ESPEN指南外科臨床營養(yǎng)

1、ESPEN指南：外科臨床營養(yǎng)初期經(jīng)口飼養(yǎng)是手術(shù)患者營養(yǎng)的首選方式。營養(yǎng)療法可防止大手術(shù)后飼養(yǎng)不足的風(fēng)險?？紤]到營養(yǎng)不良和飼養(yǎng)不足是術(shù)后并發(fā)癥的風(fēng)險要素，初期腸內(nèi)飼養(yǎng)關(guān)于任何有營養(yǎng)風(fēng)險的手術(shù)患者尤其重要，特別是那些進(jìn)行上消化道手術(shù)的患者。該指南的重點是涵蓋術(shù)后加快痊愈外科（ERAS）觀點和進(jìn)行大手術(shù)患者的特別營養(yǎng)需求，比如癌癥，固然供給最正確圍手術(shù)期醫(yī)療，可是仍舊出現(xiàn)嚴(yán)重并發(fā)癥。從代謝和營養(yǎng)角度而言，圍手術(shù)期治療重點包含：將營養(yǎng)整合入患者整體管理防止長時間術(shù)前禁食術(shù)后盡早從頭成立經(jīng)口飼養(yǎng)一旦營養(yǎng)風(fēng)險變得顯然，初期開始營養(yǎng)療法代謝控制，比如血糖減少加重應(yīng)激有關(guān)分解代謝或影響胃腸功能的要素縮短用于術(shù)

2、后呼吸機管理的麻醉藥物使用時間初期活動以促使蛋白質(zhì)合成和肌肉功能恢復(fù)縮寫B(tài)M：生物醫(yī)學(xué)終點GPP：優(yōu)秀實踐重點。依據(jù)指南擬訂小組臨床經(jīng)驗介紹的最正確實踐方法。HE：醫(yī)療衛(wèi)生經(jīng)濟終點IE：整合傳統(tǒng)終點與患者報告終點QL：生活質(zhì)量TF：管飼該指南共提出37項臨床實踐介紹建議：對大部分患者從子夜開始術(shù)前禁食是不用要的。被以為無任何誤吸風(fēng)險的手術(shù)患者在麻醉前兩個小時應(yīng)喝清流質(zhì)。麻醉前六小時前應(yīng)贊同進(jìn)食固體食品（BM、IE、QL）。介紹等級：A，高度共鳴（97%贊同）為了減少圍術(shù)期不適癥狀包含憂慮，前一天夜晚和術(shù)前兩小時應(yīng)賜予經(jīng)口進(jìn)食碳水化合物辦理（而非夜間禁食）（B，QL）。為改良術(shù)后胰島素抵擋和縮短

3、住院時間，對大手術(shù)患者可考慮術(shù)前使用碳水化合物（0，BM、HE）。介紹等級：A/B，高度共鳴（100%贊同）在達(dá)成過程中由工作小組依據(jù)最新薈萃剖析下調(diào)等級（工作小組內(nèi)成員100%同意）一般狀況下，術(shù)后經(jīng)口營養(yǎng)攝取應(yīng)連續(xù)不中止（BM、IE）。介紹等級：A，高度共鳴（90%贊同）建議依據(jù)個人耐受性和實行的手術(shù)種類來調(diào)整經(jīng)口攝取，特別關(guān)注老年患者。介紹等級：GPP，高度共鳴（100%贊同）5.大部分患者應(yīng)在術(shù)后數(shù)小時內(nèi)開始經(jīng)口進(jìn)食清流質(zhì)。介紹等級：A，高度共鳴（100%同意）6.建議在大手術(shù)前后評定營養(yǎng)狀況。介紹等級：GPP，高度共鳴（100%贊同）營養(yǎng)不良患者和存在營養(yǎng)風(fēng)險的患者有指征進(jìn)行圍手術(shù)期

4、營養(yǎng)療法。假如估計患者在圍手術(shù)期不可以進(jìn)食超出5天，也應(yīng)啟動圍手術(shù)期營養(yǎng)療法。估計患者經(jīng)口攝取少，不可以維持介紹攝取量的50%以上超出7天也是指征。在這些狀況下，建議立刻賜予營養(yǎng)療法（首選腸內(nèi)門路ONS或TF）。介紹等級：GPP，高度共鳴（92%贊同）8.假如能量和營養(yǎng)需求不可以僅經(jīng)過經(jīng)口和腸道攝取知足（能量需求的50%）超出7天，建議腸內(nèi)結(jié)合腸外營養(yǎng)（GPP）。假若有營養(yǎng)療法指征，但有腸內(nèi)營養(yǎng)禁忌證如腸阻塞（A），應(yīng)趕快賜予腸外營養(yǎng)（BM）。介紹等級：GPP/A，高度共鳴（100%贊同）對使用腸外營養(yǎng)，應(yīng)首選全合一（三腔袋或藥房配制），而非多瓶輸注系統(tǒng)（BM、HE）。介紹等級：B，高度共鳴（

5、100%贊同）介紹按標(biāo)準(zhǔn)化操作流程（SOP）進(jìn)行營養(yǎng)支持，以保證有效的營養(yǎng)支持療法。介紹等級：GPP，高度共鳴（100%贊同）對因腸內(nèi)飼養(yǎng)不足而需要專用PN的患者可考慮靜脈增補谷氨酰胺（0，BM、HE）。介紹等級B，共鳴（76%贊同），在達(dá)成過程中由工作小組依據(jù)近來的PRCT下調(diào)等級（工作小組內(nèi)成員100%贊同）12.僅對因腸內(nèi)飼養(yǎng)不足而需要腸外營養(yǎng)的患者應(yīng)試慮術(shù)后腸外營養(yǎng)包含使用-3脂肪酸（BM、HE）。介紹等級：B，大部分贊同（65%贊同）對接受癌癥大手術(shù)營養(yǎng)不良的患者應(yīng)在圍手術(shù)期或起碼術(shù)后使用富含免疫營養(yǎng)素（精氨酸、-3脂肪酸、核苷酸）的特定配方（B，BM、HE）。當(dāng)前沒有明確的憑證表示

6、在圍手術(shù)期使用這些富含免疫營養(yǎng)素的配方優(yōu)于標(biāo)準(zhǔn)的口服營養(yǎng)增補劑。介紹等級：B/0，共鳴（89%贊同）有嚴(yán)重營養(yǎng)風(fēng)險的患者應(yīng)在大手術(shù)前接受營養(yǎng)療法（A），即便手術(shù)，包含那些癌癥，一定推延（BM）。這個時間為714天是適合的。介紹等級：A/0，高度共鳴（95%贊同）只需可行，應(yīng)首選經(jīng)口/腸內(nèi)門路（A，BM、HE、QL）。介紹等級：A，高度共鳴（100%贊同）當(dāng)患者從正常的食品中獲得的能量不可以知足需求，建議鼓舞這些患者術(shù)前采納口服營養(yǎng)增補劑，不論他們的營養(yǎng)狀況怎樣。介紹等級：GPP，共鳴（86%贊同）術(shù)前應(yīng)付全部營養(yǎng)不良的癌癥患者和進(jìn)行腹部大手術(shù)的高風(fēng)險患者賜予口服營養(yǎng)增補劑（BM、HE）。患肌肉

7、減少癥的老年人是一群特別的高風(fēng)險患者。介紹等級：A，高度共識（97%贊同）18.免疫調(diào)理型口服營養(yǎng)增補劑包含精氨酸、-3脂肪酸和核苷酸可首選（0，BM、HE），術(shù)前使用57天（GPP）。介紹等級：0/GPP，大部分贊同，64%贊同術(shù)前腸內(nèi)營養(yǎng)/口服營養(yǎng)增補劑應(yīng)在住院前使用，以防止不用要的住院治療和降低院內(nèi)感染的風(fēng)險（BM、HE、QL）。介紹等級：GPP，高度共鳴（91%贊同）20.術(shù)前PN只用于營養(yǎng)不良患者或存在嚴(yán)重營養(yǎng)風(fēng)險而能量需求不可以經(jīng)過EN完整知足的患者（A，BM）。建議使用714天。介紹等級：A/0，高度共鳴（100%贊同）21.對不可以初期開始經(jīng)口營養(yǎng)攝取、經(jīng)口攝取不足（50%）超

8、出7天的患者應(yīng)盡早啟動TF（24小時內(nèi)）。特別高風(fēng)險人群包含：接受頭頸部或胃腸癌癥大手術(shù)的患者（A，BM）嚴(yán)重創(chuàng)傷包含顱腦損害的患者（A，BM）手術(shù)時有顯然營養(yǎng)不良的患者（A，BM，GPP）介紹等級：A/GPP，高度共鳴（97%贊同）對大部分患者，標(biāo)準(zhǔn)整蛋白配方是適合的。為防止因技術(shù)原由堵管和感染風(fēng)險，一般不建議使用廚房制備的飲食（勻漿膳）進(jìn)行TF。介紹等級：GPP，高度共鳴（94%贊同）至于營養(yǎng)不良患者的特別方面，對全部接受上消化道和胰腺大手術(shù)患者進(jìn)行TF應(yīng)試慮擱置鼻空腸管（NJ）或行針刺導(dǎo)管空腸造口術(shù)（NCJ，BM）。介紹等級：B，高度共鳴（95%贊同）若有TF指征，應(yīng)在術(shù)后24小時內(nèi)啟動

9、（BM）。介紹等級：A，高度共鳴（91%贊同）建議以較慢的輸注速率開始TF（如10最大20ml/h），因為腸道耐受性有限，增添輸注速率要慎重、個體化。達(dá)到目標(biāo)攝取量的時間差異會很大，可能需要57天。介紹等級：GPP，共鳴（85%贊同）假如一定長久TF（4周），如重癥顱腦損害，建議經(jīng)皮置管（如經(jīng)皮內(nèi)鏡下胃造口PEG）。介紹等級：GPP，高度共鳴（94%贊同）如必需，在住院時期按期評定營養(yǎng)狀況，建議圍手術(shù)期接受營養(yǎng)療法和經(jīng)過經(jīng)口門路仍不可以知足能量需求的患者出院后連續(xù)營養(yǎng)療法包含合理的飲食指導(dǎo)。介紹等級：GPP，高度共鳴（97%贊同）營養(yǎng)不良是影響移植后預(yù)后的主要要素，所以建議對營養(yǎng)狀況進(jìn)行監(jiān)測。

10、對營養(yǎng)不良患者，建議賜予額外的口服營養(yǎng)增補劑甚至TF。介紹等級：GPP，高度共鳴（100%贊同）在平等候移植的患者進(jìn)行監(jiān)測時，一定按期評定營養(yǎng)狀況和賜予合理的飲食指導(dǎo)建議。介紹等級：GPP，高度共鳴（100%贊同）對活體供者和受者的介紹建議與腹部大手術(shù)患者同樣。介紹等級：GPP，高度共鳴（97%贊同）心臟、肺、肝、胰、腎移植術(shù)后，建議在24小時內(nèi)盡早攝取正常食品或進(jìn)行腸內(nèi)營養(yǎng)。介紹等級：GPP，高度共鳴（100%贊同）即便在小腸移植后，腸內(nèi)營養(yǎng)也可盡早啟動，但在第一周內(nèi)加量應(yīng)特別當(dāng)心。介紹等級：GPP，高度共鳴（93%贊同）必需時應(yīng)腸內(nèi)結(jié)合腸外營養(yǎng)。建議對全部移植患者進(jìn)行長久營養(yǎng)監(jiān)測和合理的飲

11、食指導(dǎo)。介紹等級：GPP，高度共鳴（100%贊同）34.減肥手術(shù)后建議初期經(jīng)口攝取。介紹等級：0，高度共鳴（100%贊同）簡單的減肥手術(shù)不需要腸外營養(yǎng)。介紹等級：0，高度共鳴（100%贊同）萬一出現(xiàn)較大并發(fā)癥需要再次開腹手術(shù)，可考慮使用鼻空腸管/針刺導(dǎo)管空腸造口術(shù)。介紹等級：0，共鳴（87%贊同）更多的介紹建議與那些接受腹部大手術(shù)的患者同樣。介紹等級：0，高度共鳴（94%贊同）ClinNutr.2017Jun;36(3):623-650.ESPENguideline:Clinicalnutritioninsurgery.WeimannA,BragaM,CarliF,HigashiguchiT,

12、HbnerM,KlekS,LavianoA,LjungqvistO,LoboDN,MartindaleR,WaitzbergDL,BischoffSC,SingerP.KlinikumSt.Georg,Leipzig,Germany;SanRaffaeleHospital,Milan,Italy;McGillUniversity,MontrealGeneralHospital,Montreal,Canada;FujitaHealthUniversity,Toyoake,Aichi,Japan;CentreHospitalierUniversitaireVaudois(CHUV),Lausann

13、e,Switzerland;StanleyDudricksMemorialHospital,Skawina,Krakau,Poland;UniversitaLaSapienzaRoma,Roma,Italy;OrebroUniversity,Orebro,Sweden;NottinghamUniversityHospitalsandUniversityofNottingham,QueensMedicalCentre,Nottingham,UK;OregonHealth&ScienceUniversity,Portland,OR,USA;UniversityofSaoPaulo,SaoPaulo

14、,Brazil;UniversitatHohenheim,Stuttgart,Germany;RabinMedicalCenter,BeilinsonHospital,PetahTikva,Israel.Earlyoralfeedingisthepreferredmodeofnutritionforsurgicalpatients.Avoidanceofanynutritionaltherapybearstheriskofunderfeedingduringthepostoperativecourseaftermajorsurgery.Consideringthatmalnutritionan

15、dunderfeedingareriskfactorsforpostoperativecomplications,earlyenteralfeedingisespeciallyrelevantforanysurgicalpatientatnutritionalrisk,especiallyforthoseundergoinguppergastrointestinalsurgery.ThefocusofthisguidelineistocovernutritionalaspectsoftheEnhancedRecoveryAfterSurgery(ERAS)conceptandthespecia

16、lnutritionalneedsofpatientsundergoingmajorsurgery,e.g.forcancer,andofthosedevelopingseverecomplicationsdespitebestperioperativecare.Fromametabolicandnutritionalpointofview,thekeyaspectsofperioperativecareinclude:integrationofnutritionintotheoverallmanagementofthepatientavoidanceoflongperiodsofpreope

17、rativefastingre-establishmentoforalfeedingasearlyaspossibleaftersurgerystartofnutritionaltherapyearly,assoonasanutritionalriskbecomesapparentreductionoffactorswhichexacerbatestress-relatedcatabolismorimpairgastrointestinalfunctionminimizedtimeonparalyticagentsforventilatormanagementinthepostoperativ

18、eperiodearlymobilisationtofacilitateproteinsynthesisandmusclefunctionTheguidelinepresents37recommendationsforclinicalpractice.BM:biomedicalendpointsGPP:Goodpracticepoints.RecommendedbestpracticebasedontheclinicalexperienceoftheguidelinedevelopmentgroupHE:healthcareeconomyendpointIE:integrationofclas

19、sicalandpatient-reportedendpointsQL:qualityoflifeTF:tubefeeding1.Preoperativefastingfrommidnightisunnecessaryinmostpatients.Patientsundergoingsurgery,whoareconsideredtohavenospecificriskofaspiration,shalldrinkclearfluidsuntiltwohoursbeforeanaesthesia.Solidsshallbealloweduntilsixhoursbeforeanaesthesi

20、a(BM,IE,QL).GradeofrecommendationA-strongconsensus(97%agreement)Inordertoreduceperioperativediscomfortincludinganxietyoralpreoperativecarbohydratetreatment(insteadofovernightfasting)thenightbeforeandtwohoursbeforesurgeryshouldbeadministered(B)(QL).Toimpactpostoperativeinsulinresistanceandhospitallen

21、gthofstay,preoperativecarbohydratescanbeconsideredinpatientsundergoingmajorsurgery(0)(BM,HE).ConsensusConference:GradeofrecommendationA/B-strongconsensus(100%agreement)-downgradedbytheworkinggroupduringthefinalizationprocessaccordingtotheveryrecentmeta-analysis(with100%agreementwithintheworkinggroup

22、members)Ingeneral,oralnutritionalintakeshallbecontinuedaftersurgerywithoutinterruption(BM,IE).GradeofrecommendationA-strongconsensus(90%agreement)Itisrecommendedtoadaptoralintakeaccordingtoindividualtoleranceandtothetypeofsurgerycarriedoutwithspecialcautiontoelderlypatients.GradeofrecommendationGPP-

23、strongconsensus(100%agreement)Oralintake,includingclearliquids,shallbeinitiatedwithinhoursaftersurgeryinmostpatients.GradeofrecommendationA-strongconsensus(100%agreement)Itisrecommendedtoassessthenutritionalstatusbeforeandaftermajorsurgery.GradeofrecommendationGPP-strongconsensus(100%agreement)Perio

24、perativenutritionaltherapyisindicatedinpatientswithmalnutritionandthoseatnutritionalrisk.Perioperativenutritionaltherapyshouldalsobeinitiated,ifitisanticipatedthatthepatientwillbeunabletoeatformorethanfivedaysperioperatively.Itisalsoindicatedinpatientsexpectedtohaveloworalintakeandwhocannotmaintaina

25、bove50%ofrecommendedintakeformorethansevendays.Inthesesituations,itisrecommendedtoinitiatenutritionaltherapy(preferablybytheenteralroute-ONS-TF)withoutdelay.GradeofrecommendationGPP-strongconsensus(92%agreement)Iftheenergyandnutrientrequirementscannotbemetbyoralandenteralintakealone(50%ofcaloricrequ

26、irement)formorethansevendays,acombinationofenteralandparenteralnutritionisrecommended(GPP).Parenteralnutritionshallbeadministeredassoonaspossibleifnutritiontherapyisindicatedandthereisacontraindicationforenteralnutrition,suchasinintestinalobstruction(A)(BM).GradeofrecommendationGPP/A-strongconsensus

27、(100%agreement)Foradministrationofparenteralnutritionanall-in-one(three-chamberbagorpharmacyprepared)shouldbepreferredinsteadofmultibottlesystem(BM,HE).GradeofrecommendationB-strongconsensus(100%agreement)Standardisedoperatingprocedures(SOP)fornutritionalsupportarerecommendedtosecureaneffectivenutri

28、tionalsupporttherapy.GradeofrecommendationGPP-strongconsensus(100%agreement)Parenteralglutaminesupplementationmaybeconsideredinpatientswhocannotbefedadequatelyenterallyand,therefore,requireexclusivePN(0)(BM,HE).ConsensusConference:GradeofrecommendationB-consensus(76%agreement)-downgradedbytheworking

29、groupduringthefinalizationprocessaccordingtotherecentPRCT(with100%agreementwithintheworkinggroupmembers).Postoperativeparenteralnutritionincludingomega-3-fattyacidsshouldbeconsideredonlyinpatientswhocannotbeadequatelyfedenterallyand,therefore,requireparenteralnutrition(BM,HE).GradeofrecommendationB-

30、majorityagreement(65%agreement)Peri-oratleastpostoperativeadministrationofspecificformulaenrichedwithimmunonutrients(arginine,omega-3-fattyacids,ribonucleotides)shouldbegiveninmalnourishedpatientsundergoingmajorcancersurgery(B)(BM,HE).Thereiscurrentlynoclearevidencefortheuseoftheseformulaeenrichedwi

31、thimmunonutrientsvs.standardoralnutritionalsupplementsexclusivelyinthepreoperativeperiod.GradeofrecommendationB/0-consensus(89%agreement)Patientswithseverenutritionalriskshallreceivenutritionaltherapypriortomajorsurgery(A)evenifoperationsincludingthoseforcancerhavetobedelayed(BM).Aperiodof7-14daysma

32、ybeappropriate.GradeofrecommendationA/0-strongconsensus(95%agreement)Wheneverfeasible,theoral/enteralrouteshallbepreferred(A)(BM,HE,QL).GradeofrecommendationA-strongconsensus(100%agreement)Whenpatientsdonotmeettheirenergyneedsfromnormalfooditisrecommendedtoencouragethesepatientstotakeoralnutritional

33、supplementsduringthepreoperativeperiodunrelatedtotheirnutritionalstatus.GradeofrecommendationGPP-consensus(86%agreement)Preoperatively,oralnutritionalsupplementsshallbegiventoallmalnourishedcancerandhigh-riskpatientsundergoingmajorabdominalsurgery(BM,HE).Aspecialgroupofhigh-riskpatientsaretheelderly

34、peoplewithsarcopenia.GradeofrecommendationA-strongconsensus(97%agreement)Immunemodulatingoralnutritionalsupplementsincludingarginine,omega-3fattyacidsandnucleotidescanbepreferred(0)(BM,HE)andadministeredforfivetosevendayspreoperatively(GPP).Gradeofrecommendation0/GPP-majorityagreement,64%agreementPr

35、eoperativeenteralnutrition/oralnutritionalsupplementsshouldpreferablybeadministeredpriortohospitaladmissiontoavoidunnecessaryhospitalizationandtolowertheriskofnosocomialinfections(BM,HE,QL).GradeofrecommendationGPP-strongconsensus(91%agreement)PreoperativePNshallbeadministeredonlyinpatientswithmalnu

36、tritionorseverenutritionalriskwhereenergyrequirementcannotbeadequatelymetbyEN(A)(BM).Aperiodof7-14daysisrecommended.GradeofrecommendationA/0-strongconsensus(100%agreement)Earlytubefeeding(within24h)shallbeinitiatedinpatientsinwhomearlyoralnutritioncannotbestarted,andinwhomoralintakewillbeinadequate(

37、4weeks)isnecessary,e.g.insevereheadinjury,placementofapercutaneoustube(e.g.percutaneousendoscopicgastrostomy-PEG)isrecommended.GradeofrecommendationGPP-strongconsensus(94%agreement)Regularreassessmentofnutritionalstatusduringthestayinhospitaland,ifnecessary,continuationofnutritiontherapyincludingqua

38、lifieddietarycounsellingafterdischarge,isadvisedforpatientswhohavereceivednutritiontherapyperioperativelyandstilldonotcoverappropriatelytheirenergyrequirementsviatheoralroute.GradeofrecommendationGPP-strongconsensus(97%agreement)Malnutritionisamajorfactorinfluencingoutcomeaftertransplantation,somoni

39、toringofthenutritionalstatusisrecommended.Inmalnutrition,additionaloralnutritionalsupplementsoreventubefeedingisadvised.GradeofrecommendationGPP-strongconsensus(100%agreement)Regularassessmentofnutritionalstatusandqualifieddietarycounsellingshallberequiredwhilemonitoringpatientsonthewaitinglistbeforetransplantation.GradeofrecommendationGPP-strongconsensus(100%agreement)Recommendationsforthelivingdonorandrecipientarenotdifferentfrom