.根據(jù)專家共識，我們建議燒傷患者盡早開始EN（如果可能，應(yīng)在損傷后4-6小時內(nèi)開始）N. SEPSIS 全身性感染（膿毒癥）Question: Are patients with severe sepsis candidates for early EN therapy?問題：嚴重全身性患者是否適宜進行早期EN治療？N1. Based on expert consensus, we suggest that critically ill patients receive EN therapy within 2448 hours of making the diagnosis of severe sepsis/septic shock as soon as resuscitation is complete and the patient is hemodynamically stable.根據(jù)專家共識，一旦復(fù)蘇完成且血流動力學(xué)穩(wěn)定，我們建議應(yīng)當(dāng)在診斷嚴重全身性感染或感染性休克后24-48小時內(nèi)給予EN治療。Question: Should exclusive or supplemental PN added to EN providing 80% of target energy goal over the first week. We suggest delivery of 1.22 g protein/kg/day.根據(jù)專家共識，我們建議在全身性感染早期給予滋養(yǎng)型喂養(yǎng)策略（定義為10-20 kcal/h或不超過500 kcal/day），如果耐受良好，則24-48小時后開始增加喂養(yǎng)量，第一周內(nèi)達到80%目標(biāo)量。我們建議蛋白質(zhì)供給量為1.2-2.0 g/kg/天。Question: Is there any advantage to providing immune or metabolic-modulating enteral formulations (arginine with other agents, including EPA, DHA, glutamine, and nucleic acid) in sepsis?問題：全身性感染患者使用免疫調(diào)節(jié)或代謝調(diào)節(jié)型腸內(nèi)營養(yǎng)制劑（添加精氨酸或其他藥物，包括EPA，DHA，谷氨酰胺和核酸）是否有益？N5. We suggest that immune-modulating formulas not be used routinely in patients with severe sepsis.Quality of Evidence: Moderate我們建議嚴重全身性感染患者不贏常規(guī)使用免疫調(diào)節(jié)配方的EN制劑?！咀C據(jù)質(zhì)量：中】O. POSTOPERATIVE MAJOR SURGERY (SICU ADMISSION EXPECTED) 外科大手術(shù)后（計劃收入SICU）Question: Is the use of a nutrition risk indicator to identify patients who will most likely benefit from postoperative nutrition therapy more useful than traditional markers of nutrition assessment?問題：與傳統(tǒng)營養(yǎng)評價指標(biāo)相比，使用營養(yǎng)風(fēng)險指標(biāo)能否更好地確定那些最可能從術(shù)后營養(yǎng)治療中獲益的患者？O1. Based on expert consensus, we suggest that determination of nutrition risk (for example, NRS-2002 or NUTRIC score) be performed on all postoperative patients in the ICU and that traditional visceral protein levels (serum albumin, prealbumin, and transferrin concentrations) should not be used as markers of nutrition status.根據(jù)專家共識，我們建議對所有ICU術(shù)后患者評估營養(yǎng)風(fēng)險（例如，NRS-2002或NUTRIC評分）；傳統(tǒng)指標(biāo)即內(nèi)臟蛋白水平（血漿白蛋白，前白蛋白與轉(zhuǎn)鐵蛋白）不應(yīng)作為營養(yǎng)狀態(tài)評價指標(biāo)。Question: What is the benefit of providing EN early in the postoperative setting compared to providing PN or STD?問題：與給予PN或標(biāo)準靜脈補液治療(STD)相比，術(shù)后早期EN的益處有哪些？O2. We suggest that EN be provided when feasible in the postoperative period within 24 hours of surgery, as it results in better outcomes than use of PN or STD.Quality of Evidence: Very Low我們建議，如有可能，術(shù)后24小時內(nèi)應(yīng)給予EN，因為EN的預(yù)后較PN或STD更好?！咀C據(jù)質(zhì)量：非常低】Question: Should immune-modulating formulas be used routinely to improve outcomes in a postoperative patient?問題：術(shù)后患者是否應(yīng)當(dāng)常規(guī)使用免疫調(diào)節(jié)配方以改善預(yù)后？O3. We suggest the routine use of an immune-modulating formula (containing both arginine and fish oils) in the SICU for the postoperative patient who requires EN therapy.Quality of Evidence: Moderate to Low對于需要EN治療的SICU術(shù)后患者，我們建議常規(guī)給予免疫調(diào)節(jié)配方腸內(nèi)營養(yǎng)制劑（含精氨酸與魚油）?！咀C據(jù)質(zhì)量：中到低】Question: Is it appropriate to provide EN to a SICU patient in the presence of difficult postoperative situations such as OA, bowel wall edema, fresh intestinal anastomosis, vasopressor therapy, or ileus?問題：術(shù)后病情復(fù)雜的SICU患者（如開放腹腔、腸壁水腫、小腸吻合術(shù)后、血管活性藥物治療或腸梗阻）接受EN是否恰當(dāng)？O4. We suggest enteral feeding for many patients in difficult postoperative situations such as prolonged ileus, intestinal anastomosis, OA, and need of vasopressors for hemodynamic support. Each case should be individualized based on perceived safety and clinical judgment.Quality of Evidence: Low to Very Low對許多術(shù)后病情復(fù)雜的患者（如長期腸梗阻、腸吻合，開放腹腔，需要血管活性藥維持血流動力學(xué)），我們建議應(yīng)當(dāng)在保證安全及臨床判斷的基礎(chǔ)上進行個體化治療?！咀C據(jù)質(zhì)量：低至很低】Question: When should PN be used in the postoperative ICU patient?問題：術(shù)后ICU患者何時應(yīng)用PN？O5.