用EN须尽早-早期肠内.ppt
用EN须尽早-早期肠内营养（EEN）,一项Meta分析纳入了6个RCT，研究24h内给予ICU患者早期肠内营养（EEN）相对于24h后开始EN，对患者临床结局的影响,Doig GS,et al.Early enteral nutrition,provided within 24 h of injury or intensive care unit admission,significantly reduces mortality in critically ill patients:a meta-analysis of randomized controlled trials.Intensive Care Med,2009;35:201827,EEN可降低ICU患者的死亡率,Doig GS,et al.Early enteral nutrition,provided within 24 h of injury or intensive care unit admission,significantly reduces mortality in critically ill patients:a meta-analysis of randomized controlled trials.Intensive Care Med,2009;35:201827,EEN可降低ICU患者肺炎的发生率,Doig GS,et al.Early enteral nutrition,provided within 24 h of injury or intensive care unit admission,significantly reduces mortality in critically ill patients:a meta-analysis of randomized controlled trials.Intensive Care Med,2009;35:201827,EEN对外科术后患者的影响,一项研究纳入1173例胃肠外科术后患者，24h内给予EEN的试验组，与不给于EN的对照组相比，对临床结局的影响,Lewis SJ,et al.Early enteral nutrition within 24 h of intestinal surgery versus later commencement of feeding:a systematic review and meta-analysis.J Gastrointest Surg,2009;13(3):569-75.,EEN降低外科患者的死亡率,Lewis SJ,et al.Early enteral nutrition within 24 h of intestinal surgery versus later commencement of feeding:a systematic review and meta-analysis.J Gastrointest Surg,2009;13(3):569-75.,EEN对烧伤患者的影响,Mosier MJ,et al.Early enteral nutrition in burns:compliance with guidelines and associated outcomes in a multicenter study.J Burn Care Res,2011;32(1):104-9.,一项研究纳入153例烧伤患者，试验组给予24h内EEN，对照组在烧伤24h后开始EN。,EEN影响烧伤患者的ICU住院时间,Mosier MJ,et al.Early enteral nutrition in burns:compliance with guidelines and associated outcomes in a multicenter study.J Burn Care Res,2011;32(1):104-9.,EEN对颅脑外伤患者的影响,Chiang YH,et al.Early Enteral Nutrition and Clinical Outcomes of Severe Traumatic Brain Injury Patients in Acute Stage:A Multi-Center Cohort Study.J Neurotrauma,2011 Aug 4.Epub ahead of print,GCS评分4-8分的严重创伤性脑损伤患者中，试验组145例在受伤后48h内接受EN，对照组152例给予静脉补液治疗,EEN 提高sTBI患者的生存率和GCS 恢复，改善预后，尤其对GCS 评分6-8的患者效果显著,HR,95%CI：8.5824.91,Chiang YH,et al.Early Enteral Nutrition and Clinical Outcomes of Severe Traumatic Brain Injury Patients in Acute Stage:A Multi-Center Cohort Study.J Neurotrauma,2011 Aug 4.Epub ahead of print,P0.05,早期空肠喂养改善SAP的临床结局,Hegazi R,et al.Early jejunal feeding initiation and clinical outcomes in patients with severe acute pancreatitis.JPEN J Parenter Enteral Nutr,2011,35(1):91-6.Erratum in:JPEN J Parenter Enteral Nutr,2011,;35(2):276.,一项回顾性研究，观察ICU中早期空肠喂养对SAP患者临床结局的影响,早期开始DJF直接影响患者的死亡率,17天,7天,Hegazi R,et al.Early jejunal feeding initiation and clinical outcomes in patients with severe acute pancreatitis.JPEN J Parenter Enteral Nutr,2011,35(1):91-6.Erratum in:JPEN J Parenter Enteral Nutr,2011,;35(2):276.,（天）,P0.05,及早达到目标量可缩短住院时间,A组：从未达目标量；B组：开始DJF后超过3天达目标量；C组：开始DJF后3天内达目标量,Hegazi R,et al.Early jejunal feeding initiation and clinical outcomes in patients with severe acute pancreatitis.JPEN J Parenter Enteral Nutr,2011,35(1):91-6.Erratum in:JPEN J Parenter Enteral Nutr,2011,;35(2):276.,45.3,18.0,10.0,P0.05,P0.05,结肠癌术后患者早期口服营养补充（ONS）,Lobato Dias Consoli M,et al.Early postoperative oral feeding impacts positively in patients undergoing colonic resection:results of a pilot study.Nutr Hosp,2010;25(5):806-9.,两组均术前12h禁食，早期EN组术后第1天起即给予500ml口服EN制剂，传统治疗组排气后才恢复进食POD：术后天数,结肠癌术后患者早期ONS,早期ONS组（n=15）,传统治疗组（n=14）,7%,7%,86%,7%,Lobato Dias Consoli M,et al.Early postoperative oral feeding impacts positively in patients undergoing colonic resection:results of a pilot study.Nutr Hosp,2010;25(5):806-9.,46%,47%,早期ONS组较传统组患者的营养状况差，但两组吻合口瘘的发生率相似,P0.05,结肠癌术后早期ONS促进肠功能恢复缩短住院时间,早期ONS组患者肠蠕动恢复所需时间显著缩短（D1排气，对照组D2排气），住院时间显著提前（中位数3天，对照组5天）；对照组的腹泻发生率是试验组的1.86倍（P0.05）,Lobato Dias Consoli M,et al.Early postoperative oral feeding impacts positively in patients undergoing colonic resection:results of a pilot study.Nutr Hosp,2010;25(5):806-9.,P0.05,EEN的必要性,大量研究证实EEN对降低并发症的发生率、加速康复、降低死亡率、缩短住院时间意义重大空肠喂养有助SAP和有反流、误吸风险的患者实现EEN，同时行胃肠减压，可降低风险结肠癌术后早期ONS虽短期内不利营养状态的改善，但可加速康复、缩短住院时间,有人认为只给EN，不能提供机体足够的能量，尽快纠正负担平衡到底用EN还是PN呢？,最新一项大规模的临床研究中，2312例ICU患者48h内给予EN+PN；2328例ICU患者给予早期EN，8天后才给予PN，观察早期PN和晚期PN对临床结局的影响,Casaer MP,et al.Early versus Late Parenteral Nutrition in Critically Ill Adults.N Engl J Med,2011;365(6):506-17.,晚期PN组患者存活出ICU比例高,HR：1.0695%CI：1.001.13P=0.04,晚期PN组患者存活出院比例高,HR：1.0695%CI：1.001.13P=0.04,首选EN，EN为主，PN必要时作补充,有营养风险，但无营养不良的患者入住ICU开始早期EN，如果7d内无法达到目标量时，第8天开始联用PN Casaer MP,et al.N Engl J Med,2011如果患者入ICU前身体健康且没有营养不良，肠外营养应在住院7d后才开始。EN达到摄入量的60%以上，不必联用PN,ASPEN 2009,ASPEN 2009,什么时候用PN？,患者已存在营养不良，但消化道不能耐受EN时，可用PN患者已存在营养不良，EN不能很快达到目标量，应同时开展EN和PNEN开始后在57天后，仍无法达到目标量的60%，应以PN做补充（SPN）,尽快达到目标量是否正确？,EN的目标量,能量,蛋白质,Singer P,et al.The tight calorie control study(TICACOS):a prospective,randomized,controlled pilot study of nutritional support in critically ill patients.Intensive Care Med,2011;37(4):601-9.,一项前瞻性、随机对照研究中，入选130例ICU患者，随机分为两组，一组按每48h直接测热法结果，给予营养支持，另一组按25kcal/kg/d给予营养支持,用公式法和测热法计算目标量,高能高蛋白VS低能低蛋白,EN早期给予ICU患者25kcal/kg/d，即相对于直接测热法结果，低热卡低蛋白的营养支持，可减少机械通气时间、ICU住院时间和感染发生例数，但急性期后仍给予25kcal/kg/d，可增加死亡率，提示急性期应给予低氮低热卡喂养，康复期应逐渐增加能量和蛋白的摄入。,Singer P,et al.The tight calorie control study(TICACOS):a prospective,randomized,controlled pilot study of nutritional support in critically ill patients.Intensive Care Med,2011;37(4):601-9.,无需急着达到目标量,患者在经历创伤、大手术、休克等应激后，机体的消化吸收、合成代谢需要一段时间恢复，所需时间与应激程度相关过快达到能量和蛋白的目标量，于预后无益，甚至有害当应激过后，机体的合成代谢增强，对能量和蛋白质的需求增加时，应及时增加，以满足机体需求EN由慢到快，由少到多的输注方式正好符合人体对营养的需求，这也是没有营养不良的患者无需早期给予PN的原因,
