2016重症营养1

SCCM/ASPEN成年危重病患者营养支持治疗实施与评估指南(1/6)

2016年02月15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：清华大学长庚医院周华许媛

A. NUTRITION ASSESSMENT 营养评估

Question: Does the use of a nutrition risk indicator identify patients who will most likely benefit from nutrition therapy?

问题：营养风险筛查工具能否鉴别哪些患者最可能从营养治疗中获益？

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合并症、胃肠道功能以及误吸风险的评估。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。

Question: What is the best method for determining energy needs in the critically ill adult patient?

问题：确定成年危重病患者能量需求的最佳方法是什么？

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.

[Quality of Evidence: Very Low]。

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。

［证据质量：非常低］

A3b. Based on expert consensus, in the absence of IC, we suggest that a published predictive equation or a simplistic weight-based equation (25–30 kcal/kg/ day) be used to determine energy requirements. (see section Q for obesity recommendations.)

根据专家共识，当没有IC时，我们建议使用已发表的预测公式或基于体重的简化公式(25–30 kcal/kg/ day)确定能量需求。（见Q部分有关肥胖患者的推荐意见。）

Question: Should protein provision be monitored independently from energy provision in critically ill adult patients?

问题：对于成年危重病患者，除能量提供外，是否需要单独监测提供的蛋白质量？

A4. Based on expert consensus, we suggest an ongoing evaluation of adequacy of protein provision be performed.

根据专家共识，我们建议连续评估蛋白质供给的充分性。

B. INITIATE EN 开始肠内营养(EN)

Question: What is the benefit of early EN in critically ill adult patients compared to withholding or delaying this therapy?

问题：对于成年危重病患者而言，与不给予或延迟给予EN相比，早期EN有何益处？

B1. We recommend that nutrition support therapy in the form of early EN be initiated within 24–48 hours in the critically ill patient who is unable to maintain volitional intake.

[Quality of Evidence: Very Low]

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。

［证据质量：非常低］

Question: Is there a difference in outcome between the use of EN or PN for adult critically ill patients?

问题：成年危重病患者使用EN或PN对预后的影响有何不同？

B2. We suggest the use of EN over PN in critically ill patients who require nutrition support therapy.

[Quality of Evidence: Low to Very Low]

对于需要营养支持治疗的危重病患者，我们建议首选EN而非PN的营养供给方式。

［证据质量：低至非常低］

Question: Is the clinical evidence of contractility (bowel sounds, flatus) required prior to initiating EN in critically ill adult patients?

问题：在成年危重病患者开始EN前是否需要有肠道蠕动的证据（肠鸣音，排气）？

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，我们建议，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。

Question: What is the preferred level of infusion of EN within the GI tract for critically ill patients? How does the level of infusion of EN affect patient outcomes?

问题：危重病患者胃肠道输注EN的最佳速度是多少？EN输注速度如何影响患者预后？

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（见D4部分）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。

［证据质量：中至高］

B4b. Based on expert consensus we suggest that, in most critically ill patients, it is acceptable to initiate EN in the stomach.

基于专家的共识，我们建议经胃开始喂养是多数危重病患者可接受的EN方式。

Question: Is EN safe during periods of hemodynamic instability in adult critically ill patients?

问题：对于成年危重病患者，血流动力学不稳定时EN是否安全？

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.

根据专家共识，我们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. DOSING OF EN EN的剂量

Question: What population of patients in the ICU setting does not require nutrition support therapy over the first week of hospitalization?

问题：哪些患者住ICU的第一周内无需营养支持治疗？

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.

根据专家共识，我们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。

Question: For which population of patients in the ICU setting is it appropriate to provide trophic EN over the first week of hospitalization?

问题：哪些ICU患者在住院第一周内适合滋养型喂养(trophic EN)？

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.

[Quality of Evidence: High]

对于急性呼吸窘迫综合征(ARDS)/急性肺损伤(ALI)患者以及预期机械通气时间≥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。

［证据质量：高］

Question: What population of patients in the ICU requires full EN (as close as

possible to target nutrition goals) beginning in the first week of hospitalization?

How soon should target nutrition goals be reached in these patients?

问题：哪些ICU患者住院第一周需要足量EN（尽可能接近目标喂养量）？这些患者应多长

时间达到目标量？

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 24–48 hours while monitoring for refeeding syndrome. Efforts to provide > 80% of estimated or calculated goal energy and protein

within 48–72 hours should be made in order to achieve the clinical benefit of EN over the first week of hospitalization.

根据专家共识，我们建议具有高营养风险患者（如：NRS-2002 > 5 或不考虑IL-6情况下NUTRIC 评分≥5）或严重营养不良患者，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小时提供> 80%预计蛋白质与能量供给目标，从入院第一周的EN中获益。

Question: Does the amount of protein provided make a difference in clinical outcomes of adult critically ill patients?

问题：蛋白质供给量对成年危重病患者临床结局有何不同影响？

C4. We suggest that sufficient (high-dose) protein should be provided. Protein requirements are expected to be in the range of 1.2–2.0g/kg actual body weight per day, and may likely be even higher in burn or multi- trauma patients (see sections M and P).

[Quality of Evidence: Very Low]

我们建议充分的（大剂量的）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（见M和P部分）。

［证据质量：非常低］