2016重症营养5.doc

SCCM/ASPEN成年危重病患者营养支持治疗实施与评估指南(5/6)
2016年02月29日 ⁄ 指南导读, 进展交流 ⁄ 暂无评论
Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)
成年危重病患者营养支持治疗的实施与评估指南：美国危重病医学会(SCCM)与美国肠外肠内营养学会(ASPEN)
Taylor BE, McClave SA, Martindale RG, et al. Crit Care Med 2016; 44: 390-438
翻译：清华大学长庚医院 张振宇 许媛

M. SURGICAL SUBSETS外科部分
TRAUMA创伤
Question: Does the nutrition therapy approach for the trauma patient differ from that for other critically ill patients?
问题：创伤患者的营养治疗方案与其他危重病患者有何不同？
M1a. We suggest that, similar to other critically ill patients, early enteral feeding with a high protein polymeric diet be initiated in the immediate post-trauma period (within 24 to 48 hours of injury) once the patient is hemodynamically stable.
[Quality of Evidence: Very Low]
与其他危重病患者相似，我们建议一旦创伤患者血流动力学稳定，应尽早（创伤后24-48小时）开始高蛋白配方肠内营养。
【证据质量：非常低】

Question: Should immune-modulation formulas be used routinely to improve outcomes in a patient with severe trauma?
问题：严重创伤患者是否应常规使用免疫调节配方以改善预后？
M1b. We suggest that immune-modulating formulations containing arginine and FO be considered in patients with severe trauma.
[Quality of Evidence: Very Low]
我们建议严重创伤患者给予富含精氨酸与鱼油的免疫调节配方肠内营养。
【证据质量：非常低】

TRAUMATIC BRAIN INJURY颅脑创伤
Question: Does the approach for nutrition therapy for the TBI patient differ from that of other critically ill patients or trauma patients without head injury?
问题：TBI患者的营养治疗方案与其他危重病患者或没有颅脑损伤的其他创伤患者有何不同？
M2a. We recommend that, similar to other critically ill patients, early enteral feeding be initiated in the immediate post-trauma period (within 24 to 48 hours of injury) once the patient is hemodynamically stable.
[Quality of Evidence: Very Low]
与其他危重病患者相似，我们建议一旦患者血流动力学稳定，在创伤后（损伤24-48小时内）立即开始早期肠内营养。
【证据质量：非常低】

Question: Should immune-modulating formulas be used in a patient with TBI?
问题：TBI患者是否应当使用免疫调节配方吗？
M2b: Based on expert consensus, we suggest the use of either arginine-containing immune-modulating formulations or EPA/DHA supplement with standard enteral formula in patients with TBI.
基于专家共识，我们建议TBI患者使用含有精氨酸的免疫调节配方，或使用添加EPA/DHA的标准配方。

OPEN ABDOMEN 开放腹腔
Question: Is it safe to provide EN to patients with an OA?
问题：开放腹腔患者应用EN是否安全？
M3a. Based on expert consensus, we suggest early EN (24–48 hours post-injury) in patients treated with an OA in the absence of a bowel injury.
根据专家共识，我们建议没有肠道损伤的开放腹腔患者应尽早（伤后24-48小时）开始EN。

Question: Do patients with OA have increased protein or energy needs?
问题：开放腹腔患者的蛋白质或能量需求是否增加？
M3b. Based on expert consensus, we suggest providing an additional 15 to 30 grams protein per liter of exudate lost for patients with OA. Energy needs should be determined as for other ICU patients (see section a).
基于专家共识，我们建议开放腹腔患者按照15-30 g／每升渗液丢失量额外增加蛋白质补充。能量需求与其他ICU患者相同（见a部分）。

BURNS烧伤
Question: What mode of nutrition support should be used to feed burn patients?
问题：烧伤患者应用何种营养支持方式？
M4a. Based on expert consensus, EN should be provided to burn patients whose GI tracts are functional and for whom volitional intake is inadequate to meet estimated energy needs. PN should be reserved for those burn patients for whom EN is not feasible or not tolerated.
根据专家共识，对于保留胃肠道功能且口服饮食不能达到预计能量需求的烧伤患者，应当给予EN。不能实施EN或EN不能耐受时考虑给予PN。

Question: How should energy requirements be determined in burn patients?
问题：如何确定烧伤患者的能量需求？
M4b. Based on expert consensus, we suggest that IC be used when available to assess energy needs in burn patients with weekly repeated measures.

基于专家共识，我们建议可能时使用IC每周重复测定以评估烧伤患者的能量需要。

Question: What is the optimal quantity of protein to deliver to patients with large burns requiring ICU care?
问题：需要ICU治疗的大面积烧伤患者，理想的蛋白质补充量是多少？
M4c. Based on expert consensus, we suggest that patients with burn injury should receive protein in the range of 1.5–2g/kg/day.
根据专家共识，我们建议烧伤患者蛋白质补充量为1.5-2.0g/kg/天。

Question: When should nutrition support be initiated?
问题：何时开始营养支持？
M4d. Based on expert consensus, we suggest very early initiation of EN (if possible, within 4–6 hours of injury) in a patient with burn injury.
根据专家共识，我们建议烧伤患者尽早开始EN（如果可能，应在损伤后4-6小时内开始）

N. SEPSIS 全身性感染（脓毒症）
Question: Are patients with severe sepsis candidates for early EN therapy?
问题：严重全身性患者是否适宜进行早期EN治疗？
N1. Based on expert consensus, we suggest that critically ill patients receive EN therapy within 24–48 hours of making the diagnosis of severe sepsis/septic shock as soon as resuscitation is complete and the patient is hemodynamically stable.
根据专家共识，一旦复苏完成且血流动力学稳定，我们建议应当在诊断严重全身性感染或感染性休克后24-48小时内给予EN治疗。

Question: Should exclusive or supplemental PN added to EN providing < 60% of goal be used in the acute phase of severe sepsis or septic shock?
问题：在严重全身性感染和感染性休克的急性期，是否应当使用全肠外营养(PN)，或当EN提供能量低于目标能量60%时，给予补充性PN（SPN）？
N2. We suggest NOT using exclusive PN or supplemental PN in conjunction with EN early in the acute phase of severe sepsis or septic shock, regardless of their degree of nutrition risk.
[Quality of Evidence: Very Low]
在严重全身性感染或感染性休克的急性期，无论营养风险程度如何，我们不建议给予完全PN，或在早期EN的同时添加补充性PN。
【证据质量：非常低】

Question: What is the optimal micronutrient supplementation in sepsis?
问题：全身性感染患者最佳的微营养素补充是什么？
N3. We cannot make a recommendation regarding selenium, zinc and antioxidant supplementation in sepsis at this time due to conflicting studies
[Quality of Evidence: Moderate]
鉴于研究结果相互矛盾，目前我们尚不能推荐全身性感染患者补充硒、锌及抗氧化剂。
【证据质量：中】

Question: What are the protein and energy requirements for septic patients in the acute phase of management?
问题：全身性感染急性期治疗时蛋白质与能量需要是多少？
N4. Based on expert consensus, we suggest the provision of trophic feeding (defined as 10–20kcal/hr or up to 500 kcal/day) for the initial phase of sepsis, advancing as tolerated after 24–48 hours to > 80% of target energy goal over the first week. We suggest delivery of 1.2–2 g protein/kg/day.
根据专家共识，我们建议在全身性感染早期给予滋养型喂养策略（定义为10-20 kcal/h或不超过500 kcal/day），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。我们建议蛋白质供给量为1.2-2.0 g/kg/天。

Question: Is there any advantage to providing immune or metabolic-modulating enteral formulations (arginine with other agents, including EPA, DHA, glutamine, and nucleic acid) in sepsis?
问题：全身性感染患者使用免疫调节或代谢调节型肠内营养制剂（添加精氨酸或其他药物，包括EPA，DHA，谷氨酰胺和核酸）是否有益？
N5. We suggest that immune-modulating formulas not be used routinely in patients with severe sepsis.
[Quality of Evidence: Moderate]
我们建议严重全身性感染患者不赢常规使用免疫调节配方的EN制剂。
【证据质量：中】

O. POSTOPERATIVE MAJOR SURGERY (SICU ADMISSION EXPECTED) 外科大手术后（计划收入SICU）
Question: Is the use of a nutrition risk indicator to identify patients who will most likely benefit from postoperative nutrition therapy more useful than traditional markers of nutrition assessment?
问题：与传统营养评价指标相比，使用营养风险指标能否更好地确定那些最可能从术后营养治疗中获益的患者？
O1. Based on expert consensus, we suggest that determination of nutrition risk (for example, NRS-2002 or NUTRIC score) be performed on all postoperative patients in the ICU and that traditional visceral protein levels (serum albumin, prealbumin, and transferrin concentrations) should not be used as markers of nutrition status.
根据专家共识，我们建议对所有ICU术后患者评估营养风险（例如，NRS-2002或NUTRIC评分）；传统指标即内脏蛋白水平（血浆白蛋白，前白蛋白与转铁蛋白）不应作为营养状态评价指标。

Question: What is the benefit of providing EN early in the postoperative setting compared to providing PN or STD?
问题：与给予PN或标准静脉补液治疗(STD)相比，术后早期EN的益处有哪些？
O2. We suggest that EN be provided when feasible in the postoperative period within 24 hours of surgery, as it results in better outcomes than use of PN or STD.
[Quality of Evidence: Very Low]
我们建议，如有可能，术后24小时内应给予EN，因为EN的预后较PN或STD更好。
【证据质量：非常低】

Question: Should immune-modulating formulas be used routinely to improve outcomes in a postoperative patient?
问题：术后患者是否应当常规使用免疫调节配方以改善预后？
O3. We suggest the routine use of an immune-modulating formula (containing both arginine and fish oils) in the SICU for the postoperative patient who requires EN therapy.
[Quality of Evidence: Moderate to Low]
对于需要EN治疗的SICU术后患者，我们建议常规给予免疫调节配方肠内营养制剂（含精氨酸与鱼油）。
【证据质量：中到低】

Question: Is it appropriate to provide EN to a SICU patient in the presence of difficult postoperative situations such as OA, bowel wall edema, fresh intestinal anastomosis, vasopressor therapy, or ileus?
问题：术后病情复杂的SICU患者（如开放腹腔、肠壁水肿、小肠吻合术后、血管活性药物治疗或肠梗阻）接受EN是否恰当？
O4. We suggest enteral feeding for many patients in difficult postoperative situations such as prolonged ileus, intestinal anastomosis, OA, and need of vasopressors for hemodynamic support. Each case should be individualized based on perceived safety and clinical judgment.
[Quality of Evidence: Low to Very Low]
对许多术后病情复杂的患者（如长期肠梗阻、肠吻合，开放腹腔，需要血管活性药维持血流动力学），我们建议应当在保证安全及临床判断的基础上进行个体化治疗。
【证据质量：低至很低】

Question: When should PN be used in the postoperative ICU patient?
问题：术后ICU患者何时应用PN？
O5. Based on expert consensus, we suggest that, for the patient who has undergone major upper GI surgery and EN is not feasible, PN should be initiated (only if the duration of therapy is anticipated to be ≥ 7 days). Unless the patient is at high nutrition risk, PN should NOT be started in the immediate postoperative period, but should be delayed for 5–7 days.
根据专家共识，对于上消化道大手术且不能接受EN的患者，我们建议开始使用PN（仅当预计PN治疗≥ 7天时）。除非患者存在高营养风险，PN不应在术后立即开始，而应延迟至5-7天后开始。

Question: Is advancing to a clear liquid diet required as the first volitional intake in the postoperative ICU patient?
问题：术后ICU患者首次进食是否应从清流开始？
O6. Based on expert consensus, we suggest that, upon advancing the diet postoperatively, patients be allowed solid food as tolerated, and that clear liquids are not required as the first meal.
根据专家共识，如果术后可以进食，只要患者可以耐受，我们建议进食固体食物，而无需将清流食作为第一餐。