醫(yī)學(xué)專題歐洲ESPEN關(guān)于危重癥患者的腸內(nèi)營養(yǎng)指南

1、ESPEN Guidelines on EnteralNutrition: Intensive care程俊峰普外科12021/7/19 星期一GeriatricsLiver diseaseSurgery including organ transplantation Wasting in HIV and other chronic infectious diseasesAdult renal failureGastroenterology PancreasCardiology and pulmonology Non-surgical oncologyIntensive careESPEN G

2、uidelines on EN:ESPEN Guidelines on PN:GeriatricsHepatologysurgeryCardiology and pneumologyAdult renal failureGastroenterology Pancreashome parenteral nutrition (HPN) in adult patients22021/7/19 星期一SummaryEnteral nutrition (EN) 的定義及目的： 1、EN is the preferred way of feeding the critically ill patient

3、and counteracting for the catabolic state induced by severe diseases. 2、Intended to give evidence-based recommendations for the ICU patient, focusing particularly on those who develop a severe inflammatory response, i.e. patients who have failure of at least one organ during their ICU stay.EN的 時機及要求

4、： 1、EN should be given to all ICU patients who are not expected to be taking a full oral diet within three days. 2、 the first 24 h using a standard high-protein formula. the acute and initial phases 2025 kcal/kg/d（exogenous energy）. Recovery, 2530 kcal/kg/d. 3、Glutamine should be supplemented in pat

5、ients suffering from burns or trauma.32021/7/19 星期一SubjectRecommendationsGradeindicationAll patients who are not expected to be on a full oral diet within 3 daysCApplicationThere are no data support using early EN can improve their Prognosis，but the committee still recommend the early（24h）appropriat

6、e amount of feeding, once the patienthave a haemo-dynamically stable and a functioninggastrointestinal tract.CExogenous energy supply:the acute and initial phase:25kcal/kg/d less favourableRecovery： 25kcal/kg/d Csevere under-nutrition：the EN energy supply should up to 25kcal/kg/d，if not reached，plea

7、se add PNCIf the patient intolerance (such as high gastric residuals) to EN, metoclopramide（胃復(fù)安）or Erythromycin（紅霉素）should be considered.CRouteUse EN in patients who can be fed via the enteral route.CVia jejunal versus gastric feeding, there is no significant difference.CIf the patients tolerate EN

8、and can reach the target energy value, PN should be avoid.A42021/7/19 星期一Via EN can not be fed sufficiently, PN Should supplementCType of formulaWhole protein formulae are superior to the peptide-basedformulaeCImmune-modulating formulae (formulae enrichedwith arginine(精氨酸), nucleotides（核苷酸） and w-3

9、fatty acids) are superior to standard enteral formulae:In elective upper GI surgical patients;in patients with a mild sepsis (APACHE 15);in patients with severe sepsis, may be harmful and are not Recommended;in patients with trauma;in patients with ARDS (formulae containing o-3 fatty acids and antio

10、xidants).ABBABDue to insufficient data, no recommendation support the Immune-modulating formulae apply to the burned patients, but the trace elements (Cu, Se and Zn) should besupplemented in a higher than standard doseAthe severe illness ICU patients, should not receive an immune-modulating formula

11、enriched with arginine, nucleotides and w-3 fatty acids if the EN700ml/d.BGlutamine should be added to standard enteralformula in burned patients and trauma patientsA52021/7/19 星期一1.1 EN-when?All patients （can not be on a full oral diet within 3 days） should receive EN（C） a. It is unethical to inves

12、tigate the maximum time of ICU patient can survive without nutritional support. b. Due to increased substrate metabolism（基礎(chǔ)代謝）, the critical illness is more likely to develop under-nutrition. c. Scandinavian showed that the mortality rate of patient treat with glucose only 250-300g/d over 14 days is

13、 10 times higher on adequate TPN. d. so inadequate oral intake, the surgical patient is likely to develop within 812 days of post-operation. e. Most trials focusing the early EN or late EN after 46 days, have proved the positive effect of early EN, so we come to the title conclusion.62021/7/19 星期一1.

14、2 EN-Is early EN superior to delayed EN? There are no data support using early EN can improve their prognosis，but the committee still recommend the early(24h）appropriate amount of feeding (C). a. meta analysis and systematic review A meta analysis of 15 RCTs (surgery, trauma, head injury, burns or s

15、uffering from acute medical conditions), showed early EN can reduce the infectious complications and length of stay. systematic review of 19 studies can show early EN play a positive effect on the survival rate、length of treatment, the rate of septic. and other complications，the conclusion provide 1

16、 level evidence for using the early EN. b. Individual studies: (recommendation level C) Moore and Jones Graham和coworkers Chiarelli et al Eyer et al Hasse et al Singh et al72021/7/19 星期一No general amount recommend to be adjust EN therapy according to courseof disease. But exogenous energy supply of t

17、he acute and initial phase:25kcal/kg/d and recovery： 25kcal/kg/d may be favourable (C)Prospective observational cohort studyIbrahimA recent trial1.3 EN-how much?82021/7/19 星期一1.4 which route ?Jejunal versus gastric feeding in critically illness patient is no difference (C).Jejunal feeding apply to p

18、atient post abdominal trauma or elective abdominal surgery or intolerance to gastric feeding a.11 randomised trials92021/7/19 星期一1.5 Is a peptide-based formula preferable to a whole protein formula?Whole protein formulae are appropriate in most patients（C） Exocrine pancreatic function is reduced in

19、sepsis，the digestion and absorption of whole protein formulae should be concerned. a. four randomised trials.102021/7/19 星期一1.6 When should motility agents be used in critically ill patients?If the patient intolerance (such as high gastric residuals) to EN, metoclopramid（胃復(fù)安）or Erythromycin（紅霉素）shou

20、ld be considered , e.g. with highgastric residuals (C).Booth（Meta-analysis）Yavagalthree studies published RecentlyThe conclusion: studies do not support the routine use of motility agents in critically ill patients (A).112021/7/19 星期一2.1 EN VS PNPatients who can be fed via the enteral route should r

21、eceive EN (C). a. meta analysis and systematic review b. Individual studies Kudsk Moore Conclusion：there is no definite advantage of EN over PN except for cost reduction; but the expert opinion is patients who can be fed enterally should receive it, over aggressive EN may cause harm and avoid overfe

22、eding.122021/7/19 星期一2.2 Under what conditions should PN be added to EN?Once patient tolerate EN and can be fed approximately to the target values, PN should not be added (A).Patient cannot be fed sufficient enterally the deficit, Supplemental PN should be added (C).If patient intolerance to the EN,

23、 PN should be proposed at a equal level, avoid overfeeding(C).A. meta-analysisB. blood-sugar 132021/7/19 星期一2.3 Should vulnerable patients be treated in a different way?vulnerable patients i.e. undernourished, chronic catabolic disease.Patients with a severe under-nutrition should receive EN up 2530

24、 total kcal/kg BW/day. If these target values are not reached, supplementary PN should be given (C).A. Review Whether the severe under-nutrition patient or the chronic catabolic disease，target values should be met fully using supplementary PN if necessary（C）142021/7/19 星期一3.1 Is a immune-modulating

25、formula superior to a standard enteral formula in any group of critically ill patients?Enteral immune-modulating nutrition implies a formula enriched with several functional substrates；many of the studies have used a particular formula, enriched with arginine, nucleotides and w-3 fatty acids.A. elec

26、tive upper GI surgical patients, yes (A)B. mild sepsis patients, yes (A); severe sepsis patients, harmful and not recommend (B) Galban Bower Bertoliniimmune-modulating nutrition improves outcome only in less severe sepsis (APACHE15), whereas this effect，tends to be of harm in severe sepsis and sever

27、ely ill patientsBase on the possible association with an increased mortality in patients with severe sepsis, these formulae should not be used in patients with severe sepsis152021/7/19 星期一C. Trauma: Yes (A)D. Burns: Due to the insufficient data, no recommendation regarding supplementation with x-3 f

28、atty acids, arginine, glutamine or nucleotides can be given for burned patients. Trace elements (Cu, Se and Zn) should be supplemented in a higher than standard dose (A). Gottschlich 2 studies the second study We suggest the immune-modulating formulae should administrate critically to the burned patient. The randomized controlled trials 162021/7/19 星期一E. ARDS