最新：危重病人营养支持规范文档资料.ppt

《最新：危重病人营养支持规范文档资料.ppt》由会员分享，可在线阅读，更多相关《最新：危重病人营养支持规范文档资料.ppt（47页珍藏版）》请在三一办公上搜索。

1、危重病人营养支持存在的问题,危重病人普遍(全球性)存在营养不良1970s:USABistrian1,NZHill21980s:USAKalmath3,AustraliaZador41990s:UKMcWhirter5,AustraliaMiddleton62000s:GermanyPawellek7,UKNHS Survey营养不良影响危重病人预后8-12,Bistrian et al.,JAMA 1976;1567Hill GL et al.,Lancet 1977;689Kalmath SK et al.,J Am Diet Assoc 1986;203Zador455,7.Pawelle

2、k I et al.,ClinNutr 2008;27:728.Thomas R.Am J ClinNutr 1979;32:2469.Reinhardt GF et al.,JPEN 1980;4:35710.Askanazi J et al.,Crit Care Med 1982;16311.Lopes J et al.,Am J ClinNutr 1982.12.Bozzetti F et al.,Surg Gynecol Obstet 1975;141:712-4,各国危重病人营养不良发生率,Canadian Critical Care Nutrition Survey 2006,危重

3、病人营养支持存在的问题,To feed or not to feed the critically ill patient约35%危重病人得不到合适营养支持营养不良影响患者预后死亡率约增加3倍并发症发生率增加住院时间延长,Berger MM et al:Optimizing nutrition therapy in the ICU.Curr Opin Clin Nutr Metab Care 2009,12:159160,能量代谢与能量需求,Overfeeding 并发症以及死亡率的增加 住院时间及机械通气时间延长(1).Hoffer LJ,Am J Clin Nutr.2003;78:906

4、-11(2).Scurlock c et al:,Curr Opin Clin Nutr Metab Care 2008;11:152-155(3).Kreymann KG et al;Curr Opin Clin Nutr Metab Care 2008;11:156-159Underfeeding 同样不利于患者预后(1)Villet et al:Clin Nutr 2005;24:502-509(2)Pichard C,et al:Clin Nutr 2008;3(suppl 1):0015(3)David Dvira,Clinical Nutrition(2006)25,3744（4）

5、Berger MM et al:Curr Opin Clin Nutr Metab Care 2009,12:159160,ESPEN Guidelines Recommendation,危重病人能量摄入量应尽可能接近机 体能量消耗值以降低 能量负平衡(Grade B),Pierre Singer，et al:ESPEN Guidelines on Parenteral Nutrition:Intensive care.Clinical Nutrition 2009；28：1-14,ESPEN Guidelines Recommendation,间接测热法是决定危重病人能量消耗及能量摄入的理想

6、 方法(Grade B),Pierre Singer，et al:ESPEN Guidelines on Parenteral Nutrition:Intensive care.Clinical Nutrition 2009；28：1-14,ESPEN Guidelines Recommendation,没有条件通过间接测热法测定实际测定患者的能量消耗时，危重病人(非肥胖)推荐热卡摄入量为 2025 kcal/kg/day(Grade C),Mechanick JI,et al:Curr Opin Clin Nutr Metab Care 2008,11:666670Kreymann KG,e

7、t al:Curr Opin Clin Nutr Metab Care 2008,11:156159McClave SA,et al:JPEN 2009;33:277-36Grau T,et al:Curr Opin Clin Nutr Metab Care 2009,12:175179Pierre Singer，et al:ESPEN Guidelines on Parenteral Nutrition:Intensive care.Clinical Nutrition 2009；28：1-14,ESPEN Guidelines Recommendation,危重病人单纯PN时,至少早期可以

8、允许轻度喂养不足(Permissive underfeeding),热卡摄入量为80%目标量，病情稳定后达到目标需要量(Grade C)肥胖病人(BMI30),热卡摄入量6070%目标量,McClave SA,et al:JPEN 2009;33:277-336Pierre Singer，et al:ESPEN Guidelines on Parenteral Nutrition:Intensive care.Clinical Nutrition 2009；28：1-14,Controversy:,Parenteral,and/or,Enteral,Evidence?,危重病人营养支持供给途径

9、,信息繁多，结论不一？,Meta-analysis results regarding Enteral versus parenteral nutrition,Meta-analysis results regarding Enteral versus parenteral nutrition,营养支持时机-早期营养,营养支持时机-早期营养,早期营养已成为ICU病人常规治疗措施目前公认的早期营养是指应激后2448 h 内开始进行营养支持早期肠内营养应是ICU病人的首选早期肠内营养可减轻应激反应程度、降低炎性介质产生、维持肠道结构完整性、减少肠源性感染发生率,Kreymann KG.Early

10、nutrition support in critical care:a European perspective。Curr Opin Clin Nutr Metab Care 2008,11:156159Scurlock C.Early nutrition support in critical care:a US perspective。Curr Opin Clin Nutr Metab Care 2008,11:152155,Early vs late enteral nutrition,Artinian et al.Chest 2006;129;960-967,N=4049,Early

11、 vs late enteral nutrition,Nguyen N,et al:CCM 2008;36:14691474,P=0.049,P=0.048,Meta-analysis results regarding Early vs late enteral nutrition,Does feed quantity matter?,Jerry A.Krishnan,Chest 2003;124;297-305,Binnekade JM,Crit Care Med 2005;9:R218,403SICU病人52%住院日接受EN,第1天39%,第5天51%平均蛋白质摄入量54%,能量摄入量6

12、6%,容量为75%影响EN实施的主要障碍:置管,应用药物,治疗干预 途径:经十二指肠和空肠喂养成功率经胃喂养,危重病人能量摄入情况,The NICE-SUGAR Study Investigators.N Engl J Med 2009,Nonprotein calories administered on days 1-14(kcal/day),Villet et al Clin Nutr 2005,危重病人营养支持途径及时机,危重病人首选肠内营养途径(Grade B)肠内营养应在2448h内开始(Grade C),并在随后的4872h达到目标量(Grade E)肠内营养48h 无法达到目标

13、量，应合并应用肠外营养(Grade C),Scurlock C,et al:Curr Opin Clin Nutri Metab Care 2008,11:152155Grau T,et al:Curr Opin Clin Nutr Metab Care 2009,12:175179Pierre Singer，et al:ESPEN Guidelines on Parenteral Nutrition:Intensive care.Clinical Nutrition 2009；28：1-14 Martindale RG,et al:ASPEN Guidelines Crit Care Med

14、 2009;37:1757,Steps to maximize efficacy of nutrition support,改善危重病人结局的措施还有避免高血糖症避免免疫抑制、感染并发症减少氧化应激反应减少瘦组织群丢失,1.Mechanick JI,Chiolero R.Curr Opin Clin Nutr Metab Care 2008;11:6666702.Pierre Singer，et al:ESPEN Guidelines on Parenteral Nutrition:Intensive care.Clinical Nutrition 2009；28：1-14,目前对血糖控制的观

15、点,危重病人应避免高血糖的发生，当血糖10mmol/L 胰岛素强化治疗1,2危重病人血糖维持140180mg/d(7.810.0 mmol/L)可降低低血糖风险,改善预后1,2危重病人血糖维持110150mg/d 较合适3,Pierre Singer，et al:ESPEN Guidelines on Parenteral Nutrition:Intensive care.Clinical Nutrition 2009；28：1-14Mechanick JI,et al:Curr Opin Clin Nutr Metab Care 2008,11:666670 3.McClave SA;et

16、al:Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient.JPEN 2009;33:277-3163,Guidelines Recommendation,危重病人单纯PN时,在ICU第一周应避免应用纯大豆油来源脂肪乳剂(Grade D)McClave SA;et al:Guidelines for the provision and assessment of nutrition support therapy in the ad

17、ult critically ill patient.JPEN 2009;33:277-3163“.the experts concluded:the pure soybean lipid emulsions should not longer be used in parenteral nutrition of critically ill patients”DGEM Guideline:PN-Lipid Emulsions Adolph,et al:2007,特殊营养物质的作用评价,药理营养（Pharmaconutrition）-在标准营养基础上提供药理剂量某个免疫调节营养素免疫营养（Im

18、munonutrition）-传统的肠内膳食中添加一个或多个免疫调节物质（如精氨酸、谷氨酰胺、核苷酸、鱼油、硒等）,Effect of Glutamine:Mortality,McClave SA,et al:Nutr Clin Pract.2009;24:305-315,Effect of Glutamine:Infectious Complications,McClave SA,et al:Nutr Clin Pract.2009;24:305-315,Effect of Glutamine:Hospital Length of Stay,McClave SA,et al:Nutr Cli

19、n Pract.2009;24:305-315,Effect of-3 Fat acid on critically ill patients,Effect of-3 Fat acid on Mortality,Koch T,Heller AR Akt Ern Med 2005,p0.0005,p0.0005,p=0.032,p=0.033,p0.0005,total,Sev.Head injury,Non abd Sepsis,Pancreatitis,Multiple trauma,Peritonitis,postoperative,-1,-0,5,0,0,5,1,Effect of-3

20、Fat acid on Infection rate,unfavourable,favourable,no effect,Koch T,Heller AR Akt Ern Med 2005,N=661,Guidelines Recommendation,Addition When PN is indicated in ICU patients the amino acid solution should contain 0.20.4 g/kg/day of L-glutamine(e.g.0.30.6 g/kg/day alanyl-glutamine dipeptide)(Grade A),

21、1.Canadian Critical Care Clinical Practice Guidelines Committee 20092.Pierre Singer，et al:ESPEN Guidelines on Parenteral Nutrition:Intensive care.Clinical Nutrition 2009；28：1-143.McClave SA;et al:Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill pat

22、ient.JPEN 2009;33:277-3163,ESPEN Guidelines Recommendation,Addition of EPA and DHA to lipid emulsions has demonstrable effects on cell membranes and inflammatory processes(Grade B)Fish oil-enriched lipid emulsions probably decrease length of stay in critically ill patients.(Grade B),1.Grau T,et al:C

23、urr Opin Clin Nutr Metab Care 2009,12:1751792.Pierre Singer，et al:ESPEN Guidelines on Parenteral Nutrition:Intensive care.Clinical Nutrition 2009；28：1-14,Immunonutrition and mortality,Jones NE et al,Curr Opin Gastro 2008,24:215222,Immunonutrition on infections,Marik PEet al,Intensive Care Med(2008)3

24、4:19801990,Immunonutrition on LOS,Marik PEet al,Intensive Care Med(2008)34:19801990,Immunonutrition reduction in length of postoperative stay,Stableforth WD,et al,Int.J.Oral Maxillofac.Surg.2009;38:103110,P 0.01,ESPEN Guidelines Recommendation,Immune-modulating enteral formulations should be used fo

25、r appropriate patient population,with caution in patients with severe sepsis.For surgical ICU patients(Grade A)For medical ICU patients(Grade B),Grau T,et al:Curr Opin Clin Nutr Metab Care 2009,12:175179McClave SA;et al:ESPEN Guidelines on Parenteral Nutrition:Intensive care al:JPEN 2009;33:277-316.

26、,Combination of EPA/GLA and antioxidant vitamins,Pontes Arruda,Crit Care Med,2006；34:2325,Suvival,Nathens et al,Ann Surg,2002,ARDS,Early administration of AOX after trauma,595 patients(91%trauma)Vitamin C(1000 mg IV q 8 h)Vitamin E(1000 IU PO q 8 h)Outcome:Decrease organ failure Decrease ICU stay,Na

27、thens et al,Ann Surg,2002,MOF,Early administration of AOX after trauma,Outcome:Decrease organ failure,Effect of AOX on the mortality of critically ill patients,Jones NE et al,Curr Opin Gastro 2008,24:215222,ESPEN Guidelines Recommendation,Patients with ARDS and severe acute lung injury should be pla

28、ced on an enteral formulation characterized by an anti-inflammatory lipid profile(ie,3 fish oils,borage oil)and antioxidants.(Grade A)A combination of antioxidant vitamins and trace minerals(specifically including selenium)should be provided to all critically ill patients.(Grade B),McClave SA;et al:

29、ESPEN Guidelines on Parenteral Nutrition:Intensive care al:JPEN 2009;33:277-316.,Theoretical construct for nutrition therapy in the critically ill patient of the future,McClave SA,et al:Nutr Clin Pract.2009;24:305-315,Are we feeding these patients adequately?,Cahill NE et al:Crit Care Med 2010;38:395 401,158 ICUs from 20 countries enrolled of 2946 patients and 27944 patient days,感谢您的关注！,