2016SCCMASPEN成人危重症患者营养支持治疗指南.ppt

2016 SCCM/ASPEN成人危重症患者营养支持治疗指南解读,沧州市人民医院 重症医学科 王文生,危重症治疗的三大技术Three major techniques in ICU,机械通气,营养支持,血液净化,重症医学要做的两件事 Two important supports in ICU,器官功能支持 营养代谢支持,10/4/2019,所患的疾病不同， 却会遇到同样的问题! Same problem in different diseases!,营养不良！,创伤,外科危重症,内科危重症,贫困所导致的营养不良是人权问题,疾病所导致的营养不良同样是人权问题,.神经内分泌激素与细胞因子构成复杂的网络系统，并由此调控机体的免疫状态与炎症反应。 .在遭受打击之后，血清应激激素水平增高： 应激激素-肾上腺素（epinephrine）与皮质醇（cortisol）升高，伴随着多种生理的挑战和促皮质激素、生长激素（GH）、胰高血糖素以及儿茶酚胺水平升高，由此导致 糖、蛋白质、脂肪三大营养物质以及微量营养素的代谢改变。,重症患者的代谢变化,创伤感染 严重应激,细胞因子 神经介质 激素,糖代谢异常,脂肪分解,蛋白质消耗,免疫炎性介质 TNF IL-1、IL-6,神经介质 儿茶酚胺,内分泌介质 糖皮质激素、胰高血糖素、肾上腺素,营养是人权？ 营养治疗同“温饱” 问题一样是人权,政府和卫生职能部门 建立营养风险评估和监测的标准程序 营养不良应当成为诊断和治疗的概念被临床接受 建立营养治疗开始、监测和终止的标准程序 营养筛查、评估和监测应当作为评估医疗质量的标准 及时补充优于事后纠正 -黎介寿,Clinical Nutrition 2004,23:135-137,从营养支持(nutrition support)到 营养治疗(nutrition therapy),营养有免疫调控、减轻氧化应激、维护胃肠功能与结构、降低炎症反应、改善病人生存率等作用 JAMA Dec 17 2008:2798-2799 From Care To Cure E.S.P.E.N Guideline, 2008 (欧洲肠内与肠外营养学会) Nurition support therapy A.S.P.E.N Guideline, 2009 （美国肠内与肠外营养学会),营养支持目的,供给细胞代谢所需要的能量与营养底物，维持组织器官结构与功能 通过营养素的药理作用调理代谢紊乱，调节免疫功能，增强机体抗病能力，从而影响疾病的发展与转归，这是实现重症病人营养支持的总目标 合理的营养支持，可减少净蛋白的分解及增加合成，改善潜在和已发生的营养不良状态，防治其并发症。 营养不良对预后的影响：增加感染等并发症的发生率、延长住ICU与住院时间（LOS）、增加死亡率、增加医疗花费（Costs）,12,该指南面向医师、护士、营养师和药师，针对重症成人（18岁以上）患者，提供了最佳营养疗法的最新建议，协助医疗团队提供适当的营养疗法，可减少并发症、缩短住院时间、降低疾病严重程度、改善患者结局。,指南内容框架,14,A.营养评估,B、EN启动时机,C、热卡与蛋白质需要量,D、耐受性监测与充分性评估,E、肠内营养制剂选择,G、 何时应用PN,F、辅助治疗,H、 PN最大获益的适应症,A 营养评估,A1. Based on expert consensus, we suggest a determination of nutrition risk (for example, nutritional risk score NRS-2002, NUTRIC score) be performed on all patients admitted to the ICU for whom volitional intake is anticipated to be insufficient. High nutrition risk identifies those patients most likely to benefit from early EN therapy. 根据专家共识，我们建议对收入ICU且预计摄食不足的患者进行营养风险评估（如营养风险评分NRS-2002，NUTRIC 评分）。高营养风险患者的识别，最可能使其从早期肠内营养治疗中获益。 A2. Based on expert consensus, we suggest that nutritional assessment include an evaluation of comorbid conditions, function of the gastrointestinal (GI) tract, and risk of aspiration. We suggest not using traditional nutrition indicators or surrogate markers, as they are not validated in critical care. 根据专家共识，我们建议营养评估应当包括对于基础疾病、胃肠道功能以及反流误吸风险的评估。我们建议不要使用传统的营养指标或其替代指标，因为这些指标在ICU的应用并非得到验证。,NRS-2002,Risk3；High risk5,NUTRIC评分,Without IL-65；IL-66,A 营养评估,A3a. We suggest that indirect calorimetry (IC) be used to determine energy requirements, when available and in the absence of variables that affect the accuracy of measurement. 如果有条件且不影响测量准确性的因素时，建议应用间接能量测定(间接测热法，indirect calorimetry，IC) 确定能量需求。 A3b. Based on expert consensus, in the absence of IC, we suggest that a published predictive equation or a simplistic weight-based equation (2530 kcal/kg/ day) be used to determine energy requirements. 根据专家共识，如果无法测定IC，建议使用已发表的预测公式或基于体重的简化公式(2530 kcal/kg/ day)确定能量需求。,B 启动肠内营养时机,B1. We recommend that nutrition support therapy in the form of early EN be initiated within 2448 hours in the critically ill patient who is unable to maintain volitional intake. 对于不能维持自主进食的危重病患者，我们推荐在24-48小时内通过早期EN开始营养支持治疗。 B2. We suggest the use of EN over PN in critically ill patients who require nutrition support therapy. 对于需要营养支持治疗的危重病患者，建议首选EN而非PN的营养供给方式。,营养支持的治疗原则,If the gut works, use it first! 只要有胃肠道功能，首选肠内营养！,肠内营养的优越性：“四屏障学说”,B启动肠内营养时机,B3. Based on expert consensus, we suggest that, in the majority of MICU and SICU patient populations, while GI contractility factors should be evaluated when initiating EN, overt signs of contractility should not be required prior to initiation of EN. 基于专家共识，建议，对于多数MICU和SICU患者，尽管启用EN时需要对胃肠道蠕动情况进行评估，但此前并不需要有肠道蠕动的体征。 建议烧伤患者尽早开始EN，如果可能应在损伤后4-6小时开始。,AGI(急性胃肠损伤) 严重程度分级 AGI级 是一个自限性的阶段，但进展为胃肠道功能障碍或衰竭 风险较大 AGI 级 胃肠功能障碍，需要干预措施来重建胃肠道功能 AGI 级 胃肠功能衰竭，经干预处理后不能恢复 AGI 级 胃肠功能衰竭伴有远隔器官功能障碍，急剧出现并立即 威胁到生命,AGI分级和早期肠内营养,B启动肠内营养时机,B4a. We recommend that the level of infusion be diverted lower in the GI tract in those critically ill patients at high risk for aspiration (see section D4) or those who have shown intolerance to gastric EN. Quality of Evidence: Moderate to High 对于具有误吸高危因素或不能耐受经胃喂养的重症患者，我们推荐减慢EN输注的速度。推荐营养管路尽量放置于下段胃肠道。 B4b. Based on expert consensus we suggest that, in most critically ill patients, it is acceptable to initiate EN in the stomach. 建议经胃开始喂养是多数危重病患者可接受的EN方式。,肠内喂养途径,Dobbhoff NG Tube Entriflex NG Tube Pedi-Tube Pediatric NG Kangaroo Non-Weighted NG Tube,Endo Tube NJ Tube Dobbhoff NJ/GD Tube (见右图),EntriStar 单通道 P.E.G. 套件 (见左图) Kangaroo EntriStar 空肠喂伺管 - 经 P.E.G. 插入(见右图),1. 鼻胃管 (鼻到胃):,2. 鼻空肠 (NJ) 饲管 (从鼻腔经过屈氏韧带到空肠),3. P.E.G. 和 P.E.G./J 喂饲管 (经皮内窥镜胃造瘘术),4. 贴身胃造瘘系统及替代装置 (二级替代管),EntriStar Skin Level Gastrostomy Tube (见左图) Kangaroo Gastrostomy Feeding Tube (见右图),临床肠内营养管路的种类,肠内管饲营养,鼻肠管,鼻空肠管,胃造口,空肠造口,经皮放射显影插入,鼻十二指肠管,鼻胃管,经皮内窥镜下胃造口,手术中置入,手术中置入,经皮内窥镜置入,放射显影插入,胃减压空肠营养管,Tube guideline ,crest.2004,经皮内镜下胃造口术 (percustanous endoscopic gastrostomy, PEG),就是这么容易,鼻胃管饲,否,鼻肠管饲,是,高度肺吸入风险,鼻胃(肠)管饲,否,胃造口术,否,空肠造口术,是,高度肺吸入风险,胃肠造口术,是,预测时间4周?,管饲喂养,肠内营养途径的选择,管饲营养的投给方式,B启动肠内营养时机,B5. Based on expert consensus, we suggest that in the setting of hemodynamic compromise or instability, EN should be withheld until the patient is fully resuscitated and/or stable. Initiation/reinitiation of EN may be considered with caution in patients undergoing withdrawal of vasopressor support. 建议在血流动力学不稳定时，应当暂停EN直至患者接受了充分的复苏治疗和（或）病情稳定。对于正在撤除升压药物的患者，可以考虑谨慎开始或重新开始EN。,C 肠内营养剂量,C1. Based on expert consensus, we suggest that patients who are at low nutrition risk with normal baseline nutrition status and low disease severity (for example, NRS-2002 3 or NUTRIC score 5) who cannot maintain volitional intake do NOT require specialized nutrition therapy over the first week of hospitalization in the ICU. 建议那些营养风险较低及基础营养状况正常、疾病较轻（例如NRS-2002 3 或 NUTRIC评分 5）的患者，即使不能自主进食，住ICU的第一周内不需要特别给予营养治疗。,C 肠内营养剂量,C2. We recommend that either trophic or full nutrition by EN is appropriate for patients with acute respiratory distress syndrome (ARDS)/acute lung injury (ALI) and those expected to have a duration of mechanical ventilation 72 hours, as these two strategies of feeding have similar patient outcomes over the first week of hospitalization. 对于急性呼吸窘迫综合征(ARDS)/急性肺损伤(ALI)患者或者预期机械通气时间 72小时的患者，我们推荐给予滋养型或充分的肠内营养，这两种营养补充策略对患者住院第一周预后的影响并无差异。 全身感染早期给予滋养型喂养策略，如果耐受良好，则24-48小时后开始增加喂养量，第一周内达到80%目标量。 滋养型喂养：10-20kcal/Kg/d或不超过500kcal/d。,C 肠内营养剂量,C3. Based on expert consensus, we suggest that patients who are at high nutrition risk (for example, NRS-2002 5 or NUTRIC score 5, without interleukin-6) or severely malnourished should be advanced toward goal as quickly as tolerated over 2448 hours while monitoring for refeeding syndrome. Efforts to provide 80% of estimated or calculated goal energy and protein within 4872 hours should be made in order to achieve the clinical benefit of EN over the first week of hospitalization. 建议具有高营养风险患者（如：NRS-2002 3 或不考虑IL-6情况下NUTRIC评分 5）或严重营养不良患者（ NRS-2002 5 ）， 应在24-48小时达到并耐受目标喂养量；监测再喂养综合征。争取于48-72小时达到目标热卡及蛋白量的80%以上，这样才能在入院一周内实现EN的临床效益。,再喂养综合征是指在长期饥饿后提供再喂养(包括经口摄食、肠内或肠外营养)所引起的、与代谢异常相关的一组表现,包括严重水电解质失衡、葡萄糖耐受性下降和维生素缺乏等。遵循“先少后多、先慢后快、先盐后糖、多菜少饭、逐步过渡”二十字原则，一周后再恢复至正常需要量。,C 肠内营养剂量,C4. We suggest that sufficient (high-dose) protein should be provided. Protein requirements are expected to be in the range of 1.22.0g/kg actual body weight per day, and may likely be even higher in burn or multi- trauma patients (see sections M and P). 建议充分足够的蛋白质供给。蛋白质需求预计为1.2-2.0 g/kg （实际体重）/天，烧伤或多发伤患者对蛋白质的需求量可能更高。,D 肠内营养的耐受性与充分性,D1. Based on expert consensus, we suggest that patients should be monitored daily for tolerance of EN. We suggest that inappropriate cessation of EN should be avoided. We suggest that ordering a feeding status of nil per os (NPO) for the patient surrounding the time of diagnostic tests or procedures should be minimized to limit propagation of ileus and to prevent inadequate nutrient delivery. 根据专家共识，我们建议应每日监测EN耐受性。我们建议应当避免不恰当的中止EN。我们建议，患者在接受诊断性检查或操作期间，应当尽可能缩短禁食状态(NPO)的医嘱，防止营养供给不足。,D 肠内营养的耐受性与充分性,D2a. We suggest that GRVs not be used as part of routine care to monitor ICU patients on EN. 建议不应当把GRV作为接受EN的ICU患者常规监测的指标。 D2b. We suggest that, for those ICUs where GRVs are still utilized, holding EN for GRVs 500 ml in the absence of other signs of intolerance (see section D1) should be avoided. 对于仍然监测GRV的ICU，应当避免在GRV500 ml且无其他不耐受表现时中止EN。,D 肠内营养的耐受性与充分性,D3a. We recommend that enteral feeding protocols be designed and implemented to increase the overall percentage of goal calories provided. 推荐制定并实施肠内营养喂养方案，以提高实现目标喂养的比例。 D3b. Based on expert consensus, we suggest that use of a volume-based feeding protocol or a top-down multi-strategy protocol be considered. 建议考虑采用容量目标为指导的喂养方案或多重措施并举的喂养方案(top-down multi-strategy protocol)。,D 肠内营养的耐受性与充分性,D4. Based on expert consensus, we suggest that patients placed on EN should be assessed for risk of aspiration, and that steps to reduce risk of aspiration and aspiration pneumonia should be proactively employed. 根据专家共识，我们建议对接受EN的患者，应当评估其误吸风险，并主动采取措施以减少误吸与吸入性肺炎的风险。 D4a. We recommend diverting the level of feeding by post-pyloric enteral access device placement in patients deemed to be at high risk for aspiration (see also section B5) 对于误吸风险高的患者，我们推荐改变喂养层级，放置幽门后喂养通路。,D 肠内营养的耐受性与充分性,D4b. Based on expert consensus, we suggest that for high-risk patients or those shown to be intolerant to bolus gastric EN, delivery of EN should be switched to continuous infusion. 根据专家共识，对于高危患者或不能耐受经胃单次输注EN的患者，我们建议采用持续输注的方式给予EN。 D4c. We suggest that, in patients at high risk of aspiration, agents to promote motility, such as prokinetic medications (metoclopramide or erythromycin), be initiated where clinically feasible. 对于存在误吸高风险的患者，我们建议一旦临床情况允许，即给予药物促进胃肠蠕动，如促动力药物（甲氧氯普胺10mg qid或红霉素3-7mg/kd/d）。,D4d. Based on expert consensus, we suggest that nursing directives to reduce risk of aspiration and VAP be employed. In all intubated ICU patients receiving EN, the head of the bed should be elevated 3045 and use of chlorhexidine mouthwash twice a day should be considered. 我们建议采取相应护理措施降低误吸与VAP的风险。对于接受EN且有气管插管的所有ICU患者，床头应抬高30-45，每日2次使用洗必泰进行口腔护理。 D5.Based on expert consensus, we suggest that EN NOT be automatically interrupted for diarrhea but rather that feeds be continued while evaluating the etiology of diarrhea in an ICU patient to determine appropriate treatment. 建议不要因ICU患者发生腹泻而自动中止EN，而应继续喂养，同时查找腹泻的病因以确定适当的治疗。,E 肠内营养制剂选择,E1. Based on expert consensus, we suggest using a standard polymeric formula when initiating EN in the ICU setting. We suggest avoiding the routine use of all specialty formulas in critically ill patients in a MICU and disease-specific formulas in the SICU. 建议ICU患者开始EN时选择标准多聚体配方肠内营养制剂。我们建议MICU的危重病患者应避免常规使用各种特殊配方制剂，SICU患者应避免常规应用疾病专属配方肠内营养制剂。,华瑞系列,G 何时应用PN,G1. We suggest that, in the patient at low nutrition risk (for example, NRS-2002 3 or NUTRIC score 5), exclusive PN be withheld over the first 7 days following ICU admission if the patient cannot maintain volitional intake and if early EN is not feasible. 我们建议，对于低营养风险（如：NRS-20023或NUTRIC评分5）、不适宜早期肠内营养、且入ICU 7天仍不能保证经口摄食量的患者，7天后给予PN支持。,G2. We recommend that, in patients at either low or high nutrition risk, use of supplemental PN be considered after 7 to 10 days if unable to meet 60% of energy and protein requirements by the enteral route alone. 无论低或高营养风险患者，接受肠内营养7-10天，如果经EN摄入能量与蛋白质量仍不足目标的60%，我们推荐应考虑给予补充型PN。,1.糖类/葡萄糖 糖类是非蛋白质热量（NPC）的主要来源之一，每克糖提供4kcal热量。 外源葡萄糖供给量一般从100-150g/d开始，占NPC的50-60%，葡萄糖：脂肪比例保持在60:40-50:50，同时注意葡萄糖的输注速度，2.5-4mg/（kg.min）。 监测血糖水平，需要时应用胰岛素控制，最高不超过9.9mmol/L（180mg/L）。如果超过10.0mmol/L，应用胰岛素。,营养要素,2.脂肪与脂肪乳剂 脂肪是NPC的另一部分来源，同时提供机体必需脂肪酸，参与细胞膜磷脂的构成及作为携带脂溶性维生素的载体。 每克脂肪提供9kcal热量，糖脂双能源供能有助于减轻葡萄糖的代谢负荷和营养支持中血糖升高的程度。,2.脂肪与脂肪乳剂 重症患者脂肪供给量一般为1-1.2g/（kg.d），需考虑机体对脂肪的利用和代谢能力，注意监测血脂水平及肝肾功能。 高甘油三酯血症（4-5mmol/L）不推荐使用脂肪乳剂； 重症急性胰腺炎合并高脂血症、动脉粥样硬化症患者应慎用； 老年患者，应降低脂肪的补充量0.5-1.0g/（kg.d），每周补充一次脂肪乳剂即可达到目的。,3.氨基酸/蛋白质 氨基酸是肠外营养时氮的来源，是合成蛋白质的底物。每克氮含有6.25g蛋白质。 重症患者蛋白质补充量一般从1.2-2.0g/(kg.d）开始，相当于氮0.2-0.25/(kg.d)。 支链氨基酸：是在肝外代谢的氨基酸，应用于肝功能障碍患者，有助于减轻肝脏代谢负担，防治肝性脑病。,谷氨酰胺（Gln）：是体内含量最丰富的非必需氨基酸。Gln具有重要的生理作用，它是快速生长细胞（免疫细胞、小肠和肺泡上皮）的重要能源。改善氮平衡,促进肌肉蛋白合成，维持肠道的完整性，支持免疫功能，改善肿瘤治疗效果。 专家共识：推荐危重症患者肠外营养期间无需常规补充谷氨酰胺。,4.维生素与微量元素：危重症患者每日应补充12种必需的维生素A、C、D、E、K、B12、B1、B2、叶酸、烟酸、泛酸、生物素。微量元素包含：Ca、Cl-、铬、Cu、I、Mg、P、Se、Na、Zn。,5.电解质：每日常规补充的电解质主要有钾、钠、氯、钙、镁、磷。 每日维持生理平衡的推荐量：钠80-100mmol 钾60-80mmol 氯50-100mmol 醋酸盐50-100mmol 镁8-16mmol 钙5-10mmol 磷15-30mmol 有额外丢失的还需充分考虑到增加额外丢失量，在监测下补充。,肠外营养支持途径 经中心静脉肠外营养 锁骨下静脉、颈内静脉、股静脉、PICC（经外周静脉中心静脉置管） 经外周静脉肠外营养,中心静脉营养（ CV-PN ） 外周静脉营养（ PV-PN ）,优点,局限性,置管技术 置管并发症 导管相关性感染,优点,局限性,PH值 4.5 或9.0时，内膜损伤. 渗透压450mosm/l 中度静脉炎 渗透压600mosm/l 静脉炎 刺激性药物皮肤血管 尽量 600mosm，输完冲洗， 细针、多更换部位（1-2天）,PH 渗透压,PV-PN,简单易行 穿刺并发症 导管相关性感染,中心静脉输注,All in one 全合一、三升袋,三 升 袋,病人,白蛋白,三 升 袋,胰岛素,大泵,注射泵,病人,三 升 袋,大泵,终端 过滤器,病人,前后盐水冲洗,血糖高,免疫力低下,PN输注法单输,病人,对肝脑肾有影响,病人,脂肪超载综合症：发热急性胃肠溃疡溶血血小板积聚等 脂肪廓清障碍：前列腺素增加肺气体交换障碍高脂血症等 海蓝组织细胞综合症：肝脾肿大等,脂肪乳输入8小时 造成破乳 使用三通连接,葡,萄,糖,脂,肪,乳,病人,葡,萄,糖,脂,肪,乳,病人,PN输注法-串输,4-7h,8-12h,3-5h,脂 肪 乳,氨 基 酸,葡 萄 糖,三通,H PN最大获益的适应症,H1. We suggest that hypocaloric PN dosing ( 20 kcal/kg/day or 80% of estimated energy needs) with adequate protein ( 1.2g protein/kg/day) be considered in appropriate patients (high risk or severely malnourished) requiring PN, initially over the first week of hospitalization in the ICU. 对于高营养风险或严重营养不良、需要PN支持的患者，我们建议住ICU第一周内给予低热卡PN（20 kcal/kg/day 或能量需要目标的80%），以及充分的蛋白质补充（ 1.2 g/kg/day）。,H PN最大获益的适应症,H2. Based on expert consensus, use of standardized commercially available PN versus compounded PN admixtures in the ICU patient has no advantage in terms of clinical outcomes. 根据专家共识，标准商品化的PN制剂（多腔袋）与配置PN液相比，未见任何影响ICU患者临床结局的优势。,H PN最大获益的适应症,H3. We recommend a target blood glucose range of 140 or 1