ICU病人的早期肠内营养：当前的实践与挑战2011-8-6威海 [兼容模式].pdf

ICU病人的早期肠内营养病人的早期肠内营养：ICU病人的早期肠内营养病人的早期肠内营养：当前的实践与挑战当前的实践与挑战李维勤李维勤南京大学医学院南京军区总医院重症监护中心全军普通外科研究所SICU加拿大重症病人危重病人营养支持指危重病人营养支持指加拿大重症病人营养支持指南.JPEN 2003;27:355 373危重病人营养支持指危重病人营养支持指导意见（草案）导意见（草案）中华医学会重症医学分会中华医学会重症医学分会JPEN 2003;27:3553732006年年5月月共同的推荐:早期肠内营养！重症病人营养指南重症病人营养指南ESPEN Guidelines on Enteral Nutrition:Intensive care重症病人营养指南重症病人营养指南-2009 ASPEN/SCCMCrit Care Med 2009；37（5）Clinical Nutrition(2006)25,210223；2009 ASPEN/SCCM要点要点2009 ASPEN/SCCM要点要点 更强调肠内营养，早期肠内营养更激进应当在入ICU后最初2448小时内早期开始肠内营养应当在入ICU后最初24-48小时内早期开始肠内营养，应当在48-72小时内达到喂养目标 肠鸣音存在与否以及是否排气排便均不影响开始肠内喂养喂养 如果在入住ICU的最初7天内不能进行早期 EN，无需进行营养支持治疗（标准治疗）行营养支持治疗（标准治疗）Crit Care Med 2009；37（5）：）：17571761中国ICU的营养支持方式(2008)全球全球全球全球全球全球全球全球一为什么要早期肠内营养？、为什么要早期肠内营养？危重病人的早期肠内营养危重病人的早期肠内营养原理与研究假设门静脉门静脉淋巴系统细菌/内毒素图片脏器4四个肠源性感染肠源性感染?早期肠内营养相比延迟肠内营养相比延迟肠内营养早期肠内营养改善重病人预后早期肠内营养改善重病人预后？相比延迟肠内营养相比延迟肠内营养，早期肠内营养改善重病人预后早期肠内营养改善重病人预后？Canadian clinical practice guidelines for nutrition support in mechanicallyCanadian clinical practice guidelines for nutrition support in mechanically ventilated,critically ill adult patients.J Parenter Enteral Nutr.2003 Sep-Oct;27(5):355-73.早期肠内营养能改善营养摄取，降低危重病人死亡率，显著降低感染并发率著降低感染并发率 虽然有报道了早期行肠内营养的安全性问题。但是考虑到肠内营养的益处，同时早期肠内营养可行性较好，委员会还是推荐早期使用肠内营养支持。还是推荐早期使用肠内营养支持。委员会将早期肠内营养定义为“进入ICU内24-48小时”关于EEN 的荟萃分析Early enteral nutrition provided within 24 h of关于EEN 的荟萃分析Early enteral nutrition,provided within 24 h of injury or intensive care unit admission,significantly reduces mortality in critically illsignificantly reduces mortality in critically ill patients:a meta-analysis of randomised controlled trialscontrolled trialsIntensive Care Med.2009;35(12):2018-27.Six RCTs,234 participants EEN reduces mortality OR=0 34EEN reduces mortality OR 0.34 EEN reduce pneumonia(OR=0.31).截至2011年6月共有22个RCT 研究20个截至2011年6月，共有22个RCTs研究，20个结果支持EENEarly enteral nutrition in burns:compliance with guidelines and associated outcomes in a multicenter study.yJ Burn Care Res.2011 Jan-Feb;32(1):104-9Early hypocaloric enteral nutritional supplementation in acute organophosphate poisoning-a prospective randomized trialgpppgppClin Toxicol(Phila).2009 May;47(5):419-24.Effect of evidence-based feeding guidelines on mortality of critically ill adults:a cluster randomized controlled trialcritically ill adults:a cluster randomized controlled trial.JAMA.2008 Dec 17;300(23):2731-41.The impact of delaying enteral feeding on gastric emptying,plasma cholecystokinin,and peptide YY concentrations in criticallyplasma cholecystokinin,and peptide YY concentrations in critically ill patients.Crit Care Med.2008 May;36(5):1469-74.早期肠内营养的瓶颈在哪里？二、ICU病人早期肠内营养如何提高耐受性如何提高耐受性？ICU 患者EN相关并发症ICU 患者EN相关并发症中心中心37GI 并发症并发症56.3%上消化道不耐受上消化道不耐受56 7中心中心37病人病人400上消化道不耐受上消化道不耐受：high HGRV吐吐 返流返流56.7391APACHE II18.2NGT91%呕呕吐吐/返流返流17.7便秘便秘15.7NGT91%EN days9.8腹泻腹泻14.7腹胀腹胀13.2腹胀腹胀13.2误吸误吸1.5改进肠内营养耐受能做什么？监测监测病因处理幽门后喂养（小肠喂养）适当的制剂和消化液/酶补充优化输注技术优化输注技术EN 的耐受性监测些什么1、根据病人疼痛和/或腹胀的主诉1、根据病人疼痛和/或腹胀的主诉 体格检查，排气排便，腹部影像学检查结果确定2测定胃残液量2、测定胃残液量 胃残液量测定是目前临床最常用的方法 胃残液量测定的具体的操作方法目前尚无标准化的流程的流程 胃残留量200ml可维持原速度，如果200ml，应暂停或降低速度肠系膜静脉广泛血栓形成肠系膜静脉广泛血栓形成 腹腔血性渗液约2000ml Treitz韧带下40cm空肠坏死约50cm，远端肠坏死约50cm，远端小肠水肿，系膜V广泛血栓形成血栓形成 SMA主干及分支搏动良好SMV壁厚扩张好，SMV壁厚，扩张15机械性肠梗阻机械性肠梗阻机械性肠梗阻机械性肠梗阻 男28岁 男，28岁 SAP 持续腹胀 持续腹胀 腹腔高压休克 休克1617181920改进肠内营养耐受能做什么？监测监测病因处理幽门后喂养（小肠喂养）适当的制剂和消化液/酶补充优化输注技术优化输注技术ICU病人腹泻的常见原因病人腹泻的常见原因 病理生理基础 肠粘膜结构改变：坏死脱落、糜烂消化酶减少肠系膜血流减少：缺血缺氧 肠道水肿：低蛋白血症、输注大量晶体低蛋白血症、输注大量晶体 菌群失调：抗生素相关腹泻抗生素相关腹泻 肠内营养输注技术不良 肠内营养输注技术不良 药物：导泻剂、含山梨糖醇的 混悬糖浆等腹胀的原因腹胀的原因腹腔内感染、炎症腹腔内感染、炎症包括吸收不良包括吸收不良电解质紊乱电解质紊乱电解质紊乱电解质紊乱肠系膜血流减少：休克肠系膜血流减少：休克 sepsis肠道菌群改变肠道菌群改变颅内压增高颅内压增高颅内压增高颅内压增高药物：镇静剂、钙离子拮抗剂、抗胆碱类药物：镇静剂、钙离子拮抗剂、抗胆碱类改进肠内营养耐受能做什么？监测监测病因处理幽门后喂养（小肠喂养）适当的制剂和消化液/酶补充优化输注技术优化输注技术小肠喂养小肠喂养小肠喂养小肠喂养途径的建立途径的建立途径的建立途径的建立内镜引导下内镜引导下X线引导下线引导下X线引导下线引导下螺旋营养管螺旋营养管水囊管水囊管无线电导航无线电导航无线电导航无线电导航PEGJ：通过PEG间接性空肠造口Percutaneous Endoscopic Gastrojejunostomy 空肠管空肠管空肠管空肠管递递 送送递递 送送与经胃与经胃 VS 经小肠营养能否改善预后？经小肠营养能否改善预后？与经胃营养比较经小肠营养减少肺炎与经胃营养比较，经小肠营养减少肺炎发生率，提高危重病人的热卡和蛋白的摄取量，同时减少营养用至全量的时间Canadian clinical practice guidelines for nutrition support in mechanically ventilated,critically ill adult patients.J Parenter Enteral Nutr.2003 Sep-Oct;27(5):355-73.Gastric versus transpyloric feeding in severe traumatic brain injury:a prospective,randomized trial.Intensive Care Med.2010 Sep;36(9):1532-9RCT研究104例 TBI104例 TBIPatients were randomized to TPF or GF groupsThe TPF group had a lower incidence of pneumoniaThe TPF group had a lower incidence of pneumonia The TPF group received higher amounts of diet The TPF had lesser incidence of increased gastric residualsCONCLUSIONS:Enteral nutrition delivered through the transpyloric route reduces the incidence of overall and late pneumonia andreduces the incidence of overall and late pneumonia and improves nutritional efficacy in severe TBI patients.2009 ASPEN/SCCM要点要点2009 ASPEN/SCCM要点要点ICU中可进行经胃或经小肠喂养：ICU中可进行经胃或经小肠喂养：如果误吸危险性很大或经胃喂养后表现不耐受，则应通过留置在小肠的营养管对重症病病人进行喂养（C 级）如果反复因胃残余量过多终止肠道喂养，则可以转换为经小肠喂养（胃残余量过多的定义各个医院间存在差别）（E 级）注释：痹误吸高风险：胃潴留、连续镇静或肌松、肠道麻痹或需要鼻胃引流的病人改进肠内营养耐受能做什么？监测监测病因处理幽门后喂养（小肠喂养）适当的制剂和消化液/酶补充优化输注技术优化输注技术肠内营养营养制剂影响耐受性？胃肠道功能胃肠道功能正常整蛋白为氮源的膳食整蛋白为氮源的膳食中等低下短肽类(水解蛋白)为氮源的配方短肽类(水解蛋白)为氮源的配方显著低下短肽类、结晶氨基酸为氮源的配方危重病人的营养支持危重病人的营养支持制剂的选择制剂的选择病人能经病人能经口口进食吗进食吗?危重病人的营养支持危重病人的营养支持制剂的选择制剂的选择病人能经进食吗病人能经进食吗胃肠是否有功能？胃肠是否有功能？无无是是否否经口进食经口进食(能摄入80以上的营养)肠外营养肠外营养无无是是有有(营养)消化吸收功能障碍消化吸收功能障碍？预消化配方预消化配方否否消化吸收功能障碍消化吸收功能障碍？预消化配方预消化配方肠道功能问题？肠道功能问题？膳食纤维配方膳食纤维配方是是高血糖？高血糖？低糖配方低糖配方是是是是否否否否否否高血脂？高血脂？低脂配方低脂配方需要限制水的摄入需要限制水的摄入？高热卡配方高热卡配方是是需要限制水的摄入需要限制水的摄入高热卡配方高热卡配方标准配方标准配方短肽配方短肽配方 容易吸收 低脂肪（9%）容易耐受 低粪渣 低粪渣 血糖容易高消化吸收不良消化吸收不良胃肠功能障碍早期肠内营养刚刚开始时早期肠内营养刚刚开始时胰十二指肠切除术后腹腔脓肿腹腔脓肿急性肾功能衰竭脓肿引流后即行肠内营养支持肠内营养支持EN：短肽配方+得每通0.6g,1/6h 肠液收集与回输(fistuloclysis)短肽配方得每通0.45g,1/8h坏死性急性胰腺炎恢复后坏死性急性胰腺炎恢复后1818个月的酶分布个月的酶分布坏死性急性胰腺炎恢复后坏死性急性胰腺炎恢复后1818个月的酶分布个月的酶分布胰腺功能胰腺功能正常(13%)正常(13%)胰腺功能不足胰腺功能不足胰腺功能不足胰腺功能不足1级(81%)胰腺功能不足1级(81%)胰腺功能不足2级(6%)-正常低限值2级(6%)-正常低限值Bozkurt T et al.,Bozkurt T et al.,Hepato-GastroenterolHepato-Gastroenterol42,199542,1995改进肠内营养耐受能做什么？监测监测病因处理幽门后喂养（小肠喂养）适当的制剂和消化液/酶补充优化输注技术优化输注技术逐渐加大浓度逐渐加大浓度控制速度控制速度消化液回输、添加消化酶消化液回输、添加消化酶保证无菌保证无菌、不变质不变质保证无菌保证无菌、不变质不变质加热器加热器如何提高肠内营养耐受：如何提高肠内营养耐受：2009 ASPEN/SCCM要点要点2009 ASPEN/SCCM要点要点1、应当避免不恰当终止 EN（E 级），胃残余量 400 ml?Replace 400mlMaintain rate Replace aspirate&increase rate by30ml/hour NoNoNoYesNo yHas target rate been achieved?Aspirate 6hrly x 2Aspirate after 6 hoursIs volume 400 ml?Replace 400 ml.Commence prokinetic agent of choice.Reduce rate by30ml/hour or to aYesNoYes pyAspirate 8 hrly x 3 Aspirate 12 hrly x 2 Any aspirate 400ml?Continue with 12 hourly aspirationReduce rate by 30ml/hour or to a minimum of 10ml/hour.Aspirate after 6 hoursIs volume 400ml?Replace 400ml&reduce toYesNoYesNo Prokinetic medication for consideration Metoclopramide 10 mg QID,IV/NG Erythromycin 200 mg BD,IV/NG Reasons for temporary cessation GIT disturbances:suspected bowel obstruction(vomiting,abdominal distension),excessive diarrhoea.NOTE:Reduce/cease insulin infusion when feeds stopped.pReplace 400ml&reduce to 10ml/hour.Consider NJ tube or TPN.如何提如何提高高肠肠内内营营养养耐受：耐受：高内养高内养2009 ASPEN/SCCM要点要点3、应当对接受EN的病人评估误吸的危险，采取降低误吸危险的措施（E 级）低误吸危险的措施级床头应抬高至30-45（C 级）持续输注EN（D 级）持续输注EN（D 级）使用促进胃肠运动的药物,如促动力药（胃复安和红霉素镇静剂爱维莫素）或镇静药拮抗剂（纳洛酮和爱维莫潘）（C 级）可以考虑通过留置幽门后喂养管进行喂养（C 级）三、早期肠内营养摄入不足怎么办？early PN:PN is initiated within 24-48 hours after ICU admission up to a calculated nutritional target.late PN:PN completing EN is initiated when the target is not late PN:PN completing EN is initiated when the target is not reached on day 8.In both groups,the same early EN protocol is applied.ResultsResultsready for ICU discharge:all clinical conditions for ICU discharge have been fulfilled(no longer in need for vital organ support and receiving at least 2/3 of the caloric requirements as oral feeds)or earlier when the tit itllt tpatient is actually sent to a regular plicated pulmonary,complicated pulmonary,esophageal,abdominal,or pelvic surgery,mean APACHE II score of 2711Csco e o1.The duration of ICU stay of these patients was 6(2-16)days in the Late PN group and 7(3-19)days in the Early PN group.2.There was a relative increase of 20%in the likelihood of earlier discharge alive from the ICU(OR1.20;(1.00 to 1.44)(;()3.The rate of infection was lower in the late-initiation group(29.9%)than in the early initiation group(40 2%P=0 01)the early initiation group(40.2%,P=0.01).ConclusionIlithli iti tif PN tConclusion In conclusion,the early initiation of PN to supplement insufficient EN during the first week after ICU admission in severelyfirst week after ICU admission in severely ill patients at risk for malnutrition appears to be inferior to the strategy of gywithholding PN until day 8 while providing vitamins,trace elements,and minerals.Late PN was associated with fewer i ftihdd linfections,enhanced recovery,and lower health care costs.didl b ld randomized,open-label study from August 20,2003 through July 8,2009 from two ICUs at a single academic center patients expected to require mechanical ventilation for at least 72 hrs and intended to initiate or continue enteral nutritionleast 72 hrs and intended to initiate or continue enteral nutritionFull-energy feedingFull-energy feeding protocolthe trophic groupthe trophic group enteral nutrition initiated at 10 mL/hr.Gastric residual volumes(GRVs)were checked every 12 hrs.In patients still ventilated at 144 hrs,enteral nutritionIn patients still ventilated at 144 hrs,enteral nutrition was advanced to full-energy target feeding rates using the same protocol as for the full-energy feeding groupthe same protocol as for the full energy feeding group For study days 15,patients receiving enteral nutrition in the full-energy group averaged 1418686 kcal/day compared toenergy group averaged 1418686 kcal/day compared to 300149 kcal/day for the trophic group(p.001),representing an average delivery of 74.8%38.5%and 15.8%11%of gytargeted goal daily calories,respectively.Both groups received similar amounts of calories and protein daily for study days 712.Kaplan-Meier curves demonstrated similar 28-day il l tsurvival plots for both groups(pgroups(p.24)ConclusionsConclusions Initial trophic enteral nutrition in mechanically ventilated patients with acute respiratory ppyfailure results in clinical outcomes similar to those of early advancement to full-energythose of early advancement to full energy enteral nutrition with fewer episodes of GI i t lintolerance.谢谢谢谢