ESPEN指南：外科臨床營(yíng)養(yǎng)

1、ESPEN指南：外科臨床營(yíng)養(yǎng)早期經(jīng)口喂養(yǎng)是手術(shù)患者營(yíng)養(yǎng)的首選方式。 營(yíng)養(yǎng)療法可避免大手術(shù)后喂養(yǎng)不 足的風(fēng)險(xiǎn)?？紤]到營(yíng)養(yǎng)不良和喂養(yǎng)不足是術(shù)后并發(fā)癥的風(fēng)險(xiǎn)因素，早期腸內(nèi)喂養(yǎng)對(duì)于任何有營(yíng)養(yǎng)風(fēng)險(xiǎn)的手術(shù)患者尤為重要，特別是那些進(jìn)行上消化道手術(shù)的患者。 該指南的重點(diǎn)是涵蓋術(shù)后加速康復(fù)外科（ERAS）概念和進(jìn)行大手術(shù)患者的特殊 營(yíng)養(yǎng)需求，例如癌癥，雖然提供最佳圍手術(shù)期醫(yī)療，但是仍然出現(xiàn)嚴(yán)重并發(fā)癥。 從代謝和營(yíng)養(yǎng)角度而言，圍手術(shù)期治療重點(diǎn)包括：將營(yíng)養(yǎng)整合入患者整體管理避免長(zhǎng)時(shí)間術(shù)前禁食術(shù)后盡早重新建立經(jīng)口喂養(yǎng)一旦營(yíng)養(yǎng)風(fēng)險(xiǎn)變得明顯，早期開(kāi)始營(yíng)養(yǎng)療法代謝控制，例如血糖減少加重應(yīng)激相關(guān)分解代謝或影響胃腸功能的因素縮

2、短用于術(shù)后呼吸機(jī)管理的麻醉藥物使用時(shí)間早期活動(dòng)以促進(jìn)蛋白質(zhì)合成和肌肉功能恢復(fù)縮寫(xiě)B(tài)M:生物醫(yī)學(xué)終點(diǎn)GPP:良好實(shí)踐要點(diǎn)。根據(jù)指南制定小組臨床經(jīng)驗(yàn)推薦的最佳實(shí)踐方法。HE:醫(yī)療衛(wèi)生經(jīng)濟(jì)終點(diǎn)IE:整合傳統(tǒng)終點(diǎn)與患者報(bào)告終點(diǎn)QL:生活質(zhì)量TF:管飼該指南共提出37項(xiàng)臨床實(shí)踐推薦意見(jiàn)：.對(duì)大多數(shù)患者從午夜開(kāi)始術(shù)前禁食是不必要的。被認(rèn)為無(wú)任何誤吸風(fēng)險(xiǎn)的手術(shù)患 者在麻醉前兩個(gè)小時(shí)應(yīng)喝清流質(zhì)。麻醉前六小時(shí)前應(yīng)允許進(jìn)食固體食物（ BM、 IE、QL）。推薦等級(jí)：A,高度共識(shí)（97%同意）.為了減少圍術(shù)期不適癥狀包括焦慮，前一天晚上和術(shù)前兩小時(shí)應(yīng)給予經(jīng)口進(jìn)食碳 水化合物處理（而非夜間禁食）（B, QL）。為改善

3、術(shù)后胰島素抵抗和縮短住院 時(shí)間，對(duì)大手術(shù)患者可考慮術(shù)前使用碳水化合物（0, BM、HE）。推薦等級(jí)： A/B,高度共識(shí)（100%同意）在完成過(guò)程中由工作小組根據(jù)最新薈萃分析下調(diào) 等級(jí)（工作小組內(nèi)成員100%同意）.一般情況下，術(shù)后經(jīng)口營(yíng)養(yǎng)攝入應(yīng)持續(xù)不中斷（BM、IE）。推薦等級(jí)：A,高度 共識(shí)（90%同意）.建議根據(jù)個(gè)人耐受性和實(shí)施的手術(shù)類型來(lái)調(diào)整經(jīng)口攝入，特別關(guān)注老年患者。推 薦等級(jí)：GPP,高度共識(shí)（100%同意）.大多數(shù)患者應(yīng)在術(shù)后數(shù)小時(shí)內(nèi)開(kāi)始經(jīng)口進(jìn)食清流質(zhì)。 推薦等級(jí)：A,高度共識(shí)（100% 同意）.建議在大手術(shù)前后評(píng)定營(yíng)養(yǎng)狀況。推薦等級(jí)：GPP,高度共識(shí)（100%同意）.營(yíng)養(yǎng)不良患者

4、和存在營(yíng)養(yǎng)風(fēng)險(xiǎn)的患者有指征進(jìn)行圍手術(shù)期營(yíng)養(yǎng)療法。如果預(yù)計(jì)患 者在圍手術(shù)期不能進(jìn)食超過(guò)5天，也應(yīng)啟動(dòng)圍手術(shù)期營(yíng)養(yǎng)療法。預(yù)計(jì)患者經(jīng)口攝 入少，不能維持推薦攝入量的50%以上超過(guò)7天也是指征。在這些情況下，建 議立即給予營(yíng)養(yǎng)療法（首選腸內(nèi)途徑 ONS或TF）。推薦等級(jí)：GPP,高度共 識(shí)（92%同意）.如果能量和營(yíng)養(yǎng)需求不能僅通過(guò)經(jīng)口和腸道攝入滿足（能量需求的50%）超過(guò)7天，建議腸內(nèi)聯(lián)合腸外營(yíng)養(yǎng)（GPP） o如果有營(yíng)養(yǎng)療法指征，但有腸內(nèi)營(yíng)養(yǎng)禁 忌證如腸梗阻（A）,應(yīng)盡快給予腸外營(yíng)養(yǎng)（BM）。推薦等級(jí)：GPP/A,高度 共識(shí)（100%同意）.對(duì)使用腸外營(yíng)養(yǎng)，應(yīng)首選全合一（三腔袋或藥房配制），而非多瓶

5、輸注系統(tǒng)（BM、 HE）。推薦等級(jí)：B,高度共識(shí)（100%同意）.推薦按標(biāo)準(zhǔn)化操作流程（SOP）進(jìn)行營(yíng)養(yǎng)支持，以確保有效的營(yíng)養(yǎng)支持療法。推 薦等級(jí)：GPP,高度共識(shí)（100%同意）.對(duì)因腸內(nèi)喂養(yǎng)不足而需要專用 PN的患者可考慮靜 脈補(bǔ)充谷氨酰胺（0,BM、HE）。 推薦等級(jí)B,共識(shí)（76%同意），在完成過(guò)程中由工作小組根據(jù)最近的 PRCT 下調(diào)等級(jí)（工作小組內(nèi)成員100%同意）.僅對(duì)因腸內(nèi)喂養(yǎng)不足而需要腸外營(yíng)養(yǎng)的患者應(yīng)考慮術(shù)后腸外營(yíng)養(yǎng)包括使用-3脂肪酸（BM、HE）。推薦等級(jí)：B,大多數(shù)同意（65%同意）.對(duì)接受癌癥大手術(shù)營(yíng)養(yǎng)不良的患者應(yīng)在圍手術(shù)期或至少術(shù)后使用富含免疫營(yíng)養(yǎng) 素（精氨酸、-3脂

6、肪酸、核甘酸）的特定配方（B, BM、HE）。目前沒(méi)有明 確的證據(jù)表明在圍手術(shù)期使用這些富含免疫營(yíng)養(yǎng)素的配方優(yōu)于標(biāo)準(zhǔn)的口服營(yíng)養(yǎng) 補(bǔ)充劑。推薦等級(jí)：B/0,共識(shí)（89%同意）.有嚴(yán)重營(yíng)養(yǎng)風(fēng)險(xiǎn)的患者應(yīng)在大手術(shù)前接受營(yíng)養(yǎng)療法（ A）,即使手術(shù)，包括那些 癌癥，必須推遲（BM）。這個(gè)時(shí)間為714天是合適的。推薦等級(jí)：A/0,高 度共識(shí)（95%同意）.只要可行，應(yīng)首選經(jīng)口 /腸內(nèi)途徑（A, BM、HE、QL）。推薦等級(jí)：A,高度共 識(shí)（100%同意）.當(dāng)患者從正常的食物中獲取的能量不能滿足需求，建議鼓勵(lì)這些患者術(shù)前采取口服營(yíng)養(yǎng)補(bǔ)充劑，不管他們的營(yíng)養(yǎng)狀況如何。推薦等級(jí)：GPP,共識(shí)（86%同意）.術(shù)前應(yīng)對(duì)

7、所有營(yíng)養(yǎng)不良的癌癥患者和進(jìn)行腹部大手術(shù)的高風(fēng)險(xiǎn)患者給予口服營(yíng) 養(yǎng)補(bǔ)充劑（BM、HE）?；技∪鉁p少癥的老年人是一群特殊的高風(fēng)險(xiǎn)患者。推薦 等級(jí)：A,高度共識(shí)（97%同意）.免疫調(diào)節(jié)型口服營(yíng)養(yǎng)補(bǔ)充劑包括精氨酸、-3脂肪酸和核甘酸可首選（0, BM、HE）,術(shù)前使用57天（GPP）。推薦等級(jí)：0/GPP ,大多數(shù)同意，64%同意.術(shù)前腸內(nèi)營(yíng)養(yǎng)/口服營(yíng)養(yǎng)補(bǔ)充劑應(yīng)在入院前使用，以避免不必要的住院治療和降 低院內(nèi)感染的風(fēng)險(xiǎn)（BM、HE、QL）。推薦等級(jí)：GPP,高度共識(shí)（91%同意）.術(shù)前PN只用于營(yíng)養(yǎng)不良患者或存在嚴(yán)重營(yíng)養(yǎng)風(fēng)險(xiǎn)而能量需求不能通過(guò)EN完全滿足的患者（A, BM）。建議使用714大。推薦等級(jí)

8、：A/0,高度共識(shí)（100% 同意）.對(duì)不能早期開(kāi)始經(jīng)口營(yíng)養(yǎng)攝入、經(jīng)口攝入不足（50%）超過(guò)7天的患者應(yīng)盡早啟動(dòng)TF （24小時(shí)內(nèi)）。特別高風(fēng)險(xiǎn)人群包括：接受頭頸部或胃腸癌癥大手術(shù)的 患者（A, BM）嚴(yán)重創(chuàng)傷包括顱腦損傷的患者（A, BM）手術(shù)時(shí)有明顯營(yíng)養(yǎng)不 良的患者（A, BM, GPP）推薦等級(jí)：A/GPP ,高度共識(shí)（97%同意）.對(duì)大多數(shù)患者，標(biāo)準(zhǔn)整蛋白配方是合適的。為避免因技術(shù)原因堵管和感染風(fēng)險(xiǎn)， 一般不建議使用廚房制備的膳食（勻漿膳）進(jìn)行 TF。推薦等級(jí)：GPP,高度共 識(shí)（94%同意）.至于營(yíng)養(yǎng)不良患者的特殊方面，對(duì)所有接受上消化道和胰腺大手術(shù)患者進(jìn)行TF應(yīng)考慮放置鼻空腸管（N

9、J）或行針刺導(dǎo)管空腸造口術(shù)（NCJ, BM）。推薦等級(jí)： B,高度共識(shí)（95%同意）.如有TF指征，應(yīng)在術(shù)后24小時(shí)內(nèi)啟動(dòng)（BM）。推薦等級(jí)：A,高度共識(shí)（91% 同意）.建議以較慢的輸注速率開(kāi)始 TF （如10最大20ml/h ）,由于腸道耐受性有限， 增加輸注速率要謹(jǐn)慎、個(gè)體化。達(dá)到目標(biāo)攝入量的時(shí)間差別會(huì)很大，可能需要5 7大。推薦等級(jí)：GPP,共識(shí)（85%同意）.如果必須長(zhǎng)期TF （4周），如重癥顱腦損傷，建議經(jīng)皮置管（如經(jīng)皮內(nèi)鏡下 胃造口一PEG）。推薦等級(jí)：GPP,高度共識(shí)（94%同意）.如必要，在住院期間定期評(píng)定營(yíng)養(yǎng)狀況，建議圍手術(shù)期接受營(yíng)養(yǎng)療法和通過(guò)經(jīng)口 途徑仍不能滿足能量需求的

10、患者出院后繼續(xù)營(yíng)養(yǎng)療法包括合理的膳食指導(dǎo)。推薦等級(jí)：GPP,高度共識(shí)（97%同意）.營(yíng)養(yǎng)不良是影響移植后預(yù)后的主要因素，因此建議對(duì)營(yíng)養(yǎng)狀況進(jìn)行監(jiān)測(cè)。 對(duì)營(yíng)養(yǎng)不良患者，建議給予額外的口服營(yíng)養(yǎng)補(bǔ)充劑甚至TFo推薦等級(jí)：GPP,高度共識(shí)（100%同意）.在對(duì)等待移植的患者進(jìn)行監(jiān)測(cè)時(shí)，必須定期評(píng)定營(yíng)養(yǎng)狀況和給予合理的膳食指導(dǎo) 建議。推薦等級(jí)：GPP,高度共識(shí)（100%同意）.對(duì)活體供者和受者的推薦意見(jiàn)與腹部大手術(shù)患者相同。推薦等級(jí)：GPP,高度共識(shí)（97%同意）.心臟、肺、肝、胰、腎移植術(shù)后，建議在 24小時(shí)內(nèi)盡早攝入正常食物或進(jìn)行腸 內(nèi)營(yíng)養(yǎng)。推薦等級(jí)：GPP,高度共識(shí)（100%同意）.即使在小腸移植

11、后，腸內(nèi)營(yíng)養(yǎng)也可盡早啟動(dòng)，但在第一周內(nèi)加量應(yīng)非常小心。推 薦等級(jí)：GPP,高度共識(shí)（93%同意）.必要時(shí)應(yīng)腸內(nèi)聯(lián)合腸外營(yíng)養(yǎng)。建議對(duì)所有移植患者進(jìn)行長(zhǎng)期營(yíng)養(yǎng)監(jiān)測(cè)和合理的膳 食指導(dǎo)。推薦等級(jí)：GPP,高度共識(shí)（100%同意）.減肥手術(shù)后建議早期經(jīng)口攝入。推薦等級(jí)： 0,高度共識(shí)（100%同意）.簡(jiǎn)單的減肥手術(shù)不需要腸外營(yíng)養(yǎng)。推薦等級(jí)： 0,高度共識(shí)（100%同意）.萬(wàn)一出現(xiàn)較大并發(fā)癥需要再次開(kāi)腹手術(shù)，可考慮使用鼻空腸管/針刺導(dǎo)管空腸造口術(shù)。推薦等級(jí)：0,共識(shí)（87%同意）.更多的推薦意見(jiàn)與那些接受腹部大手術(shù)的患者相同。推薦等級(jí)：0,高度共識(shí)（94%同意）Clin Nutr. 2017 Jun;36

12、（3）:623-650.ESPEN guideline: Clinical nutrition in surgery.Weimann A, Braga M, Carli F, Higashiguchi T, Hibner M, Klek S, Laviano A,Ljungqvist O, Lobo DN, Martindale R, Waitzberg DL, Bischoff SC, Singer P.Klinikum St. Georg, Leipzig, Germany; San Raffaele Hospital, Milan, Italy;McGill University, Mo

13、ntreal General Hospital, Montreal, Canada; Fujita Health University, Toyoake, Aichi, Japan; Centre Hospitalier Universitaire Vaudois （CHUV）, Lausanne, Switzerland; Stanley Dudricks Memorial Hospital,Skawina, Krakau, Poland; Universita La Sapienza Roma, Roma, Italy; Orebro University, Orebro, Sweden;

14、 Nottingham University Hospitals and University of Nottingham, Queens Medical Centre, Nottingham, UK; Oregon Health & Science University, Portland, OR, USA; University of Sao Paulo, Sao Paulo, Brazil; Universitat Hohenheim, Stuttgart, Germany; Rabin Medical Center, Beilinson Hospital, Petah Tikva, I

15、srael.Early oral feeding is the preferred mode of nutrition for surgical patients.Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications,

16、early enteral feeding is especially relevant for any surgical patient at nutritional risk,especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional need

17、s of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include:? integration of nutrition into the overall management of the patient?

18、avoidance of long periods of preoperative fasting? re-establishment of oral feeding as early as possible after surgery? start of nutritional therapy early, as soon as a nutritional risk becomes apparent ? metabolic control e.g. of blood glucose? reduction of factors which exacerbate stress-related c

19、atabolism or impair gastrointestinal function? minimized time on paralytic agents for ventilator management in the postoperative period? early mobilisation to facilitate protein synthesis and muscle function The guideline presents 37 recommendations for clinical practice.BM: biomedical endpointsGPP:

20、 Good practice points. Recommended best practice based on the clinical experience of the guideline development groupHE: health care economy endpointIE: integration of classical and patient-reported endpointsQL: quality of life TF: tube feedingPreoperative fasting from midnight is unnecessary in most

21、 patients. Patients undergoing surgery, who are considered to have no specific risk of aspiration, shall drink clear fluids until two hours before anaesthesia. Solids shall be allowed until six hours before anaesthesia (BM, IE, QL). Grade of recommendation A - strong consensus (97% agreement)In orde

22、r to reduce perioperative discomfort including anxiety oral preoperative carbohydrate treatment (instead of overnight fasting) the night before and two hours before surgery should be administered (B) (QL). To impact postoperative insulin resistance and hospital length of stay, preoperative carbohydr

23、ates can be considered in patients undergoing major surgery (0) (BM, HE). Consensus Conference: Grade of recommendation A/B - strong consensus (100% agreement)- downgraded by the working group during the finalization process according to the very recent meta-analysis (with 100% agreement within the

24、working group members)In general, oral nutritional intake shall be continued after surgery without interruption (BM, IE). Grade of recommendation A - strong consensus (90% agreement)It is recommended to adapt oral intake according to individual tolerance and to the type of surgery carried out with s

25、pecial caution to elderly patients. Grade of recommendation GPP - strong consensus (100% agreement)Oral intake, including clear liquids, shall be initiated within hours after surgery in most patients. Grade of recommendation A - strong consensus (100% agreement)It is recommended to assess the nutrit

26、ional status before and after major surgery. Grade of recommendation GPP - strong consensus (100% agreement)Perioperative nutritional therapy is indicated in patients with malnutrition and those at nutritional risk. Perioperative nutritional therapy should also be initiated, if it is anticipated tha

27、t the patient will be unable to eat for more than five days perioperatively. It is also indicated in patients expected to have low oral intake and who cannot maintain above 50% of recommended intake for more than seven days. In these situations, it is recommended to initiate nutritional therapy (pre

28、ferably by the enteral route - ONS-TF) without delay. Grade of recommendation GPP - strong consensus (92% agreement)If the energy and nutrient requirements cannot be met by oral and enteral intake alone (50% of caloric requirement) for more than seven days, acombination of enteral and parenteral nut

29、rition is recommended (GPP). Parenteral nutrition shall be administered as soon as possible if nutrition therapy is indicated and there is a contraindication for enteral nutrition, such as in intestinal obstruction (A) (BM). Grade of recommendation GPP/A - strong consensus (100% agreement)For admini

30、stration of parenteral nutrition an all-in-one (three-chamber bag or pharmacy prepared) should be preferred instead of multibottle system (BM, HE). Grade of recommendation B - strong consensus (100% agreement)Standardised operating procedures (SOP) for nutritional support arerecommended to secure an

31、 effective nutritional support therapy. Grade of recommendation GPP - strong consensus (100% agreement)Parenteral glutamine supplementation may be considered in patients whocannot be fed adequately enterally and, therefore, require exclusive PN (0) (BM, HE). Consensus Conference: Grade of recommenda

32、tion B - consensus (76% agreement) - downgraded by the working group during the finalization process according to the recent PRCT (with 100% agreement within the working group members).Postoperative parenteral nutrition including omega-3-fatty acids should be considered only in patients who cannot b

33、e adequately fed enterally and, therefore, require parenteral nutrition (BM, HE). Grade of recommendation B - majority agreement (65% agreement)Peri- or at least postoperative administration of specific formula enriched with immunonutrients (arginine, omega-3-fatty acids, ribonucleotides) should be

34、given in malnourished patients undergoing major cancer surgery (B) (BM, HE). There is currently no clear evidence for the use of these formulae enriched with immunonutrients vs. standard oral nutritional supplements exclusively in the preoperative period. Grade of recommendation B/0 - consensus (89%

35、 agreement)Patients with severe nutritional risk shall receive nutritional therapy prior tomajor surgery (A) even if operations including those for cancer have to be delayed (BM). A period of 7-14 days may be appropriate. Grade of recommendation A/0 - strong consensus (95% agreement)Whenever feasibl

36、e, the oral/enteral route shall be preferred (A) (BM, HE, QL).Grade of recommendation A - strong consensus (100% agreement)When patients do not meet their energy needs from normal food it is recommended to encourage these patients to take oral nutritional supplements during the preoperative period u

37、nrelated to their nutritional status. Grade of recommendation GPP - consensus (86% agreement)Preoperatively, oral nutritional supplements shall be given to all malnourishedcancer and high-risk patients undergoing major abdominal surgery (BM, HE). A special group of high-risk patients are the elderly

38、 people with sarcopenia.Grade of recommendation A - strong consensus (97% agreement)Immune modulating oral nutritional supplements including arginine, omega-3fatty acids and nucleotides can be preferred (0) (BM, HE) and administered for five to seven days preoperatively (GPP). Grade of recommendatio

39、n 0/GPP - majority agreement, 64% agreementPreoperative enteral nutrition/oral nutritional supplements should preferably be administered prior to hospital admission to avoid unnecessary hospitalization and to lower the risk of nosocomial infections (BM, HE, QL). Grade of recommendation GPP - strong

40、consensus (91% agreement)Preoperative PN shall be administered only in patients with malnutrition or severe nutritional risk where energy requirement cannot be adequately met by EN (A) (BM). A period of 7-14 days is recommended. Grade of recommendation A/0 - strong consensus (100% agreement)Early tu

41、be feeding (within 24 h) shall be initiated in patients in whom early oral nutrition cannot be started, and in whom oral intake will be inadequate (4 weeks) is necessary, e.g. in severe head injury, placementofa percutaneous tube (e.g. percutaneous endoscopic gastrostomy - PEG) is recommended. Grade

42、 of recommendation GPP - strong consensus (94% agreement)Regular reassessment of nutritional status during the stay in hospital and, if necessary, continuation of nutrition therapy including qualified dietary counselling after discharge, is advised for patients who have received nutrition therapy pe

43、rioperatively and still do not cover appropriately their energy requirements via the oral route. Grade of recommendation GPP - strong consensus (97% agreement)Malnutrition is a major factor influencing outcome after transplantation, somonitoring of the nutritional status is recommended. In malnutrit

44、ion, additional oral nutritional supplements or even tube feeding is advised. Grade of recommendation GPP - strong consensus (100% agreement)Regular assessment of nutritional status and qualified dietary counselling shall be required while monitoring patients on the waiting list before transplantation. Grade of recommendation GPP - strong consensus (100% agreement)Recommendations for the living donor and recipient are not different from those for patients undergoing major abdominal surgery. Grad